California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.73 - Pervasive Developmental Disorder and Autism Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Health plans subject to Section
					 1374.73 of the Act shall comply
					 with this section.
(a) Requirements
(1) For health plans that provide hospital,
				  medical or surgical coverage under contract with the Healthy Families Program
				  or the Board of Administration of the California Public Employees' Retirement
				  System, section
				  1374.73 of the Act does not
				  affect, reduce or limit the obligation to provide coverage for the diagnosis
				  and medically necessary treatment of pervasive developmental disorder (PDD) and
				  autism, including medically necessary behavioral health treatment, pursuant to
				  Health and Safety Code section
				  1374.72.
(2) Nothing in subdivision (a)(1) of this
				  section shall be construed to mandate coverage of services that are not
				  medically necessary or preclude a plan from performing utilization review in
				  accordance with the Act.
(3) Each
				  health plan that is subject to the requirements of section
				  1374.73 of the Act shall submit a
				  report to the Department no later than December 31, 2012, demonstrating that
				  the health plan has an adequate network of qualified autism service providers,
				  qualified autism service professionals and/or qualified autism service
				  paraprofessionals. The required report shall include the following information:
(A) The name of each qualified autism service
				  provider entity or organization/group, listed by county and zip code. For each
				  identified qualified autism service provider entity or organization/group,
				  state the following information:
1. The number
				  of individual qualified autism service providers available to the entity or
				  organization/group;
2. The number
				  of qualified autism service professionals available to the entity or
				  organization/group; and,
3. The
				  number of qualified autism service paraprofessionals available to the entity or
				  organization/group.
(B)
				  The number of the health plan's individual qualified autism service providers,
				  listed by county and zip code. For each qualified autism service provider
				  identified, state the following information:
1. The number of qualified autism service
				  professionals available to the qualified autism service provider pursuant to
				  Health and Safety Code section
				  1374.73(c)(4)(B);
				  and,
2. The number of qualified
				  autism service paraprofessionals available to the qualified autism service
				  provider pursuant to Health and Safety Code section
				  1374.73(c)(5)(A).
(C) A description of how the health plan is
				  determining provider network adequacy, including how geographic accessibility
				  and timely access for health plan enrollees to medically necessary PDD and
				  autism health care services is being met. This information should include:
1. Data describing the adequacy of the health
				  plan's provider network for each region or service area, including utilization
				  data and information on the health plan's enrollee population, such as age,
				  gender and other relevant factors used by the health plan; and,
2. A description of the health plan's system
				  for monitoring and evaluating provider network adequacy in each region or
				  service area.
(D) Upon
				  request, the health plan shall submit within 30 calendar days any additional
				  information the Director may request to determine the adequacy of the plan's
				  network to ensure that health plan enrollees are receiving medically necessary
				  PDD and autism health care services, including timely screening, diagnosis,
				  evaluation and treatment.