Section 2698.301 - Minimum Scope of Benefits(a) The basic minimum scope of benefits offered by participating health plans to subscribers, dependent subscribers and enrolled dependents must comply with all requirements of the Knox-Keene Health Care Service Plan Act of 1975 including amendments as well as its applicable regulations, and shall include all of the benefits and services listed in this section. Except as required by the applicable statute and regulations, no other benefits shall be permitted to be offered by a participating health plan unless specifically provided for in the program contract with the participating health plan. The basic minimum scope of benefits shall be as follows: (1) Hospital inpatient care in a hospital licensed pursuant to subdivision (a) of section 1250 of the Health and Safety Code, including all of the following benefits and services: (A) Semi-private room, including meals and general nursing services; and private room and special diets when prescribed as medically necessary.(B) Hospital services, including use of operating room and related facilities, intensive care unit and services, labor and delivery room, and anesthesia.(C) Drugs, medications, and parenteral solutions administered while an inpatient.(D) Dressings, casts, equipment, oxygen services, and radiation therapy.(E) Respiratory and physical therapy.(F) Diagnostic laboratory and x-ray services.(G) Special duty nursing as medically necessary.(H) Administration of blood and blood products.(I) Other diagnostic, therapeutic or rehabilitative services (including occupational, physical and speech therapy) as appropriate.(J) Medically necessary inpatient alcohol and substance abuse detoxification.(K) General anesthesia and associated facility charges in connection with dental procedures rendered in a hospital, when the clinical status or underlying medical condition of a subscriber, enrolled dependent or dependent subscriber requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital. This benefit is only available to subscribers, enrolled dependents or dependent subscribers under seven years of age; the developmentally disabled, regardless of age; and subscribers, enrolled dependents or dependent subscribers whose health is compromised and for whom general anesthesia is medically necessary, regardless of age. Nothing in this section shall require a participating health plan to cover any charges for the dental procedure itself, including, but not limited to, the professional fee of the dentist.
(2) Medical and surgical services, provided on an outpatient basis whenever medically appropriate, including all of the following: (A) Physician services including consultations, referrals, office and hospital visits and surgical services performed by a physician and surgeon.(B) Diagnostic laboratory services, diagnostic and therapeutic radiological services and other diagnostic services that shall include but not limited to nuclear medicine, ultrasound, electrocardiography and electroencephalography.(C) Dressings, casts and use of castroom, anesthesia, and oxygen services when medically necessary.(D) Blood, blood derivatives and their administration.(E) Radiation therapy and chemotherapy, of proven benefit.(F) Comprehensive preventive care of adults and children. 1. Comprehensive preventive care of children shall be consistent with the Recommendations for Preventive Pediatric Health Care as adopted by the American Academy of Pediatrics in September of 1987.2. Comprehensive preventive care services for adults and children shall in include periodic health evaluations, immunizations and laboratory services in connection with periodic health evaluations.3. Immunizations for children shall: a. Be consistent with the most current version of the Recommended Childhood Immunization Schedule/United States, jointly adopted by the American Academy of Pediatrics, the Advisory Committee on immunizations Practices (ACIP) and the American Academy of Family Physicians, unless the State Department of Health Care Services determines, within 45 days of the published date of the schedule, that the schedule is not consistent with the purposes of this section.b. Include immunizations required for travel as recommended by the ACIP. iv. Immunizations for adults shall include: a. Immunizations for adults as recommended by the U.S. Public Health Service.b. Immunizations required for travel as recommended by the ACIP.(G) General anesthesia and associated facility charges in connection with dental procedures rendered in a surgery center setting, when the clinical status or underlying medical condition of a subscriber, enrolled dependent or dependent subscriber requires dental procedures that ordinarily would not require general anesthesia to be rendered in a surgery center setting. This benefit is only available to subscribers, enrolled dependents or dependent subscribers under seven years of age; the developmentally disabled, regardless of age; and subscribers, enrolled dependents or dependent subscribers whose health is compromised and for whom general anesthesia is medically necessary, regardless of age. Nothing in this section shall require a participating health plan to cover any charges for the dental procedure itself, including, but not limited to, the professional fee of the dentist.
(H) Nothing in this section shall preclude the reimbursement of physician assistants, nurse practitioners or other advanced practice nurses who provide covered services within their scope of licensure.(3) Family planning services including a variety of prescriptive contraceptive methods approved by the federal Food and Drug Administration, and reproductive sterilization.(4) Comprehensive maternity and perinatal care, including the services of a physician and surgeon, certified nurse midwife or nurse practitioner, and all necessary hospital services, including services relating to complications of pregnancy, are covered services. Nothing in this section shall preclude the direct reimbursement of nurse practitioners or other advanced practice nurses in providing covered services.(5) Emergency care including out-of-area coverage. Emergency ambulance transportation including transportation provided through the "911" emergency response system.(6) Reconstructive Surgery: Surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following; (B) create a normal appearance to the extent possible. Includes reconstructive surgery to restore and achieve symmetry incident to mastectomy.
(7) 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. Also includes insulin, glucagon, syringes and needles and pen delivery systems for the administration of insulin, blood glucose testing strips, ketone urine testing strips, lancets and lancet puncture devices in medically appropriate quantities for the monitoring and treatment of insulin dependent, non-insulin dependent and gestational diabetes.(8) Mental Health benefits, are covered as follows:(A) For severe mental illnesses, and serious emotional disturbances of children, inpatient services, outpatient services, partial hospitalization services and prescription medications. Severe mental illnesses include schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa.(B) Except as specified in Subsection (A) above, mental health benefits are limited to the following: 1. Inpatient care for a period of 10 days in each calendar year.2. 15 outpatient visits in each calendar year.(9) Medical rehabilitation and the services of occupational therapists, physical therapists, and speech therapists as appropriate on an outpatient basis.(10) Durable medical equipment, including prosthetics to restore and achieve symmetry incident to a mastectomy and to restore a method of speaking incident to a laryngectomy. Covered services also include blood glucose monitors and blood glucose monitors for the visually impaired for insulin dependent, non-insulin dependent and gestational diabetes; insulin pumps and all related necessary supplies; visual aids to assist the visually impaired with proper dosing of insulin and podiatric devices to prevent or treat diabetes complications.(11) Home Health Services: Health services provided at the home by health care personnel. Includes visits by Registered Nurses, Licensed Vocational Nurses, and home health aides; physical, occupational and speech therapy; and respiratory therapy when prescribed by a licensed practitioner acting within the scope of his or her licensure.(12) The following human organ transplants: corneal, human heart, heart-lung, liver, bone-marrow and kidney transplantation. Transplants other than corneal shall be subject to the following restrictions:(A) Pre-operative evaluation, surgery, and follow-up care shall be provided at centers that have been designated by the participating health plan 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.(13) Hospice services pursuant to Health and Safety Code section 1368.2.(14) 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.Cal. Code Regs. Tit. 10, § 2698.301
1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order including amendment of subsections (a)(3), (8) and (11), transmitted to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Editorial correction of printing error in subsection (a)(1)(C) (Register 91, No. 27).
4. Amendment of section and NOTE filed 3-22-2002 as an emergency; operative 3-22-2002 (Register 2002, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-22-2002 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 3-22-2002 order, including further amendment of subsections (a)(1)(I), (a)(9) and (a)(11) transmitted to OAL 7-19-2002 and filed 8-29-2002 (Register 2002, No. 35).
6. Amendment of subsections (a), (a)(1)(K), (a)(2)(G) and (a)(8)(A), repealer of subsection (a)(12)(C) and subsection relettering filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).
8. Amendment of subsection (a)(2)(F) and new subsections (a)(2)(F)1.-3.iv.b. filed 1-14-2009; operative 2-13-2009 (Register 2009, No. 3). Note: Authority cited: Sections 12711 and 12712, Insurance Code. Reference: Sections 12711 and 12712, Insurance Code.
1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order including amendment of subsections (a)(3), (8) and (11), transmitted to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Editorial correction of printing error in subsection (a)(1)(C) (Register 91, No. 27).
4. Amendment of section and Note filed 3-22-2002 as an emergency; operative 3-22-2002 (Register 2002, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-22-2002 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 3-22-2002 order, including further amendment of subsections (a)(1)(I), (a)(9) and (a)(11) transmitted to OAL 7-19-2002 and filed 8-29-2002 (Register 2002, No. 35).
6. Amendment of subsections (a), (a)(1)(K), (a)(2)(G) and (a)(8)(A), repealer of subsection (a)(12)(C) and subsection relettering filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).
8. Amendment of subsection (a)(2)(F) and new subsections (a)(2)(F)1.-3.iv.b. filed 1-14-2009; operative 2-13-2009 (Register 2009, No. 3).