California Health and Safety Code 1367.68 – (a) Any provision in a health care service plan contract …
(a) Any provision in a health care service plan contract entered into, amended, or renewed in this state on or after July 1, 1995, that excludes coverage for any surgical procedure for any condition directly affecting the upper or lower jawbone, or associated bone joints, shall have no force or effect as to any enrollee if that provision results in any failure to provide medically-necessary basic health care services to the enrollee pursuant to the plan’s definition of medical necessity.
(b) For purposes of this section, “plan contract” means every plan contract, except a specialized health care service plan contract, that covers hospital, medical, or surgical expenses.
Terms Used In California Health and Safety Code 1367.68
- Basic health care services: includes ambulance and ambulance transport services provided through the "911" emergency response system. See California Health and Safety Code 1345
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means a person who is enrolled in a plan and who is a recipient of services from the plan. See California Health and Safety Code 1345
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
- specialized health care service plan: means either of the following:
California Health and Safety Code 1345
- State: means the State of California, unless applied to the different parts of the United States. See California Health and Safety Code 23
(c) Nothing in this section shall be construed to prohibit a plan from excluding coverage for dental services provided that any exclusion does not result in any failure to provide medically-necessary basic health care services.
(Added by Stats. 1994, Ch. 1282, Sec. 1. Effective January 1, 1995.)