12693.60. Coverage provided to subscribers shall meet the federal
coverage requirements in Section 2103 of Title XXI of the Social
Security Act. The covered health benefits provided to subscribers
shall be equivalent to those provided to state employees through the
Public Employees' Retirement System on January 1, 1998, except that
the plans may provide a mechanism for inpatient hospital care
provided under the mental health benefit through which applicants may
agree to a treatment plan in which each inpatient day may be
substituted for two residential treatment days or three day treatment
program days.
12693.61. The following provisions apply for subscribers who have
been identified by the participating health plans as potentially
seriously emotionally disturbed.
(a) Participating plans, to the extent feasible, including plans
receiving purchasing credits shall develop memoranda of
understanding, consistent with criteria established by the board in
consultation with the State Department of Mental Health, for referral
of subscribers who are seriously emotionally disturbed to a county
mental health department. This referral does not relieve a
participating plan from providing the mental health coverage
specified in its contract, including assessment of, and development
of, a treatment plan for serious emotional disturbance. Plans may
contract with county mental health departments to provide for all, or
a portion of, the services provided under the program's mental
health benefit.
(b) The board shall establish an accounting process under which
counties providing services to subscribers who have been determined
to be seriously emotionally disturbed pursuant to Section 5600.3 of
the Welfare and Institutions Code can claim federal reimbursement for
the services. The board shall reimburse counties pursuant to the
rates set by the State Department of Mental Health in accordance with
Sections 5705, 5716, 5718, 5720, 5724, and 5778 of the Welfare and
Institutions Code. The actual amount reimbursed by the board shall be
the federal share of the cost of the subscriber.
(c) This section shall only become operative with federal approval
of the State Child Health Plan and the approval of federal financial
participation.
(d) Counties choosing to enter into a memorandum of understanding
pursuant to subdivision (a) shall provide the nonfederal share of
cost for the subscriber.
12693.615. (a) The board shall establish the required subscriber
copayment levels for specific benefits consistent with the
limitations of Section 2103 of Title XXI of the Social Security Act.
The copayment levels established by the board shall, to the extent
possible, reflect the copayment levels established for state
employees, effective January 1, 1998, through the Public Employees'
Retirement System. Under no circumstances shall copayments exceed the
copayment level established for state employees, effective, January
1, 1998, through the Public Employees' Retirement System. Total
annual copayments charged to subscribers shall not exceed two hundred
fifty dollars ($250) per family. The board shall instruct
participating health plans to work with their provider networks to
provide for extended payment plans for subscribers utilizing a
significant number of health services for which copayments are
charged. The board shall track the number of subscribers who meet the
copayment maximum in each year and make adjustments in the amount if
a significant number of subscribers reach the copayment maximum.
(b) No deductibles shall be charged to subscribers for health
benefits.
(c) Coverage provided to subscribers shall not contain any
preexisting condition exclusion requirements.
(d) No participating health, dental, or vision plan shall exclude
any subscriber on the basis of any actual or expected health
condition or claims experience of that subscriber or a member of that
subscriber's family.
(e) There shall be no variations in rates charged to subscribers
including premiums and copayments, on the basis of any actual or
expected health condition or claims experience of any subscriber or
subscriber's family member. The only variation in rates charged to
subscribers, including copayments and premiums, that shall be
permitted is that which is expressly authorized by Section 12693.43.
(f) There shall be no copayments for preventive services as
defined in Section 1367.35 of the Health and Safety Code.
(g) There shall be no annual or lifetime benefit maximums in any
of the coverage provided under the program.
(h) Plans that receive purchasing credits pursuant to Section
12693.39 shall comply with subdivisions (b), (c), (d), (e), (f), and
(g).
12693.62. Notwithstanding any other provision of law, for a
subscriber who is determined by the California Children's Services
Program to be eligible for benefits under the program pursuant to
Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of
Division 106 of the Health and Safety Code, a participating plan
shall not be responsible for the provision of, or payment for, the
particular services authorized by the California Children's Services
Program for the particular subscriber for the treatment of a
California Children's Services Program eligible medical condition.
Participating plans shall refer a child who they reasonably suspect
of having a medical condition that is eligible for services under the
California Children's Services Program to the California Children's
Services Program. The California Children's Services Program shall
provide case management and authorization of services if the child is
found to be medically eligible for the California Children's
Services Program. Diagnosis and treatment services that are
authorized by the California Children's Services Program shall be
performed by paneled providers for that program and approved special
care centers of that program in accordance with treatment plans
approved by the California Children's Services Program. All other
services provided under the participating plan shall be available to
the subscriber.
12693.60. Coverage provided to subscribers shall meet the federal
coverage requirements in Section 2103 of Title XXI of the Social
Security Act. The covered health benefits provided to subscribers
shall be equivalent to those provided to state employees through the
Public Employees' Retirement System on January 1, 1998, except that
the plans may provide a mechanism for inpatient hospital care
provided under the mental health benefit through which applicants may
agree to a treatment plan in which each inpatient day may be
substituted for two residential treatment days or three day treatment
program days.
12693.61. The following provisions apply for subscribers who have
been identified by the participating health plans as potentially
seriously emotionally disturbed.
(a) Participating plans, to the extent feasible, including plans
receiving purchasing credits shall develop memoranda of
understanding, consistent with criteria established by the board in
consultation with the State Department of Mental Health, for referral
of subscribers who are seriously emotionally disturbed to a county
mental health department. This referral does not relieve a
participating plan from providing the mental health coverage
specified in its contract, including assessment of, and development
of, a treatment plan for serious emotional disturbance. Plans may
contract with county mental health departments to provide for all, or
a portion of, the services provided under the program's mental
health benefit.
(b) The board shall establish an accounting process under which
counties providing services to subscribers who have been determined
to be seriously emotionally disturbed pursuant to Section 5600.3 of
the Welfare and Institutions Code can claim federal reimbursement for
the services. The board shall reimburse counties pursuant to the
rates set by the State Department of Mental Health in accordance with
Sections 5705, 5716, 5718, 5720, 5724, and 5778 of the Welfare and
Institutions Code. The actual amount reimbursed by the board shall be
the federal share of the cost of the subscriber.
(c) This section shall only become operative with federal approval
of the State Child Health Plan and the approval of federal financial
participation.
(d) Counties choosing to enter into a memorandum of understanding
pursuant to subdivision (a) shall provide the nonfederal share of
cost for the subscriber.
12693.615. (a) The board shall establish the required subscriber
copayment levels for specific benefits consistent with the
limitations of Section 2103 of Title XXI of the Social Security Act.
The copayment levels established by the board shall, to the extent
possible, reflect the copayment levels established for state
employees, effective January 1, 1998, through the Public Employees'
Retirement System. Under no circumstances shall copayments exceed the
copayment level established for state employees, effective, January
1, 1998, through the Public Employees' Retirement System. Total
annual copayments charged to subscribers shall not exceed two hundred
fifty dollars ($250) per family. The board shall instruct
participating health plans to work with their provider networks to
provide for extended payment plans for subscribers utilizing a
significant number of health services for which copayments are
charged. The board shall track the number of subscribers who meet the
copayment maximum in each year and make adjustments in the amount if
a significant number of subscribers reach the copayment maximum.
(b) No deductibles shall be charged to subscribers for health
benefits.
(c) Coverage provided to subscribers shall not contain any
preexisting condition exclusion requirements.
(d) No participating health, dental, or vision plan shall exclude
any subscriber on the basis of any actual or expected health
condition or claims experience of that subscriber or a member of that
subscriber's family.
(e) There shall be no variations in rates charged to subscribers
including premiums and copayments, on the basis of any actual or
expected health condition or claims experience of any subscriber or
subscriber's family member. The only variation in rates charged to
subscribers, including copayments and premiums, that shall be
permitted is that which is expressly authorized by Section 12693.43.
(f) There shall be no copayments for preventive services as
defined in Section 1367.35 of the Health and Safety Code.
(g) There shall be no annual or lifetime benefit maximums in any
of the coverage provided under the program.
(h) Plans that receive purchasing credits pursuant to Section
12693.39 shall comply with subdivisions (b), (c), (d), (e), (f), and
(g).
12693.62. Notwithstanding any other provision of law, for a
subscriber who is determined by the California Children's Services
Program to be eligible for benefits under the program pursuant to
Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of
Division 106 of the Health and Safety Code, a participating plan
shall not be responsible for the provision of, or payment for, the
particular services authorized by the California Children's Services
Program for the particular subscriber for the treatment of a
California Children's Services Program eligible medical condition.
Participating plans shall refer a child who they reasonably suspect
of having a medical condition that is eligible for services under the
California Children's Services Program to the California Children's
Services Program. The California Children's Services Program shall
provide case management and authorization of services if the child is
found to be medically eligible for the California Children's
Services Program. Diagnosis and treatment services that are
authorized by the California Children's Services Program shall be
performed by paneled providers for that program and approved special
care centers of that program in accordance with treatment plans
approved by the California Children's Services Program. All other
services provided under the participating plan shall be available to
the subscriber.
12693.60. Coverage provided to subscribers shall meet the federal
coverage requirements in Section 2103 of Title XXI of the Social
Security Act. The covered health benefits provided to subscribers
shall be equivalent to those provided to state employees through the
Public Employees' Retirement System on January 1, 1998, except that
the plans may provide a mechanism for inpatient hospital care
provided under the mental health benefit through which applicants may
agree to a treatment plan in which each inpatient day may be
substituted for two residential treatment days or three day treatment
program days.
12693.61. The following provisions apply for subscribers who have
been identified by the participating health plans as potentially
seriously emotionally disturbed.
(a) Participating plans, to the extent feasible, including plans
receiving purchasing credits shall develop memoranda of
understanding, consistent with criteria established by the board in
consultation with the State Department of Mental Health, for referral
of subscribers who are seriously emotionally disturbed to a county
mental health department. This referral does not relieve a
participating plan from providing the mental health coverage
specified in its contract, including assessment of, and development
of, a treatment plan for serious emotional disturbance. Plans may
contract with county mental health departments to provide for all, or
a portion of, the services provided under the program's mental
health benefit.
(b) The board shall establish an accounting process under which
counties providing services to subscribers who have been determined
to be seriously emotionally disturbed pursuant to Section 5600.3 of
the Welfare and Institutions Code can claim federal reimbursement for
the services. The board shall reimburse counties pursuant to the
rates set by the State Department of Mental Health in accordance with
Sections 5705, 5716, 5718, 5720, 5724, and 5778 of the Welfare and
Institutions Code. The actual amount reimbursed by the board shall be
the federal share of the cost of the subscriber.
(c) This section shall only become operative with federal approval
of the State Child Health Plan and the approval of federal financial
participation.
(d) Counties choosing to enter into a memorandum of understanding
pursuant to subdivision (a) shall provide the nonfederal share of
cost for the subscriber.
12693.615. (a) The board shall establish the required subscriber
copayment levels for specific benefits consistent with the
limitations of Section 2103 of Title XXI of the Social Security Act.
The copayment levels established by the board shall, to the extent
possible, reflect the copayment levels established for state
employees, effective January 1, 1998, through the Public Employees'
Retirement System. Under no circumstances shall copayments exceed the
copayment level established for state employees, effective, January
1, 1998, through the Public Employees' Retirement System. Total
annual copayments charged to subscribers shall not exceed two hundred
fifty dollars ($250) per family. The board shall instruct
participating health plans to work with their provider networks to
provide for extended payment plans for subscribers utilizing a
significant number of health services for which copayments are
charged. The board shall track the number of subscribers who meet the
copayment maximum in each year and make adjustments in the amount if
a significant number of subscribers reach the copayment maximum.
(b) No deductibles shall be charged to subscribers for health
benefits.
(c) Coverage provided to subscribers shall not contain any
preexisting condition exclusion requirements.
(d) No participating health, dental, or vision plan shall exclude
any subscriber on the basis of any actual or expected health
condition or claims experience of that subscriber or a member of that
subscriber's family.
(e) There shall be no variations in rates charged to subscribers
including premiums and copayments, on the basis of any actual or
expected health condition or claims experience of any subscriber or
subscriber's family member. The only variation in rates charged to
subscribers, including copayments and premiums, that shall be
permitted is that which is expressly authorized by Section 12693.43.
(f) There shall be no copayments for preventive services as
defined in Section 1367.35 of the Health and Safety Code.
(g) There shall be no annual or lifetime benefit maximums in any
of the coverage provided under the program.
(h) Plans that receive purchasing credits pursuant to Section
12693.39 shall comply with subdivisions (b), (c), (d), (e), (f), and
(g).
12693.62. Notwithstanding any other provision of law, for a
subscriber who is determined by the California Children's Services
Program to be eligible for benefits under the program pursuant to
Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of
Division 106 of the Health and Safety Code, a participating plan
shall not be responsible for the provision of, or payment for, the
particular services authorized by the California Children's Services
Program for the particular subscriber for the treatment of a
California Children's Services Program eligible medical condition.
Participating plans shall refer a child who they reasonably suspect
of having a medical condition that is eligible for services under the
California Children's Services Program to the California Children's
Services Program. The California Children's Services Program shall
provide case management and authorization of services if the child is
found to be medically eligible for the California Children's
Services Program. Diagnosis and treatment services that are
authorized by the California Children's Services Program shall be
performed by paneled providers for that program and approved special
care centers of that program in accordance with treatment plans
approved by the California Children's Services Program. All other
services provided under the participating plan shall be available to
the subscriber.
