California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 3 - Benefits › Section 2699.6200 - Scope of Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.