Section 2699.6203 - Excluded Health Benefits(a) Health benefits plans offered under this program shall exclude the following benefits: (1) Services, supplies, items, procedures or equipment which are not medically necessary. "Medically necessary" as applied to the diagnosis or treatment of illness is an article or service that is not investigational and is necessary because: (A) It is appropriate and is provided in accordance with accepted medical standards in the state of California, and could not be omitted without adversely affecting the patient's condition or the quality of medical care rendered; and(B) As to inpatient care, it could not have been provided in a physician's office, in the outpatient department of a hospital, or in a less costly facility without adversely affecting the patient's condition or the quality of medical care rendered; and(C) If the proposed article or service is not commonly used, its application or proposed application has been preceded by a thorough review and application of conventional therapies; and(D) The service or article has been demonstrated to be of significantly greater therapeutic value than other, less expensive, services or articles.(2) Any services which are received prior to the enrollee's effective date of coverage.(3) Custodial, domiciliary care, or rest cures for which facilities and/or services of a general acute care hospital are not medically required. Custodial care is care that does not require the regular services of trained medical or health professionals and that is designed primarily to assist in activities of daily living. Custodial care includes, but is not limited to, help in walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets, and supervision of medications which are ordinarily self-administered.(4) Personal or comfort items or a private room in a hospital unless medically necessary.(5) Emergency facility services for nonemergency conditions.(6) Those medical, surgical (including implants), or other health care procedures, services, products, drugs, or devices which are either: (A) Experimental or investigational or which are not recognized in accord with generally accepted medical standards as being safe and effective for use in the treatment in question, or(B) Outmoded or not efficacious.(7) Transportation except as specified in Section 1300.67(g) of Title 10 of the California Code of Regulations.(8) Implants, except those that are medically necessary and are neither cosmetic, experimental, or investigational.(9) Sex change operations, reversal of voluntary sterilization, conception by artificial means, and non-prescription contraceptive supplies and devices.(10) Eye glasses, contact lenses, routine eye examinations (including eye refractions) except when provided as part of routine examination under preventive care for minors, hearing aids, orthopedic shoes, orthodontic appliances, and routine foot care.(11) Long-term care benefits, including long-term skilled nursing care in a licesed facility and respite care are excluded except as a participating health plan shall determine they are less costly alternatives to the basic minimum benefits. This section does not exclude short-term skilled nursing care benefits as provided pursuant to Section 2699.6200(a)(12).(12) Dental Services and dental appliances.(13) Treatment of obesity by medical and surgical means, except for treatment of morbid obesity. In no instance shall treatment for morbid obesity be provided primarily for cosmetic reasons.(14) Cosmetic surgery, except as specifically provided in Section 2699.6200(a)(2).(15) Conditions resulting from acts of war (declared or not).(16) Treatment for any bodily injury or sickness arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which benefits are provided or payable under any Worker's Compensation benefit plan.(b) A health benefit plan with a point of service option that is offered by a health maintenance organization or a health benefit plan with a point of service option that is offered by an exclusive provider organization may exclude the following benefits and services when the enrollee receives them from providers who do not contract with the health maintenance organization or exclusive provider organization or when the enrollee receives them in violation of the health benefit plan's established procedures: (1) outpatient prescription drugs,(2) human organ transplants,(3) treatment for infertility, including tests,(4) mental health benefits,(5) outpatient chemical dependency and alcoholism benefits,(6) preventive and health education services.(c) A health benefit plan with a point of service option that is offered by a health maintenance organization or a health benefit plan with a point of service option that is offered by an exclusive provider organization may exclude coverage for durable medical equipment prescribed by a provider who does not contract with the health maintenance organization or exclusive provider organization. However, if the prescription is obtained in accordance with established health plan procedures coverage shall not be excluded.Cal. Code Regs. Tit. 10, § 2699.6203
1. Renumbering and amendment of former section 2699.631 to section 2699.6203 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of section heading and new subsections (b)-(c) filed 5-2-96; operative 6-1-96 (Register 96, No. 18).
3. Amendment of subsections (a)(1), (a)(11) and (b)(3) filed 5-8-97; operative 7-1-97 (Register 97, No. 19). Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
1. Renumbering and amendment of former section 2699.631 to section 2699.6203 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of section heading and new subsections (b)-(c) filed 5-2-96; operative 6-1-96 (Register 96, No. 18).
3. Amendment of subsections (a)(1), (a)(11) and (b)(3) filed 5-8-97; operative 7-1-97 (Register 97, No. 19).