Scripps Health Plan — Evidence of Coverage: member notice of updates (excerpt)
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Summarizes changes to the Scripps Health Plan Evidence of Coverage affecting member benefits, coverage definitions, cost sharing, and administrative processes; intended for plan members and internal staff.
Corrected the number of days of newborn coverage, electing a PCP and qualifying event days from 31 days of life to 30 days of life.
Added maternal mental health as a covered condition.
Added canceled, rescinded or non-renewal of enrollment coverage as reasons for requesting an expedited decision.
Added authorization language for continuous glucose monitors and related necessary supplies (diabetic equipment).
Updated pharmacy section to reflect change to mail order pharmacy and excluded weight loss/weight management from pharmacy coverage.
Removed exclusions for menotropins, storage of sperm and cryopreservation.
Coverage changes and criteria summary
inv-01: Coverage changes and clarifications
Selected coverage clarifications and additions from the Evidence of Coverage excerpt:
Additions
- Diabetic eye exam added to the list of preventive health services.
- Maternal mental health added as a covered condition.
- Coverage added for wigs under certain conditions.
Removals/Exclusions
- Removed infertility-related exclusions: menotropins, storage of sperm, and cryopreservation.
- Added exclusion language: weight loss or any form of weight management excluded from pharmacy benefit coverage.
inv-02: Benefit updates and clarifications
Summary of coverage additions, clarifications, and removals found in this section:
Coverage additions
- Medical treatment coverage added for teeth impacted in the jaw bone (teeth, gums, jaw joints or jaw bones).
- Authorization added for continuous glucose monitors (CGMs) and related necessary supplies under diabetic equipment.
- Coverage added for wigs under certain conditions.
Clarifications
- Outpatient mental health and substance use disorder services that are part of behavioral health treatment must be coordinated through the member's PCP.
- Clarified when prosthetic lenses are covered.
Removals/Administrative
- Removed infertility exclusions: menotropins, storage of sperm, and cryopreservation.
- Removed language outlining member financial responsibility for urgent care services.
- Prescription drug benefit updated to reflect change to mail order pharmacy; added pharmacy exclusion for weight-management products.
inv-03: Benefit updates and clarifications
Coverage stance and criteria highlights from excerpt:
ANY of the following
- Dental/Oral Surgery: Added coverage for teeth impacted in the jaw bone, gums, jaw joints or jaw bones.
- Diabetes equipment: authorization language added to include continuous glucose monitors and all related necessary supplies.
- Infertility: removed exclusions for menotropins, sperm storage and cryopreservation.
- Pharmacy: clarified exclusion — weight loss and any form of weight management are excluded from pharmacy benefit coverage.
- Behavioral health process requirement: outpatient mental health and substance use disorder services must be coordinated through the member's PCP.
- Durable Medical Equipment/Vision: clarified when prosthetic lenses are covered; wigs coverage added under certain conditions.
inv-04: Benefit update items
Summarized coverage stance items present in this section:
ANY of the following
- Pharmacy: updated to reflect change to mail order pharmacy; added exclusion for weight loss/weight management products.
- Diabetes Care: Continuous glucose monitors and related necessary supplies are authorized/included under diabetic equipment.
- Dental/Oral Surgery: coverage added or clarified for teeth impacted in the jaw bone, gums, jaw joints or jaw bones.
- Infertility: removed exclusions for menotropins, sperm storage and cryopreservation.
- Private Duty Nursing: exclusion clarified to specify family member limitation.
- Urgent Care: removed prior language that outlined member financial responsibility for urgent care services.
- Sexual Dysfunction: exclusion related to sexual dysfunction removed.
- Behavioral Health: outpatient mental health and substance use disorder services require coordination through member's PCP.
- Bariatric Surgery: benefit coverage referenced/updated (details in benefit section).
inv-05: Benefit updates and clarifications
Summarized coverage stances and clarifications present in this portion:
ANY of the following
- Continuous glucose monitors and related necessary supplies are authorized under diabetic equipment.
- Coverage added for teeth impacted in the jaw bone (teeth, gums, jaw joints or jaw bones).
- Sexual dysfunction exclusion removed.
- Clarification: Private Duty Nursing exclusion applies to family members (clarified limitation).
- Coordination requirement: outpatient mental health and substance use disorder services (part of behavioral health treatment) must be coordinated through the member's PCP.
- Administrative: prescription drug benefit language updated to reflect change to mail order pharmacy and the pharmacy exclusion for weight-management products.
inv-06: Coverage and exclusions updates
Document notes additions and clarifications to covered services and exclusions.
ANY of the following
- Dental: Added coverage for teeth impacted in the jaw bone, gums, jaw joints or jaw bones.
- Prescription Drugs: Updated to reflect change to mail order pharmacy benefit coverage.
- Diabetic Equipment: Authorization language expanded to include continuous glucose monitors and all related necessary supplies.
- Private Duty Nursing: exclusion clarified to specify family member.
- Sexual Dysfunction: exclusion removed.
- Administrative: Termination of Group Membership verbiage changed from 15 days after notification of non-payment to 30 days; added language on benefit notification, enrollment and COBRA/Cal‑COBRA payment options.
Preventive services and code notes
| Diabetic eye exam added to the list of preventive health services (no specific billing code provided in source). |
| No specific code provided in this segment; general member notice introduction only. |
| No codes listed |
| No codes listed |
Actions, authorizations, and grievance updates for providers
Accept canceled/rescinded/non‑renewal as expedited decision reason
Canceled, rescinded, or non‑renewal of a member's enrollment coverage is now an accepted reason to request an expedited decision.
Authorize CGMs and related diabetic supplies
Authorization is required for continuous glucose monitors (CGMs) and all related necessary supplies; CGMs and related supplies are included under diabetic equipment authorization.
- Providers must request prior authorization for CGMs and related supplies as part of diabetic equipment requests.
Coordinate behavioral health treatment through member's PCP
Outpatient mental health and substance use disorder services that are part of behavioral health treatment must be coordinated through the member's primary care provider (PCP).
- Ensure treatment plans and referrals reflect PCP coordination per member care management.
Use updated authorization language for CGMs
Authorization language was added to explicitly include continuous glucose monitors and related supplies under diabetes/diabetic equipment authorizations.
- Use the updated diabetic equipment authorization criteria when submitting requests for CGMs and supplies.
Prior authorization required for CGMs and supplies
Continuous glucose monitors and related supplies are added to the diabetic equipment authorization requirement; providers must obtain authorization for these items.
- Submit clinical justification and supply needs with DME authorization requests for CGMs.
Diabetic equipment authorization updated to include CGMs
Authorization language across diabetic equipment was updated to explicitly cover continuous glucose monitors and all related necessary supplies.
- Confirm CGM devices and consumables are included in DME authorization submissions.
Include enrollment cancellation/non‑renewal as expedited grievance reason
Canceled, rescinded, or non‑renewal of enrollment are now listed in the grievance process as valid reasons to request an expedited grievance decision.
- When filing an expedited grievance for these reasons, mark the request as expedited per grievance procedures.
Ensure PCP coordination for behavioral health services
Outpatient mental health and substance use disorder services that are part of behavioral health treatment must be coordinated through the member's PCP; providers must ensure PCP involvement in care coordination.
- Document PCP coordination in behavioral health treatment plans and referrals.
Diabetic equipment authorization covers CGMs and supplies
Diabetic equipment language was expanded to include authorization for continuous glucose monitors and all related necessary supplies; providers must include CGMs and supplies in DME authorization requests.
- Include device and supplies details and clinical rationale when requesting authorization.
Follow updated enrollment/termination and COBRA procedures (30‑day termination)
Scripps Health Plan's member materials now include language outlining the Plan's responsibility for benefit notification, enrollment procedures, and Individual Continuation/COBRA and Cal‑COBRA payment options; termination verbiage was changed to 30 days after notification of non‑payment.
- Follow updated enrollment and termination procedures and COBRA payment options when advising members.
Expedited grievance: enrollment cancellation/non‑renewal conditions
Canceled, rescinded, or non‑renewal of enrollment were added as reasons that may justify requesting an expedited decision in the grievance process.
- Mark grievances citing these enrollment changes as expedited per the updated grievance criteria.
Key definitions and operational terms
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