California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 22 - Essential Health Benefits › Section 2594.3 - Essential Health Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Essential health benefits are defined to
				  include all of the following:
(1) Health
				  benefits within the ten categories of essential health benefits enumerated in
				  subdivision (a)(1) of section
				  10112.27. Provided that a
				  stand-alone pediatric dental plan is certified to be offered on the Exchange, a
				  health insurer participating in the Exchange may, but is not required to, omit
				  coverage of the pediatric oral essential health benefit in a health insurance
				  policy sold on the Exchange, as permitted by section
				  1302(b)(4)(F) of
				  PPACA (42 U.S.C. §
												18022(b)(4)(F)). A health
				  insurance policy sold on the Exchange shall not omit coverage of the pediatric
				  oral essential health benefit when sold outside of the Exchange pursuant to
				  subdivision (c)(1) of Insurance Code section
				  10112.3 or
				  otherwise.
(2) Medically necessary
				  basic health care services, as defined in subdivision (b) of section
				  1345
				  of the Health and Safety Code and section
				  1300.67 of Title 28 of the
				  California Code of Regulations.
(3)
				  The health benefits mandated to be covered by the base-benchmark plan pursuant
				  to all of the following:
(A) The sections of
				  the Health and Safety Code enumerated in subdivisions (a)(2)(A)(ii) and
				  (a)(2)(A)(iv) of section
				  10112.27 of
				  the Insurance Code.
(B) Subdivision
				  (a) of section
				  1300.67.24 of Title 28 of the
				  California Code of Regulations.
(C)
				  Section 1300.68.2 of Title 28 of the
				  California Code of Regulations.
(4) Durable medical equipment for home use
				  and prosthetic and orthotic devices covered by the base-benchmark plan,
				  including, but not limited to, all of the following:
(A) Diabetic Shoes and Inserts: off-the-shelf
				  depth-inlay shoes; custom-molded shoes; custom-molded multiple density inserts;
				  fitting, modification, and follow-up care for podiatric devices; repair or
				  replacement of podiatric devices.
(B) Glucose Monitors, Infusion Pumps, and
				  Related Supplies: external single or multiple channel electric or
				  battery-operated ambulatory infusion pumps; home blood glucose monitors; blood
				  glucose test or reagent strips for home blood glucose monitors; interstitial
				  glucose monitors; programmable and non-programmable implantable infusion pumps;
				  infusion pump used for uninterrupted parenteral administration of medication;
				  infusion sets for external insulin pumps; infusion supplies for external drug
				  infusion pumps; lancets; calibrator solution/chips; single or multi-channel
				  stationary parenteral infusion pumps; replacement batteries for home blood
				  glucose monitors and infusion pumps; spring-powered device for lancet; syringe
				  with needle for insulin pump.
(C)
				  Respiratory Drug Delivery Devices: large and small volume nebulizers;
				  disposable and non-disposable administration sets; aerosol compressors; aerosol
				  mask; disposable and non-disposable corrugated tubing for nebulizers;
				  disposable and non-disposable filters for aerosol compressors; peak expiratory
				  flow rate meter; distilled water for nebulizer; water collection device for
				  nebulizer.
(D) Tracheostomy
				  Equipment: artificial larynx; replacement battery for artificial larynx;
				  tracheo-esophageal voice prosthesis; tracheostomy supplies, including: adhesive
				  disc, filter, inner cannula, tube, tube plug/stop, tube collar/holder, cleaning
				  brush, mask, speaking valve, gauze, sterile water, waterproof tape, and
				  tracheostomy care kits.
(E) Canes
				  and Crutches: adjustable and fixed canes, including standard curved handle and
				  quad canes; adjustable and fixed crutches, including underarm and forearm
				  crutches; replacement supplies for canes and crutches, including handgrips,
				  tips, and underarm pads.
(F) Dry
				  pressure pad for a mattress.
(G)
				  Cervical traction equipment (over door).
(H) Osteogenesis Stimulation Devices:
				  non-invasive electrical osteogenesis stimulators, for spinal and non-spinal
				  applications; non-invasive low density ultrasound osteogenesis
				  stimulator.
(I) Enteral and
				  Parenteral Nutrition: enteral formula and additives, adult and pediatric,
				  including for inherited diseases of metabolism; enteral feeding supply kits;
				  enteral nutrition infusion pump; enteral tubing; gastrostomy/jejunostomy tube
				  and tubing adaptor; nasogastric tubing; parenteral nutrition infusion pump;
				  parenteral nutrition solutions; stomach tube; supplies for self-administered
				  injections.
(J) Hospital grade
				  breast pump and double breast pump kit.
(K) IV pole.
(L) Phototherapy (bilirubin) light with
				  photometer.
(M) Compression burn
				  garment; lymphedema gradient compression stocking; light compression bandage;
				  manual compression garment; moderate compression bandage.
(N) Non-segmental home model pneumatic
				  compressor for the lower extremities.
(O) Prosthetic Devices Incident to
				  Mastectomy: prosthetic devices incident to a mastectomy, including custom-made
				  prostheses when medically necessary; adhesive skin support attachment for use
				  with external breast prosthesis; and brassieres for breast
				  prostheses.
(P) Prosthetic devices
				  to replace all or part of an external facial body part that has been removed or
				  impaired as a result of disease, injury, or congenital
				  defect.
(5) Health
				  benefits covered by the base-benchmark plan not otherwise required to be
				  covered under Chapter 2.2 (commencing with section
				  1340) of Division 2 of the Health
				  and Safety Code, including, but not limited to, all of the following:
(A) Acupuncture services.
(B) Chemical dependency and substance use
				  disorder services.
(C) Contact
				  lenses to treat aniridia and aphakia.
(D) Health benefits for prenatal diagnosis of
				  fetal genetic disorders.
(E) Home
				  hemodialysis and home peritoneal dialysis equipment and medical
				  supplies.
(F) Mental health
				  services.
(G) Nonemergency licensed
				  ambulance and psychiatric transport van services when the vehicle transports
				  the insured to or from covered services and the use of other means of
				  transportation may endanger the insured's health.
(H) Organ, tissue, or bone marrow transplant
				  donation services for an actual or potential living transplant donor, including
				  for harvesting of organs, tissue, or bone marrow and treatment of
				  complications, when the transplant recipient is covered by the health insurance
				  policy.
(I) Ostomy and urological
				  supplies:
(i) Ostomy supplies: adhesives;
				  adhesive remover; ostomy belt; hernia belts; catheter; skin wash/cleaner;
				  bedside drainage bag and bottle; urinary leg bags; gauze pads; irrigation
				  faceplate; irrigation sleeve; irrigation bag; irrigation cone/catheter;
				  lubricant; urinary connectors; gas filters; ostomy deodorants; drain tube
				  attachment devices; gloves; stoma caps; colostomy plug; ostomy inserts; urinary
				  and ostomy pouches; barriers; pouch closures; ostomy rings; ostomy face plates;
				  skin barrier; skin sealant; waterproof and non-waterproof tape.
(ii) Urological supplies: adhesive catheter
				  skin attachment; catheter insertion trays with and without catheter and bag;
				  male and female external collecting devices; male external catheter with
				  integral collection chamber; irrigation tubing sets; indwelling catheters;
				  foley catheters; intermittent catheters; cleaners; skin sealants; bedside and
				  leg drainage bags; bedside bag drainage bottle; catheter leg straps; irrigation
				  tray; irrigation syringe; lubricating gel; sterile individual packets; tubing
				  and connectors; catheter clamp or plug; penile clamp; urethral clamp or
				  compression device; waterproof and non-waterproof tape; catheter anchoring
				  device.
(iii) Incontinence supplies
				  for hospice patients: disposable incontinence underpads; adult incontinence
				  garments.
(J) Skilled
				  nursing facility services.
(6) Pediatric services, including all of the
				  following:
(A) The following health benefits
				  for pediatric oral care:
(i) Dental and
				  orthodontic benefits covered by the base-benchmark plan.
(ii) Dental benefits covered by the Medi-Cal
				  Dental Program.
(iii) Orthodontic
				  benefits when medically necessary to prevent disease and promote oral health,
				  restore oral structures to health and function, and treat emergency
				  conditions.
(B) The
				  following health benefits for pediatric vision care:
(i) Vision benefits covered by the
				  base-benchmark plan.
(ii) Vision
				  benefits covered by the Federal Employees Dental and Vision Insurance Program
				  plan.