Cal. Code Regs. tit. 28 § 1300.74.73

Current through Register 2024 Notice Reg. No. 40, October 4, 2024

Section 1300.74.73 - Pervasive Developmental Disorder and Autism Coverage

Health plans subject to Section 1374.73 of the Act shall comply with this section.

(a) Requirements

(1) For health plans that provide hospital, medical or surgical coverage under contract with the Healthy Families Program or the Board of Administration of the California Public Employees' Retirement System, section 1374.73 of the Act does not affect, reduce or limit the obligation to provide coverage for the diagnosis and medically necessary treatment of pervasive developmental disorder (PDD) and autism, including medically necessary behavioral health treatment, pursuant to Health and Safety Code section 1374.72.

(2) Nothing in subdivision (a)(1) of this section shall be construed to mandate coverage of services that are not medically necessary or preclude a plan from performing utilization review in accordance with the Act.

(3) Each health plan that is subject to the requirements of section 1374.73 of the Act shall submit a report to the Department no later than December 31, 2012, demonstrating that the health plan has an adequate network of qualified autism service providers, qualified autism service professionals and/or qualified autism service paraprofessionals. The required report shall include the following information:

(A) The name of each qualified autism service provider entity or organization/group, listed by county and zip code. For each identified qualified autism service provider entity or organization/group, state the following information:

1. The number of individual qualified autism service providers available to the entity or organization/group;

2. The number of qualified autism service professionals available to the entity or organization/group; and,

3. The number of qualified autism service paraprofessionals available to the entity or organization/group.

(B) The number of the health plan's individual qualified autism service providers, listed by county and zip code. For each qualified autism service provider identified, state the following information:

1. The number of qualified autism service professionals available to the qualified autism service provider pursuant to Health and Safety Code section 1374.73(c)(4)(B); and,

2. The number of qualified autism service paraprofessionals available to the qualified autism service provider pursuant to Health and Safety Code section 1374.73(c)(5)(A).

(C) A description of how the health plan is determining provider network adequacy, including how geographic accessibility and timely access for health plan enrollees to medically necessary PDD and autism health care services is being met. This information should include:

1. Data describing the adequacy of the health plan's provider network for each region or service area, including utilization data and information on the health plan's enrollee population, such as age, gender and other relevant factors used by the health plan; and,

2. A description of the health plan's system for monitoring and evaluating provider network adequacy in each region or service area.

(D) Upon request, the health plan shall submit within 30 calendar days any additional information the Director may request to determine the adequacy of the plan's network to ensure that health plan enrollees are receiving medically necessary PDD and autism health care services, including timely screening, diagnosis, evaluation and treatment.

Cal. Code Regs. Tit. 28, § 1300.74.73

1. New section filed 9-6-2012 as an emergency; operative 9-6-2012 (Register 2012, No. 36). A Certificate of Compliance must be transmitted to OAL by 3-5-2013 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 9-6-2012 order transmitted to OAL 2-28-2013 and filed 4-8-2013 (Register 2013, No. 15).

Note: Authority cited: Section 1344, Health and Safety Code. Reference: Sections 1345, 1367, 1374.72 and 1374.73, Health and Safety Code.