California Code of Regulations
Title 10 - Investment
Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program
Article 3 - Health, Dental and Vision Benefits
Section 2699.6721 - Scope of Vision Benefits

Universal Citation: 10 CA Code of Regs 2699.6721

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The basic scope of benefits offered by a participating vision plan must comply with all requirements of the Knox-Keene Health Care Service Plan Act of 1975, including amendments as well as its applicable regulations, and shall include all of the benefits and services listed in this section, subject to the exclusions listed in Section 2699.6723. No other vision benefits shall be permitted to be offered by a participating vision plan as part of the program. The basic scope of vision benefits shall be as follows:

(1) Examinations: Each subscriber shall be entitled to a comprehensive vision examination, including a complete analysis of the eyes and related structures, as appropriate, to determine the presence of vision problems or other abnormalities as follows:
(A) Case history: Review of subscriber's main reason for the visit, past history, medications, general health, ocular symptoms, and family history.

(B) Evaluation of the health status of the visual system; including:
1. External and internal examination, including direct and/or indirect ophthalmoscopy;

2. Assessment of neurological integrity, including that of pupillary reflexes and extraocular muscles;

3. Biomicroscopy of the anterior segment of the eye, including observation of the cornea, lens, iris, conjunctiva, lids and lashes;

4. Screening of gross visual fields; and

5. Pressure testing through tonometry.

(C) Evaluation of refractive status, including:
1. Evaluation for visual acuity;

2. Evaluation of subjective, refractive, and accommodative function; and

3. Objective testing of a patient's prescription through retinoscopy.

(D) Binocular function test.

(E) Diagnosis and treatment plan, if needed.

(F) Examinations are limited to once each twelve consecutive month period.

(2) When the vision examination indicates that corrective lenses are necessary, each subscriber is entitled to necessary frames and lenses, including coverage for single vision, bifocal, trifocal, lenticular, and polycarbonate lenses as appropriate.

Frames and lenses are limited to once each twelve consecutive month period.

(3) Contact lenses shall be covered as follows:
(A) Necessary contact lenses shall be covered in full upon prior authorization from the vision plan, for certain conditions. These conditions may include the following:
1. Following cataract surgery;

2. To correct extreme visual acuity problems that cannot be corrected with spectacle lenses;

3. Certain conditions of Anisometropia; and

4. Keratoconus.

(B) Elective contact lenses may be chosen instead of corrective lenses and a frame a maximum benefit allowance of $100, which includes examinations, fittings and lenses.

(C) Contact lenses are limited to once each twelve consecutive month period.

(4) A low vision benefit shall be provided to subscribers who have severe visual problems that are not correctable with regular lenses. This benefit requires prior approval from the participating vision plan. With this prior approval, supplementary testing and supplemental care, including low vision therapy as visually necessary or appropriate, shall be provided.

For subscriber parents, the covered person is required to pay a $5 copayment for any approved Low Vision services.

(5)
(A) Participating vision plans shall be responsible for identifying subscribers under the age of 21 who have conditions for which they may be eligible to receive services under the California Children's Services (CCS) Program, and shall refer these individuals to the local CCS program for determination of eligibility.

(B) The plan is excused from responsibility from providing a covered service to treat the subscriber's CCS condition only to the extent that the treatment is authorized by the CCS program and provided by a CCS provider as described in the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, Section 41412.

(C) If a subscriber is determined by the CCS Program to be eligible for CCS benefits, participating vision plans shall provide services unrelated to the CCS eligible condition and shall ensure coordination of services between plan providers, CCS providers, and the local CCS program.

(b)

(1) The scope of vision benefits shall also include all vision benefits which are covered under the California Children's Services Program (Health and Safety Code Section 123800 et seq.) provided the subscriber meets the medical eligibility requirements of that program, as determined by that program.

(2) When a subscriber under the age of 21 is determined by the California Children's Services Program to be eligible for vision benefits under that program, a participating vision plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children's Services Program for the particular subscriber for the treatment of a California Children's Services Program eligible medical condition. All other services provided under the participating vision plan shall be available to the subscriber.

(c) If, pursuant to any Workers' Compensation, Employer's Liability Law, or other legislation of similar purpose or import, a third party is responsible for all or part of the cost of vision services to treat any bodily injury or sickness arising from or sustained in the course of any occupation or employment for compensation, profit or gain, the participating vision plan shall provide the services at the time of need, and the subscriber or applicant shall cooperate to assure that the participating vision plan is reimbursed for such services.

(d) Coverage provided under the Healthy Families Program is secondary to all other coverage, except Medi-Cal. Benefits paid under this Program are determined after benefits have been paid as a result of a subscriber's enrollment in any other vision care program. If vision services are eligible for reimbursement by insurance or covered under any other insurance or vision care service plan, the participating vision plan shall provide the services at the time of need, and the subscriber or applicant shall cooperate to assure that the participating vision plan is reimbursed for such services.

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. New subsection (d) filed 3-21-2000 as an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-21-2000 order transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No. 29).
5. Renumbering of former section 2699.6721 to section 2699.6725 and renumbering of former section 2699.6717 to section 2699.6721, including amendment of section and 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.
6. Certificate of Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
7. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).
8. Amendment of subsection (a)(2) filed 1-15-2009, deemed an emergency pursuant to Chapter 758, Statutes of 2008; operative 1-15-2009 (Register 2009, No. 3). A Certificate of Compliance must be transmitted to OAL by 7-14-2009 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 1-15-2009 order transmitted to OAL 7-13-2009 and filed 8-19-2009 (Register 2009, No. 34).
10. Amendment of subsections (a)(1)(F), (a)(2) and (a)(3)(C) and amendment of NOTE filed 6-24-2010 as an emergency; operative 7-1-2010 pursuant to Government Code section 11346.1(d) (Register 2010, No. 26). A Certificate of Compliance must be transmitted to OAL by 12-28-2010 or the emergency action will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 6-24-2010 order transmitted to OAL 12-21-2010 and filed 2-2-2011 (Register 2011, No. 5).
12. Redesignation and amendment of former subsection (a)(5) as subsection (a)(5)(A), new subsections (a)(5)(B)-(C) and amendment of NOTE filed 6-30-2011, deemed an emergency pursuant to Insurance Code section 12693.22; operative 6-30-2011 (Register 2011, No. 26). A Certificate of Compliance must be transmitted to OAL by 12-27-2011 or the emergency action will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 6-30-2011 order transmitted to OAL 12-20-2011 and filed 2-3-2012 (Register 2012, No. 5).

Note: Authority cited: Sections 12693.21, 12693.22, 12693.62 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.22, 12693.62, 12693.65, 12693.66 and 12693.755, Insurance Code.

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