California

Health and Safety Code - HSC

17,661 sections, each with the official text and a plain-English explanation of what it means for you.

• § 1357.025 — Nothing in this article shall be construed to preclude the application of this chapter to either of the following: (a) An association, trust, or other organization acting as a “health care service pla
• § 1357.03 — (a) (1) Upon the effective date of this article, a plan shall fairly and affirmatively offer, market, and sell all of the plan’s health care service plan contracts that are sold to small employers or
• § 1357.035 — (a) Between July 26, 1993, and October 24, 1993, as well as 60 days prior to the expiration of an existing plan contract that expires prior to July 1, 1994, or, for plan contracts expiring after July
• § 1357.04 — (a) After a small employer submits a completed application form for a plan contract, the plan shall, within 30 days, notify the employer of the employer’s actual premium charges for that plan contract
• § 1357.05 — Except in the case of a late enrollee, or for satisfaction of a preexisting condition clause in the case of initial coverage of an eligible employee, a plan may not exclude any eligible employee or de
• § 1357.06 — (a) (1) Preexisting condition provisions of a plan contract shall not exclude coverage for a period beyond six months following the individual’s effective date of coverage and may only relate to condi
• § 1357.07 — No plan contract may exclude late enrollees from coverage for more than 12 months from the date of the late enrollees application for coverage.
• § 1357.08 — All health care service plan contracts offered to a small employer shall provide to subscribers and enrollees at least all of the basic health care services included in subdivision (b) of Section 1345
• § 1357.09 — No plan shall be required to offer a health care service plan contract or accept applications for the contract pursuant to this article in the case of any of the following: (a) To a small employer, if
• § 1357.10 — The director may require a plan to discontinue the offering of contracts or acceptance of applications from any small employer or group with more than 50 employees upon a determination by the director
• § 1357.12 — Premiums for contracts offered or delivered by plans on or after the effective date of this article shall be subject to the following requirements: (a) (1) The premium for new business shall be determ
• § 1357.13 — Plans shall apply standard employee risk rates consistently with respect to all small employers.
• § 1357.14 — In connection with the offering for sale of any plan contract to a small employer, each plan shall make a reasonable disclosure, as part of its solicitation and sales materials, of the following: (a)
• § 1357.15 — (a) At least 20 business days prior to renewing or amending a plan contract subject to this article which will be in force on the operative date of this article, a plan shall file a notice of material
• § 1357.16 — (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified associations may assume responsibility for p
• § 1357.17 — The director may issue regulations that are necessary to carry out the purposes of this article.
• § 1357.19 — This article shall not apply to a health care service plan contract that is subject to Article 3.
• § 1357.50 — (a) For purposes of this article, the following definitions shall apply: (1) “Health benefit plan” means a health care service plan contract that provides medical, hospital, and surgical benefits.
• § 1357.500 — As used in this article, the following definitions shall apply: (a) “Child” means a child described in Section 22775 of the Government Code and subdivisions (n) to (p), inclusive, of Section 599.
• § 1357.501 — This article shall apply only to nongrandfathered small employer health care service plan contracts and only with respect to plan years beginning on or after January 1, 2014.
• § 1357.502 — (a) A health care service plan providing or arranging for the provision of essential health benefits, as defined by the state pursuant to Section 1302 of PPACA, to small employers shall be subject to
• § 1357.502.5 — Nothing in this article shall be construed to preclude the application of this chapter to either of the following: (a) An association, trust, or other organization acting as a “health care service pla
• § 1357.503 — (a) (1) Each plan shall fairly and affirmatively offer, market, and sell all of the plan’s small employer health care service plan contracts to all small employers in each service area in which the pl
• § 1357.503.035 — (a) For plan contracts subject to this article, an association that meets the definition of a guaranteed association, as set forth in Section 1357.
• § 1357.504 — (a) With respect to small employer health care service plan contracts offered outside the Exchange, after a small employer submits a completed application form for a plan contract, the health care ser
• § 1357.505 — (a) Notwithstanding paragraph (2) of subdivision (a) of Section 1357.
• § 1357.506 — A small employer health care service plan contract shall not impose a preexisting condition provision or a waiting or affiliation period upon any individual.
• § 1357.507 — Nothing in this article shall be construed as prohibiting a health care service plan from restricting enrollment of late enrollees to open enrollment periods provided under Section 1357.
• § 1357.508 — A small employer health care service plan contract shall provide to subscribers and enrollees at least all of the essential health benefits as defined by the state pursuant to Section 1302 of PPACA.
• § 1357.509 — (a) To the extent permitted by PPACA, a plan shall not be required to offer a health care service plan contract or accept applications for the contract pursuant to this article in the case of any of t
• § 1357.51 — (a) A health benefit plan for group coverage shall not impose any preexisting condition provision or waivered condition provision upon any enrollee.
• § 1357.510 — The director may require a plan to discontinue the offering of contracts or acceptance of applications from any small employer or group upon a determination by the director that the plan does not have
• § 1357.512 — (a) The premium rate for a small employer health care service plan contract issued, amended, or renewed on or after January 1, 2014, shall vary with respect to the particular coverage involved only by
• § 1357.514 — In connection with the offering for sale of a small employer health care service plan contract subject to this article, each plan shall make a reasonable disclosure, as part of its solicitation and sa
• § 1357.515 — (a) At least 20 business days prior to renewing or amending a plan contract subject to this article which will be in force on the operative date of this article, a plan shall file a notice of material
• § 1357.516 — (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified associations may assume responsibility for p
• § 1357.52 — A health benefit plan for group coverage shall not establish rules for eligibility, including continued eligibility, of an individual, or dependent of an individual, to enroll under the terms of the p
• § 1357.55 — This article shall become operative on January 1, 2014.
• § 1357.600 — As used in this article, the following definitions shall apply: (a) “Dependent” means the spouse or registered domestic partner, or child, of an eligible employee, subject to applicable terms of the h
• § 1357.601 — This article shall apply only to grandfathered small group health care service plan contracts and only with respect to plan years commencing on or after January 1, 2014.
• § 1357.602 — (a) A health care service plan providing or arranging for the provision of basic health care services to small employers shall be subject to this article if either of the following conditions are met:
• § 1357.603 — Nothing in this article shall be construed to preclude the application of this chapter to either of the following: (a) An association, trust, or other organization acting as a “health care service pla
• § 1357.604 — (a) (1) A plan shall fairly and affirmatively renew a grandfathered health plan contract with a small employer.
• § 1357.606 — (a) For plan contracts expiring after July 1, 1994, 60 days prior to July 1, 1994, an association that meets the definition of a guaranteed association, as set forth in Section 1357.
• § 1357.607 — A small employer health care service plan contract shall not impose a preexisting condition provision or a waiting or affiliation period upon any individual.
• § 1357.608 — Nothing in this article shall be construed as prohibiting a health care service plan from restricting enrollment of late enrollees to open enrollment periods consistent with federal law.
• § 1357.609 — All grandfathered small employer health care service plan contracts shall provide to subscribers and enrollees at least all of the basic health care services included in subdivision (b) of Section 134
• § 1357.610 — (a) No plan shall be required by the provisions of this article: (1) To offer coverage under a small employer’s health care service plan contract to an otherwise eligible employee or dependent, when t
• § 1357.611 — (a) The director may require a plan to discontinue the renewal of grandfathered small employer health care service plan contracts or the offering or acceptance of applications from any group upon a de
• § 1357.612 — Premiums for grandfathered contracts renewed by plans on or after January 1, 2014, shall be subject to the following requirements: (a) (1) The premium for in force business shall be determined for an
• § 1357.613 — Plans shall apply standard employee risk rates consistently with respect to all small employers.
• § 1357.614 — In connection with the renewal of a grandfathered small employer health care service plan contract, each plan shall make a reasonable disclosure, as part of its solicitation and sales materials, of th
• § 1357.615 — (a) At least 20 business days prior to renewing or amending a small employer health care service plan contract subject to this article, a plan shall file a notice of material modification with the dir
• § 1357.616 — (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified associations may assume responsibility for p
• § 1357.618 — (a) The department may adopt emergency regulations implementing this article no later than August 31, 2013.
• § 1358.1 — Every health care service plan that offers any contract that primarily or solely supplements Medicare or that is advertised or represented as a supplement to Medicare, shall, in addition to complying
• § 1358.10 — (a) (1) This section shall apply to Medicare Select contracts, as defined in this section.
• § 1358.11 — (a) (1) An issuer shall not deny or condition the offering or effectiveness of any Medicare supplement contract available for sale in this state, nor discriminate in the pricing of a contract because
• § 1358.12 — (a) (1) With respect to the guaranteed issue of a Medicare supplement contract, eligible persons are those individuals described in subdivision (b) who seek to enroll under the contract during the per
• § 1358.13 — (a) An issuer shall comply with Section 1882(c)(3) of the federal Social Security Act (as enacted by Section 4081(b)(2)(C) of the federal Omnibus Budget Reconciliation Act of 1987 (OBRA), Public Law 1
• § 1358.14 — (a) (1) (A) With respect to loss ratio standards, a Medicare supplement contract shall not be advertised, solicited, or issued for delivery unless the contract can be expected, as estimated for the en
• § 1358.145 — (a) The calculation of actual or expected loss ratios shall be pursuant to the formula in subdivision (a) of Section 1358.
• § 1358.146 — The following format shall be used for reporting loss ratio experience: MEDICARE SUPPLEMENT HEALTH CARE SERVICE PLAN CONTRACT EXPERIENCE EXHIBIT For the year ended December 31, 20__.
• § 1358.15 — (a) An issuer shall not advertise, solicit, or issue for delivery a Medicare supplement contract to a resident of this state unless the contract has been filed with and approved by the director in acc
• § 1358.16 — (a) An issuer or other entity may provide a commission or other compensation to a solicitor or other representative for the sale of a Medicare supplement contract only if the first year commission or
• § 1358.17 — (a) (1) Medicare supplement contracts shall include a renewal or continuation provision.
• § 1358.18 — In the interest of full and fair disclosure, and to ensure the availability of necessary consumer information to potential subscribers or enrollees not possessing a special knowledge of Medicare, heal
• § 1358.19 — An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio, or television medium to the director for review or approval.
• § 1358.2 — The purpose of this article is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement contracts, to facilitate public understanding a
• § 1358.20 — (a) An issuer, directly or through solicitors or other representatives, shall do each of the following: (1) Establish marketing procedures to ensure that any comparison of Medicare supplement coverage
• § 1358.21 — (a) In recommending the purchase or replacement of any Medicare supplement coverage, an issuer or its representative shall make reasonable efforts to determine the appropriateness of a recommended pur
• § 1358.22 — (a) On or before March 1 of each year, an issuer shall report the following information for every individual resident of this state for which the issuer has in force more than one Medicare supplement
• § 1358.225 — (a) Every issuer shall, by June 30 of each year, file with the director a list of its Medicare supplement contracts offered or issued or outstanding in this state as of the end of the previous calenda
• § 1358.23 — (a) If a Medicare supplement contract replaces another Medicare supplement policy or certificate, or contract, the replacing issuer shall waive any time periods applicable to preexisting conditions, w
• § 1358.24 — This section applies to all contracts that become effective on or after May 21, 2009.
• § 1358.3 — (a) Except as otherwise provided in this section or in Sections 1358.
• § 1358.4 — The following definitions apply for the purposes of this article: (a) “Applicant” means: (1) An individual enrollee who seeks to contract for health coverage, in the case of an individual Medicare sup
• § 1358.5 — (a) A contract shall not be advertised, solicited, or issued for delivery as a Medicare supplement contract unless the contract contains definitions or terms that conform to the requirements of this s
• § 1358.6 — (a) (1) Except for permitted preexisting condition clauses as described in Sections 1358.
• § 1358.7 — A contract shall not be advertised, solicited, or issued for delivery as a Medicare supplement contract prior to January 1, 2001, unless it meets or exceeds requirements applicable pursuant to this co
• § 1358.8 — The following standards are applicable to all Medicare supplement contracts advertised, solicited, or issued for delivery on or after January 1, 2001, and with an effective date prior to June 1, 2010.
• § 1358.81 — The following standards are applicable to all Medicare supplement contracts delivered or issued for delivery in this state with an effective date on or after June 1, 2010.
• § 1358.9 — The following standards are applicable to all Medicare supplement contracts delivered or issued for delivery in this state on or after July 21, 1992, and with an effective date prior to June 1, 2010.
• § 1358.91 — The following standards are applicable to all Medicare supplement contracts delivered or issued for delivery in this state with an effective date on or after June 1, 2010.
• § 1358.92 — The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for Medicare on or after January
• § 1359 — (a) The director may require that solicitors and solicitor firms, and principal persons engaged in the supervision of solicitation for plans of solicitor firms, meet such reasonable and appropriate st
• § 1360 — (a) No plan, solicitor, solicitor firm, or representative shall use or permit the use of any advertising or solicitation which is untrue or misleading, or any form of evidence of coverage which is dec
• § 1360.1 — It is unlawful for any person, including a plan, subject to this chapter to represent or imply in any manner that the person or plan has been sponsored, recommended, or approved, or that the person’s
• § 1360.5 — (a) For purposes of this section, “Exchange” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code.
• § 1361 — (a) Except as provided in subdivision (b), no plan shall publish or distribute, or allow to be published or distributed on its behalf, any advertisement not subject to Section 1352.
• § 1361.1 — (a) It is an unfair business practice for a solicitor, solicitor firm, or representative of a health care service plan to sell, solicit, or negotiate the purchase of health care coverage products by a
• § 1362 — As used in Sections 1363 and 1364: (a) “Benefits and coverage” means the health care services available under a plan contract.
• § 1363 — (a) (1) The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may req
• § 1363.01 — (a) Every plan that covers prescription drug benefits shall provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary.
• § 1363.02 — (a) The Legislature finds and declares that the right of every patient to receive basic information necessary to give full and informed consent is a fundamental tenet of good public health policy and
• § 1363.03 — (a) Every health care service plan that covers prescription drug benefits and that issues a card to enrollees for claims processing purposes shall issue to each of its enrollees a uniform card contain
• § 1363.04 — (a) For plan years on and after January 1, 2021, or 12 months after regulations are adopted under subdivision (f), whichever occurs later, a health care service plan that issues, sells, renews, or off
• § 1363.05 — (a) For every plan contract that provides or supplements Medicare benefits, a plan shall include within its disclosure form the following statement in at least 12-point type: “For additional informati
• § 1363.06 — (a) The Department of Managed Health Care and the Department of Insurance shall compile information as required by this section and Section 10127.
• § 1363.07 — (a) Each health care service plan shall send copies of the comparative benefit matrix prepared pursuant to Section 1363.
• § 1363.1 — Any health care service plan that includes terms that require binding arbitration to settle disputes and that restrict, or provide for a waiver of, the right to a jury trial shall include, in clear an
• § 1363.2 — On or before July 1, 1999, the disclosure form required pursuant to Section 1363 shall also contain a statement that enrollees are encouraged to use appropriately the “911” emergency response system,
• § 1363.3 — (a) The department may develop standard templates for a schedule of benefits, an explanation of benefits, a cost-sharing summary, or any similar document.
• § 1363.5 — (a) A plan shall disclose or provide for the disclosure to the director and to network providers the process the plan, its contracting provider groups, or any entity with which the plan contracts for
• § 1364 — Where the director finds it necessary in the interest of full and fair disclosure, all advertising and other consumer information disseminated by a plan for the purpose of influencing persons to becom
• § 1364.1 — Within 30 days of receiving the notice required by Section 1255.
• § 1364.5 — (a) On or before July 1, 2001, every health care service plan shall file with the director a copy of their policies and procedures to protect the security of patient medical information to ensure comp
• § 1365 — (a) An enrollment or a subscription shall not be canceled or not renewed except for the following reasons: (1) (A) Except as otherwise specified in subparagraph (C), for nonpayment of the required pre
• § 1365.5 — (a) No health care service plan or specialized health care service plan shall refuse to enter into any contract or shall cancel or decline to renew or reinstate any contract because of the race, color
• § 1366 — (a) No plan may use in its name, any of the words “insurance,” “casualty,” “surety,” “mutual,” or any other words descriptive of the insurance, casualty, or surety business or use any name similar to
• § 1366.1 — (a) The department shall adopt regulations on or before July 1, 2003, that establish an extended geographic accessibility standard for access to health care providers served by a health care service p
• § 1366.2 — (a) A full health care service plan shall make available to a group subscriber, upon request, the termination date of all major health care provider contracts that are for services in the geographic a
• § 1366.20 — (a) This article shall be known as the California Continuation Benefits Replacement Act, or “Cal-COBRA.
• § 1366.21 — The definitions contained in this section govern the construction of this article.
• § 1366.22 — The continuation coverage requirements of this article do not apply to the following individuals: (a) Individuals who are entitled to Medicare benefits or become entitled to Medicare benefits pursuant
• § 1366.23 — (a) Every health care service plan, including a specialized health care service plan contract, that provides coverage under a group benefit plan to an employer, as defined in Section 1366.
• § 1366.24 — (a) Every health care service plan evidence of coverage, provided for group benefit plans subject to this article, that is issued, amended, or renewed on or after January 1, 1999, shall disclose to co
• § 1366.25 — (a) Every group contract between a health care service plan and an employer subject to this article that is issued, amended, or renewed on or after July 1, 1998, shall require the employer to notify t
• § 1366.26 — A qualified beneficiary electing continuation coverage shall pay to the health care service plan, on or before the due date of each payment but not more frequently than on a monthly basis, not more th
• § 1366.27 — (a) The continuation coverage provided pursuant to this article shall terminate at the first to occur of the following: (1) In the case of a qualified beneficiary who is eligible for continuation cove
• § 1366.28 — A health care service plan subject to this article shall not be obligated to provide continuation coverage to a qualified beneficiary pursuant to this article if an enrollee fails to make the notifica
• § 1366.29 — (a) A health care service plan shall offer an enrollee who has exhausted continuation coverage under COBRA the opportunity to continue coverage for up to 36 months from the date the enrollee’s continu
• § 1366.3 — (a) On and after January 1, 2005, a health care service plan issuing individual plan contracts that ceases to offer individual coverage in this state shall offer coverage to the subscribers who had be
• § 1366.35 — (a) A health care service plan providing coverage for hospital, medical, or surgical benefits under an individual health care service plan contract may not, with respect to a federally eligible define
• § 1366.4 — (a) A medical group, physician, or independent practice association that contracts with a health care service plan may enter into contracts with licensed nonphysician providers to provide services, as
• § 1366.50 — (a) (1) On and after January 1, 2014, a health care service plan providing individual or group health care coverage shall provide to enrollees or subscribers who cease to be enrolled in coverage a not
• § 1366.6 — (a) For purposes of this section, the following definitions shall apply: (1) “Exchange” means the California Health Benefit Exchange established in Title 22 (commencing with Section 100500) of the Gov
• § 1367 — A health care service plan and, if applicable, a specialized health care service plan shall meet the following requirements: (a) Facilities located in this state including, but not limited to, clinics
• § 1367.001 — (a) An individual or group health care service plan contract shall not establish either of the following: (1) Lifetime limits on the dollar value of any covered benefits for an enrollee, whether provi
• § 1367.002 — (a) A group or individual nongrandfathered health care service plan contract shall, at a minimum, provide coverage for and shall not impose any cost-sharing requirements for any of the following: (1)
• § 1367.003 — (a) A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including
• § 1367.004 — (a) A health care service plan that issues, sells, renews, or offers a contract covering dental services shall file a report with the department by July 31 of each year, which shall be known as the ML
• § 1367.005 — (a) An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall include, at a minimum, coverage for essential health benefits pursuant
• § 1367.006 — (a) This section shall apply to nongrandfathered individual and group health care service plan contracts that provide coverage for essential health benefits, as defined in Section 1367.
• § 1367.0061 — (a) For a health care service plan contract issued, amended, or renewed on or after July 1, 2022, in the individual or group market, a health care service plan shall monitor an enrollee’s accrual towa
• § 1367.007 — (a) (1) For a small employer health care service plan contract offered, sold, or renewed on or after January 1, 2014, the deductible under the plan shall not exceed: (A) Two thousand dollars ($2,000)
• § 1367.008 — (a) Levels of coverage for the nongrandfathered individual market are defined as follows: (1) Bronze level: A health care service plan contract in the bronze level shall provide a level of coverage th
• § 1367.0085 — Notwithstanding paragraph (1) of subdivision (b) of Section 1367.
• § 1367.009 — (a) Levels of coverage for the nongrandfathered small group market are defined as follows: (1) Bronze level: A health care service plan contract in the bronze level shall provide a level of coverage t
• § 1367.01 — (a) A health care service plan and any entity with which it contracts for services that include utilization review or utilization management functions, that prospectively, retrospectively, or concurre
• § 1367.010 — (a) (1) A nongrandfathered health care service plan, except a health care service plan offering a specialized health care service plan contract, that offers, amends, or renews a large group health car
• § 1367.012 — (a) (1) A small employer health care service plan contract in effect on December 31, 2013, and still in effect as of the effective date of this section, that does not qualify as a grandfathered health
• § 1367.015 — In addition to complying with subdivision (h) of Section 1367.
• § 1367.016 — (a) A health care service plan shall accept premium payments from the following third-party entities without the need to comply with subdivision (c): (1) A Ryan White HIV/AIDS Program under Title XXVI
• § 1367.02 — (a) On or before July 1, 1999, for purposes of public disclosure, every health care service plan shall file with the department a description of any policies and procedures related to economic profili
• § 1367.025 — (a) On or before July 1, 2026, the department shall issue instructions to health care service plans to report all covered health care services subject to prior authorization, the percentage rate at wh
• § 1367.03 — (a) A health care service plan that provides or arranges for the provision of hospital or physician services, including a specialized mental health plan that provides physician or hospital services, o
• § 1367.031 — (a) A health care service plan contract that is issued, renewed, or amended on or after July 1, 2017, shall provide information to an enrollee regarding the standards for timely access to care adopted
• § 1367.035 — (a) As part of the reports submitted to the department pursuant to subdivision (f) of Section 1367.
• § 1367.04 — (a) Not later than January 1, 2006, the department shall develop and adopt regulations establishing standards and requirements to provide health care service plan enrollees with appropriate access to
• § 1367.041 — (a) A health care service plan that advertises or markets products in the individual or small group health care service plan markets, or allows any other person or business to market or advertise on i
• § 1367.042 — (a) A health care service plan shall notify enrollees and members of the public of all of the following information: (1) The availability of language assistance services, including oral interpretation
• § 1367.043 — (a) (1) Within six months after the department issues guidance pursuant to paragraph (1) of subdivision (e), and no later than March 1, 2025, a health care service plan that issues, sells, renews, or
• § 1367.045 — (a) If a health care service plan contract offered, issued, delivered, amended, or renewed on or after January 1, 2021, contains a provision that reserves discretionary authority to the plan, or an ag
• § 1367.05 — (a) Nothing in this chapter shall prohibit a health care service plan from entering into a contract with a dental college approved by the Board of Dental Examiners of California under which the dental
• § 1367.06 — (a) A health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after January 1, 2005, that covers outpatient pres
• § 1367.07 — Within one year after a health care service plan’s assessment pursuant to subdivision (b) of Section 1367.
• § 1367.08 — A health care service plan shall annually disclose to the governing board of a public agency that is the subscriber of a group contract, the name and address of, and amount paid to, any agent, broker,
• § 1367.09 — (a) An enrollee with coverage for Medicare benefits who is discharged from an acute care hospital shall be allowed to return to a skilled nursing facility in which the enrollee resided prior to hospit
• § 1367.1 — Subdivision (i) of Section 1367 shall apply to transitionally licensed plans only insofar as it relates to contracts entered into, amended, delivered, or renewed in this state on or after October 1, 1
• § 1367.10 — (a) Every health care service plan shall include within its disclosure form and within its evidence of coverage a statement clearly describing how participation in the plan may affect the choice of ph
• § 1367.12 — No health care service plan that administers Medicare coverage and federal employee programs may require that more than one form be submitted per claim in order to receive payment or reimbursement und
• § 1367.15 — (a) This section shall apply to individual health care service plan contracts and plan contracts sold to employer groups with fewer than two eligible employees as defined in subdivision (b) of Section
• § 1367.18 — (a) Every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses on a group basis shall offer coverage for orthotic and prosthetic
• § 1367.19 — On and after January 1, 1991, every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses on a group basis shall offer coverage a
• § 1367.2 — (a) On and after January 1, 1990, every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall offer coverage for the treatment of alcoholism under such te
• § 1367.20 — Every health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall provide to members of the public, upon request, a copy of the most current list
• § 1367.205 — (a) In addition to the list required to be provided under Section 1367.
• § 1367.206 — (a) If there is more than one drug that is clinically appropriate for the treatment of a medical condition, a health care service plan that provides coverage for prescription drugs may require step th
• § 1367.207 — (a) A health care service plan contract issued, amended, delivered, or renewed on or after July 1, 2023, that provides prescription drug benefits and maintains one or more drug formularies shall do al
• § 1367.2075 — (a) A health care service plan contract issued, amended, or renewed on or after January 1, 2026, that provides prescription drug coverage shall not calculate an enrollee’s cost sharing at an amount th
• § 1367.21 — (a) A health care service plan contract that covers prescription drug benefits shall not be issued, amended, delivered, or renewed in this state if the plan limits or excludes coverage for a drug on t
• § 1367.215 — (a) Every health care service plan contract that covers prescription drug benefits shall provide coverage for appropriately prescribed pain management medications for terminally ill patients when medi
• § 1367.22 — (a) A health care service plan contract, issued, amended, or renewed on or after July 1, 1999, that covers prescription drug benefits shall not limit or exclude coverage for a drug for an enrollee if
• § 1367.23 — (a) On and after January 1, 1994, every group health care service plan contract, which is issued, amended, or renewed, shall include a provision requiring the health care service plan to notify the gr
• § 1367.24 — (a) Every health care service plan that provides prescription drug benefits shall maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary nonf
• § 1367.241 — (a) Notwithstanding any other law, on and after January 1, 2013, a health care service plan that provides coverage for prescription drugs shall accept only the prior authorization form developed pursu
• § 1367.243 — (a) (1) A health care service plan that reports rate information pursuant to Section 1385.
• § 1367.244 — (a) A request for an exception to a health care service plan’s step therapy process for prescription drugs may be submitted in the same manner as a request for prior authorization for prescription dru
• § 1367.25 — (a) A group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or after January 1, 2000, to December 31, 2
• § 1367.251 — (a) (1) A health care service plan, except for a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or after January 1, 2023, shall not impose a deductibl
• § 1367.255 — (a) (1) A health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2024, except for a grandfathered health plan or a qualifying health plan for a health savings
• § 1367.27 — (a) Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to th
• § 1367.28 — Within six months after the department issues guidance pursuant to paragraph (1) of subdivision (e) of Section 1367.
• § 1367.29 — (a) On and after July 1, 2011, in accordance with subdivision (b), a health care service plan that provides coverage for professional mental health services, including a specialized health care servic
• § 1367.3 — (a) Every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall offer benefits for the comprehensive preventive care of children.
• § 1367.30 — Notwithstanding any other provision of law, every group health care service plan contract marketed, issued, or delivered to a resident of this state, regardless of the situs of the contract or the sub
• § 1367.31 — (a) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2017, shall be prohibited from requiring an enrollee to receive a referral prior to receiving
• § 1367.32 — (a) A health care service plan that provides health coverage to the employees of a religious employer that does not include coverage and benefits for both abortion and contraception shall provide, in
• § 1367.33 — Notwithstanding any other law, a plan directly operated by a bona fide public or private institution of higher learning that directly provides health care services only to its students, faculty, staff
• § 1367.34 — (a) (1) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2022, shall provide coverage for home test kits for sexually transmitted diseases (STD), i
• § 1367.35 — (a) On and after January 1, 1993, every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall provide benefits for the comprehensive preventive care of ch
• § 1367.36 — (a) A risk-based contract between a health care service plan and a physician or physician group that is issued, amended, delivered, or renewed in this state on or after January 1, 2001, shall not incl
• § 1367.37 — (a) (1) A health care service plan contract issued, amended, or renewed on or after July 1, 2025, excluding a specialized health care service plan contract, shall provide coverage for emergency room m
• § 1367.38 — (a) A health care service plan contract issued, amended, or renewed on or after January 1, 2025, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune Neuropsych
• § 1367.39 — (a) A health care service plan contract issued, amended, or renewed on or after January 1, 2022, that provides coverage for pediatric services and preventive care, as required by this chapter, includi
• § 1367.4 — No plan issuing, providing, or administering any contract of individual or group coverage providing medical, surgical, or dental expense benefits applied for and issued on or after January 1, 1986, sh