Section 1367.18 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.18
. (a) Every health care service plan, except a specialized
health care service plan, that covers hospital, medical, or surgical
expenses on a group basis shall offer coverage for orthotic and
prosthetic devices and services under the terms and conditions that
may be agreed upon between the group subscriber and the plan. Every
plan shall communicate the availability of that coverage to all group
contractholders and to all prospective group contractholders with
whom they are negotiating. Any coverage for prosthetic devices shall
include original and replacement devices, as prescribed by a
physician and surgeon or doctor of podiatric medicine acting within
the scope of his or her license. Any coverage for orthotic devices
shall provide for coverage when the device, including original and
replacement devices, is prescribed by a physician and surgeon or
doctor of podiatric medicine acting within the scope of his or her
license, or is ordered by a licensed health care provider acting
within the scope of his or her license. Every plan shall have the
right to conduct a utilization review to determine medical necessity
prior to authorizing these services.
(b) Notwithstanding subdivision (a), on and after July 1, 2007,
the amount of the benefit for orthotic and prosthetic devices and
services shall be no less than the annual and lifetime benefit
maximums applicable to the basic health care services required to be
provided under Section 1367. If the contract does not include any
annual or lifetime benefit maximums applicable to basic health care
services, the amount of the benefit for orthotic and prosthetic
devices and services shall not be subject to an annual or lifetime
maximum benefit level. Any copayment, coinsurance, deductible, and
maximum out-of-pocket amount applied to the benefit for orthotic and
prosthetic devices and services shall be no more than the most common
amounts applied to the basic health care services required to be
provided under Section 1367.