Cal. Code Regs. Tit. 10, § 2699.6703 - Excluded Health Benefits

(a) Health benefit plans offered under this program shall exclude all of the following:

(1) Any benefits specified as excluded within Section 2699.6700.

(2) Any benefits in excess of limits specified in Section 2699.6700.

(3) Services, supplies, items, procedures or equipment, which are not medically necessary as determined by the plan, unless otherwise specified in Section 2699.6700.

(4) Any benefits that are received prior to the subscriber's effective date of coverage. This exclusion does not apply to covered benefits to treat complications arising from services received prior to the subscriber's effective date of coverage.

(5) Any benefits that are received subsequent to the time the subscriber's coverage ends.

(6) Experimental or investigational services, including any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supply which is not recognized as being in accordance with generally accepted professional medical standards, or for which the safety and efficiency have not been determined for use in the treatment of a particular illness, injury or medical condition for which the item or service in question is recommended or prescribed. This section does not exclude clinical trials for cancer patients as provided pursuant to subsection 2699.6700(a)(21).

(7) Medical services that are received in an emergency care setting for conditions that are not emergencies if the subscriber reasonably should have known that an emergency care situation did not exist.

(8) Eyeglasses, except for those eyeglasses or contact lenses necessary after cataract surgery which are covered under Subsection 2699.6700(a)(3)(A).

(9) The diagnosis and treatment of infertility is not covered unless provided in conjunction with covered gynecological services. Treatments of medical conditions of the reproductive system are not excluded.

(10) Long-term care benefits including long-term skilled nursing care in a licensed facility and respite care are excluded except as a participating health plan shall determine they are less costly, satisfactory alternatives to the basic minimum benefits. This section does not exclude short-term skilled nursing care or hospice benefits as provided pursuant to Subsection 2699.6700(a)(13) and (a)(18).

(11) Cosmetic surgery that is solely performed to alter or reshape normal structures of the body in order to improve appearance.

Notes

Cal. Code Regs. Tit. 10, § 2699.6703

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment of subsections (a)(8)-(a)(11), new subsection (a)(13) and amendment of NOTE filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 4-29-2002 order, including repealer of subsection (a)(10) and subsection renumbering, transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
5. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).

Note: Authority cited: Sections 12693.21 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.60 and 12693.755, Insurance Code.

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment of subsections (a)(8)-(a)(11), new subsection (a)(13) and amendment of Note filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 4-29-2002 order, including repealer of subsection (a)(10) and subsection renumbering, transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
5. Amendment filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).