Section 2594.3 - Essential Health Benefits(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 of Title 281300.67 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 of Title 281300.67.24 of Title 28 of the California Code of Regulations.(C) Section of Title 281300.68.2 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.(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.(b) Essential health benefits do not include the following: (1) Routine non-pediatric eye exam services for refraction to determine the need for vision correction and provide a prescription for eyeglass lenses, but not excluding examination of the eye for other purposes, including preventive screening for conditions such as hypertension, diabetes, glaucoma, or macular degeneration.(2) The cost sharing provisions or network limitations of the base-benchmark plan, the Medi-Cal Dental Program, or the Federal Employees Dental and Vision Insurance Program plan, except to the extent otherwise required to comply with provisions of the Insurance Code, and as otherwise applicable to all individual and small group health insurance policies.Cal. Code Regs. Tit. 10, § 2594.3
1. New section filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013, No. 50). Pursuant to Insurance Code section 10112.27(o)(2) a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-9-2013 order, including amendment of subsection (a)(1), transmitted to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 9).
4. Change without regulatory effect amending subsections (a)(6)(A)(ii) and (b)(2) and amending NOTE filed 1-3-2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 1). Note: Authority cited: Sections 10112.27, 12921 and 12926, Insurance Code. Reference: Sections 10112.27 and 10112.3, Insurance Code.
1. New section filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013, No. 50). Pursuant to Insurance Code section 10112.27(o)(2) a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-9-2013 order, including amendment of subsection (a)(1), transmitted to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to Government Code section 11343.4(b)(3)(Register 2014, No. 9).
4. Change without regulatory effect amending subsections (a)(6)(A)(ii) and (b)(2) and amending Note filed 1-3-2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 1).