Healthy FamiliesVision Benefits and Copayments

Section § 12693.65

Explanation

This law mandates that vision benefits must be provided to subscribers and comply with federal requirements. The benefits should generally match those given to state employees, except for tinted and photochromatic lenses unless medically necessary.

The board sets subscriber copayment levels for these benefits to be in line with what state employees pay. From March 2011 to June 2012, any changes the board makes to vision benefits due to this law are considered urgent and necessary for public welfare, with exemptions from certain governmental review processes.

(a)CA Insurance Code § 12693.65(a) Vision benefits shall be provided to subscribers and shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act.
(b)CA Insurance Code § 12693.65(b) The covered benefits shall be equivalent to those provided to state employees through the Department of Human Resources, except for tinted lenses and also photochromatic lenses, unless otherwise deemed medically necessary.
(c)CA Insurance Code § 12693.65(c) The board shall establish the required subscriber copayment levels for vision 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 provided to state employees through the Department of Human Resources.
(d)CA Insurance Code § 12693.65(d) From March 1, 2011, to June 30, 2012, inclusive, the adoption and readoption, by the board, of regulations to modify vision benefits pursuant to this section, including, but not limited to, restriction of providers through which covered vision benefits may be obtained, restriction of benefits for services from nonparticipating providers, or restriction of products and materials provided as benefits pursuant to this section, shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that it describe facts showing the need for immediate action and from review by the Office of Administrative Law.
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Section § 12693.66

Explanation

If a subscriber is eligible for the California Children’s Services Program, their participating health plan does not have to pay for or provide the specific services authorized by that program for treating the eligible medical condition. However, the subscriber can still access all other services the health plan offers.

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. All other services provided under the participating plan shall be available to the subscriber.
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