1. (a) No contract shall be made or approved for a basic health benefits plan which does not include in its coverage the following benefits. The payment schedule for such benefits must be sufficient in the judgment of the Board to meet the major share of usual, customary or reasonable charges for such services.

   1. (1) Hospital benefits.

      1. (A) In-hospital.

         Coverage must be extended to enrolled employees, annuitants, and family members to provide benefits in the event of confinement in a hospital because of injury or sickness.

         Hospital “room and board benefits” must be provided for at least the first 31 days of hospital confinement. “Miscellaneous hospital benefits” must be provided for hospital charges incurred over and above those for room and board, such as charges for the use of operating and cystoscopic rooms, anesthetic supplies, anesthesia when supplied by the hospital as a regular service and administered by a salaried employee, ordinary splints, plaster casts, and surgical dressings.

      2. (B) Outpatient--hospital.

         Coverage must be extended to enrolled employees, annuitants, and family members to provide benefits because of accidental bodily injury, surgery or emergency treatment for sickness when not admitted to a hospital or confined as a registered bed patient. Such benefits shall include but are not limited to: 1. Charges for use of operating and cystoscopic rooms, 2. Charges for anesthetic supplies and anesthesia when supplied by the hospital as a regular service and administered by a salaried employee, and 3. Charges for ordinary splints, plaster casts and surgical dressings.

   2. (2) Surgical Benefits In and Out of the Hospital.

      Coverage must be extended to enrolled employees, annuitants and family members to provide benefits in the event of surgical operations performed because of injury or sickness.

   3. (3) In-hospital medical benefits.

      Coverage must be extended to enrolled employees, annuitants, and family members to provide benefits for medical services rendered by attending physicians or physician anesthetists, other than those of a surgeon as described above, while a registered bed patient in a hospital.

   4. (4) Outpatient medical benefits.

      Coverage must be extended to enrolled employees, annuitants and family members to provide benefits for medical services rendered on an outpatient basis. Such services shall include those of a physician and surgeon for usual medical services and a physician anesthetist.

   5. (5) Diagnostic, X-ray, and laboratory examinations benefits in and out of the hospital. Coverage must be extended to enrolled employees, annuitants, and family members and shall include those services of medical and paramedical personnel such as, but not restricted to, a pathologist, or a roentgenologist to provide for all ordinary clinical and pathological laboratory services and X-ray examinations. Such services may be rendered either by physicians or by salaried hospital or clinical personnel as appropriate.
   6. (6) Maternity benefits. Coverage must be extended to each enrolled employee, annuitant, and covered family member to provide medical and hospital benefits for maternity care.

   7. (7) Ambulance service benefits. Coverage must be extended to enrolled employees, annuitants, and family members to provide benefits for necessary local professional ambulance service to a hospital.

      Determination of usual, customary, and reasonable charges for purposes of this subsection 599.510(a) shall take into account the Relative Value Studies of the California Medical Association with respect to any service included in such Studies.

2. (b) There shall be excluded from coverage set forth above:

   1. (1) charges incurred in connection with bodily injury or disease covered by worker's compensation statutes or similar legislation.
   2. (2) charges for which the claimant has been or is entitled to be reimbursed under any other basic hospital, surgical or medical plan not subject to these rules for which the employer shall have paid any part of the costs. Premiums or other consideration paid for the coverage not provided shall be returned to the person, state agency or contracting agency equitably entitled thereto.
   3. (3) charges incurred during confinement in a hospital owned or operated by the United States Government, charges for services, treatments or supplies furnished by or for the United States Government or paid for by said United States Government, or charges incurred during confinement in a hospital owned or operated by a state, province, or political subdivision, unless there is an unconditional requirement to pay these charges without regard to any rights against others, contractual or otherwise.
   4. (4) services and charges for services for which the claimant is entitled to have payment made on his or her behalf under Part A or Part B, Title XVIII of the Social Security Act.
   5. (5) charges in accordance with such other exclusions as may be agreed to by the Board.

3. (c) There may be excluded from coverage set forth above:

   1. (1) charges incurred by or on behalf of a family member or services received by a family member during a continuous period of hospitalization which commenced before the effective date of the enrollment if eligibility to enroll including him or her in coverage of a plan derives from other than an open enrollment period; and
   2. (2) charges incurred or services received by an employee, annuitant, or family member during a continuous period of hospitalization which commenced before the effective date of his or her enrollment if eligibility to enroll derives from an open enrollment period. Such exclusion shall no longer apply upon the 91st day of enrollment in the plan.

Note: Authority cited: Sections 22794 and 22796, Government Code. Reference: Sections 22796, 22850, 22853 and 22860, Government Code.

History

1. Amendment of subsection (b)(2) filed 7-31-68 as an emergency; effective upon filing (Register 68, No. 29). For prior history, see Register 66, No. 10.

2. Certificate of Compliance--Section 11422.1, Gov. Code, filed 11-27-68 (Register 68, No. 45).

3. Amendment of subsection (b)(2) filed 8-5-76; effective thirtieth day thereafter (Register 76, No. 32).

4. Amendment of subsections (a)(6) and (b)(1) filed 6-15-79; designated effective 8-1-79 (Register 79, No. 24).

5. Amendment filed 6-27-80; designated effective 8-1-80 (Register 80, No. 26).

6. Amendment filed 6-9-86; effective thirtieth day thereafter (Register 86, No. 24).

7. Editorial correction of Authority cite (Register 95, No. 5).

8. Change without regulatory effect amending Note filed 10-31-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 44).