§152.19. Covered benefits.
45 C.F.R. § 152.19
Required benefits. Each benefit plan offered by a PCIP shall cover at least the following categories and the items and services:
Hospital inpatient services
Hospital outpatient services
Mental health and substance abuse services
Professional services for the diagnosis or treatment of injury, illness, or condition
Non-custodial skilled nursing services
Home health services
Durable medical equipment and supplies
Diagnostic x-rays and laboratory tests
Physical therapy services (occupational therapy, physical therapy, speech therapy)
Hospice
Emergency services, consistent with § 152.22(b), and ambulance services
Prescription drugs
Preventive care
Maternity care
Excluded services. Benefit plans offered by a PCIP shall not cover the following services:
Cosmetic surgery or other treatment for cosmetic purposes except to restore bodily function or correct deformity resulting from disease.
Custodial care except for hospice care associated with the palliation of terminal illness.
In vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy.
Abortion services except when the life of the woman would be endangered or when the pregnancy is the result of an act of rape or incest.
Experimental care except as part of an FDA-approved clinical trial.
Notes, amendments, and revision history
Authority
Authority: Sec. 1101 of the Patient Protection and Affordable Care Act (Pub. L. 111-148).
Source
Source: 75 FR 45029, July 30, 2010, unless otherwise noted.