Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Health benefit plans offered under this
program shall exclude all of the following:
(1) Any benefits specified as excluded within
Section 2699.6700.
(2) Any benefits in excess of limits
specified in Section
2699.6700.
(3) Services, supplies, items, procedures or
equipment, which are not medically necessary as determined by the plan, unless
otherwise specified in Section
2699.6700.
(4) Any benefits that are received prior to
the subscriber's effective date of coverage. This exclusion does not apply to
covered benefits to treat complications arising from services received prior to
the subscriber's effective date of coverage.
(5) Any benefits that are received subsequent
to the time the subscriber's coverage ends.
(6) Experimental or investigational services,
including any treatment, therapy, procedure, drug or drug usage, facility or
facility usage, equipment or equipment usage, device or device usage, or supply
which is not recognized as being in accordance with generally accepted
professional medical standards, or for which the safety and efficiency have not
been determined for use in the treatment of a particular illness, injury or
medical condition for which the item or service in question is recommended or
prescribed. This section does not exclude clinical trials for cancer patients
as provided pursuant to subsection
2699.6700(a)(21).
(7) Medical services that are received in an
emergency care setting for conditions that are not emergencies if the
subscriber reasonably should have known that an emergency care situation did
not exist.
(8) Eyeglasses, except
for those eyeglasses or contact lenses necessary after cataract surgery which
are covered under Subsection
2699.6700(a)(3)(A).
(9) The diagnosis and treatment of
infertility is not covered unless provided in conjunction with covered
gynecological services. Treatments of medical conditions of the reproductive
system are not excluded.
(10)
Long-term care benefits including long-term skilled nursing care in a licensed
facility and respite care are excluded except as a participating health plan
shall determine they are less costly, satisfactory alternatives to the basic
minimum benefits. This section does not exclude short-term skilled nursing care
or hospice benefits as provided pursuant to Subsection
2699.6700(a)(13) and
(a)(18).
(11) Cosmetic surgery that is solely
performed to alter or reshape normal structures of the body in order to improve
appearance.
1. New section
filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A
Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency
language will be repealed by operation of law on the following
day.
2. Certificate of Compliance as to 2-20-98 order transmitted to
OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment of
subsections (a)(8)-(a)(11), new subsection (a)(13) and amendment of NOTE filed
4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18).
Pursuant to Chapter 946, Statutes of 2000, section
2, a Certificate of Compliance
must be transmitted to OAL by 10-28-2002 or emergency language will be repealed
by operation of law on the following day.
4. Certificate of
Compliance as to 4-29-2002 order, including repealer of subsection (a)(10) and
subsection renumbering, transmitted to OAL 10-28-2002 and filed 12-12-2002
(Register 2002, No. 50).
5. Amendment filed 9-15-2008; operative
10-15-2008 (Register 2008, No. 38).
Note: Authority cited: Sections
12693.21
and
12693.755,
Insurance Code. Reference: Sections
12693.21,
12693.60
and
12693.755,
Insurance Code.
