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 2699.6725 - Share of Cost for Vision Benefits

Universal Citation: 10 CA Code of Regs 2699.6725

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

(a) A participating vision plan shall require copayments for benefits provided to subscribers utilizing the services of the vision plan's panel of approved providers subject to the following except that subscribers with household income at or below 150% of the Federal Poverty Level shall pay a $5 copayment when a copayment is required:

(1) Examinations: $10 copayment per examination.

(2) Frames and lenses: $10 copayment, for frames with lenses, or for frames or lenses when purchased separately. No additional copayment for tinted or photochromic lenses when otherwise deemed medically necessary, or polycarbonate lenses.

A frame allowance of $35 is provided by the vision plan. The subscriber is responsible for any costs exceeding this allowance. The participating vision plan shall ensure that a selection of frames that do not cost more than the frame allowance is available to all subscribers.

The following options are considered cosmetic and any costs associated with the selection of these options will be the financial responsibility of the applicant.

(A) Blended lenses (bifocals which do not have a visible dividing line).

(B) Contact lenses except as specified in Section 2699.6721(a)(3).

(C) Oversized lenses (larger than standard lens blank to accommodate prescriptions).

(D) Progressive multifocal lenses.

(E) Coated or laminated lenses.

(F) UV protected lenses.

(G) Other optional cosmetic processes.

(H) A frame that costs more than the plan's allowance.

(3) Necessary contact lenses, as defined in Subsection 2699.6721(a)(3): No copayment.

(4) Elective contact lenses: an allowance of $100 will be provided by the vision plan toward the cost of an examination, contact lens evaluation, fitting costs and materials. This allowance will be in lieu of all benefits including examination and material costs. The subscriber is responsible for any costs exceeding this allowance.

(5) Low vision benefits:
(A) Supplementary testing: No copayment; and

(B) Supplemental care: $10 copayment.

(b) Services from providers not included in the vision plan's panel of approved providers:

When a subscriber obtains services from a provider not included in the vision plan's panel of approved providers, the applicant will be responsible for paying the provider for all services and materials received at the time of their appointment. The participating vision plan will reimburse the applicant within fourteen (14) calendar days after receipt of the paid itemized bill or statement, according to the schedule of allowances as follows:

(1) Professional fees:
(A) Vision exams, up to $35.00

(2) Materials:
(A) Each single vision lens -- up to $7.50 or a pair of single vision lenses up to $15.00.

(B) Each bifocal lens -- up to $15.00 or a pair of bifocal lenses up to $30.00.

(C) Each trifocal lens -- up to $20.00 or a pair of trifocal lenses up to $40.00.

(D) Each lenticular lens -- up to $45.00 or a pair of lenticular lenses up to $90.00.

(E) Frame up to $25.00.

(F) Tinted or photochromic lenses when otherwise deemed medically necessary -- up to $5.00.

(G) Polycarbonate lenses -- up to $10.00.

(H) Each pair of necessary contact lenses -- up to $250.00.

(I) Each pair of elective contact lenses -- up to $100.00. Determination of whether contact lenses are necessary or elective when obtained from providers not included in the vision plan's panel of approved providers will be the responsibility of the vision plan. Reimbursement for elective contact lenses is in lieu of all benefits, including examination and materials.

(3) Low vision benefits: Low vision benefits obtained from a provider not included in the vision plan's panel of approved providers will be reimbursed in accordance with what the participating vision plan would pay a provider included in the vision plan's panel of approved providers for this benefit.

(c) No deductibles shall be charged to subscribers for vision benefits.

(d) For subscriber parents who receive vision services from one of the participating member doctors, covered services as described are provided with no additional out-of-pocket costs after an applicable copayment. Additional services selected for cosmetic purposes are the financial responsibility of the patient.

(e) No copayments shall apply if the applicant has submitted acceptable documentation as described in Section 2699.6600(c)(1)(GG) that the applicant or the subscriber is American Indian or Alaska Native. However, there is no limitation on the payments required under Subsection (b) above.

1. Renumbering of former section 2699.6721 to section 2699.6725, 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.
2. Certificate of Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
3. Amendment of subsection (e) filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).
5. Amendment of subsection (e) filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
7. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).
8. Amendment of subsections (a)(2) and (b)(2)(F) 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)-(a)(2) and (a)(5)(B) and amendment of NOTE filed 10-29-2009; operative 11-1-2009 pursuant to Government Code section 11346.1(d) (Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL by 4-30-2010 or emergency action will be repealed by operation of law on the following day. This regulatory action is deemed to meet the emergency standard and is exempt from OAL review pursuant to Insurance Code section 12693.22.
11. Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010 and filed 6-9-2010 (Register 2010, No. 24).
12. Amendment of subsections (a)(2), (a)(4), (b)(2)(A)-(E) and (b)(2)(I) 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 and 12693.755, Insurance Code.

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