This law outlines the requirements for health care service plans in California. It specifies that all facilities used by the plan must be properly licensed, and personnel must have necessary certifications. Equipment must also be legally licensed, and services should ensure continuity of care. They must be accessible, potentially using telehealth when appropriate.

The statute mandates fair contracts with providers, including dispute resolution mechanisms. Health plans must offer basic health services and can charge co-pays but must disclose such charges. They can set service coverage limits, provided they are disclosed and approved. Optometrists using pharmaceuticals can participate without federal registration. Plans cannot dictate pricing but must comply with all stated requirements even when delegating duties.

This law states that health insurance plans can't set limits on how much they will pay for covered benefits in a person's lifetime or each year. However, they can set limits on specific benefits that aren't considered essential health benefits, as long as it's allowed by state law. This rule doesn't apply to certain programs like Medi-Cal or specialized plans that don't cover essential benefits or Medicare supplement policies.

This law outlines the rules for health care service plans and their partners when reviewing and deciding on medical service requests based on necessity. Plans must have clear policies for approving, modifying, or denying these requests and must communicate decisions within specified timeframes, especially in urgent cases. Only licensed physicians or qualified health professionals can make decisions regarding medical necessity. The policies and criteria used must be clinically sound and transparent. Plans utilizing AI or software tools for these purposes must adhere to specific requirements, ensuring these tools enhance rather than replace professional judgment. This includes being non-discriminatory, compliant with privacy laws, and regularly reviewed for accuracy. These rules also integrate requirements for ensuring adequate communication and response times in critical health situations.

This law states that certain rules in another law (Subdivision (i) of Section 1367) are applicable to health insurance plans that are temporarily licensed, but only for contracts that started, changed, were delivered, or renewed in California on or after October 1, 1977.

This law ensures that certain health care plans in California provide essential preventive care services without extra costs to the patient. It mandates that from January 1, 2025, plans cover various preventive items and services that are recommended by specific health authorities like the United States Preventive Services Task Force and the CDC, without imposing additional cost-sharing fees, such as co-pays or deductibles.

The services covered include evidence-based screenings, immunizations, and preventive care tailored for infants, children, adolescents, and women. Even if the recommendations change during the plan year, coverage must continue. However, if a service is deemed unsafe or recalled, coverage does not have to continue.

This law does not stop plans from offering additional preventive services, and it requires coordination with the Department of Insurance to implement regulations. It also specifies that the requirements do not apply to plans that do not cover essential health benefits or conflict with federal guidelines for health savings accounts.

This law requires health care service plans to provide detailed descriptions of their economic profiling policies to the state's health department by July 1, 1999. Economic profiling is when a doctor or medical group's economic factors, like costs or use of services, are evaluated. These descriptions must show how these profiles are used to decide on things like utilization review or provider penalties, and ensure they're fair by considering factors like patient age and illness severity. Changes to these profiles need to be filed too. The department makes these filings public unless they contain confidential information. Also, plans must share profiling data with the profiled doctors or groups upon request, until 60 days after their contract ends.

This law requires that starting January 1, 1990, every group health care plan that covers hospital, medical, or surgical expenses must offer coverage for alcoholism treatment. This offer must be communicated to all current and potential group subscribers.

If the group agrees, coverage can also extend to treatment for chemical dependency or nicotine use. Treatment must be provided in licensed facilities.

This law requires health care service plans (excluding those offering only dental or vision services) to provide rebates if they don't spend enough of their premium revenue on clinical services and improving health care quality. Specifically, plans in the large group market have to spend at least 85% of revenue, while small group or individual markets must spend at least 80%. If these percentages aren't met, enrollees get a rebate by September 30 of the next year. The law also aligns with federal rules for medical loss ratio standards, but it doesn't apply to Medi-Cal services or affect certain financial regulations.

This law mandates health care service plans in California to ensure timely access to medical care for their enrollees. It specifies time frames for different types of appointments, such as urgent care, non-urgent primary care, and specialist visits, ensuring they happen within a reasonable period. The law requires health care plans to maintain sufficient provider networks and implement processes to ensure prompt service. It also includes interpreter services at appointments, telephone triage or screening services available 24/7, and the management of plan customer service wait times.

The law enforces these provisions with penalties for noncompliance, and requires plans to report on their compliance. It encourages plans to provide access to care even when certain providers are unavailable or outside the network. The law includes standards specific to dental, vision, chiropractic, and acupuncture plans, and it applies to services for Medi-Cal beneficiaries as well. It emphasizes transparency by having plans report their performance and the department to publicly disclose compliance information.

This law requires health insurance plans that cover hospital, medical, or surgical expenses on a group basis to offer benefits for comprehensive preventive care for children aged 17 and 18. The plans must inform current and potential group contract holders about these benefits. The preventive care must align with recommendations from the American Academy of Pediatrics and the official immunization schedule.

These benefits include regular health check-ups, necessary immunizations, lab services related to health evaluations, and blood lead level screenings for children at risk of lead poisoning. Only licensed medical professionals, such as doctors, nurse practitioners, and physician assistants, are authorized to offer these services.

This California law requires dental health care service plans to file an annual report with the department, called the Medical Loss Ratio (MLR) report, by July 31. This report, covering the calendar year, needs to detail financial information similar to a federal form from 2013 and must be organized by market and product type.

If the director believes a financial examination is necessary to verify the plan's report, they must notify the plan 30 days in advance. The plan then has 30 days to submit the requested documents, although extensions may be granted for good reasons.

Information filed must be made public, except for certain state program contracts like Medi-Cal. The department can give temporary guidance to ensure compliance, but this won’t replace permanent regulations. Consultation with the Department of Insurance is required for this guidance.

This law requires that health care service plans in California offer language assistance for their non-Medi-Cal enrollees by January 1, 2006. These regulations ensure that enrollees who speak languages other than English can access translations of vital documents and interpretation services, so they can fully understand their healthcare benefits.

It sets standards for the translation of documents based on the size of the health plan's enrollment and the language preferences indicated by an enrollee needs assessment. Larger health plans must translate vital documents into more languages compared to smaller plans.

The law also dictates the standards for the quality and timeliness of interpretation services, ensuring that interpreters are proficient in both English and the target language, and well-versed in healthcare terminology.

Additionally, the law includes requirements for periodic assessments of enrollees' language preferences, continuous updates every three years, and public input to adapt services based on cultural and linguistic changes. There are also standards for working with health care providers to comply with these regulations.

Health and dental insurance plans in California, starting from January 1, 1986, cannot deny or limit coverage or charge higher rates only because a person is blind or partially blind. This includes individual and group policies.

'Blindness or partial blindness' is defined by specific criteria regarding the lack of clear vision and limited field of view, as certified by an eye specialist.

This law mandates that individual or small group health care plans in California, issued or renewed from January 1, 2017, must include essential health benefits as defined by federal law. Essential health benefits cover a range of services including ambulatory, emergency, hospitalization, maternity and newborn care, mental health, prescription drugs, and more. Specific benefits mirror those offered by a Kaiser health plan from 2014 and include previously mandated services like diabetes care, cancer screenings, and mental health parity.

The law also outlines pediatric vision and oral care requirements, requires plans to comply with mental health parity laws, and prohibits plans from substituting required benefits, except under specific conditions for prescription drugs. It also states that this section doesn't impose cost obligations on the state for additional benefits beyond what's defined as essential health benefits.

This California law allows health care plans to contract with dental colleges for dental care services. These services can be provided by dental students, dental hygiene students, or instructors, all working under certain conditions of the Business and Professions Code.

The law also requires that health plans notify their enrollees that they may receive dental care from students and instructors at these colleges. This information must be included in their coverage details and provider listings.

This law says that any health care service plan contract created or changed on or after January 1, 2002, cannot have rules that stop health facilities from following the rules laid out in Section 1262.5.

This law applies to non-grandfathered health insurance plans in California, both individual and group, issued on or after January 1, 2015. These plans must include caps on annual out-of-pocket expenses for essential health benefits, including emergency care. The caps cannot exceed the limits set by federal law under the Affordable Care Act (ACA). For family coverage, individuals within the family cannot have higher out-of-pocket maximums or deductibles than individual plans. This section also ensures that anyone with a deductible under a high-deductible health plan adheres to specific deductible amounts set by tax code standards. The law also clarifies that terms like "plan year" refer to different durations depending on whether it's individual or group coverage.

This California law mandates that health care service plans, issued or changed since 2005, must cover certain asthma-related products and education for children. Specifically, plans have to cover inhaler spacers, nebulizers, face masks, tubing, and peak flow meters when these are medically necessary for treating pediatric asthma. Coverage must align with normal terms like copayments and deductibles, and the details of this coverage must be included in the plan's documents given to subscribers.

The amount of equipment provided can be limited, as long as it doesn't disrupt the child's treatment prescribed by their doctor. Plans must also allow for a quick approval process for more equipment if needed. Furthermore, plans can't reduce or eliminate this coverage, and they're required to offer asthma education to ensure proper device usage.

This section mandates that all general health care service plans in California must provide coverage for breast cancer screening, diagnosis, and treatment. Specialized plans are not included. The coverage should not be denied based on a person's family history of breast cancer or previous diagnostic procedures if cancer hasn't been confirmed.

Plan contracts must include screenings and diagnoses of breast cancer based on medical guidelines upon a doctor's referral. Treatment coverage after a mastectomy must include prosthetic devices and reconstructive surgery aimed at restoring symmetry. These treatments are subject to regular copayment and deductible terms.

'Mastectomy' is defined as the necessary medical removal of part or all of the breast. 'Prosthetic devices' refer to all necessary initial and subsequent devices prescribed by a doctor.

This law sets a limit on the deductibles for small employer health plans in California starting from January 1, 2014. For individual plans, the deductible cannot go over $2,000, and for other plans, it cannot exceed $4,000. These amounts will be adjusted based on federal guidelines. The deductible limits should not change the plan's overall value, except that plans at the 'bronze level' may have higher deductibles if necessary to meet cost standards. Importantly, deductibles cannot apply to preventive services. This law is in alignment with the federal Affordable Care Act.

This law requires health care service plans to report to the department within one year after an assessment on cultural appropriateness. They must cover several areas: (a) collecting data about enrollees' demographics, (b) educating staff who interact with enrollees about their diverse needs, (c) promoting workforce diversity through hiring, (d) evaluating their programs based on enrollee feedback, (e) informing providers about the ethnic mix of enrollees and relevant strategies, and (f) providing educational information to enrollees about services offered. The plans should use existing communication methods where possible.

Starting January 1, 1980, any group health insurance plan that includes maternity coverage must also offer coverage for prenatal genetic testing in high-risk pregnancies. This requirement applies to plans covering hospital, medical, or surgical costs. Additionally, insurers must inform all existing and potential group clients about this available coverage.

This law outlines different levels of health insurance coverage available in California's nongrandfathered individual market, specifying bronze, silver, gold, and platinum plans, which cover 60%, 70%, 80%, and 90% of healthcare costs, respectively. These coverage levels must align with a specific range and depend on essential health benefits. There is also a provision for catastrophic plans, which offer limited coverage until the enrollee reaches certain out-of-pocket costs, with some restrictions regarding who can purchase them. These plans can be purchased by individuals under 30 or those with a hardship exemption. The law references the federal Patient Protection and Affordable Care Act for guidelines.

This law requires health care service plans to disclose each year to public agencies that subscribe to their group plans, the names, addresses, and payments made to any agents or brokers involved in their transactions. This disclosure is mandatory alongside any other existing compensation disclosure laws.

This law ensures that health care plans issued or changed after January 1, 1981, cannot deny or limit coverage, or charge different rates, based solely on a physical or mental impairment. There is an exception if the decision is supported by proven actuarial principles or sound underwriting practices.

However, this rule doesn't apply to certain health maintenance organizations as long as they announce their enrollment periods publicly at least 30 days in advance in a local newspaper.

This section of California law explains the different levels of health coverage available for small businesses not covered by older plans ('nongrandfathered'). These levels include Bronze, Silver, Gold, and Platinum, each covering a different percentage of health care costs—60%, 70%, 80%, and 90% respectively.

The law mandates how these coverage percentages, known as actuarial values, should be calculated and specifies that they should not vary by more than 2% from these targets. It ensures that calculations are based on standard health benefits for non-elderly people, excluding those on government plans like Medicare or Medi-Cal.

Additionally, any contributions employers make to health savings accounts must count toward these actuarial values. The law also empowers the state's public health department to use specific methods and calculators, refined for California's unique market, to determine these values.

This California law sets out the rules for enrollees with Medicare who are discharged from acute care to return to their prior skilled nursing facility or retirement community. The enrollee can return if they meet residence conditions and their doctors agree it's appropriate. The facility must be within the service area and meet specific standards set by the health care plan, like care quality and administrative procedures. The facility must accept reimbursement from the healthcare plan at agreed rates and cannot charge the enrollee beyond these rates. This reimbursement covers services included in the Medicare contract. The rules don't force facilities to take patients who weren't their residents before. These provisions apply to contracts issued or renewed after January 1, 1999.

This law ensures that health care service plans in California cannot discriminate against conditions related to diethylstilbestrol (DES), a drug previously used in pregnancy, by excluding or limiting coverage. Any plan that tries to do so after January 1, 1981, is invalid.

Health care plans that are not considered "grandfathered" must offer large group plans with a minimum value of 60% or more, when sold or renewed. This rule does not apply to certain limited coverage plans mentioned in federal regulations. "Large group" plans do not include those for small businesses. The 60% minimum value is calculated based on federal guidelines. "Plan year" follows a specific definition in federal regulations.

This law requires health care service plans to give clear information about how being in the plan might limit your choice of doctors, hospitals, or other providers. They must explain how they pay these providers and if there are any financial bonuses or incentives involved. People can ask for more details about these financial incentives.

If someone asks, the plan or provider must share a summary about any bonuses or incentives and how these relate to referrals. All this information should be straightforward, so consumers can compare different plans. Additionally, prospective enrollees must be clearly informed that joining a plan could affect their choice of providers. If there's a list of providers, it should include a notice that a full list of facilities offering specific types of care can be requested.

This law allows small employer health plans that were active as of December 31, 2013, and not grandfathered by the Affordable Care Act (ACA), to be renewed until the end of 2015. After 2015, these plans can continue if they are updated to meet the law's requirements by 2016. Health plans must notify employers about their option to renew, explaining that newer plans may offer better benefits and federal tax credits through Covered California.

Employers must be informed about other available plans' costs and benefits. Plans renewed through 2015 are exempt from certain requirements, but must comply with specific statutes by January 1, 2016. The law can only be applied as long as it aligns with the ACA, and specific terms are defined to clarify the application.

This law mandates that any health care service plan managing Medicare and federal employee programs cannot demand more than one form per claim to process payments or reimbursements. Essentially, they have to keep it simple and efficient by using a single form per claim.

This law states that when a health care service plan is deciding whether to approve, change, or deny requests for mental health services, they cannot base their decision on whether the admission to the hospital was voluntary or involuntary, or on how the patient was transported to the health facility.

This law focuses on health care service plans, specifically concerning "blocks of business" for individual contracts and small employer groups with fewer than two eligible employees. A "block of business" refers to a group of insurance plans with the same terms and benefits. A "closed block of business" is a group of plans where the insurer stops selling new contracts.

Insurers can't close a block of business unless they allow existing members to access other open plans with similar terms without new health evaluations, or they use financial data from both open and closed blocks to set premiums without unfair hikes. A block of business is presumed closed if it loses 12% of its contracts in 12 months or falls below 1,000 enrollees, with some exceptions.

Health care plans must notify authorities of any block closures and document the closure process for five years. They are prohibited from misleading practices about block statuses. The law also outlines compliance timelines for existing closed blocks and areas it does not apply to, such as certain small employer and Medicare-related plans.

This law requires that health care service plans must accept premium payments from certain third parties without extra requirements, like government programs or family members, but not from financially interested entities unless they meet specific conditions.

If financially interested entities wish to make these payments, they must provide full-year assistance, notify enrollees of any changes, and not condition assistance on specific treatments or coverage. They must also disclose enrollee information and ensure payments are based on financial need.

Financially interested entities have a structured reimbursement process with varying terms based on their relationship with the health care provider and must participate in an independent dispute resolution process for payment disagreements.

Health care plans can recoup overpayments with interest if third parties fail in disclosure, and must report details of third-party payments annually. The law includes protections against coverage denial based on third-party payments and maintains existing privacy laws.

This law requires health care service plans in California that cover hospital, medical, or surgical expenses to offer coverage for orthotic and prosthetic devices and services to group subscribers. This coverage must be discussed with current and potential group contractholders. Prosthetic device coverage must include both original and replacements, as long as they are prescribed by a qualified medical professional.

Orthotic device coverage must also include original and replacement devices when prescribed or ordered by a licensed health care provider. Plans can perform a review to confirm medical necessity before providing services.

From July 1, 2007, the benefits for these devices and services cannot be less than the benefits for basic health care services. If there are no set annual or lifetime maximums for basic health care services, then these devices and services are also not subject to such maximums. Cost-sharing measures like copayments and deductibles must not exceed the most common amounts applied to basic services.

Starting from January 1, 1991, health care service plans in California, that are not specialized and cover hospital, medical, or surgical costs on a group basis, are required to offer an option for coverage of special footwear. This is meant for individuals with foot disfigurements, which can be caused by conditions like cerebral palsy, arthritis, polio, spina bifida, diabetes, as well as from accidents or developmental disabilities. The specifics of this coverage option can be negotiated between the health plan and the group contract holder.

If you're in California and your health plan offers prescription drug coverage, you can ask for a copy of their drug list. This list will show which medications are preferred and sorted by type. If the plan has multiple drug lists, they'll let you know so you can pick which one you want to see.

This California law specifies that health plans offering prescription drug benefits can't limit or exclude coverage for approved drugs just because they're prescribed for different uses than FDA-approved uses, if certain conditions are met. These conditions include that the drug is FDA-approved, prescribed for life-threatening or chronic, seriously debilitating conditions, and recognized by authoritative bodies or supported by medical journals.

For mifepristone, health plans must cover it even if used off-label, like for abortion, unless there are health or safety concerns. The prescriber is responsible for providing necessary documentation to the plan upon request. Additionally, the coverage must include medically necessary services related to drug administration.

Plans can use formularies or copayments to manage off-label drug use. If a plan denies coverage citing experimental status, this decision is reviewable. The requirements don't apply to Medi-Cal services under specific health plan acts.

If you've been prescribed a drug that's covered by your health plan and your doctor continues to prescribe it as safe and effective for your condition, your plan cannot stop covering it. However, doctors can still prescribe other appropriate drugs or allow generic substitutes. This rule applies only if the drug is used as approved by the FDA, so other uses aren't covered by this section but are addressed in another regulation. Also, it doesn't interfere with other legal requirements for continuous care or qualified medical decisions. Finally, your plan is allowed to charge copays or deductibles for drugs, as long as these costs are disclosed and approved by the plan director.

This law requires that starting January 1, 1994, any group health care plan contract includes a rule that the health care service plan must notify the contractholders in writing if the plan is canceled.

The group contractholders must then quickly mail a clear, true copy of the cancellation notice to each subscriber and provide proof of mailing to the health care plan.

This notification must also explain, in simple language, the conversion rights subscribers have when the plan is terminated.

This law requires health care service plans providing prescription drug benefits to have a quick process for doctors to get approval for necessary drugs not on the plan's formulary. Plans must keep this process documented and accessible to both the department and prescribing doctors.

If a request for a nonformulary drug is denied by the plan, they must provide written reasons and info on how to appeal the decision. These rules don't apply when the drug was prescribed following certain existing provisions.

Health plans also need to keep detailed records of their drug formularies, decision-making processes, and relationships with providers that affect drug prescribing. The department will review these during audits but keep confidential information private.

Special rules apply to Medi-Cal plans, and nothing in this law prevents enrollees from filing grievances or requesting independent medical reviews through other established processes.

This law mandates that most health care service plans in California cover FDA-approved contraceptive methods for enrollees from January 1, 2000 onwards. As of January 1, 2016, plans must cover all FDA-approved contraceptives, including those available over-the-counter, without cost-sharing if they are in-network. From January 1, 2024, a prescription isn't required for over-the-counter contraceptives, which must be available without cost-sharing.

Religious employers can request plans that exclude contraceptive coverage if it opposes their religious beliefs. The law also covers up to a 12-month supply of self-administered hormonal contraceptives in one dispensing. Exceptions apply to out-of-network services unless otherwise allowed, and contraceptives need not be covered for experimental use. The law ensures that contraceptives needed for other medical reasons or preventive health are still covered.

This law requires health care service plans to keep an accurate and updated directory of providers. Starting July 1, 2016, these directories must be available online and accessible to the public without restrictions, showing which providers are currently under contract and accepting new patients. By July 31, 2017, provider directories must follow specific naming standards. Updates to online directories are required at least weekly and quarterly for printed versions, as providers' statuses or information change.

Directories should include comprehensive provider information, such as contact details, specialty, and whether they accept new patients. Health plans must promptly correct inaccuracies reported in directories and can delay payments to providers who don't verify their information. Inaccurate directory information leading to enrollee issues may result in the health plan covering additional costs.

The law ensures enrollees have access to accurate provider information, language services, and full access to covered services. Plans must also comply with procedures for confirming directory information and handling provider changes in the network.

This California law requires full-service health care plans to update their provider directories and call centers by March 1, 2025, to list which in-network providers offer gender-affirming services. These services include various surgical procedures, hormone therapies, and other gender-related treatments. Providers can request to be added or removed from this list of service offerings. Additionally, this law does not change existing obligations under the Unruh Civil Rights Act for businesses to provide equal services to all individuals.

This law requires health care service plans that cover professional mental health services to give enrollees an identification card starting July 1, 2011. This card helps access health benefits information, like knowing which providers are in-network and for claims purposes. At a minimum, the card must list the health plan's name, the enrollee's ID number, a contact phone number for assistance, and the plan's website address.

Health plans must issue this card when someone enrolls or if there's any change in coverage affecting the card's information. Plans don't need to issue a separate card for mental health if their general health card meets these requirements. If the duty to issue the card is given to another party, they must also follow these rules.

The law doesn't prevent plans from using electronic data standards but does exempt certain types of insurance, like Medicare supplements and accident-only insurance, unless they are behavioral health-only plans tied to other health plans that require ID cards.

This law states that all group health care service plan contracts delivered to California residents must comply with Section 1374.58, no matter where the contract was made or where the subscriber lives.

This law requires health care service plans in California to provide enrollees with annual information about their rights to timely access to health care services, including interpreter services. These details must be conveyed in specific ways: within coverage documents, newsletters, provider directories, and websites starting from various specified dates. The goal is to ensure that patients and providers understand appointment wait times for different types of care and know how to access help if they can't get a timely referral. Additionally, health care plans must inform their contracting providers about these obligations and how to seek assistance or file complaints if there are issues with accessing care.

This requirement also applies to Medi-Cal managed care plans with California's Department of Health Care Services.

This law ensures that from January 1, 2017, health care plans in California can't require patients to get a referral to access reproductive and sexual health care services. This includes services detailed in other specific code sections but doesn't cover services needing referrals under a different rule. This rule applies to everyone, even minors. Health plans can set sensible rules for using these health services, but they can't be stricter than those for other health providers. No prior approval is needed to directly access these services. Plans can't have extra rules about contraceptive drugs that go beyond existing laws. Some health plans where no referrals are needed or those under certain welfare rules are exempt from this law.

This law requires health insurance plans from religious employers in California, which don't cover abortion and contraception, to inform employees initially and every year about which abortion and contraception services are not covered by their plan. They must also provide information on services available at no cost through the California Reproductive Health Equity Program. Definitions for terms like abortion, contraception, and religious employer are noted, and it mentions that this law doesn't change other legal requirements in the chapter.

This law says that starting January 1, 2024, any health plan operated by a college or university that provides healthcare only to its students, faculty, staff, and their dependents must include contraceptive coverage as outlined in certain other sections.

This law requires that all health care service plans in California, starting January 1, 2022, must cover the costs of home test kits for sexually transmitted diseases (STDs), including the costs associated with processing the tests. These kits are for tests that a clinician orders or are provided for home use based on clinical guidelines and patient needs. The coverage applies when these tests are ordered by in-network providers.

The term 'home test kit' refers to products recommended by organizations like the CDC or the Preventive Services Task Force, which are FDA-approved and allow individuals to collect their own samples for STD, including HIV testing, at home. However, this rule does not apply to plans under certain state-managed health services, such as Medi-Cal, which have their own regulations.

This law requires health care service plans to submit detailed data about their network adequacy to the department. This includes information on provider locations, specialties, admitting privileges, and capacity to serve patients. Additionally, any grievances regarding network adequacy from the previous year must be reported.

If a plan uses different networks for its Medi-Cal, individual market, or small group lines, it must submit data for each separately. The department will review these submissions for compliance, and the same data must also be shared with the State Department of Health Care Services for Medi-Cal providers. The department must avoid duplicate reporting, but can request additional information if necessary. Plans will be notified by November 1 if additional data requirements will be imposed in the following year. Health care plans can require providers to comply with these reporting requirements.

This law requires health care plans in California to cover comprehensive preventive care for children 16 years or younger when provided through group plans. The care must include regular health check-ups, immunizations, and necessary lab tests, following guidelines set by the American Academy of Pediatrics and the Childhood Immunization Schedule. Plans must inform current and prospective group members about these benefits. Exceptions apply for plans exempted by certain regulations.

This law states that health care contracts in California cannot force physicians or physician groups to bear the financial burden of acquiring vaccines for children, as of January 1, 2001. Physicians won't have to cover these costs unless they have explicitly agreed to in their contracts.

If a contract doesn't include children's immunizations, health care plans must reimburse physicians based on the lowest of the actual cost, average wholesale price, or the lowest available cost through the health care plan's offered sources. Payment must be made within 45 days after receiving proof of service.

Doctors can choose to assume financial risk for vaccines, but only if agreed upon through negotiation with the health care plan using data from past experiences. Nonetheless, no plan can force them into this financial risk. Acquisition costs for required vaccines cannot be included in a physician's fixed capitation rate.

This law requires that most health care plans, starting July 1, 2025, must cover emergency room and follow-up care for individuals who have been victims of rape or sexual assault, without imposing any extra costs like co-pays or deductibles, for up to nine months after treatment begins. Follow-up care covers medical services related to the incident. The no-cost provision applies if claims are submitted with specific diagnostic codes related to rape or sexual assault.

Health care plans cannot require victims to file a police report or for the perpetrator to be charged or convicted to access this coverage. Generally, follow-up care should be provided within the plan's network, but plans must coordinate care outside the network if necessary services aren't available in-network, especially in emergencies.

For high deductible health plans, this law applies once the deductible for the year is met. Any cost sharing excludes premiums. Coverage is also considered part of 'sensitive services' under specific civil code sections.

This law requires health care plans in California to cover the prevention, diagnosis, and treatment of PANDAS and PANS for contracts issued, amended, or renewed on or after January 1, 2025. Coverage must include various treatments like antibiotics and immunotherapy, as long as they are medically necessary according to expert guidelines. There cannot be higher costs for these treatments than for other benefits, and authorizations for care must be timely.

Importantly, plans cannot deny treatment based on previous treatments or differing diagnostic names and must follow specific expert treatment guidelines. Until official codes are available, PANDAS and PANS are to be categorized as autoimmune encephalitis for billing purposes.

This law mandates that health care service plan contracts issued, amended, or renewed from January 1, 2022, covering pediatric and preventive care must include coverage for screenings of adverse childhood experiences (ACEs). Cost-sharing can still apply if legally authorized.

ACEs refer to harmful or threatening experiences that negatively impact a child’s wellbeing in various aspects such as physical or emotional health.

The health department may issue guidance to implement this requirement, and such guidance will be based on existing Medi-Cal rules. However, health plans can offer more than the minimum Medi-Cal requirements.

This California law requires health care service plans that market or advertise in non-English languages in individual or small group markets to provide key documents in those languages. This includes welcome letters, application materials, and notices about translation services, grievance filing, and summaries of benefits. It ensures language accessibility for limited-English speakers.

All translations must be done by trained and qualified translators. The law doesn't apply to specialized plans that don't offer essential health benefits.

This law requires health care service plans to have a pharmacy and therapeutics committee that manages the list of approved drugs. Starting in 2017, these committees must include various medical professionals and meet regularly to review and update drug lists based on scientific evidence and best practices. Members must avoid conflicts of interest, and at least 20% must be free from conflicts with drug manufacturers. The committee must ensure the drug lists cover a wide range of treatments, adhere to accepted medical guidelines, and allow fair patient access. Policies must be reviewed annually to handle exceptions and new drug approvals effectively.

This law requires health care service plans to inform their members and the public about certain key aspects: language assistance services available for free, auxiliary aids for individuals with disabilities, and assurance of non-discrimination based on various characteristics like race, gender, or disability.

Members should be informed about grievance and discrimination complaint procedures both initially and every year upon renewal. Details must be prominent in coverage documents, annual communications, and on the health plan's website.

Some specialized plans may request an exemption from these requirements unless they provide mental health benefits, in which case they do not qualify for such exemptions unless they are employee assistance programs. Exemptions must be publicly disclosed on the department's website. This regulation does not apply to certain Medi-Cal managed care plans.

This law states that starting from January 1, 2017, health plans that offer essential health benefits must allow enrollees to get their prescription drugs at an in-network retail pharmacy, unless the drug requires special handling, restricted distribution, or extra care that a retail pharmacy can't provide.

Additionally, health plans for individuals or small groups can charge different cost-sharing amounts for drugs obtained at a retail pharmacy. However, any cost-sharing paid must count toward the annual limit on out-of-pocket expenses.

This law requires health care service plans in California to ensure their staff complete cultural competency training focused on trans-inclusive health care for transgender, gender diverse, and intersex individuals. This training aims to improve communication, address health inequities, and respect gender identities.

The training includes the history and impact of exclusion, correct use of names and pronouns, and provides perspectives from relevant groups. Plans must also adhere to approved curricula. If a complaint about providing trans-inclusive care is filed and upheld, staff must take refresher courses.

If discrimination based on gender identity is reported, these complaints are reviewed and potentially referred to the Civil Rights Department. The department monitors and publicly reports related complaints. Health care plans also need to comply with evolving department guidance and regulations expected by July 1, 2027.

Starting January 1, 2019, health insurance plans in California must adjust the cost that someone pays for a partial prescription fill, but this only applies to pills and capsules that you swallow. It links to another rule about how prescriptions are to be dispensed.

This law states that any health care plan contract from January 1, 2021, onward cannot include a clause that gives the insurance company, or their agent, discretionary power to decide who qualifies for benefits or how contract terms are interpreted in a way that goes against California law. If it does, that clause will be invalid.

Discretionary authority means giving the power to decide who gets benefits or how the contract is understood, especially if it would lead to the contract being reviewed favorably for the insurer in court. However, health plans can still have provisions that explain how decisions are typically made as long as it doesn't result in favorable legal interpretations for the insurer.

This rule applies to both group and individual health plan contracts.

This law mandates that any health plan started or changed after January 1, 2002, must cover an AIDS vaccine approved by the FDA and recommended by the U.S. Public Health Service. It doesn't require coverage for AIDS vaccine clinical trials or investigational new drugs. Health plans can't pass the costs of these vaccines to other providers unless certain conditions are met. Plans are still allowed to negotiate best prices for vaccines, and the law doesn’t limit government oversight on how plans include prescription drugs.

Starting January 1, 2009, any health care service plan contract, whether new or amended, must include coverage for HIV testing. This applies even if the test isn't directly related to the main medical issue being treated.

This law regulates how much a health care plan can charge enrollees for prescription drugs at the pharmacy counter. Enrollees should pay the lower amount between their plan's cost-sharing price or the drug's retail price. Pharmacies can't charge more than the retail price for the drug, even if the cost-sharing amount is higher. Payments at the pharmacy count towards the deductible and out-of-pocket limits as if the enrollee paid the higher cost-sharing amount.

This law prevents contracts between health care service plans and providers from restricting the plan's ability to share cost and quality information with consumers and buyers. Such contracts must allow transparent sharing about the cost of treatments and quality of services.

If any contract clause contradicts this rule, it is null and void. The health care plan must give providers a 30-day notice to review the data and methods used to formulate cost and quality info before it’s shared with consumers.

The shared information should adjust for different patient characteristics to ensure fairness. Websites sharing the data must include a statement acknowledging potential disagreements about data interpretation. Providers can also link to their own websites for their responses.

This section specifies definitions for terms like 'consumers,' 'providers,' and 'purchasers' used within the law. Additionally, other sections, such as Section 1390, do not apply to this law.

This law says that health care contracts can't stop claims data from being shared if the plan was issued or changed on or after January 1, 2013. This information can be shared with certain qualified entities, as long as all state and federal privacy rules, like HIPAA, are followed. It defines key terms: a "provider" is a facility like a hospital, and a "supplier" is a doctor or similar practitioner.

This law requires health care service plans (except specialized ones) in California to cover certain supplies and equipment for managing diabetes, like blood glucose monitors and insulin pumps, if they are deemed medically necessary. This coverage applies to both insulin-dependent and non-insulin-dependent diabetes, and even gestational diabetes. The law also mandates coverage for outpatient diabetes education and training to help individuals manage their condition properly.

It specifies that copayments for these diabetes-related supplies and training cannot be higher than those for similar plan benefits. The plans must also disclose these benefits clearly in their coverage documents and cannot reduce existing coverage due to this law. Additionally, the section ensures the health department's authority to monitor plan compliance, particularly when prescription drug coverage is involved.

This law requires that any group or individual health care plan in California that offers maternity benefits must include coverage for the California Prenatal Screening Program, without needing any extra payments like copayments or deductibles from the patient. Health plans cannot force participation in this program to qualify for other services, and they must compensate service providers according to state-set rates.

This law requires health care service plans in California, beginning July 1, 2022, to keep track of each enrollee’s progress toward their annual deductible and out-of-pocket maximum for covered health benefits. They must provide monthly updates on these balances whenever benefits are used and allow enrollees to ask for their latest balance at any time. This applies to both individual and group plans.

Plans must send these updates by mail unless an enrollee chooses to receive them electronically. Enrollees can opt back into mailed updates if they previously opted out. The law also mandates that health plans inform enrollees about their rights under this section, including how to get information and change their notification preferences.

If claims payment is outsourced to another entity, that entity must also follow this law, but the main health care plan remains ultimately responsible for compliance.

This law requires that any health care plan in California covering a laryngectomy—a surgery to remove all or part of the larynx—must also cover prosthetic devices that help patients speak again. This rule applies to plans issued, amended, delivered, or renewed from January 1, 1993, onward. If a plan contradicts this law, it is invalid. The coverage for these prosthetic devices will have the same deductible and coinsurance terms as the laryngectomy itself. However, it does not include electronic voice machines.

This law ensures that health care plans in California providing maternity coverage cannot limit inpatient hospital care to less than 48 hours after a regular delivery or less than 96 hours after a C-section, unless the mother and doctors agree and a follow-up visit is scheduled within 48 hours of discharge. Health plans cannot pay providers less for following these rules, nor encourage mothers or providers to avoid or reduce this care. Plans also must notify covered women about these rights, especially during prenatal care and for those covered by PPOs. Additionally, plans can negotiate reimbursement with providers for these services.

This California law mandates that most health care service plans cover reconstructive surgery needed to fix abnormal body structures due to things like birth defects or injuries, to either improve function or appearance. It sets clear distinctions between reconstructive and cosmetic surgery, making sure the latter isn't covered. Only qualified doctors can deny treatment requests, and reconstructive surgery includes certain dental services for cleft palate as of mid-2010. Health plans can use various criteria to evaluate surgery requests, and for Medi-Cal services, surgery must offer more than minimal appearance improvements. Some exceptions apply for certain Medi-Cal plans that don't cover specific programs.

This law requires health care service plans in California that are issued, amended, or renewed after January 1, 1999, to cover screening and diagnosis of prostate cancer. This includes tests like the prostate-specific antigen test and digital rectal examinations, when deemed medically necessary and appropriate.

The law does not create a new benefit nor does it prevent insurance plans from applying deductibles or copayments for these services. It also does not require plans to cover services provided by nonparticipating providers unless the patient is referred by a participating physician or nurse practitioner.

This California law requires that health care service plans (excluding specialized ones) provide coverage for mammography for both screening and diagnostic purposes. This coverage is available when a participating health professional such as a nurse practitioner, nurse-midwife, physician assistant, or physician refers the patient.

The law allows for copayments and deductibles to apply and does not extend coverage to other procedures unless specified by the plan. Also, the mammography services must be provided by a participating provider unless specifically referred to an outside provider by the plan's in-network health professional.

This California law requires most health care plans to cover annual cervical cancer screenings, starting from January 1, 2002, if referred by a doctor, nurse practitioner, or certified nurse-midwife. The types of screenings covered include Pap tests and FDA-approved human papillomavirus (HPV) tests. This coverage is not a new benefit but ensures screenings are covered if the plan already includes cervical cancer treatment.

Starting January 1, 2024, health care plans must also cover the HPV vaccine with no cost to the patient, meaning no deductibles or co-payments are allowed, for those approved by the FDA.

If you have a health care plan in California that covers hospital, medical, or surgical services, it must also cover diagnosis, treatment, and management of osteoporosis. This has been mandatory for all plans issued or updated after January 1, 1994. Coverage can include any FDA-approved technologies that are considered medically necessary, like bone mass measurements.

If you're in California and your health plan contract was set up or changed after July 1, 1995, it can't exclude coverage for surgeries on the upper or lower jawbone, or related joints, if that exclusion means you don't get medically necessary basic healthcare. This rule applies to all health plan contracts covering hospital, medical, or surgical expenses, but not to specialized plans.

Furthermore, while dental services can be excluded from coverage, this cannot lead to a denial of necessary basic healthcare services.

This law requires that starting January 1, 1995, all health care service plans in California that offer hospital, medical, or surgical coverage must allow obstetrician-gynecologists to serve as primary care physicians if they meet certain criteria. This means these specialists can manage a patient's primary care, covering a wide range of health issues including prevention, acute and chronic conditions, and mental health needs.

This law requires health care service plans to cover general anesthesia and facility charges for certain dental procedures if they need to be done in a hospital or surgery center. The coverage is mainly for patients under seven years old, those with developmental disabilities, and others whose health requires it. This does not include coverage for the dentist's fees or the dental procedure itself. The plan might ask for advance permission before covering these charges, and this doesn't affect coverage for basic health services.

This law allows for more flexibility in the coverage value of a bronze-level health insurance plan that isn’t grandfathered. It can have a slightly higher or lower actuarial value if it meets certain criteria. Specifically, the plan must either cover and pay for at least one major service beyond preventive care before a deductible applies, or qualify as a high deductible health plan according to federal tax code standards. The actuarial value can vary within a range of +5% to -2%.

This law section outlines requirements for health care plans that cover prescription drugs and have drug formularies. These plans must post their drug lists online in a way that's easy for everyone to search and access, including enrollees and agencies. They must update these lists every month. Once a standard template is developed, plans will have to use it to present the drug information clearly.

The template, developed with input from public meetings, needs to show various details such as cost-sharing tiers, utilization controls like prior authorization, preferred drugs, and educate enrollees about obtaining non-listed necessary drugs. It must also show which medications, including generics and brand names, are covered and their formulary tier.

This law allows health plans to use step therapy, where patients must try certain drugs before others, to cover prescriptions if multiple drugs can treat a condition. However, exceptions must be granted quickly if a doctor justifies that the required drug isn't suitable, considering the patient's health history and professional judgement.

The law outlines reasons for exceptions, like previous adverse reactions, ineffectiveness, or stability on a current medication. Both healthcare providers and patients can appeal if their exception requests are denied.

The law doesn't stop doctors from prescribing appropriate medication and allows for generic trials before brand coverage. Also, plans must comply with these rules from January 1, 2022, when contracting utilization review services.

This California law requires health care plans providing prescription drug benefits to supply detailed information about prescription drug eligibility, formulary options, cost-sharing details, and any usage management requirements to both enrollees and their prescribing providers upon request. They must provide this information in real-time using standard technology formats and ensure details are up-to-date within one business day of any changes.

Health plans cannot obstruct these requests or limit prescribing providers from sharing this information, offering alternatives, or discussing drug costs with enrollees. Additionally, providers cannot be penalized for prescribing cost-effective or suitable drug alternatives.

The law also confirms that disclosure rules must comply with federal privacy laws, like HIPAA, and that existing obligations concerning prescription drug coverage or disclosures remain unchanged.

This law requires health care plans in California to cover prescribed pain medications for terminally ill patients when necessary. The plan must decide on these requests within 72 hours of receiving the required information. If they deny the request or need more information, they must inform the provider within one business day, explaining why. If the time limit passes with no decision, the treatment is considered approved. Providers must then notify the health care plan when proceeding with the treatment, confirming expired timeframes, patient's details, and treatment location. However, this section doesn't cover medications prescribed for off-label uses, which are handled differently. The department still has the authority to ensure plans comply with these rules.

This law requires health care service plans in California to use a standardized form or electronic process for prior authorization of prescription drugs, starting January 1, 2013. If insurers don't respond to prior authorization requests within 72 hours (or 24 in urgent situations), they automatically approve the request. Different rules apply for plans with certain financial or operational setups. The form must not exceed two pages and must be electronically accessible. Both the Department of Insurance and stakeholder input informed its creation. Plans must explain decisions promptly and allow independent review if initial requests are denied.

This law requires health care service plans to report detailed information about prescription drugs, including the 25 most prescribed, 25 most costly, and 25 with the biggest annual cost increase, to a department each year by October 1. This helps assess how drug costs affect health insurance premiums. The department then compiles and publicly shares a report showing the overall impact, ensuring no specific plan details are disclosed. Specialty drugs are defined by Medicare standards. The public report is published by January 1, and included in a public meeting. Information, aside from the public report, remains confidential.

This law section allows individuals to request an exception to a health plan's step therapy process, which is a sequence of trying more cost-effective medications before the prescribed one. You can submit these requests just like prior authorization requests for drugs. Health plans must handle them the same way. The law also requires that step therapy exception requests be part of a standardized form used for prior authorizations. A step therapy exception means covering the specific drug a doctor prescribes, rather than following a usual step therapy process.

This California law mandates that, starting January 1, 2023, most health care service plans must cover abortion services, including related preabortion and follow-up care, without any cost to the patient—no deductibles, copayments, or coinsurance. Additionally, plans cannot impose limitations like requiring prior approval or setting annual or lifetime caps for outpatient abortion services. These rules also apply to Medi-Cal managed care plans and their providers.

If a health care plan delegates duties related to abortion coverage to another entity, that entity must also comply with these rules. However, this section doesn't require coverage for experimental treatments and does not prevent the health department from ensuring compliance.

For high-deductible health plans, the no-cost provision applies after meeting the deductible. The department can provide interpretation and guidance on this law, with formal regulations to follow by January 1, 2026.

This law states that from January 1, 2024, health care service plans can't charge for vasectomy procedures through deductibles or copays, except for grandfathered plans and health savings account plans. Even then, cost-sharing must be minimal to allow tax benefits. Such procedures should have no delays or restrictions like prior authorizations. Coverage applies equally to spouses and dependents.

Medi-Cal plans must cover vasectomies unless their responsibility is outlined differently by the State Department, where the coverage might be on a fee-for-service basis. Religious employers can request plans without vasectomy coverage if it conflicts with their beliefs, but must inform enrollees annually. This rule doesn't prevent state oversight or require coverage of experimental treatments.

This law states that medically necessary pasteurized donor human milk provided by a licensed tissue bank is considered a basic health care service in California. This means it should be included as a part of required health care benefits.

This law requires health care plans to create a maternal mental health program focused on quality and cost-effective care. It mandates at least one mental health screening during pregnancy and one during the early postpartum period, with additional screenings if needed. The program must include guidelines for diagnosis, treatment, and referrals, and share these with medical providers. Plans are advised to enhance services like doula coverage and provider training.

"Maternal mental health" covers conditions during pregnancy and postpartum, including postpartum depression. Specialized health plans, aside from those offering mental health services, are exempt. Medi-Cal plans must adhere to state quality measures and seek necessary federal approvals without risking funding.

This law requires health care service plans in California to create programs by January 1, 2025, aimed at reducing racial disparities in maternal and infant health by using doulas. These programs can be part of or expansions to existing maternal health programs.

If a Medi-Cal managed care plan already covers doula services, it complies with this law's requirements. The law defines a Medi-Cal managed care plan according to another specific legal definition.

By January 1, 2027, the relevant departments must report to the Legislature on the effectiveness of these programs, which can include data on care quality, access improvements, barriers, and more.

This law states that starting January 1, 2025, health care providers can bill separately for devices, implants, or professional services related to immediate postpartum contraception if the birth happens in a general acute care hospital or licensed birth center. These items should not be included in the standard payment for obstetric procedures.

Immediate postpartum contraception refers to inserting devices like IUDs or implants before a patient leaves the hospital or birth center. The law ensures that this billing practice does not prevent patients from having direct access to contraceptive services and informed consent.

This California law mandates that health care plans covering mastectomies and lymph node dissections must allow the attending doctor and patient to decide the length of hospital stay without needing prior approval from the plan. These plans must also cover prosthetic devices and reconstructive surgeries to restore symmetry, as well as any complications, like lymphedema. Coverage extends to both the affected and healthy breast if needed to achieve normal appearance. Only licensed physicians can deny care requests based on this law. Health plans cannot manipulate care provisions or financial arrangements to reduce coverage quality. Notice of such coverage must be included in service plans from July 1, 1999, but retrospective reviews and quality checks are still permitted.

This law requires that health insurance plans providing coverage for oral cancer medications, starting January 1, 2015, must limit the cost that patients pay to a maximum of $250 for a 30-day supply. This applies regardless of any deductible. However, plans classified as 'high deductible health plans' have to apply this rule only after the enrollee has met their yearly deductible. Furthermore, these medications should be administered according to medical standards. This law does not apply to plans covering only dental or vision care, or to plans related to the Medicare Program.

This law ensures that health care plans, except specialized ones, cover cancer screening tests. For plans issued from July 1, 2022, onward, no prior authorization is needed for biomarker testing for patients with advanced cancer stages 3 or 4 to monitor cancer's progress or return. Biomarker testing involves checking a patient's biospecimen, like blood or tissue, for DNA or RNA changes to guide treatment. However, prior authorization can still be required for biomarker tests not linked to FDA-approved treatments for these cancer stages. The law doesn't change any rights to biomarker testing in clinical trials.

This law requires certain health care plans in California to cover medically necessary biomarker testing starting July 1, 2024. Biomarker tests can help diagnose, manage, or monitor a patient's condition and should meet specific criteria such as FDA approval or adherence to recognized clinical guidelines. The law details the conditions under which these tests must be covered and emphasizes minimizing care disruption, such as avoiding repeated biopsies. It outlines exceptions, like Medi-Cal managed care contracts, and defines key terms related to biomarker testing. Restrictions on testing can be contested through grievance processes.

This section mandates that any health care service plan contract, except specialized ones, must cover colorectal cancer screenings at no cost to the patient if the screening has an A or B rating from the United States Preventive Services Task Force. This includes any follow-up colonoscopy if the initial test suggests one is necessary. However, if the services are provided by out-of-network providers, the plan may require cost-sharing.

This law ensures that women in California can directly access obstetrical and gynecological services without needing a referral from another doctor. Health care plans must allow members to go directly to an OB/GYN or a family physician who provides these services. While health plans can set up rules about using these services, they cannot make them more restrictive than those for other primary care services. Plans can require OB/GYNs to communicate with a woman's primary care doctor about her care, but no prior approval is needed to access these services. This section also notes that it doesn't lessen the requirements outlined in another part of the law (Section 1367.69).

This law requires health care plans to have a grievance system where members can submit complaints and receive responses. Plans must inform members annually about how to file grievances and provide forms for them. They must acknowledge grievances in writing within five days and provide details about the complaint process, unless resolved by the next business day. Grievances should be documented and reviewed regularly. Plans must give clear written responses to grievances, explaining reasons and, if relevant, medical necessity. During disputes about canceling or not renewing contracts, plans must continue coverage until a decision is made. If unsatisfied with a plan's grievance process, enrollees can bring their case to the department, which will review and possibly penalize the plan for mishandling complaints. The department also oversees cases where health services are delayed or denied and ensures necessary care is provided or reimbursed. Plans must keep a record of unresolved grievances older than 30 days and report them quarterly to the director. Enrollees can choose mediation before escalating the issue to the department. The law ensures rights to independent review in plan cancellation cases as required by federal law.

This law section outlines the requirements for a health plan's grievance system. Generally, grievances should be resolved within 30 days. However, for urgent cases that pose an immediate and serious threat to a patient’s health, such as severe pain or potential loss of life, the resolution must be expedited. Enrollees and subscribers must be informed of their right to notify the department about such grievances and receive a statement on the status of their grievance within three days. The section also mentions specific regulations for health plans that cover outpatient prescription drugs, excluding certain Medi-Cal managed care contracts.

This section of the Health and Safety Code covers what a health plan must do if it denies coverage to a terminally ill enrollee for treatments considered experimental. First, the plan has to provide the reasons for denial, suggest alternatives that are covered, and offer grievance procedures for the enrollee within five business days. If the enrollee files a complaint requesting a conference, the plan must arrange this within 30 days, and even sooner if medical urgency is determined. This conference lets the enrollee discuss the denial with someone from the plan who can make decisions. The law also does not change any other existing rights or responsibilities under related health sections.

This law requires the director to set up a toll-free number to receive complaints about health care service plans. It mandates that every health care service plan must include specific contact information on documents like contracts, coverage evidence, grievance procedures, and complaint forms. This information includes the toll-free number, TDD line, the plan's number, and their website in bold type. It informs enrollees that they can contact the department if their grievance isn't resolved or in emergency cases, and they may qualify for an Independent Medical Review (IMR) for unbiased evaluations on certain medical decisions.

If you have a group health care plan in California (not a specialized one), it must cover hospice care if issued after January 1, 2002. The hospice care must at least match what Medicare offers. You can still get normal health care while you receive certain early hospice services, before fully opting into hospice care.

California's definitions and regulations about hospice care refer to federal definitions but adapt these to suit state needs, ensuring the best coverage for people. These rules don't apply if you're using the Medicare program for hospice care.

This California law explains the process for filing grievances with a healthcare plan. Generally, if you have a problem, you may need to go through the plan's grievance process for up to 30 days before taking your complaint to the Department of Managed Health Care or using the independent medical review system. However, if your situation needs urgent attention, the department can skip this waiting period. If the complaint doesn't relate to compliance issues, it might be sent to another government agency for investigation.

This section became effective in 2001, but only if a specific bill, Assembly Bill 55, was passed.

This law allows the director to investigate health care service plans if they don’t follow the rules about handling complaints. If a plan fails and causes significant harm to a member, the director can impose fines after giving notice and a chance for a hearing. These fines go into a special fund and are in addition to any other actions the director might take.

If a health care plan repeatedly fails to address complaints properly, knowing it's their responsibility, the director can penalize them. These penalties are not the only option for enforcing the rules, and they can be used alongside other legal actions. Any fines collected are used for specified purposes to improve the system.

This section establishes that due to health care reform in 2010, California has decided to transfer consumer assistance activities to the Department of Managed Health Care. The Department, alongside contracted community organizations, will help Californians navigate health care coverage, handle complaints, and educate consumers.

These community organizations must be non-profits experienced in aiding health care consumers, particularly those with special needs like limited English skills. Additionally, these organizations need expertise in collecting and reporting data about the consumers they assist.

This law mandates that health care plans must cover and reimburse services performed by pharmacists if they are within the pharmacist's licensed skills at in-network pharmacies, or at out-of-network pharmacies if that's part of the plan. However, this only applies if the pharmacist's services are legally allowed and comparable services by other health care providers are covered. The law also prevents duplicate payments for the same service and does not affect payments to physicians.

This law ensures that if you are part of a health care plan in California and you're affected by a state of emergency or health emergency, the plan must provide access to necessary medical care. When such an emergency is declared, your health plan must quickly report on any disruption in services and how they are addressing your health needs. This includes more flexible rules on medical service approvals, prescription refills, and access to providers, even outside your network if necessary. You can also expect a toll-free number for answers to emergency-related questions.

Additionally, the law emphasizes that the Governor's and director's powers remain intact and the director can provide guidance for health plans on complying with this law during emergencies. This guidance is not constrained by typical bureaucratic procedures.

This law, effective from July 1, 2003, requires health plans with websites to provide an easy way for subscribers to file grievances online. The websites must have a clear "GRIEVANCE FORM" link, and process submissions securely.

The online grievance system needs approval from the Department of Managed Health Care and must let users enter and edit information easily. It must also contain a link to the department's website with a statement explaining where subscribers can get help with grievances.

There are exceptions for certain plans and temporary exemptions for plans lacking necessary technology until January 1, 2006. The law also details terms related to the web tools used, such as HTML and hyperlinks.

Plans offering mental health services need to provide specific information online unless they contract out these services, in which case a link suffices.

Health care service plans covering mental health services in California need to have certain information available on their websites or provide a link to it. This includes a contact number for mental health benefit support, a link to prescription drug lists, and summaries of how they review and authorize services. They must also offer details about how enrollees can file grievances, request continuity of care, and seek independent medical reviews. This information should be updated quarterly and made available in hard copy if requested, and may be accessed through a secure site for enrollees. The law doesn’t apply to certain insurance types like Medicare supplements and worker assistance programs. If a plan contracts out mental health services, it can link to the contracted entity’s site for compliance.

This law mandates that health care service plans must notify families about the perks of behavioral health screenings for kids and teenagers ages 8 to 18. They have to explain how these screenings can help detect mental health issues like depression and anxiety. Plans must send this notice every year. However, this requirement doesn't apply to certain Medi-Cal managed care plans.

This law requires health plans to create ways for their subscribers and enrollees to have a say in setting the plan's public policies. These policies are actions taken by the plan's staff to ensure patient comfort, dignity, and convenience in their healthcare facilities.

This section requires health plans to have procedures for reviewing medical care quality, personnel performance, service use, and costs. People who participate in these reviews are protected from lawsuits as long as they act without intent to harm, seek out the facts, and believe their actions are justified. The details from these reviews are protected and cannot be shared or used in court. However, this protection does not apply if the person involved is a party to a lawsuit related to the review's content or in certain other specified cases, like when applying for hospital privileges or during actions against insurance companies. The section clarifies that health care plans themselves are not immune from lawsuits.

This law allows health plans to use subcommittees for peer review activities and to delegate responsibilities to them. These subcommittees can include mostly non-physician health care providers. However, the health plan must control the delegated authority and can revoke it when needed. Participants in these subcommittees have the same legal protections as those participating in regular peer review committees.

This law states that if someone appeals a contested healthcare claim, the health plan must have a medical professional review the case. The reviewer, who could be a medical director or another qualified healthcare provider, must decide if they are capable of assessing the clinical issues in the claim. If they aren't, they must consult with someone who is qualified before making a decision. 'Qualified' means having the right education, training, and expertise to understand the specific health issues involved. This process is used for claims disputed due to questions about clinical issues or the necessity or type of treatment proposed or given. The plan also decides if a specialist should be involved in evaluating the claim.

This law requires every health care service plan to offer an external, independent review process for patients seeking coverage for experimental or investigational therapies. This review is available if the patient's condition is life-threatening or seriously debilitating, and their physician certifies that standard treatments haven't worked, aren't suitable, or the recommended treatment would be better.

The process confirms whether the treatment should be covered, based on medical and scientific evidence. Enrollees denied such treatments can request a review, and if it's urgent, a quicker process is in place. The decision-makers rely on credible medical sources and peer-reviewed studies to make their recommendations.

This law ensures that health care plans in California issued after January 1, 2020, cannot deny coverage or discriminate against patients participating in approved clinical trials. A "qualified enrollee" participating in such trials should receive the same coverage for routine patient care costs as other patients, whether the trial is with an in-network or out-of-network provider. However, if the trial is available through an in-network provider, patients might be required to use those services. The law defines "approved clinical trials" and clarifies what costs are covered, excluding the experimental treatment itself. It also protects enrollees' rights to independent medical reviews and ensures that offering coverage does not hold health service plans liable. This rule doesn't apply to specialized health care plans.

This law requires health care plans to pay or dispute claims within 30-45 working days. If claims aren’t paid on time, interest is added automatically, with a penalty fee if interest isn't included. A claim may be disputed if the necessary information to assess it isn't provided.

Specialized plans, especially for vision care, can use a proven method to detect and reclaim fraud-related overpayments, subject to strict guidelines. This includes notifying providers about suspected fraud, detailing the method used for fraud detection, and allowing providers to challenge these findings.

Providers have 45 working days to dispute a fraud notice. If no reimbursement is made, the plan can offset overpayments against current claims. These rules stay effective until January 1, 2026, and apply to various entities involved in processing claims, but exclude claims outside the scope of optometry practice.

This law requires health care service plans in California, including specialized ones, to reimburse complete claims within 30 days. If a claim is incomplete or denied, the plan must provide written notice specifying issues or reasons for denial. Interest at 15% per year accrues on late claims, and plans must automatically include this in payments. Specialized plans, particularly those offering vision care, can use statistical methods for fraud recovery, provided these methods are approved by the department and follow specific auditing standards. Providers can dispute fraud findings, and specialized plans have a process to notify providers and potentially offset overpayments against future claims. The law also outlines that compliance with these rules can't be waived even if third-party entities handle the claims, and there's a provision for the department to amend regulations without following normal procedures until the end of 2027. This law is set to become effective on January 1, 2026.

This California law outlines what happens if a healthcare provider is overpaid by a health care service plan. When a plan identifies an overpayment, it must notify the provider in writing. The provider then has 30 working days to repay, unless they contest the overpayment by providing written notice within the same time. If repayment isn't made on time for uncontested amounts, interest at 10% per year starts to accrue after the 30 days.

Additionally, certain payments to pharmacists for partial medication fills aren't considered overpayments. For dental plans, specific instructions must be given with overpayment notices, including how to dispute the charges and detailed claim information.

This law prohibits health care service plans from asking for a refund or paying providers less just because those providers have contracts with other approved health care service plans.

This law requires that group health care plans allow Medi-Cal beneficiaries to assign their right to reimbursement for covered health services directly to the State Department of Health Services, starting January 1, 1994. However, this rule does not apply to beneficiaries receiving services under specific contracts outlined in other sections of the Welfare and Institutions Code.