(a) The basic scope of benefits offered by participating carriers as a health benefits plan shall include all of the benefits and services listed in this section, subject to the exclusions listed in Section 2699.6203. No other benefits shall be permitted to be offered by a participating carrier. The basic scope of benefits shall be as follows:
(1) Those benefits described in Section 1300.67 of Title 10 of the California Code of Regulations.
(2) Plastic and reconstructive surgical services limited to the following:
(A) Surgery to correct a physical functional disorder resulting from a disease or congenital anomaly.
(B) Surgery to correct a physical functional disorder following either an injury or incidental to any other surgery.
(C) Reconstructive surgery and associated procedures following a mastectomy which resulted from disease, illness, or injury, and internal breast prosthesis required incidental to the surgery.
(3) Prescription drugs, limited to drugs approved by the federal Food and Drug Administration, generic equivalents approved as substitutable by the federal Food and Drug Administration, or drugs approved by the federal Food and Drug Administration as Treatment Investigational New Drugs or classified as Group C cancer drugs by the National Cancer Institute to be used only for the purposes approved by the federal Food and Drug Administration or the National Cancer Institute.
(4) Mental Health benefits, limited to the following:
(A) Inpatient care in a health facility licensed pursuant to Chapter 2 of Division 2 of the Health and Safety Code (Section 1250 et seq.), for a total of ten (10) days in each benefit year,
1. Residential treatment may be substituted for inpatient care days at a ratio of two (2) residential treatment days to one (1) inpatient day, and
2. Intensive outpatient treatment may be substituted for inpatient care days at a ratio of three (3) intensive outpatient days to one (1) inpatient day.
(B) Twenty (20) outpatient visits in each benefit year.
(5) Outpatient medical rehabilitation and the outpatient services of occupational therapists, physical therapists, and speech therapists for treatment of acute conditions or the acute phase of chronic conditions if such conditions are subject to continuing significant improvement within a period of two (2) months.
(6) Durable medical equipment, prosthetic devices, orthotic devices and oxygen and oxygen equipment, limited to equipment and devices which:
(A) are intended for repeated use over a prolonged period,
(B) are not considered disposable, with the exception of ostomy bags,
(C) are ordered by a licensed health care provider acting within the scope of his or her license,
(D) are intended for the exclusive use of the enrollee,
(E) do not duplicate the function of another piece of equipment or device covered by the carrier for the enrollee,
(F) are generally not useful to a person in the absence of illness or injury,
(G) primarily serve a medical purpose, and
(H) are appropriate for use in the home.
Medically necessary repair or replacement of covered durable medical equipment, prosthetic devices, and orthotic devices is a benefit when prescribed by a physician or ordered by a licensed health care provider acting within the scope of his or her license, and when not caused by misuse or loss.
(7) Human organ transplants, including reasonable medical and hospital expenses of a donor or individual identified as a prospective donor if the expenses are directly related to the transplant, other than corneal, shall be subject to the following restrictions:
(A) Preoperative evaluation, surgery, and follow-up care shall be provided at centers that have been designated by the participating carrier as having documented skills, resources, commitment and record of favorable outcomes to qualify the centers to provide such care.
(B) Patients shall be selected by the patient-selection committee of the designated centers and subject to prior authorization.
(C) Only anti-rejection drugs, biological products, and other procedures that have been established as safe and effective, and no longer investigational, are covered.
(8) Chemical dependency and alcoholism benefits, limited to the following:
(A) Detoxification of chemical dependency or alcohol abuse,
(B) Outpatient treatment limited, at the participating carrier's discretion, to either of the following:
1. A maximum payment of $20 per day, and a maximum payment of $400 per person for all outpatient chemical dependency and alcoholism benefits in each benefit year, or
2. Alternative arrangements that have been approved by the program and are described in the carrier's evidence of coverage document.
(9) Hospice care when a participating health plan determines it is a less costly alternative to other of the basic minimum benefits.
(10) Home health care and home health services as described in Section 1374.10(b) of the California Health and Safety Code. This does not preclude a carrier from providing other health care benefits in the home.
(11) Supplies, equipment, and services for the treatment and/or control of diabetes, even when such items, tests and services are available without a prescription, including:
(A) Supplies and equipment such as:
1. insulin,
2. syringes,
3. lancets,
4. insulin pumps and all related necessary supplies,
5. ketone urine testing strips for type I diabetes,
6. blood glucose meters, and
7. blood glucose meter testing strips in medically appropriate quantities for:
a. the monitoring and treatment of insulin dependent diabetes
b. the monitoring and treatment of non-insulin dependent diabetes
c. the monitoring and treatment of diabetes in pregnancy
(B) Diabetes education programs,
(C) Laboratory tests appropriate for the management of diabetes, including at a minimum: cholesterol, triglycerides, microalbuminuria, HDL/LDL and Hemoglobin A-1C (Glycohemogolobin), and
(D) Dilated retinal eye exam
(12) Short-term skilled nursing care provided in a skilled nursing facility or a skilled nursing bed in an acute care hospital, limited to a maximum of sixty (60) days in each benefit year.
This benefit does not cover conditions which are long-term or chronic in nature and require ongoing inpatient skilled nursing care, other than care for an acute phase of such a condition, or care at the inception of such a condition which is appropriate for stabilization prior to release from inpatient care.
(13) This part shall not be construed to prohibit a plan's ability to impose cost-control mechanisms. Such mechanisms may include but are not limited to requiring prior authorization for benefits or providing benefits in alternative settings or using alternative methods.
(14) Nothing in this section shall preclude the direct reimbursement of physician assistants, nurse practitioners or other advanced practice nurses who provide covered services within their scope of licensure.
1. Relocation of article heading and renumbering of former section 2699.630 to section 2699.6200 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of subsection (a) filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
4. Amendment of subsection (a)(6), new subsections (a)(6)(A)-(H), (a)(10)-(12) and subsection renumbering filed 5-8-97; operative 7-1-97 (Register 97, No. 19).
This database is current through 6/21/24 Register 2024, No. 25.
