§ 2699.6700. Scope of Health Benefits.
10 CA ADC § 2699.6700Barclays Official California Code of Regulations
10 CCR § 2699.6700
§ 2699.6700. Scope of Health Benefits.
(a) The basic scope of benefits offered by participating health plans 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 this section and Section 2699.6703. No other benefits shall be permitted to be offered by a participating health plan as part of the program. The basic scope of benefits shall include:
(A) Inpatient Hospital Services: General hospital services, in a room of two or more, with customary furnishings and equipment, meals (including special diets as medically necessary), and general nursing care. All necessary ancillary services such as: use of operating room and related facilities; intensive care unit and services; drugs, medications, and biologicals; anesthesia and oxygen; diagnostic laboratory and x-ray services; special duty nursing; physical, occupational, and speech therapy, respiratory therapy; administration of blood and blood products; other diagnostic, therapeutic and rehabilitative services as appropriate; and coordinated discharge planning, including the planning of such continuing care as may be necessary.
Exclusions: Personal or comfort items or a private room in a hospital are excluded unless medically necessary.
(B) Outpatient Services: Diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility. Includes hospital services which can reasonably be provided on an ambulatory basis and related services and supplies in connection with these services including operating room, treatment room, ancillary services, and medications which are supplied by the hospital or facility for use during the subscriber's stay at the facility. Includes physical, occupational, and speech therapy, if necessary.
(C) Inpatient and Outpatient Services include coverage for general anesthesia and associated facility charges, and outpatient services in connection with dental procedures when the use of a hospital or surgery center is necessary because of the subscriber's medical condition or clinical status or because of the severity of the dental procedure. This benefit is only available to subscribers under seven years of age; the developmentally disabled, regardless of age; and subscribers whose health is compromised and for whom general anesthesia is medically necessary, regardless of age.
Participating health plans shall coordinate such services with the subscriber's participating dental plan. Services of the dentist or oral surgeon for dental procedures are excluded.
(2) Professional Services: Services and consultations by a physician or other licensed health care provider acting within the scope of his or her license. Includes services of a surgeon, assistant surgeon and anesthesiologist (inpatient or outpatient); inpatient hospital and skilled nursing facility visits; professional office visits including visits for examinations, allergy tests and treatments, radiation therapy, chemotherapy, and dialysis treatment; specialist office visits, and home visits.
(A) Vision Services: For subscriber children, vision testing, eye refractions to determine the need for corrective lenses, and dilated retinal eye exams. For subscriber parents, eye refraction is optional for plan. Includes cataract spectacles, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after cataract surgery. Also one pair of conventional eyeglasses or conventional contact lenses are covered if necessary after cataract surgery with insertion of an intraocular lens.
Hearing Aid: Monaural or binaural hearing aids including ear mold(s), the hearing aid instrument, the initial battery, cords and other ancillary equipment. Visits for fitting, counseling, adjustments, repairs, etc., at no charge for a one-year period following the provision of a covered hearing aid.
Limitation: For subscriber parents, this benefit is limited to a maximum of $1000 per member every thirty-six months for the hearing instrument and ancillary equipment.
Exclusions: The purchase of batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase, charges for a hearing aid which exceeds specifications prescribed for correction of a hearing loss. Replacement parts for hearing aids, repair of hearing aid after the covered one-year warranty period, replacement of a hearing aid more than once in any period of thirty-six months, and surgically implanted hearing devices.
(C) Immunizations for Subscriber Children: Immunizations consistent with the most current version of the Recommended Childhood Immunization Schedule/United States adopted by the Advisory Committee on Immunization Practices (ACIP). Includes immunizations required for travel as recommended by the ACIP, and other age appropriate immunizations as recommended by the ACIP.
Immunizations for Subscriber Parents: Immunizations for adults as recommended by the ACIP. Immunizations required for travel as recommended by the ACIP. Immunizations such as Hepatitis B for individuals at occupational risk, and other age appropriate immunizations as recommended by the ACIP.
(b) All routine diagnostic testing and laboratory services appropriate for such examinations. This includes coverage for the screening and diagnosis of prostate cancer including but not limited to, prostate-specific antigen testing and digital rectal examination, when medically necessary and consistent with good medical practice.
3. The frequency of health examinations described in subsections (a)(3)(D)1.(a) and (a)(3)(D)2.(a) shall not be increased for reasons which are unrelated to the medical needs of the subscriber including: a subscriber's desire for physical examinations; or reports or related services for the purpose of obtaining or maintaining employment, licenses, insurance, or a school sports clearance.
(F) Family Planning Services: Voluntary family planning services including, counseling and surgical procedures for sterilization as permitted by state and federal law, diaphragms, and coverage for other federal Food and Drug Administration approved devices and contraceptive drugs pursuant to the prescription drug benefit.
(G) Maternity Services: Professional and hospital services relating to maternity care including pre-natal and postpartum care and complications of pregnancy, prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy, labor and delivery care, newborn examinations and nursery care while the mother is hospitalized, and coverage for participation in the statewide prenatal testing program administered by the State Department of Health Services known as the Expanded Alpha Feto Protein Program.
(I) Health Education Services: Includes information regarding personal health behavior and health care, and recommendations regarding the optimal use of health care services. Includes diabetes outpatient self-management training, education, and medical nutrition therapy necessary to enable a subscriber to properly use equipment and supplies provided for the management and treatment of insulin-using diabetes, non-insulin using diabetes, and gestational diabetes.
(4) Diagnostic Laboratory Services: Diagnostic laboratory services, diagnostic imaging, and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, treat, and follow-up on the care of subscribers. Other diagnostic services, which shall include, but not be limited to, elecrocardiography, electro-encephalography, and mammography for screening or diagnostic purposes. Laboratory tests appropriate for the management of diabetes, including at a minimum: cholesterol, triglycerides, microalbuminuria, HDL/LDL and Hemoglobin A-1C (Glycohemoglobin).
Insulin, glucagon, syringes and needles and pen delivery systems for the administration of insulin, blood glucose testing strips, kerotine urine testing strips, lancets and lancet puncture devices in medically appropriate quantities for the monitoring and treatment of insulin dependent, non-insulin dependent and gestational diabetes.
Prenatal vitamins and fluoride supplements included with vitamins or independent of vitamins which require a prescription.
All FDA approved oral and injectable contraceptive drugs and prescription contraceptive devices are covered including internally implanted time release contraceptives.
One cycle or course of treatment of tobacco cessation drugs in each twelve (12) consecutive month period. The health plan must also require the subscriber to attend tobacco use cessation classes or programs in conjunction with tobacco cessation drugs.
For subscriber parents, plans can require subscribers to pay a portion or all the cost of the smoking cessation classes or programs. Plans can also require the subscriber parent to pay the cost of the smoking cessation drug initially and reimburse the subscriber parent minus the copayment(s) upon the successful completion of a smoking cessation program.
Drugs administered while a subscriber is a patient or resident in a rest home, nursing home, convalescent hospital or similar facility when prescribed by a plan physician in connection with a covered service and obtained through a plan designated pharmacy.
Health plans may specify that generic equivalent prescription drugs must be dispensed if available, provided that no medical contraindications exist. The use of a formulary, maximum allowable cost (MAC) method, and mail order programs by health plans is encouraged.
Exclusions: Experimental or investigational drugs; drugs or medications prescribed solely for cosmetic purposes; patent or over-the-counter medicines, including non-prescription contraceptive jellies, ointments, foams, condoms, etc., even if prescribed by a doctor; medicines not requiring a written prescription order (except insulin and smoking cessation drugs as previously described); and dietary supplements (except for formulas or special food products to treat phenylketonuria or PKU); and appetite suppressants or any other diet drugs or medications, unless necessary for the treatment of morbid obesity.
(6) Durable Medical Equipment: Medical equipment appropriate for use in the home which: 1) is intended for repeated use; 2) is generally not useful to a person in the absence of illness or injury; and 3) primarily serves a medical purpose. The health plan may determine whether to rent or purchase standard equipment. Repair or replacement is covered unless necessitated by misuse or loss.
Includes oxygen and oxygen equipment; blood glucose monitors and blood glucose monitors for the visually impaired as medically appropriate for insulin dependent, non-insulin dependent, and gestational diabetes; insulin pumps and all related supplies; visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin; apnea monitors; podiatric devices to prevent or treat diabetes complications; pulmoaides and related supplies; nebulizer machines, face masks, tubing and related supplies, peak flow meters and spacer devices for metered dose inhalers; ostomy bags and urinary catheters and supplies.
Exclusions: Coverage for comfort or convenience items; disposable supplies except ostomy bags and urinary catheters and supplies consistent with Medicare coverage guidelines; exercise and hygiene equipment; experimental or research equipment; devices not medical in nature such as sauna baths and elevators, or modifications to the home or automobile; deluxe equipment; or more than one piece of equipment that serve the same function.
(7) Orthotics and Prosthetics: Orthotics and prosthetics including replacement prosthetic devices, and replacement orthotic devices when prescribed by a licensed provider acting within the scope of his or her licensure. Coverage for the initial and subsequent prosthetic devices and installation accessories to restore a method of speaking incident to a laryngectomy, and therapeutic footwear for diabetics. Also includes prosthetic devices to restore and achieve symmetry incident to mastectomy.
Exclusions: Corrective shoes and arch supports, except for therapeutic footwear and inserts for individuals with diabetes; non-rigid devices such as elastic knee supports, corsets, elastic stockings, and garter belts; dental appliances; electronic voice producing machines; or more than one device for the same part of the body. Also does not include eyeglasses (except for eyeglasses or contact lenses necessary after cataract surgery).
Non-emergency transportation for the transfer of a subscriber from a hospital to another hospital or facility or facility to home when the transportation is:
Exclusions: Coverage for public transportation, including transportation by airplane, passenger car, taxi or other form of public conveyance.
(9) Emergency Health Care Services: Twenty-four hour emergency care for a medical or psychiatric condition, including active labor or severe pain, manifesting itself by acute symptoms of a sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
2. a. Plans shall be responsible for identifying subscriber children who may have a Serious Emotional Disturbances (SED) condition, as defined in California Health and Safety Code section 1374.72, or may have a serious mental disorder, as defined in Welfare and Institutions Code section 5600.3, and shall refer these individuals to their respective county mental health department for evaluation. The plan and the county shall coordinate services for the subscriber.
b. The plan is excused from responsibility for providing a covered service to treat a subscriber child's serious emotional disturbance or serious mental disorder only to the extent that the treatment is authorized and provided by a County Mental Health Department as defined in Welfare and Institutions Code Section 5600.3.
3. Plans must provide services with no inpatient day limits for severe mental illnesses including schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, and bulimia nervosa.
4. a. For the benefit year commencing July 1, 2009, plans may limit inpatient coverage to 38 days per benefit year for illnesses that meet neither the criteria for severe mental illnesses nor the criteria for SED of a child or for a serious mental disorder. Plans, with the agreement of the subscriber or applicant or other responsible adult if appropriate, may substitute for each day of inpatient hospitalization any of the following: two (2) days of residential treatment, three (3) days of day care treatment, or four (4) outpatient visits.
1. Mental health care when ordered and performed by a participating mental health provider. This includes the treatment of children who have experienced family dysfunction or trauma, including child abuse and neglect, domestic violence, substance abuse in the family, or divorce and bereavement. Family members may be involved in the treatment to the extent the plan determines it is appropriate for the health and recovery of the child.
2. a. Plans shall be responsible for identifying subscriber children who may have a Serious Emotional Disturbances (SED) condition, as defined in California Health and Safety Code section 1374.72, or may have a serious mental disorder, as defined in Welfare and Institutions Code section 5600.3, and shall refer these individuals to their county mental health department for evaluation. The plan and the county shall coordinate services for the subscriber.
b. The plan is excused from responsibility for providing a covered service to treat a subscriber child's serious emotional disturbance or serious mental disorder only to the extent that the treatment is authorized and provided by a County Mental Health Department as defined in Welfare and Institutions Code Section 5600.3.
3. Plans must provide services with no out patient visit limits for severe mental illnesses including schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, and bulimia nervosa.
4. a. For the benefit year commencing July 1, 2009, plans must provide up to 25 visits per benefit year for illnesses that meet neither the criteria for severe mental illnesses, nor the criteria for SED of a child or a serious mental disorder. Participating plans may elect to provide additional visits. Plans may provide group therapy at a reduced copayment.
(12) Home Health Services: Health services provided at the home by health care personnel. Includes visits by Registered Nurses, Licensed Vocational Nurses, and home health aides; physical, occupational and speech therapy; and respiratory therapy when prescribed by a licensed practitioner acting within the scope of his or her licensure.
Home health services are limited to those services that are prescribed or directed by the attending physician or other appropriate authority designated by the plan. If a basic health service can be provided in more than one medically appropriate setting, it is within the discretion of the attending physician or other appropriate authority designated by the plan to choose the setting for providing the care. Plans shall exercise prudent medical case management to ensure that appropriate care is rendered in the appropriate setting. Medical case management may include consideration of whether a particular service or setting is cost-effective when there is a choice among several medically appropriate alternative services or settings.
Exclusions: Custodial care.
(A) Services prescribed by a plan physician or nurse practitioner and provided in a licensed skilled nursing facility. Includes skilled nursing on a 24-hour per day basis; bed and board; x-ray and laboratory procedures; respiratory therapy; physical, occupational and speech therapy; medical social services; prescribed drugs and medications; medical supplies; and appliances and equipment ordinarily furnished by the skilled nursing facility. This benefit shall be limited to a maximum of 100 days per benefit year.
(A) These are optional benefits which plans may offer. If offered, the plan must provide a self referral benefit, and cannot require referral from a primary care or other physician or health professional. Coverage is limited to a maximum of 20 visits each per benefit year. Plans may provide a combined chiropractic/acupuncture benefit with a minimum of 20 visits allowed for both disciplines.
The hospice benefit shall include nursing care, medical social services, home health aide services, physician services, drugs, medical supplies and appliances, counseling and bereavement services, physical therapy, occupational therapy, speech therapy, short-term inpatient care, pain control, and symptom management.
The hospice benefit may include, at the option of the health plan, homemaker services, services of volunteers, and short-term inpatient respite care.
Individuals who elect hospice care are not entitled to any other benefits under the plan for the terminal illness while the hospice election is in effect. The hospice election may be revoked at any time.
(19) Transplants: Coverage for organ transplants and bone marrow transplants which are not experimental or investigational. Includes reasonable medical and hospital expenses of a donor or an individual identified as a prospective donor if these expenses are directly related to the transplant for a subscriber.
Charges for testing of relatives for matching bone marrow transplants.
Charges associated with the search and testing of unrelated bone marrow donors through a recognized Donor Registry and charges associated with the procurement of donor organs through a recognized Donor Transplant Bank, if the expenses are directly related to the anticipated transplant of a subscriber.
(21) Clinical Trial for Cancer Patients: Coverage for a subscriber's participation in a clinical trial when the subscriber has been diagnosed with cancer and has been accepted into a phase I through phase IV clinical trial for cancer, and the subscriber's treating physician recommends participation in the clinical trial after determining that participation will have a meaningful potential to benefit the subscriber. Coverage includes the payment of costs associated with the provision of routine patient care, including drugs, items, devices and services that would otherwise be covered if they were not provided in connection with an approved clinical trial program; services required for the provision of the investigational drug, item, device or service; services required for the clinically appropriate monitoring of the investigational drug, item, device, or service; services provided for the prevention of complications arising from the provision of the investigational drug, item, device, or service; and services needed for the reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including diagnosis or treatment of complications.
Exclusions: Provisions of non-FDA-approved drugs or devices that are the subject of the trial; services other than health care services, such as travel, housing, and other non-clinical expenses that a member may incur due to participation in the trial; any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient; services that are otherwise not a benefit (other than those excluded on the basis that they are investigational or experimental); and services that are customarily provided by the research sponsors free of charge for any enrollee in the trial. Coverage for clinical trials may be restricted to participating hospitals and physicians in California, unless the protocol for the trial is not provided in California.
(22) Phenylketonuria (PKU): Testing and treatment of PKU, including those formulas and special food products that are part of a diet prescribed by a licensed physician and managed by a health care professional in consultation with a physician who specializes in the treatment of metabolic disease, provided that the diet is deemed necessary to avert the development of serious physical or mental disabilities or to promote normal development or function as a consequence of PKU.
(23)(A) Participating health 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 health plans shall provide primary care and services unrelated to the CCS eligible condition and shall ensure coordination of services between plan providers, CCS providers, and the local CCS Program.
(2) When a subscriber under the age of 21 is determined by the CCS Program to be eligible for benefits under that program, a participating health plan shall not be responsible for the provision of, or payment for, the particular services authorized by the CCS Program for the particular subscriber for the treatment of CCS eligible medical condition. All other services provided under the participating health plan shall be available to the subscriber.
(2) The plan is excused from responsibility for providing a covered service to treat a subscriber child's serious emotional disturbance or serious mental disorder only to the extent that the treatment is authorized and provided by a County Mental Health Department as defined in Welfare and Institutions Code Section 5600.3.
(e) If, pursuant to any Workers' Compensation, Employer's Liability Law, or other legislation of similar purpose or import, benefits are provided or payable or payable 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 health plan shall provide the services at the time of need, and the subscriber or applicant shall cooperate to assure that the participating health plan is reimbursed for such services.
(f) 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 health care program. If medical services are eligible for reimbursement by insurance or covered under any other insurance or health care service plan, the participating health plan shall provide the services at the time of need, and the subscriber or applicant shall cooperate to assure that the participating health plan is reimbursed for such services.
Credits
Note: Authority cited: Sections 12693.21, 12693.22, 12693.62 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.22, 12693.60, 12693.61, 12693.62 and 12693.755, Insurance Code.
History
1. New article 3 (sections 2699.6700-2699.6721) and 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. Editorial correction of article heading (Register 2001, No. 43).
4. 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.
5. Certificate of Compliance as to 4-29-2002 order, including amendment of subsections (a)(12)(A)-(B), transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
6. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).
7. Amendment of subsections (a)(5) and (a)(10)(A), new subsections (a)(10)(A)1.-4.b., amendment of subsection (a)(10)(B), new subsections (a)(10)(B)1.-4.b., amendment of subsections (a)(11) and (a)(11)(B), new subsection (a)(11)(C), amendment of subsection (a)(13), new subsections (a)(13)(A)-(C), amendment of subsection (a)(15), new subsections (a)(15)(A)-(B), repealer and new subsection (d)(2) 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.
8. Amendment of subsection (a)(3)(B) and redesignation and amendment of subsection (a)(3)(D) as subsections (a)(3)(D)-(a)(3)(D)3. filed 7-30-2010; operative 8-29-2010 (Register 2010, No. 31).
9. Editorial correction of subsections (a)(10)(B)3. and (a)(1)(B)4.b. (Register 2011, No. 5).
10. Certificate of Compliance as to 6-24-2010 order transmitted to OAL 12-21-2010 and filed 2-2-2011 (Register 2011, No. 5).
11. Redesignation and amendment of former subsection (a)(23) as subsection (a)(23)(A), new subsections (a)(23)(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.
12. Certificate of Compliance as to 6-30-2011 order transmitted to OAL 12-20-2011 and filed 2-3-2012 (Register 2012, No. 5).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 10, § 2699.6700, 10 CA ADC § 2699.6700
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