28 CA ADC § 1300.67


      28 CCR s 1300.67

      Cal. Admin. Code tit. 28, s 1300.67


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 7. STANDARDS
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.67. Scope of Basic Health Care Services.

      The basic health care services required to be provided by a health care 
      service plan to its enrollees shall include, where medically necessary, 
      subject to any copayment, deductible, or limitation of which the Director 
      may approve:

      (a) Physician services, which shall be provided by physicians licensed to 
      practice medicine or osteopathy in accordance with applicable California 
      law. There shall also be provided consultation with and referral by 
      physicians to other physicians.

      (1) The plan may also include, when provided by the plan, consultation and 
      referral (physician or, if permitted by law, patient initiated) to other 
      health professionals who are defined as dentists, nurses, podiatrists, 
      optometrists, physician's assistants, clinical psychologists, social 
      workers, pharmacists, nutritionists, occupational therapists, physical 
      therapists and other professionals engaged in the delivery of health 
      services who are licensed to practice, are certified, or practice under 
      authority of the plan, a medical group, or individual practice association 
      or other authority authorized by applicable California law.

      (b) Inpatient hospital services, which shall mean short-term general 
      hospital services, including room with customary furnishings and 
      equipment, meals (including special diets as medically necessary), general 
      nursing care, use of operating room and related facilities, intensive care 
      unit and services, drugs, medications, biologicals, anesthesia and oxygen 
      services, diagnostic laboratory and x-ray services, special duty nursing 
      as medically necessary, physical therapy, respiratory therapy, 
      administration of blood and blood products, and other diagnostic, 
      therapeutic and rehabilitative services as appropriate, and coordinated 
      discharge planning including the planning of such continuing care as may 
      be necessary, both medically and as a means of preventing possible early 
      rehospitalization.

      (c) Ambulatory care services, (outpatient hospital services) which shall 
      include diagnostic and treatment services, physical therapy, speech 
      therapy, occupational therapy services as appropriate, and those hospital 
      services which can reasonably be provided on an ambulatory basis. Such 
      services may be provided at a hospital, any other appropriate licensed 
      facility, or any appropriate facility which is not required by law to be 
      licensed, if the professionals delivering such services are licensed to 
      practice, are certified, or practice under the authority of the plan, a 
      medical group, or individual practice association or other authority 
      authorized by applicable California law.

      (d) Diagnostic laboratory services, diagnostic and therapeutic 
      radiological services, and other diagnostic services, which shall include, 
      but not be limited to, electrocardiography and electroencephalography.

      (e) Home health services, which shall include, where medically 
      appropriate, health services provided at the home of an enrollee as 
      prescribed or directed by a physician or osteopath licensed to practice in 
      California. Such home health services shall include diagnostic and 
      treatment services which can reasonably be provided in the home, including 
      nursing care, performed by a registered nurse, public health nurse, 
      licensed vocational nurse or licensed home health aide.

      (1) Home health services may also include such rehabilitation, physical, 
      occupational or other therapy, as the physician shall determine to be 
      medically appropriate.

      (f) Preventive health services (including services for the detection of 
      asymptomatic diseases), which shall include, under a physician's 
      supervision,

      (1) reasonable health appraisal examinations on a periodic basis;

      (2) a variety of voluntary family planning services;

      (3) prenatal care;

      (4) vision and hearing testing for persons through age 16;

      (5) immunizations for children in accordance with the recommendations of 
      the American Academy of Pediatrics and immunizations for adults as 
      recommended by the U.S. Public Health Service;

      (6) venereal disease tests;

      (7) cytology examinations on a reasonable periodic basis;

      (8) effective health education services, including information regarding 
      personal health behavior and health care, and recommendations re- garding 
      the optimal use of health care services provided by the plan or health 
      care organizations affiliated with the plan.

      (g)(1) Emergency health care services which shall be available and 
      accessible to enrollees on a twenty-four hour a day, seven days a week, 
      basis within the health care service plan area. Emergency health care 
      services shall include ambulance services for the area served by the plan 
      to transport the enrollee to the nearest twenty-four hour emergency 
      facility with physician coverage, designated by the Health Care Service 
      Plan.

      (2) Coverage and payment for out-of-area emergencies or urgently needed 
      services involving enrollees shall be provided on a reimbursement or 
      fee-for-service basis and instructions to enrollees must be clear 
      regarding procedures to be followed in securing such services or benefits. 
      Emergency services defined in section 1317.1 include active labor. 
      "Urgently needed services" are those services necessary to prevent serious 
      deterioration of the health of an enrollee, resulting from an unforeseen 
      illness, injury, or complication of an existing condition, including 
      pregnancy, for which treatment cannot be delayed until the enrollee 
      returns to the plan's service area. "Urgently needed services" includes 
      maternity services necessary to prevent serious deterioration of the 
      health of the enrollee or the enrollee's fetus, based on the enrollee's 
      reasonable belief that she has a pregnancy-related condition for which 
      treatment cannot be delayed until the enrollee returns to the plan's 
      service area.

      (h) Hospice services as set forth in Section 1300.68.2.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Sections 1317.1, 1345 and 1367, Health and Safety Code. 


       HISTORY 
         
      1. Amendment of subsection (c) filed 1-12-83; effective thirtieth day
      thereafter (Register 83, No. 3).

      2. Change without regulatory effect amending introductory paragraph filed 
      12-
      22-2000 pursuant to section 100, title 1, California Code of Regulations 
      (Register 2000, No. 51).

      3. New subsection (h) filed 6-26-2001; operative 7-26-2001 (Register 2001, 

      No. 26).

      4. Redesignation and amendment of former subsection (g) as new subsections 

      (g)(1)-(2) filed 9-16-2003; operative 10-16-2003 (Register 2003, No. 38).
      28 CA ADC s 1300.67

      END OF DOCUMENT

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