CHAPTER 2.2. Health Care Service Plans [1340. - 1399.874.]

Chapter 2.2 added by Stats. 1975, Ch. 941.

§§ 1340–1399.874 · 629 sections

1. ARTICLE 1. General §§ 1340–1345.5 · 36 sections

   • § 1340 This chapter shall be known and may be cited as the Knox-Keene Health Care Service Plan Act of 1975.
   • § 1341 (a) There is in state government, in the California Health and Human Services Agency, a Department of Managed Health Care that has charge of the execution of…
   • § 1341.1 The director shall have his or her principal office in the City of Sacramento, and may establish branch offices in the City and County of San Francisco, in the…
   • § 1341.2 In accordance with the laws governing the state civil service, the director shall employ and, with the approval of the Department of Finance, fix the…
   • § 1341.3 The director shall adopt a seal bearing the inscription: “Director, Department of Managed Health Care, State of California.” The seal shall be affixed to or…
   • § 1341.4 (a) In order to effectively support the Department of Managed Health Care in the administration of this law, there is hereby established in the State Treasury,…
   • § 1341.45 (a) There is hereby created in the State Treasury the Managed Care Administrative Fines and Penalties Fund. (b) The fines and administrative penalties…
   • § 1341.5 (a) The director, as a general rule, shall publish or make available for public inspection any information filed with or obtained by the department, unless the…
   • § 1341.6 (a) The Attorney General shall render to the director opinions upon all questions of law, relating to the construction or interpretation of any law under the…
   • § 1341.7 (a) Neither the director nor any of the director’s assistants, clerks, or deputies shall be interested as a director, officer, shareholder, member other than a…
   • § 1341.8 The director shall have the powers of a head of a department pursuant to Chapter 2 (commencing with Section 11150) of Part 1 of Division 3 of Title 2 of the…
   • § 1341.9 The director and department succeed to, and are vested with, all duties, powers, purposes, responsibilities, and jurisdiction of the Commissioner of…
   • § 1341.10 The department may use the unexpended balance of funds available for use in connection with the performance of the functions of the Department of Corporations…
   • § 1341.11 All officers and employees of the Department of Corporations who, on the operative date of this section, are performing any duty, power, purpose,…
   • § 1341.12 The department shall have possession and control of all records, papers, offices, equipment, supplies, moneys, funds, appropriations, licenses, permits,…
   • § 1341.13 All officers or employees of the department employed after the operative date of this section shall be appointed by the director.
   • § 1341.14 (a) Any regulation, order, or other action, adopted, prescribed, taken, or performed by the Department of Corporations or by an officer of the Department of…
   • § 1342 It is the intent and purpose of the Legislature to promote the delivery and the quality of health and medical care to the people of the State of California who…
   • § 1342.2 (a) Notwithstanding any other law, a health care service plan contract that covers medical, surgical, and hospital benefits, excluding a specialized health…
   • § 1342.3 (a) A health care service plan contract that covers medical, surgical, and hospital benefits, excluding a specialized health care service plan contract, shall…
   • § 1342.4 (a) The Department of Managed Health Care and the Department of Insurance shall maintain a joint senior level working group to ensure clarity for health care…
   • § 1342.5 The director shall consult with the Insurance Commissioner prior to adopting any regulations applicable to health care service plans subject to this chapter…
   • § 1342.6 It is the intent of the Legislature to ensure that the citizens of this state receive high-quality health care coverage in the most efficient and…
   • § 1342.7 (a) The Legislature finds that in enacting Sections 1367.215, 1367.25, 1367.45, 1367.51, and 1374.72, it did not intend to limit the department’s authority to…
   • § 1342.71 (a) The Legislature hereby finds and declares all of the following: (1) The federal Patient Protection and Affordable Care Act, its implementing regulations…
   • § 1342.73 (a) (1) With respect to an individual or group health care service plan contract subject to Section 1367.006, the copayment, coinsurance, or any other form of…
   • § 1342.74 (a) (1) Notwithstanding Section 1342.71, a health care service plan shall not subject antiretroviral drugs that are medically necessary for the prevention of…
   • § 1342.75 (a) Notwithstanding any other law, a group or individual health care service plan offering an outpatient prescription drug benefit shall provide coverage for…
   • § 1342.8 The State Department of Health Services and the department shall coordinate, to the extent feasible, audits or surveys of physician offices required by this…
   • § 1343 (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section…
   • § 1343.1 This chapter shall not apply to any program developed under the authority of Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the…
   • § 1343.3 (a) The director, no later than May 1, 2021, may authorize one pilot program in southern California whereby providers approved by the department may undertake…
   • § 1343.5 In any proceeding under this chapter, the burden of proving an exemption or an exception from a definition is upon the person claiming it.
   • § 1344 (a) The director may from time to time adopt, amend, and rescind any rules, forms, and orders that are necessary to carry out the provisions of this chapter,…
   • § 1345 As used in this chapter: (a) “Advertisement” means any written or printed communication or any communication by means of recorded telephone messages or by…
   • § 1345.5 (a) “Minimum essential coverage” means any of the following: (1) Coverage under any of the following government-sponsored programs: (A) The Medicare program…
2. ARTICLE 2. Administration §§ 1346–1348.96 · 15 sections

   • § 1346 (a) The director shall administer and enforce this chapter and shall have the following powers: (1) Recommend and propose the enactment of any legislation…
   • § 1346.1 The department shall maintain a database indicating for each county, the names of the health care service plans that operate in that particular county.
   • § 1346.2 The director shall, in coordination with the Insurance Commissioner, review the Internet portal developed by the United States Secretary of Health and Human…
   • § 1346.4 (a) The Legislature finds and declares all of the following: (1) That millions of Californians are insured under health care service plans regulated by the…
   • § 1346.5 If the director determines that an entity purporting to be a health care service plan exempt from the provisions of Section 740 of the Insurance Code is not a…
   • § 1347.15 (a) There is hereby established in the Department of Managed Health Care the Financial Solvency Standards Board composed of 11 members. The members shall…
   • § 1347.5 (a) A health care service plan providing individual coverage in the Exchange shall cooperate with requests from the Exchange to collaborate in the development…
   • § 1347.8 (a) (1) Beginning on July 1, 2023, and annually thereafter, a health care service plan providing a qualified health plan through the Exchange shall report to…
   • § 1348 (a) Every health care service plan licensed to do business in this state shall establish an antifraud plan. The purpose of the antifraud plan shall be to…
   • § 1348.5 A health care service plan shall comply with the provisions of Section 56.107 of the Civil Code to the extent required by that section. To the extent this…
   • § 1348.6 (a) No contract between a health care service plan and a physician, physician group, or other licensed health care practitioner shall contain any incentive…
   • § 1348.8 (a) A health care service plan that provides, operates, or contracts for telephone medical advice services to its enrollees and subscribers shall do all of the…
   • § 1348.9 (a) On or before July 1, 2003, the director shall adopt regulations to establish the Consumer Participation Program, which shall allow for the director to…
   • § 1348.95 (a) Commencing March 1, 2013, and at least annually thereafter, a health care service plan, not including a health care service plan offering specialized…
   • § 1348.96 Any data submitted by a health care service plan to the United States Secretary of Health and Human Services, or his or her designee, for purposes of the risk…
3. ARTICLE 3. Licensing and Fees §§ 1349–1356.3 · 17 sections

   • § 1349 It is unlawful for any person to engage in business as a plan in this state or to receive advance or periodic consideration in connection with a plan from or…
   • § 1349.1 A health care service plan which satisfies both of the following criteria is exempt from Section 1349: (a) Provides only emergency ambulance services or…
   • § 1349.2 (a) A health care service plan, including a self-insured reimbursement plan that pays for or reimburses any part of the cost of health care services, operated…
   • § 1350 (a) Consistent with federal law, a sponsor of a prescription drug plan authorized by the federal Medicare Prescription Drug, Improvement, and Modernization Act…
   • § 1351 Each application for licensure as a health care service plan or specialized health care service plan under this chapter shall be verified by an authorized…
   • § 1351.1 In addition to the requirements of Section 1351 and upon request of the director, each application shall be accompanied by authorization for disclosure to the…
   • § 1351.2 (a) If a prepaid health plan operating lawfully under the laws of Mexico elects to operate a health care service plan in this state, the prepaid health plan…
   • § 1351.3 On and after January 1, 2007, the department, in considering an application for an initial license for any entity under this chapter, shall consider any…
   • § 1352 (a) A licensed plan shall, within 30 days after any change in the information contained in its application, other than financial or statistical information,…
   • § 1352.1 (a) Except as provided in subdivision (b), no plan shall enter into any new or modified plan contract or publish or distribute, or allow to be published or…
   • § 1353 The director shall issue a license to any person filing an application pursuant to this article, if the director, upon due consideration of the application and…
   • § 1354 Upon denial of application for licensure, or the issuance of an order pursuant to Section 1352 disapproving, suspending, or postponing a material modification,…
   • § 1355 Every plan’s license issued under this chapter shall remain in effect until revoked or suspended by the director, except that every transitional license shall…
   • § 1356 (a) Each plan applying for licensure under this chapter shall reimburse the director for the actual cost of processing the application, including overhead, up…
   • § 1356.1 Notwithstanding subdivision (f) of Section 1356, as amended by Section 2.5 of Chapter 722 of the Statutes of 1991, and subdivision (d) of Section 1356, as…
   • § 1356.2 The director, by notice to all licensed health care service plans on or before October 15, 2010, may require health care service plans to pay an additional…
   • § 1356.3 (a) For the 2025–26 to 2026–27 fiscal years, inclusive, a health care service plan licensed by the department shall be assessed an annual fee in an amount…
4. ARTICLE 3.1. Small Employer Group Access to Contracts for Health Care Services §§ 1357–1357.19 · 20 sections

   • § 1357 As used in this article: (a) “Dependent” means the spouse or child of an eligible employee, subject to applicable terms of the health care plan contract…
   • § 1357.01 Every health care service plan offering plan contracts to small employer groups shall in addition to complying with the provisions of this chapter and the…
   • § 1357.02 (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…
   • § 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…
   • § 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…
   • § 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,…
   • § 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…
   • § 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…
   • § 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…
   • § 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. No premium…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1357.16 (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified…
   • § 1357.17 The director may issue regulations that are necessary to carry out the purposes of this article. Prior to the public comment period required on the regulations…
   • § 1357.19 This article shall not apply to a health care service plan contract that is subject to Article 3.16 (commencing with Section 1357.500) or Article 3.17…
5. ARTICLE 3.15. Preexisting Condition Provisions §§ 1357.50–1357.55 · 4 sections

   • § 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…
   • § 1357.51 (a) A health benefit plan for group coverage shall not impose any preexisting condition provision or waivered condition provision upon any enrollee. (b) (1) A…
   • § 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…
   • § 1357.55 This article shall become operative on January 1, 2014.
6. ARTICLE 3.16. Nongrandfathered Small Employer Plans §§ 1357.500–1357.516 · 17 sections

   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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 1357.500, except…
   • § 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…
   • § 1357.505 (a) Notwithstanding paragraph (2) of subdivision (a) of Section 1357.503, an association of employers may offer a large group health care service plan contract…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1357.516 (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified…
7. ARTICLE 3.17. Grandfathered Small Employer Plans §§ 1357.600–1357.618 · 17 sections

   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1357.604 (a) (1) A plan shall fairly and affirmatively renew a grandfathered health plan contract with a small employer. (2) Each plan shall make available to each…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1357.616 (a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified…
   • § 1357.618 (a) The department may adopt emergency regulations implementing this article no later than August 31, 2013. The department may readopt any emergency regulation…
8. ARTICLE 3.5. Additional Requirements for Medicare Supplement Contracts §§ 1358.1–1358.24 · 30 sections

   • § 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…
   • § 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…
   • § 1358.3 (a) Except as otherwise provided in this section or in Sections 1358.7, 1358.12, 1358.13, 1358.16, and 1358.21, this article shall apply to all group and…
   • § 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,…
   • § 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…
   • § 1358.6 (a) (1) Except for permitted preexisting condition clauses as described in Sections 1358.7, 1358.8, and 1358.81, a contract shall not be advertised, solicited,…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1358.10 (a) (1) This section shall apply to Medicare Select contracts, as defined in this section. (2) A contract shall not be advertised as a Medicare Select contract…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1358.145 (a) The calculation of actual or expected loss ratios shall be pursuant to the formula in subdivision (a) of Section 1358.14, and pursuant to definitions,…
   • § 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…
   • § 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…
   • § 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…
   • § 1358.17 (a) (1) Medicare supplement contracts shall include a renewal or continuation provision. The language or specifications of the provision shall be consistent…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1358.23 (a) If a Medicare supplement contract replaces another Medicare supplement policy or certificate, or contract, the replacing issuer shall waive any time…
   • § 1358.24 This section applies to all contracts that become effective on or after May 21, 2009. (a) In addition to the requirements set forth under Sections 1365.5 and…
9. ARTICLE 4. Solicitation and Enrollment §§ 1359–1366.6 · 30 sections

   • § 1359 (a) The director may require that solicitors and solicitor firms, and principal persons engaged in the supervision of solicitation for plans of solicitor…
   • § 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…
   • § 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,…
   • § 1360.5 (a) For purposes of this section, “Exchange” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code. (b) It…
   • § 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…
   • § 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…
   • § 1362 As used in Sections 1363 and 1364: (a) “Benefits and coverage” means the health care services available under a plan contract. (b) “Exception” means any…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 1363.06 (a) The Department of Managed Health Care and the Department of Insurance shall compile information as required by this section and Section 10127.14 of the…
   • § 1363.07 (a) Each health care service plan shall send copies of the comparative benefit matrix prepared pursuant to Section 1363.06 on an annual basis, or more…
   • § 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…
   • § 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…
   • § 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. The…
   • § 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…
   • § 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…
   • § 1364.1 Within 30 days of receiving the notice required by Section 1255.1, a health care service plan shall notify, or provide for the notification of, enrollees who…
   • § 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…
   • § 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…
   • § 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…
   • § 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…
   • § 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… see note
   • § 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…
   • § 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…
   • § 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…
   • § 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… see note
10. ARTICLE 4.5. California Cobra Program §§ 1366.20–1366.29 · 10 sections

    • § 1366.20 (a) This article shall be known as the California Continuation Benefits Replacement Act, or “Cal-COBRA.” (b) It is the intent of the Legislature that continued…
    • § 1366.21 The definitions contained in this section govern the construction of this article. (a) “Continuation coverage” means extended coverage under the group benefit…
    • § 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…
    • § 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…
    • § 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…
    • § 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,…
    • § 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…
    • § 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…
    • § 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…
    • § 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…
11. ARTICLE 4.6. Coverage for Federally Eligible Defined Individuals §§ 1366.35–1366.50 · 2 sections

    • § 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,…
    • § 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…
12. ARTICLE 5. Standards §§ 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…
13. ARTICLE 5.5. Health Care Service Plan Coverage Contract Changes §§ 1374.20–1374.29 · 11 sections

    • § 1374.20 (a) No group health care service plan shall change the premium rates or applicable copayments or coinsurances or deductibles for the length of the contract,…
    • § 1374.21 (a) (1) A change in premium rates or changes in coverage stated in a small group health care service plan contract shall not become effective unless the plan…
    • § 1374.22 (a) The written notice described in subdivision (a) of Section 1374.21 shall be delivered by mail at the last known address at least 60 days prior to the…
    • § 1374.23 Notwithstanding subdivision (a) of Section 1374.22, if the plan does not guarantee either premium rates or plan design or benefits for any specified time…
    • § 1374.24 There shall be no liability on the part of, and no cause of action of any nature shall arise against, any health care service plan required to provide the…
    • § 1374.25 Proof of mailing a notice and the reason therefor to the appropriate entity or individual at the most current policy or plan address shall be sufficient proof…
    • § 1374.255 (a) This section shall apply to grandfathered health care service plan contracts and nongrandfathered health care service plan contracts in the individual or…
    • § 1374.26 The director may, as required by this article, or from time to time as conditions warrant, pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of…
    • § 1374.27 The director may levy administrative penalties and may suspend or revoke the license or licenses issued to any health care service plan, after notice and…
    • § 1374.28 In addition to any other penalty provided by law or the availability of any administrative procedure, if a health care service plan, after notice and hearing,…
    • § 1374.29 The purpose of this article is to promote the public interest, to prevent unfair and unlawful health care business practices, and to promote adequate consumer…
14. ARTICLE 5.55. Appeals Seeking Independent Medical Reviews §§ 1374.30–1374.36 · 7 sections

    • § 1374.30 (a) Commencing January 1, 2001, there is hereby established in the department the Independent Medical Review System. (b) For the purposes of this chapter,…
    • § 1374.31 (a) If there is an imminent and serious threat to the health of the enrollee, as specified in subdivision (c) of Section 1374.33, all necessary information and…
    • § 1374.32 (a) The department shall contract with one or more independent medical review organizations in the state to conduct reviews for purposes of this article. The…
    • § 1374.33 (a) Upon receipt of information and documents related to a case, the medical professional reviewer or reviewers selected to conduct the review by the…
    • § 1374.34 (a) Upon receiving the decision adopted by the director pursuant to Section 1374.33 that a disputed health care service is medically necessary, the plan shall…
    • § 1374.35 (a) After considering the results of a competitive bidding process and any other relevant information on program costs, the director shall establish a…
    • § 1374.36 (a) The director shall submit to the Legislature by March 1, 2002, a report on the initial implementation of this article. The report shall include a…
15. ARTICLE 5.6. Point-of-Service Health Care Service Plan Contracts §§ 1374.60–1374.76 · 18 sections

    • § 1374.60 For purpose of this article, the following definitions shall apply: (a) A “point-of-service plan contract” means any plan contract offered by a health care…
    • § 1374.62 A point-of-service plan contract, in which any risk for out-of-network coverage or services is transferred from a health care service plan through reinsurance,…
    • § 1374.64 (a) Only a plan that has been licensed under this chapter and in operation in this state for a period of five years or more, or a plan licensed under this…
    • § 1374.65 Point-of-service plan contracts shall: (a) Provide incentives, including financial incentives, for enrollees to use in-network coverage or services. (b) Only…
    • § 1374.66 Any health care service plan that offers a point-of-service plan contract may do all of the following: (a) Limit or exclude coverage for specific types of…
    • § 1374.67 A health care service plan offering a point-of-service plan contract is subject to the following limitations: (a) A health care service plan shall limit its…
    • § 1374.68 A health care service plan that offers a point-of-service plan contract shall do all of the following: (a) Deposit with the director or, at the discretion of…
    • § 1374.69 At least 20 business days prior to offering a point-of-service plan contract, a health care service plan shall file a notice of material modification in…
    • § 1374.71 No plan formerly registered under the Knox-Mills Health Plan Act (Article 2.5 (commencing with Section 12530) of Chapter 6 of Part 2 of Division 3 of Title 2…
    • § 1374.72 (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage…
    • § 1374.721 (a) A health care service plan that provides hospital, medical, or surgical coverage shall base any medical necessity determination or the utilization review…
    • § 1374.722 (a) (1) A health care service plan contract issued, amended, renewed or delivered on or after January 1, 2024, that is required to provide coverage for…
    • § 1374.723 (a) A health care service plan contract issued, amended, renewed, or delivered on or after July 1, 2023, that covers hospital, medical, or surgical expenses…
    • § 1374.724 (a) Coverage of mental health and substance use disorder treatment pursuant to Section 1374.72 includes behavioral health crisis services that are provided to…
    • § 1374.725 For services provided to an enrollee under a health care service plan contract issued, amended, or renewed on or after July 1, 2025, a health care service plan…
    • § 1374.73 (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health…
    • § 1374.74 (a) The department, in consultation with the Department of Insurance, shall convene an Autism Advisory Task Force by February 1, 2012, in collaboration with…
    • § 1374.76 (a) No later than January 1, 2015, a large group health care service plan contract shall provide all covered mental health and substance use disorder benefits…
16. ARTICLE 6. Operation and Renewal Requirements and Procedures §§ 1375.1–1385 · 27 sections

    • § 1375.1 (a) Every plan shall have and shall demonstrate to the director that it has all of the following: (1) A fiscally sound operation and adequate provision against…
    • § 1375.2 On and after October 1, 1977, every plan operating under a transitional license shall have a fiscally sound operation.
    • § 1375.3 (a) A health care service plan shall meet and confer with the director and his or her designated representatives at least 10 business days prior to filing a…
    • § 1375.4 (a) Every contract between a health care service plan and a risk-bearing organization that is issued, amended, renewed, or delivered in this state on or after…
    • § 1375.5 No contract between a risk-bearing organization and a health care service plan that is issued, amended, delivered, or renewed in this state on or after July 1,…
    • § 1375.6 No contract between a risk-bearing organization and a health care service plan that is issued, amended, delivered, or renewed in this state on or after July 1,…
    • § 1375.61 (a) A contract between a health care service plan and a provider of health care services shall not contain any term that would result in termination or…
    • § 1375.7 (a) This section shall be known and may be cited as the Health Care Providers’ Bill of Rights. (b) No contract issued, amended, or renewed on or after January…
    • § 1375.8 (a) The Legislature finds the following: (1) Because of the nature and cost of certain medical items, the financial risk of these items is better retained by…
    • § 1375.9 (a) A health care service plan shall ensure that there is at least one full-time equivalent primary care physician for every 2,000 enrollees of the plan. The…
    • § 1376 (a) No plan shall conduct any activity regulated by this chapter in contravention of such rules and regulations as the director may prescribe as necessary or…
    • § 1376.1 The deposit requirements of Section 1300.76.1 of Title 28 of the California Code of Regulations shall not apply to any plan operated by a county, or city and…
    • § 1377 (a) Every plan which reimburses providers of health care services that do not contract in writing with the plan to provide health care services, or which…
    • § 1378 No plan shall expend for administrative costs in any fiscal year an excessive amount of the aggregate dues, fees and other periodic payments received by the…
    • § 1379 (a) Every contract between a plan and a provider of health care services shall be in writing, and shall set forth that in the event the plan fails to pay for…
    • § 1379.5 (a) On and after July 1, 2008, every contract between a plan and a health care provider who provides health care services in Mexico to an enrollee of the plan…
    • § 1380 (a) The department shall conduct periodically an onsite medical survey of the health delivery system of each plan. The survey shall include a review of the…
    • § 1380.1 (a) The Legislature finds and declares as follows: (1) Multiple medical quality audits of health care providers, as many as 25 for some physician offices,…
    • § 1380.2 (a) (1) Notwithstanding any other law, except as provided in Section 1374.197, on and after January 1, 2028, a full service health care service plan or its…
    • § 1380.3 The department shall coordinate the surveys conducted pursuant to Section 1380 with the State Department of Health Care Services, to the extent possible, in…
    • § 1381 (a) All records, books, and papers of a plan, management company, solicitor, solicitor firm, and any provider or subcontractor providing health care or other…
    • § 1382 (a) The director shall conduct an examination of the fiscal and administrative affairs of any health care service plan, and each person with whom the plan has…
    • § 1383 Every plan that is a health maintenance organization qualified under Section 1310(d) of Title XIII of the federal Public Health Service Act, shall provide the…
    • § 1383.1 (a) On or before July 1, 1997, every health care service plan shall file with the department a written policy, which is not subject to approval or disapproval…
    • § 1383.15 (a) When requested by an enrollee or participating health professional who is treating an enrollee, a health care service plan shall provide or authorize a…
    • § 1384 (a) Within 90 days after receipt of a request from the director, a plan or other person subject to this chapter shall submit to the director an audit report…
    • § 1385 Each plan, solicitor firm, and solicitor shall keep and maintain current such books of account and other records as the director may by rule require for the…
17. ARTICLE 6.1. Pharmacy Benefit Managers §§ 1385.001–1385.009 · 32 sections

    • § 1385.001 For the purposes of this article: (a) “Affiliated entity” means any of the following: (1) An applicable group purchasing organization, drug manufacturer,…
    • § 1385.0010 In addition to the requirements of Section 1385.009, and upon request of the director, an application shall be accompanied by authorization for disclosure to…
    • § 1385.0011 (a) A pharmacy benefit manager shall submit to the department financial statements prepared as of the close of its fiscal year within 120 days after the close…
    • § 1385.0012 (a) A pharmacy benefit manager licensed pursuant to this article shall submit to the Department of Health Care Access and Information all information required…
    • § 1385.0013 (a) (1) A licensed pharmacy benefit manager shall, within 30 days after a change in the information contained in its application, other than financial or…
    • § 1385.0014 Upon denial of an application for licensure, or the issuance of an order pursuant to Section 1385.0013 disapproving, suspending, or postponing a material…
    • § 1385.0015 A pharmacy benefit manager license issued under this article shall remain in effect until revoked or suspended by the director.
    • § 1385.0016 (a) A pharmacy benefit manager applying for licensure under this article shall reimburse the director for the actual cost of processing the application,…
    • § 1385.0017 (a) To support the department in the administration of this article and the effective regulation of pharmacy benefit managers under this chapter, and to…
    • § 1385.0018 (a) The director may, after appropriate notice and opportunity for a hearing, by order suspend or revoke a license issued under this article to a pharmacy…
    • § 1385.0019 (a) A pharmacy benefit manager whose license has been revoked, or suspended for more than one year, may petition the director to reinstate the license as…
    • § 1385.002 (a) The department has the authority to enforce the provisions of this article, including the authority to adopt, amend, or repeal any rules and regulations,…
    • § 1385.0020 (a) Surrender of a pharmacy benefit manager license shall become effective 30 days after receipt of an application to surrender the license or within a shorter…
    • § 1385.0021 (a) Notwithstanding the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), the director is not…
    • § 1385.0022 A pharmacy benefit manager has a fiduciary duty to its payer client that includes a duty to be fair and truthful toward the payer, to act in the payer’s best…
    • § 1385.0023 (a) The department may conduct periodic routine and nonroutine surveys of a pharmacy benefit manager. These surveys shall be conducted in accordance with…
    • § 1385.0024 (a) The Pharmacy Benefit Manager Administrative Fines and Penalties Fund is hereby created in the State Treasury. (b) On and after July 1, 2025, the fines and…
    • § 1385.0025 The provisions of this article are severable. If any provision of this article or its application is held invalid, that invalidity shall not affect other…
    • § 1385.0026 (a) A pharmacy benefit manager shall not impose any requirements, conditions, or exclusions that discriminate against a nonaffiliated pharmacy in connection…
    • § 1385.0027 A pharmacy benefit manager shall not do any of the following: (a) Require a plan participant to use only an affiliated pharmacy if there are nonaffiliated…
    • § 1385.0028 (a) A contract issued, amended, or renewed on or after January 1, 2026, between a nonaffiliated pharmacy and a pharmacy benefit manager shall not prohibit the…
    • § 1385.0029 (a) A pharmacy benefit manager shall not derive income from pharmacy benefit management services provided to a payer in this state except for income derived…
    • § 1385.003 (a) A health care service plan shall disclose to a contracted pharmacy provider or its contracting agent the prescription drug information contained in…
    • § 1385.0031 Commencing January 1, 2026, a pharmacy benefit manager shall not conduct spread pricing in this state. If a preexisting contract between a pharmacy benefit…
    • § 1385.0032 (a) Notwithstanding any other law, a pharmacy benefit manager shall not enter into, amend, enforce, or renew a contract on or after January 1, 2026, with…
    • § 1385.0033 (a) A person that violates this article shall be subject to an injunction and liable for a civil penalty of not less than one thousand dollars ($1,000) or more…
    • § 1385.0034 This article does not apply to a collectively bargained Taft-Hartley self-insured prescription drug plan offered pursuant to the federal Employee Retirement…
    • § 1385.004 (a) A health care service plan that contracts with a pharmacy benefit manager for management of any or all of its prescription drug coverage shall require the…
    • § 1385.005 (a) A pharmacy benefit manager required to register with the department pursuant to Section 1385.004 shall complete an application for registration with the…
    • § 1385.006 The failure by a health care service plan to comply with the contractual requirements and to maintain appropriate oversight of a contracted pharmacy benefit…
    • § 1385.008 On or after January 1, 2027, or the date on which the department has established the licensure process pursuant to Section 1385.009, whichever is later, a…
    • § 1385.009 An application for licensure as a pharmacy benefit manager under this article shall be verified by an authorized representative of the applicant and shall be…
18. ARTICLE 6.2. Review of Rate Increases §§ 1385.01–1385.14 · 18 sections

    • § 1385.01 For purposes of this article, the following definitions shall apply: (a) (1) “Blended” means a rating method that combines community rating and experience…
    • § 1385.02 This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan…
    • § 1385.026 The Legislature finds and declares that Sections 19 and 29 of this act, which add Sections 1385.0011 and 1385.0021, respectively, to the Health and Safety…
    • § 1385.03 (a) (1) A health care service plan shall file with the department all required rate information for grandfathered individual and grandfathered and…
    • § 1385.035 (a) It is the intent of the Legislature in enacting this section to ensure that enrollees and subscribers benefit from reductions in the rate of growth in…
    • § 1385.04 (a) For large group health care service plan contracts, all health plans shall file with the department at least 60 days prior to implementing any rate change…
    • § 1385.043 (a) A health care service plan, not including a specialized health care service plan, shall annually report to the department the information described in…
    • § 1385.045 (a) For large group health care service plan contracts, a health care service plan shall file with the department the weighted average rate increase for all…
    • § 1385.046 (a) Upon receiving notice of a rate change, a large group contractholder that has coverage that is experience rated in whole or blended and that meets the…
    • § 1385.05 Notwithstanding any provision in a contract between a health care service plan and a provider, the department may request from a health care service plan any…
    • § 1385.06 (a) A filing submitted under this article shall be actuarially sound. (b) (1) The plan shall contract with an independent actuary or actuaries consistent with…
    • § 1385.07 (a) Notwithstanding Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code, all information submitted under this article shall be…
    • § 1385.08 (a) On or before July 1, 2012, the director may issue guidance to health care service plans regarding compliance with this article. This guidance shall not be…
    • § 1385.09 A health care service plan contract subject to Section 1385.03 or 1385.04 shall file a separate schedule documenting the cost savings associated with Section…
    • § 1385.10 (a) (1) A health care service plan shall annually provide claims data at no charge to a large group purchaser if the large group purchaser requests the…
    • § 1385.11 (a) Whenever it appears to the department that any person has engaged, or is about to engage, in any act or practice constituting a violation of this article,…
    • § 1385.13 The department shall do all of the following in a manner consistent with applicable federal laws, rules, and regulations: (a) Provide data to the United States…
    • § 1385.14 (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services,…
19. ARTICLE 7. Discipline §§ 1386–1389 · 4 sections

    • § 1386 (a) The director may, after appropriate notice and opportunity for a hearing, by order suspend or revoke any license issued under this chapter to a health care…
    • § 1387 (a) (1) A person who violates a provision of this chapter, or who violates a rule or order adopted or issued pursuant to this chapter, shall be liable for a…
    • § 1388 (a) The director may, after appropriate notice and opportunity for hearing, by order, censure a person acting as a solicitor or solicitor firm, or suspend for…
    • § 1389 (a) A person whose license has been revoked, or suspended for more than one year, may petition the director to reinstate the license as provided by Section…
20. ARTICLE 7.5. Underwriting Practices §§ 1389.1–1389.8 · 10 sections

    • § 1389.1 (a) The director shall not approve any plan contract unless the director finds that the application conforms to both of the following requirements: (1) All…
    • § 1389.2 At the request of the director, a health care service plan shall provide a written statement of the actuarial basis for any medical underwriting decision on…
    • § 1389.21 (a) A health care service plan shall not rescind a plan contract, or limit any provisions of a plan contract, once an enrollee is covered under the contract…
    • § 1389.25 (a) (1) This section shall apply only to a full service health care service plan offering health coverage in the individual market in California and shall not…
    • § 1389.3 No health care service plan shall engage in the practice of postclaims underwriting. For purposes of this section, “postclaims underwriting” means the…
    • § 1389.4 (a) A full service health care service plan that issues, renews, or amends individual health plan contracts shall be subject to this section. (b) A health care… see note
    • § 1389.5 (a) This section applies to a health care service plan that provides coverage under an individual plan contract that is issued, amended, delivered, or renewed…
    • § 1389.6 Compensation of a person or entity employed by, or contracted with, a health care service plan shall not be based on, or related in any way to, the number of…
    • § 1389.7 (a) Every health care service plan that offers, issues, or renews individual plan contracts shall offer to any individual, who was covered under an individual… see note
    • § 1389.8 (a) Notwithstanding any other provision of law, an agent, broker, solicitor, solicitor firm, or representative who assists an applicant in submitting an…
21. ARTICLE 8. Other Enforcement Procedures §§ 1390–1394.3 · 12 sections

    • § 1390 (a) Any person who willfully violates any provision of this chapter or of any rule or order thereunder shall upon conviction be fined not more than twenty…
    • § 1391 (a) (1) The director may issue an order directing a plan, solicitor firm, or any representative thereof, a solicitor, or any other person to cease and desist…
    • § 1391.5 (a) If, after examination or investigation, the director has reasonable grounds to believe that irreparable loss and injury to the plan’s enrollee or enrollees…
    • § 1392 (a) (1) Whenever it appears to the director that any person has engaged, or is about to engage, in any act or practice constituting a violation of any…
    • § 1392.5 (a) This section applies to every action brought in the name of the people of the State of California by the Director of the Department of Managed Health Care…
    • § 1393 (a) The superior court of the county in which is located the principal office of the plan in this state shall, upon the filing by the director of a verified…
    • § 1393.5 (a) A person who violates Section 1349, or any person who directly or indirectly participates in the direction of the management or policies of the person in…
    • § 1393.6 For violations of Article 3.1 (commencing with Section 1357), Article 3.15 (commencing with Section 1357.50), Article 3.16 (commencing with Section 1357.500),…
    • § 1394 The civil, criminal, and administrative remedies available to the director pursuant to this article are not exclusive, and may be sought and employed in any…
    • § 1394.1 Notwithstanding any other provision of law, the director may file a verified complaint for involuntary dissolution of a health care service plan on any one or…
    • § 1394.2 Notwithstanding any other provision of law, in any involuntary dissolution of a health care service plan as provided for in Section 1394.1, or other insolvency…
    • § 1394.3 Except as provided for in Section 1394.1, and 1394.2, the involuntary dissolution of a health care service plan shall be in accordance with either of the…
22. ARTICLE 8.5. Service of Process §§ 1394.5–1394.8 · 3 sections

    • § 1394.5 When any person, including any nonresident of this state, engages in conduct prohibited or made actionable by this chapter or any rule, regulation, or order…
    • § 1394.7 (a) As used in this section the following definitions shall apply: (1) “Health care service plan” means any plan as defined in Section 1345, but this section…
    • § 1394.8 (a) As used in this section: (1) “Carrier” means a specialized health care service plan, and any of the following entities which offer coverage comparable to…
23. ARTICLE 9. Miscellaneous §§ 1395–1399.5 · 14 sections

    • § 1395 (a) Notwithstanding Article 6 (commencing with Section 650) of Chapter 1 of Division 2 of the Business and Professions Code, any health care service plan or…
    • § 1395.5 (a) Except as provided in subdivisions (b) and (c), no contract that is issued, amended, renewed, or delivered on or after January 1, 1999, between a health…
    • § 1395.6 (a) In order to prevent the improper selling, leasing, or transferring of a health care provider’s contract, it is the intent of the Legislature that every…
    • § 1395.7 (a) A staff-model dental health care service plan that arranges for or establishes credit extended by a third party shall establish and comply with policies…
    • § 1396 It is unlawful for any person willfully to make any untrue statement of material fact in any application, notice, amendment, report, or other submission filed…
    • § 1396.5 A nonprofit hospital corporation which substantially indemnified subscribers and enrollees and was operating in 1965 under Chapter 11A (commencing with Section…
    • § 1397 (a) Whenever reference is made in this chapter to a hearing before or by the director, the hearing shall be held in accordance with the Administrative…
    • § 1397.5 (a) The director shall make and file annually with the Department of Managed Health Care as a public record, an aggregate summary of grievances against plans…
    • § 1397.6 The director may contract with necessary medical consultants to assist with the health care program. These contracts shall be on a noncompetitive bid basis and…
    • § 1398.5 All references to the Knox-Mills Health Plan Act (Article 2.5 (commencing with Section 12530) of Chapter 6 of Part 2 of Division 3 of the Government Code),…
    • § 1399 (a) Surrender of a license as a health plan becomes effective 30 days after receipt of an application to surrender the license or within a shorter period of…
    • § 1399.1 (a) All orders and other actions taken by the Commissioner of Corporations pursuant to the authority contained in subdivision (c) of Section 1350 on or before…
    • § 1399.3 (a) A material change made by a health care service plan, as defined in subdivision (f) of Section 1345, to the terms and conditions of a contract between the…
    • § 1399.5 It is the intent of the Legislature that the provisions of this chapter shall be applicable to any private or public entity or political subdivision which, in…
24. ARTICLE 9.5. Claims Reviewers §§ 1399.55–1399.57 · 3 sections

    • § 1399.55 Health care service plans shall, upon rejecting a claim from a health care provider or a patient, and upon their demand, disclose the specific rationale used…
    • § 1399.56 Compensation of a person retained by a health care service plan to review claims for health care services shall not be based on either of the following: (a) A…
    • § 1399.57 This article does not apply to services or benefits provided pursuant to Medi-Cal, including services or benefits provided under Chapters 7 (commencing with…
25. ARTICLE 10. Discontinuance and Replacement of Group Health Care Service Plan Contracts §§ 1399.60–1399.64 · 5 sections

    • § 1399.60 The provisions of this article shall apply to all group health care service contracts issued in this state pursuant to this chapter.
    • § 1399.61 In this article, unless the context otherwise requires: (a) “Carrier” shall mean the health care service plan or other entity responsible for the payment of…
    • § 1399.62 (a) Every contract containing hospital, medical, or surgical expense benefits or service benefits shall contain a reasonable extension of such benefits upon…
    • § 1399.63 (a) Any carrier providing replacement coverage with respect to hospital, medical or surgical expense or service benefits within a period of 60 days from the…
    • § 1399.64 This article shall apply to all contracts issued, delivered, amended, or renewed in this state after January 1, 1977. A policy subject to the provisions of…
26. ARTICLE 10.2. Mergers and Acquisitions of Health Care Service Plans §§ 1399.65–1399.66 · 2 sections

    • § 1399.65 (a) (1) A health care service plan that intends to merge or consolidate with, or enter into an agreement resulting in its purchase, acquisition, or control by,…
    • § 1399.66 (a) Notwithstanding subdivision (d) of Section 1352, a health care service plan that files a material modification that is a transaction or agreement described…
27. ARTICLE 11. Nonprofit Plans §§ 1399.70–1399.76 · 7 sections

    • § 1399.70 (a) In addition to the information required by subdivision (a) of Section 1399.73, a nonprofit health care service plan submitting an application to the…
    • § 1399.71 (a) Any nonprofit health care service plan that intends to restructure its activities as defined in subdivision (d) shall, prior to restructuring, secure…
    • § 1399.72 (a) Any health care service plan that intends to convert from nonprofit to for-profit status, as defined in subdivision (b), shall, prior to the conversion,…
    • § 1399.73 (a) An application for a conversion or restructuring shall contain the information the director may require, by rule or order. (b) The director shall charge a…
    • § 1399.74 (a) By July 1, 1996, the director shall adopt regulations, on an emergency basis, that specify the application procedures and requirements for the…
    • § 1399.75 (a) This article shall apply to the restructuring or conversion of nonprofit mutual benefit health care service plans to the extent these plans have held or…
    • § 1399.76 This article shall not apply to a nonprofit health care service plan restructure or conversion that has been submitted as a material modification to the…
28. ARTICLE 11.1. Consumer Operated and Oriented Plans §§ 1399.80–1399.88 · 6 sections

    • § 1399.80 For purposes of this article, the following definitions shall apply: (a) “Consumer operated and oriented plan” means a nonprofit member organization or…
    • § 1399.81 The director shall have the authority to issue a license to act as a health care service plan to a CO-OP that has been organized as a nonprofit member…
    • § 1399.83 (a) A domestic or foreign CO-OP licensed as a health care service plan pursuant to this article shall be subject to all of the provisions of this chapter and…
    • § 1399.84 The director may request any documentation relating to a CO-OP’s start-up loan or solvency loan.
    • § 1399.86 (a) A CO-OP shall be subject at all times to the prohibitions in PPACA against converting or selling to a for-profit or nonconsumer-operated entity at any time…
    • § 1399.88 In addition to any applicable requirements in this chapter for maintaining a license, a CO-OP is required at all times to be in full compliance with the…
29. ARTICLE 11.5. Individual Access to Contracts for Health Care Services §§ 1399.801–1399.818 · 15 sections

    • § 1399.801 As used in this article: (a) “Creditable coverage” means: (1) Any individual or group policy, contract, or program that is written or administered by a…
    • § 1399.802 (a) Every health care service plan offering plan contracts to individuals shall, in addition to complying with the provisions of this chapter and the rules…
    • § 1399.803 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…
    • § 1399.804 (a) Commencing January 1, 2001, a plan shall fairly and affirmatively offer, market, and sell the health care service plan contracts described in subdivision…
    • § 1399.805 (a) (1) After the federally eligible defined individual submits a completed application form for a plan contract, the plan shall, within 30 days, notify the…
    • § 1399.806 A plan may not exclude any federally eligible defined individual, or his or her dependents, who would otherwise be entitled to health care services on the…
    • § 1399.809 The director may require a plan to discontinue the offering of contracts or the acceptance of applications from any individual upon a determination by the…
    • § 1399.810 All health care service plan contracts offered to a federally eligible defined individual shall be renewable with respect to the individual and dependents at…
    • § 1399.811 (a) (1) Premiums for contracts offered, delivered, amended, or renewed by plans on or after January 1, 2001, shall be subject to the following requirements:…
    • § 1399.812 Plans shall apply premiums consistently with respect to all federally eligible defined individuals who apply for coverage.
    • § 1399.813 In connection with the offering for sale of any plan contract to an individual, each plan shall make a reasonable disclosure, as part of its solicitation and…
    • § 1399.814 Nothing in this article shall be construed to require a health benefit plan to offer a contract to an individual if the plan does not otherwise offer contracts…
    • § 1399.815 (a) At least 20 business days prior to renewing or amending a plan contract subject to this article, or at least 20 business days prior to the initial offering…
    • § 1399.817 The director may issue regulations that are necessary to carry out the purposes of this article. Any rules and regulations adopted pursuant to this article may…
    • § 1399.818 This article shall apply to health care service plan contracts offered, delivered, amended, or renewed on or after January 1, 2001.
30. ARTICLE 11.7. Child Access to Health Care Coverage §§ 1399.825–1399.836 · 10 sections

    • § 1399.825 As used in this article: (a) “Child” means any individual under 19 years of age. (b) “Individual grandfathered plan coverage” means health care coverage in…
    • § 1399.826 (a) (1) During each open enrollment period, every health care service plan offering plan contracts in the individual market, other than individual…
    • § 1399.827 This article shall not apply to health care service plan contracts for coverage of Medicare services pursuant to contracts with the United States government,…
    • § 1399.828 (a) Upon the effective date of this article, a health care service plan shall fairly and affirmatively offer, market, and sell all of the plan’s health care…
    • § 1399.829 (a) A health care service plan may use the following characteristics of an eligible child for purposes of establishing the rate of the plan contract for that…
    • § 1399.832 No health care service plan shall be required to offer a health care service plan contract or accept applications for the contract pursuant to this article in…
    • § 1399.833 The director may require a health care service plan to discontinue the offering of contracts or acceptance of applications from any individual or child or…
    • § 1399.834 (a) All health care service plan contracts offered to a child or on behalf of a child to a responsible party for a child shall conform to the requirements of…
    • § 1399.835 On or before July 1, 2011, the director may issue guidance to health plans regarding compliance with this article and that guidance shall not be subject to the…
    • § 1399.836 (a) This article shall become inoperative on January 1, 2014, or the 91st calendar day following the adjournment of the 2013–14 First Extraordinary Session,… see note
31. ARTICLE 11.8. Individual Access to Health Care Coverage §§ 1399.845–1399.864 · 15 sections

    • § 1399.845 For purposes of this article, the following definitions shall apply: (a) “Child” means a child described in Section 22775 of the Government Code and…
    • § 1399.846 For the purposes of determining eligibility for small employer coverage, a sole proprietor and the sole proprietor’s spouse are not employees with respect to a…
    • § 1399.847 Except as provided in Sections 1399.858 and 1399.861, the provisions of this article shall only apply with respect to nongrandfathered individual health…
    • § 1399.848 (a) Notwithstanding paragraph (1) of subdivision (c) of Section 1399.849, with respect to individual health benefit plans offered outside of the Exchange, a…
    • § 1399.849 (a) (1) On and after October 1, 2013, a plan shall fairly and affirmatively offer, market, and sell all of the plan’s health benefit plans that are sold in the…
    • § 1399.851 (a) Commencing October 1, 2013, a health care service plan or solicitor shall not, directly or indirectly, engage in the following activities: (1) Encourage or…
    • § 1399.853 (a) An individual health benefit plan shall be renewable at the option of the enrollee except as permitted to be canceled, rescinded, or not renewed pursuant…
    • § 1399.855 (a) With respect to individual health benefit plans for policy years on or after January 1, 2014, a health care service plan may use only the following…
    • § 1399.857 (a) A health care service plan shall not be required to offer an individual health benefit plan or accept applications for the plan pursuant to Section…
    • § 1399.858 The director may require a plan to discontinue the offering of contracts or acceptance of applications from any individual, or responsible party for an…
    • § 1399.859 (a) A health care service plan that receives an application for an individual health benefit plan outside the Exchange during the initial open enrollment…
    • § 1399.861 (a) On or before October 1, 2013, and annually every October 1 thereafter, a health care service plan shall issue the following notice to all subscribers…
    • § 1399.862 Except as otherwise provided in this article, this article shall only be implemented to the extent that it meets or exceeds the requirements set forth in PPACA.
    • § 1399.863 (a) The department may adopt emergency regulations implementing this article no later than December 31, 2014. The department may readopt any emergency…
    • § 1399.864 (a) For purposes of this article, a bridge plan product shall mean an individual health benefit plan, as defined in subdivision (f) of Section 1399.845, that…
32. ARTICLE 11.9. Health Equity and Quality §§ 1399.870–1399.874 · 5 sections

    • § 1399.870 (a) (1) On or before March 1, 2022, the department shall convene a Health Equity and Quality Committee to make recommendations to the department for standard…
    • § 1399.871 (a) (1) The department shall establish standard measures and annual benchmarks for equity and quality in health care delivery. (2) A standard measure or annual…
    • § 1399.872 (a) Upon the department’s establishment or updating of standard measures and annual benchmarks pursuant to Section 1399.871, a health care service plan shall…
    • § 1399.873 (a) Except as provided by any other law, the requirements of this article apply to health care service plans that cover hospital, medical, or surgical…
    • § 1399.874 (a) This article does not restrict the director’s enforcement authority under this chapter. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of…