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 2699.6705 - Share of Cost for Health Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every participating health plan shall
				require copayments for benefits provided to subscribers, except as provided
				under federal law to subscribers who are American Indians or Alaska Natives
				receiving services at an Indian Health Service Facility, subject to the
				following:
(1) In any benefit year that the
				applicant has incurred $250 in health benefit copayments for services received
				by subscribers who live in one household and for whom the applicant applied to
				the program, the applicant shall be deemed to have met the copayment
				maximum.
(2) No deductibles shall
				be charged to subscribers for health benefits.
(3) The following specific copayments shall
				apply 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.
(A) Inpatient Facility Services provided in a
				licensed hospital, skilled nursing facility, hospice, or mental health
				facility: No copayment.
(B)
				Inpatient Professional Services provided in a licensed hospital, skilled
				nursing facility, hospice, or mental health facility: No copayment.
(C) Facility Services on an Outpatient Basis
				for Subscribers: No copayment, except for a $15 copayment per visit for
				Emergency Health Care Services. The emergency health care services copayment is
				waived if the subscriber is hospitalized.
(D) Outpatient Professional Services: $10
				copayment per office or home visit. No copayment for surgery or anesthesia;
				radiation, chemotherapy, or dialysis treatments.
(E) Outpatient Mental Health: $10 copayment
				per visit.
(F) Home Health Care: No
				copayment except for $10 per visit for physical, occupational, and speech
				therapy visits performed in the home.
(G) Alcohol and Drug Abuse Services: No
				copayment for inpatient services. $10 per visit for outpatient
				services.
(H) Hospice: No copayment
				for any services provided under this benefit.
(I) Transplants: No copayment for any
				services provided under this benefit.
(J) Physical, Occupational, and Speech
				Therapy: No copayment for therapy performed on an inpatient basis. $10
				copayment per visit for therapy performed in the home or other outpatient
				setting.
(K) Biofeedback,
				Acupuncture, and Chiropractic Visits, when offered at the participating health
				plan's option: $10 copayment per visit. For subscriber parents, copayment of
				$10 for each biofeedback visit for mental health.
(L) Diagnostic Laboratory Services,
				diagnostic and therapeutic radiological services, and other diagnostic
				services; durable medical equipment, prosthetics and orthotics; blood and blood
				products; medical transportation services: No copayment.
(M) Prescription Drugs:
1. No copayment for prescription drugs
				provided in an inpatient setting, or for drugs administered in the doctor's
				office or in an outpatient facility setting during the subscriber's stay at the
				facility. For subscriber children, no copayment for FDA approved contraceptive
				drugs.
2. For subscribers with
				household income at or below 150% of the Federal Poverty Level: a $5 copayment
				per prescription for up to 30 day supply for brand name or generic drugs,
				including tobacco use cessation drugs. $5 copayment per 90 day supply of
				maintenance drugs purchased either through a participating health plan's
				participating pharmacies or through its mail order program.
3. For subscribers with household income
				greater than 150% of the Federal Poverty Level:
a. $10 copayment per prescription for up to
				30 day supply for generic drugs, including tobacco use cessation drugs. $10
				copayment per 90 day supply of generic maintenance drugs purchased either
				through a participating health plan's participating pharmacies or through its
				mail order program.
b. $15
				copayment per prescription for up to 30 day supply for brand name drugs,
				including tobacco use cessation drugs. $10 copayment if no generic equivalent
				is available for the drug prescribed or if the use of a brand name drug is
				medically necessary.
c. $15
				copayment per 90 day supply of brand name maintenance drugs purchased either
				through a participating health plan's participating pharmacies or through its
				mail order program. $10 copayment per 90 day supply of brand name maintenance
				drugs purchased either through a participating health plan's participating
				pharmacies or through its mail order program if no generic equivalent is
				available for the drug prescribed or if the use of a brand name drug is
				medically necessary.
4.
				Maintenance drugs are drugs that are prescribed for 60 days or longer and are
				usually prescribed for chronic conditions such as arthritis, heart disease,
				diabetes or hypertension.
5. For
				subscriber parents, $5 copayment for 90 day supply of FDA approved oral and
				injectable contraceptives and contraceptive devices. No refund if the
				medication is removed. (Represents the copayment for oral contraceptives at $5
				copayment for each 90-day supply for the approximate number of months the
				medication will be effective).
(4) Preventive services
(A) Periodic Health Exams; No copayment for
				subscriber children; $5 copayment per exam for subscriber parents.
(B) A variety of voluntary family planning
				services; including contraceptive services: No copayment for subscriber
				children. For subscriber parents $5 copayment per office visit and $5 copayment
				per device.
(C) Maternity Services:
				No copayment.
(D) Vision Services:
				No copayment for subscriber children. For subscriber parents, $5 copayment per
				visit.
Eye refraction to determine the need for corrective lenses --
				  No copayment for subscriber children. For subscriber parents, optional with $5
				  copayment per exam and limited to one visit per year.
(E) Hearing Services and Hearing Aids: No
				copayment.
(F) Immunizations; No
				copayment for subscriber children. $5 copayment per visit for subscriber
				parent.
(G) Sexually Transmitted
				Disease Testing: No copayment for subscriber children. $5 copayment for
				subscriber parents.
(H) Cytology
				Examinations on a reasonable periodic basis: No copayment for subscriber
				children. For subscriber parents, $5 copayment per exam.
(I) Health Education Services: No copayment
				for subscriber children.
For subscriber parents, up to $5 copayment for diabetes
				  outpatient self-management training, education, and medical nutrition therapy
				  services. Charge may vary for other education services.
(J) Well Baby Care, Health Examinations and
				Other Office Visits for subscribers 24 months of age and under: No
				copayment.
(K) Gynecological
				Examinations and Cancer Screening: No copayment.
(5) No copayments shall apply if the
				applicant has submitted acceptable documentation as described in Subsection
				2699.6600(c)(1)(GG)
				that the applicant or the subscriber is American Indian or Alaska
				Native.
(6) Reconstructive Surgery:
				No copayment