ARTICLE 5. Standards

Article 5 added by Stats. 1975, Ch. 941.

§§ 1367–1374.198 · 207 sections

§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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,…
§ 1367.006 (a) This section shall apply to nongrandfathered individual and group health care service plan contracts that provide coverage for essential health benefits,…
§ 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…
§ 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…
§ 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…
§ 1367.0085 Notwithstanding paragraph (1) of subdivision (b) of Section 1367.008 and paragraph (1) of subdivision (b) of Section 1367.009, the actuarial value for a…
§ 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…
§ 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…
§ 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,…
§ 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…
§ 1367.015 In addition to complying with subdivision (h) of Section 1367.01, in determining whether to approve, modify, or deny requests by providers prior to,…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 1367.035 (a) As part of the reports submitted to the department pursuant to subdivision (f) of Section 1367.03 and regulations adopted pursuant to that section, a…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 1367.07 Within one year after a health care service plan’s assessment pursuant to subdivision (b) of Section 1367.04, the health care service plan shall report to the…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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,…
§ 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…
§ 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…
§ 1367.4 No plan issuing, providing, or administering any contract of individual or group coverage providing medical, surgical, or dental expense benefits applied for…
§ 1367.41 (a) Commencing January 1, 2017, a health care service plan shall maintain a pharmacy and therapeutics committee that shall be responsible for developing,…
§ 1367.42 (a) For plan years commencing on or after January 1, 2017, a plan that provides essential health benefits shall allow an enrollee to access prescription drug…
§ 1367.43 Commencing January 1, 2019, a health care service plan shall prorate an enrollee’s cost sharing for a partial fill of a prescription dispensed pursuant to…
§ 1367.45 (a) Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2002, that covers hospital, medical,…
§ 1367.46 Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2009, that covers hospital, medical, or…
§ 1367.47 (a) The maximum amount a health care service plan may require an enrollee to pay at the point of sale for a covered prescription drug is the lesser of the…
§ 1367.49 (a) A contract issued, amended, renewed, or delivered on or after January 1, 2015, by or on behalf of a health care service plan and a provider or supplier…
§ 1367.5 No health care service plan contract that is issued, amended, renewed, or delivered on and after January 1, 2002, shall contain a provision that prohibits or…
§ 1367.50 (a) No contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health care service plan and a provider or a supplier shall…
§ 1367.51 (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…
§ 1367.54 (a) Every group health care service plan contract that provides maternity benefits, except for a specialized health care service plan contract, that is issued,…
§ 1367.6 (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after…
§ 1367.61 Every health care service plan contract which provides for the surgical procedure known as a laryngectomy and which is issued, amended, delivered, or renewed…
§ 1367.62 (a) No health care service plan contract that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that…
§ 1367.624 The provision of medically necessary pasteurized donor human milk obtained from a tissue bank licensed pursuant to Chapter 4.1 (commencing with Section 1635)…
§ 1367.625 (a) A health care service plan shall develop a maternal mental health program designed to promote quality and cost-effective outcomes. The program shall…
§ 1367.626 (a) (1) On or before January 1, 2025, a health care service plan shall develop a maternal and infant health equity program that addresses racial health…
§ 1367.627 (a) A contract between a health care service plan and a health care provider issued, amended, or renewed on or after January 1, 2025, shall authorize a…
§ 1367.63 (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this…
§ 1367.635 (a) Every health care service plan contract that is issued, amended, renewed, or delivered on or after January 1, 1999, that provides coverage for surgical…
§ 1367.64 (a) Every individual or group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, or…
§ 1367.65 (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended,…
§ 1367.656 (a) Notwithstanding any other law, an individual or group health care service plan contract issued, amended, or renewed on or after January 1, 2015, that…
§ 1367.66 (a) Every individual or group health care service plan contract, except for a specialized health care service plan, issued, amended, or renewed on or after…
§ 1367.665 (a) A health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after…
§ 1367.667 (a) A health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after…
§ 1367.668 (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1,…
§ 1367.67 Every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state on…
§ 1367.68 (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…
§ 1367.69 (a) On or after January 1, 1995, every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended,…
§ 1367.695 (a) The Legislature finds and declares that the unique, private, and personal relationship between women patients and their obstetricians and gynecologists…
§ 1367.7 On and after January 1, 1980, every health care service plan contract that covers hospital, medical, or surgical expenses on a group basis, and which offers…
§ 1367.71 (a) Every health care service plan contract, other than a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or…
§ 1367.8 No plan issuing, providing, or administering any individual or group health care service plan entered into, amended, or issued on or after January 1, 1981,…
§ 1367.9 No health care service plan contract which covers hospital, medical, or surgical expenses shall be issued, amended, delivered, or renewed in this state on or…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 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…
§ 1367.205 (a) In addition to the list required to be provided under Section 1367.20, a health care service plan that provides prescription drug benefits and maintains…
§ 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…
§ 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…
§ 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…
§ 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…
§ 1367.215 (a) Every health care service plan contract that covers prescription drug benefits shall provide coverage for appropriately prescribed pain management…
§ 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…
§ 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…
§ 1367.24 (a) Every health care service plan that provides prescription drug benefits shall maintain an expeditious process by which prescribing providers may obtain…
§ 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…
§ 1367.243 (a) (1) A health care service plan that reports rate information pursuant to Section 1385.03 or 1385.045 shall report the information described in paragraph…
§ 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…
§ 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…
§ 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…
§ 1367.252 (a) A health care service plan contract that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date…
§ 1367.253 (a) A health care service plan shall base a medical necessity determination or the utilization review criteria that the plan, and an entity acting on the…
§ 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…
§ 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…
§ 1367.28 Within six months after the department issues guidance pursuant to paragraph (1) of subdivision (e) of Section 1367.043, and no later than March 1, 2025, a…
§ 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,…
§ 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,…
§ 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…
§ 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…
§ 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…
§ 1368 (a) Every plan shall do all of the following: (1) Establish and maintain a grievance system approved by the department under which enrollees may submit their…
§ 1368.01 (a) The grievance system shall require the plan to resolve grievances within 30 days, except as provided in subdivision (c). (b) The grievance system shall…
§ 1368.015 (a) Effective July 1, 2003, every plan with an internet website shall provide an online form through its internet website that subscribers or enrollees can use…
§ 1368.016 (a) A health care service plan that provides coverage for professional mental health services, including a specialized health care service plan that provides…
§ 1368.017 (a) (1) A health care service plan shall provide to enrollees a written or electronic notice regarding the benefits of a behavioral health and wellness…
§ 1368.02 (a) The director shall establish and maintain a toll-free telephone number for the purpose of receiving complaints regarding health care service plans…
§ 1368.03 (a) The department may require enrollees and subscribers to participate in a plan’s grievance process for up to 30 days before pursuing a grievance through the…
§ 1368.04 (a) The director shall investigate and take enforcement action against plans regarding grievances reviewed and found by the department to involve noncompliance…
§ 1368.05 (a) (1) By enacting this section, which was originally enacted by Assembly Bill 922 (Chapter 552 of the Statutes of 2011), the Legislature recognizes that,…
§ 1368.1 (a) A plan that denies coverage to an enrollee with a terminal illness, which for the purposes of this section refers to an incurable or irreversible condition…
§ 1368.2 (a) On and after January 1, 2002, every group health care service plan contract, except a specialized health care service plan contract, which is issued,…
§ 1368.5 (a) Every health care service plan that offers coverage for a service that is within the scope of practice of a duly licensed pharmacist shall pay or reimburse…
§ 1368.7 (a) A health care service plan shall provide an enrollee who has been displaced or whose health may otherwise be affected by a state of emergency, as declared…
§ 1369 Every plan shall establish procedures to permit subscribers and enrollees to participate in establishing the public policy of the plan. For purposes of this…
§ 1370 Every plan shall establish procedures in accordance with department regulations for continuously reviewing the quality of care, performance of medical…
§ 1370.1 Nothing in this article shall be construed to prevent a plan from utilizing subcommittees to participate in peer review activities, nor to prevent a plan from…
§ 1370.2 Upon an appeal to the plan of a contested claim, the plan shall refer the claim to the medical director or other appropriately licensed health care provider.…
§ 1370.4 (a) Every health care service plan shall provide an external, independent review process to examine the plan’s coverage decisions regarding experimental or…
§ 1370.6 (a) An individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2020, shall not: (1) Deny a qualified…
§ 1371 (a) (1) A health care service plan, including a specialized health care service plan, shall reimburse a complete claim or portion thereof, whether in state or…
§ 1371.1 (a) (1) Whenever a health care service plan, including a specialized health care service plan, determines that in reimbursing a claim for provider services an…
§ 1371.11 (a) The following definitions shall apply for purposes of this section: (1) (A) “Affirmative consent” means a dental provider’s express consent to opt in or…
§ 1371.2 No health care service plan, including a specialized health care service plan, shall request reimbursement for overpayment or reduce the level of payment to a…
§ 1371.22 If a contract between a health care service plan and a provider requires that the provider accept, as payment from the plan, the lowest payment rate charged by…
§ 1371.25 A plan, any entity contracting with a plan, and providers are each responsible for their own acts or omissions, and are not liable for the acts or omissions…
§ 1371.3 On and after January 1, 1994, every group health care service plan that provides hospital, medical, or surgical expense benefits for plan members and their…
§ 1371.30 (a) (1) By September 1, 2017, the department shall establish an independent dispute resolution process for the purpose of processing and resolving a claim…
§ 1371.31 (a) (1) For services rendered subject to Section 1371.9, effective July 1, 2017, unless otherwise agreed to by the noncontracting individual health…
§ 1371.34 (a) A complaint made by an enrollee to a health care service plan about a delay or denial of a payment of a claim shall be treated as a grievance subject to…
§ 1371.35 (a) (1) A health care service plan, including a specialized health care service plan, shall reimburse a complete claim or portion thereof, whether in state or…
§ 1371.36 (a) A health care service plan shall not deny payment of a claim on the basis that the plan, medical group, independent practice association, or other…
§ 1371.37 (a) A health care service plan is prohibited from engaging in an unfair payment pattern, as defined in this section. (b) Consistent with subdivision (a) of…
§ 1371.38 (a) The department shall, on or before July 1, 2001, adopt regulations that ensure that plans have adopted a dispute resolution mechanism pursuant to…
§ 1371.39 (a) Providers may report to the department through the toll-free provider line, email address, or another method designated by the department, instances in…
§ 1371.4 (a) A health care service plan that covers hospital, medical, or surgical expenses, or its contracting medical providers, shall provide 24-hour access for…
§ 1371.5 (a) No health care service plan that provides basic health care services shall require prior authorization or refuse to pay for any ambulance or ambulance…
§ 1371.51 (a) A health care service plan contract issued, amended, or renewed on or after July 1, 2025, shall establish a process to reimburse for services provided by a…
§ 1371.55 (a) (1) Notwithstanding Section 1367.11, a health care service plan contract issued, amended, or renewed on or after January 1, 2020, shall provide that if an…
§ 1371.56 (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require…
§ 1371.8 A health care service plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization after the provider renders…
§ 1371.9 (a) (1) Except as provided in subdivision (c), a health care service plan contract issued, amended, or renewed on or after July 1, 2017, shall provide that if…
§ 1372 Subject to the applicable provisions of this chapter, a plan may offer one or more plan contracts or specialized health care service plan contracts, except…
§ 1373 (a) (1) A plan contract may not provide an exception for other coverage if the other coverage is entitlement to Medi-Cal benefits under Chapter 7 (commencing…
§ 1373.1 Every group plan entered into, amended, or renewed on or after January 1, 1977, which provides hospital, medical, or surgical expense benefits for employees or…
§ 1373.2 Every group health care service plan entered into, amended, or renewed on or after January 1, 1976, which provides hospital, medical, or surgical expense…
§ 1373.3 An enrollee shall not be prohibited from selecting as a primary care physician any available primary care physician who contracts with the plan in the service…
§ 1373.4 (a) No health care service plan contract that is issued, amended, renewed, or delivered on or after July 1, 2003, that provides maternity coverage shall do…
§ 1373.5 When spouses are both employed as employees, and both have enrolled themselves and their eligible family members under a group health care service plan…
§ 1373.6 This section does not apply to a specialized health care service plan contract or to a plan contract that primarily or solely supplements Medicare. The…
§ 1373.620 (a) (1) At least 60 days prior to the plan renewal date, a health care service plan that does not otherwise issue individual health care service plan contracts…
§ 1373.621 (a) Except for a specialized health care service plan, every health care service plan contract that is issued, amended, delivered, or renewed in this state on…
§ 1373.622 (a) (1) After the termination of the pilot program under Section 1373.62, a health care service plan shall continue to provide coverage under the same terms…
§ 1373.65 (a) At least 75 days before the termination date of its contract with a provider group or a general acute care hospital, the health care service plan shall…
§ 1373.7 A health care service plan contract, which is written or issued for delivery outside of California and which provides benefits for California residents that…
§ 1373.8 A health care service plan contract where the plan is licensed to do business in this state and the plan provides coverage that includes California residents,…
§ 1373.9 (a) Except in the case of a specialized health care service plan, a health care service plan which negotiates and enters into a contract with professional…
§ 1373.95 (a) (1) A health care service plan, other than a specialized health care service plan that offers professional mental health services on an employer-sponsored…
§ 1373.96 (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a…
§ 1373.10 (a) On and after January 1, 1985, every health care service plan, that is not a health maintenance organization or is not a plan that enters exclusively into…
§ 1373.11 A health care service plan that offers or provides one or more podiatry services, as defined in Section 2472 of the Business and Professions Code, as a…
§ 1373.12 A health care service plan which offers or provides one or more chiropractic services, as defined in Section 7 of the Chiropractic Initiative Act, as a…
§ 1373.13 (a) It is the intent of the Legislature that all persons licensed in this state to engage in the practice of dentistry shall be accorded equal professional…
§ 1373.14 Except for a preexisting condition, any health care service plan, except a specialized health care service plan, which provides coverage on a group or…
§ 1373.18 Whenever any health care service plan, except a specialized health care service plan, negotiates and enters into a contract with providers to provide services…
§ 1373.19 Any health care service plan that includes a term that requires the parties to submit to binding arbitration shall, for those cases or disputes for which the…
§ 1373.20 (a) If a plan uses arbitration to settle disputes with enrollees or subscribers, and does not use a professional dispute resolution organization independent of…
§ 1373.21 (a) If a health care service plan uses arbitration to settle disputes with enrollees or subscribers, it shall require that an arbitration award be accompanied…
§ 1374 If a health care service plan entered into, amended, or renewed in this state on or after the effective date of this section provides in any manner for…
§ 1374.1 (a) An individual health care service plan contract issued, amended, or renewed on or after January 1, 2023, that provides dependent coverage shall make…
§ 1374.3 Notwithstanding any other provision of this chapter or of a health care service plan contract, every health care service plan shall comply with the…
§ 1374.5 A health care service plan, which is issued, renewed, or amended on or after January 1, 1988, which includes mental health services coverage in nongroup…
§ 1374.51 No plan may utilize any information regarding whether an enrollee’s psychiatric inpatient admission was made on a voluntary or involuntary basis for the…
§ 1374.55 (a) (1) A large group health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or…
§ 1374.551 (a) When a covered treatment may directly or indirectly cause iatrogenic infertility, standard fertility preservation services are a basic health care service,…
§ 1374.56 (a) On and after July 1, 2000, every health care service plan contract, except a specialized health care service plan contract, issued, amended, delivered, or…
§ 1374.57 (a) No group health care service plan that provides hospital, medical, or surgical expense benefits for employees or subscribers and their dependents shall…
§ 1374.58 (a) A group health care service plan that provides hospital, medical, or surgical expense benefits shall provide equal coverage to employers or guaranteed…
§ 1374.7 (a) No plan shall refuse to enroll any person or accept any person as a subscriber or renew any person as a subscriber after appropriate application on the…
§ 1374.75 (a) No health care service plan shall deny, refuse to enroll, refuse to renew, cancel, restrict, or otherwise terminate, exclude, or limit coverage, or charge…
§ 1374.8 (a) A health care service plan shall not release any information to an employer that would directly or indirectly indicate to the employer that an employee is…
§ 1374.9 For violations of Section 1374.7, the director may, after appropriate notice and opportunity for hearing, by order, levy administrative penalties as follows:…
§ 1374.10 (a) Every health care service plan that covers hospital, medical or surgical expenses and which is not qualified as a health maintenance organization under…
§ 1374.11 No health care service plan shall deny a claim for hospital, medical, surgical, dental, or optometric services for the sole reason that the individual served…
§ 1374.12 No health care service plan contract issued, entered into, or renewed on or after July 1, 1984, shall be deemed to contain any provision restricting the…
§ 1374.13 (a) For the purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code apply. (b) It is the intent of…
§ 1374.14 (a) (1) A contract between a health care service plan and a health care provider for the provision of health care services to an enrollee or subscriber shall…
§ 1374.141 (a) If a health care service plan offers a service via telehealth to an enrollee through a third-party corporate telehealth provider, all of the following…
§ 1374.142 (a) A health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan…
§ 1374.15 Any health care service plan shall, upon request by any public entity or political subdivision of the state with whom it has entered into a contract, disclose…
§ 1374.16 (a) Every health care service plan, except a specialized health care service plan, shall establish and implement a procedure by which an enrollee may receive a…
§ 1374.17 (a) A health care service plan shall not deny coverage that is otherwise available under the plan contract for the costs of solid organ or other tissue…
§ 1374.18 (a) To assist a provider in determining if an enrollee’s health care service plan coverage is regulated by the State of California, the health care service…
§ 1374.19 (a) This section shall only apply to a health care service plan covering dental services or a specialized health care service plan contract covering dental…
§ 1374.192 (a) Notwithstanding any other law, a health care service plan, including a specialized health care service plan and a health care service plan that issues,…
§ 1374.193 (a) A health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan…
§ 1374.194 (a) The following definitions shall apply for purposes of this section: (1) “Dental waiting period provision” means a plan contract provision that limits…
§ 1374.195 (a) With respect to a contract between a health care service plan or specialized health care service plan and a dentist to provide covered dental services to…
§ 1374.196 (a) Commencing January 1, 2027, or when final federal rules are implemented, whichever occurs later, the department shall require a health care service plan to…
§ 1374.197 (a) For provider contracts issued, amended, or renewed on and after January 1, 2023, a health care service plan that provides coverage for mental health and…
§ 1374.198 (a) Except as provided in Section 1374.197, within one year of the operative date of this section, a health care service plan or its delegate that credentials…