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California Knox-Keene Health Care Service Plan Act and Regulations

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Print Book :1 volume, softbound, updated annually
2018 Edition
ISBN: 9781522149309
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Knox Keene Act

 

The Knox-Keene Health Care Service Plan Act of 1975 (Act) at California Health & Safety Code section 1340 et seq. governs the licensing and activities of health care service plans in the State of California. The Act and corresponding regulations at title 28 of the California Code of Regulations (Act and Rules) are administered by the Department of Managed Health Care (DMHC) under the California Health and Human Services Agency.

The DMHC, created by consumer-sponsored legislation in 1999 and funded by health plan assessments, oversees full-service health plans, including all California HMOs and some PPOs, as well as specialized plans such as dental and vision. Overall, the DMHC regulates more than 95 percent of the commercial and public insurance enrollment in California.

Table of Contents

Table of Code

Sections Affected
Table of Regulations Affected

HEALTH AND SAFETY CODE
Division 2. Licensing Provisions Chapter
2.2. Health Care Service Plans
Article 1. General
Sections
1340. Citation of chapter
1341. Department of Managed Health Care
1341.1. Principal and branch offices
1341.2. Personnel of Department of Managed Health Care
1341.3. Adoption of seal
1341.4. Managed Care Fund established
1341.45. Managed Care Administrative Fines and Penalties Fund created; Transfer of monies
1341.5. Public information
1341.6. Opinions on questions of law
1341.7. Conflict of interest
1341.8. Powers of director
1341.9. Succession to powers and responsibilities
1341.10. Unexpended balance of funds
1341.11. Transfer of employees
1341.12. Possession of all property
1341.13. Appointment of officers and employees
1341.14. Preexisting regulations, orders, and proceedings
1342. Legislative intent
1342.1. [Section repealed 2007]
1342.3. [Section repealed 2006]
1342.4. Joint working group to ensure clarity for consumers in consistency and enforcement of regulations
1342.5. Consultation prior to adopting regulations
1342.6. Effect of antitrust prohibitions on health care services
1342.7. Authority of department to ensure providers of prescription drug coverage comply with Knox-Keene Health Care Service Plan Act of 1975
1342.71. Outpatient prescription drug coverage (First of two; Repealed January 1, 2020)
1342.71. Outpatient prescription drug coverage [Repealed effective January 1, 2020]
1342.71. Outpatient prescription drug coverage (Second of two; Operative January 1, 2020)
1342.8. Audits or surveys
1343. Application of chapter; Exemptions
1343.1. Exception to application of chapter
1343.5. Burden of proof
1344. Rules; Interpretive opinions; Good faith acts
1345. Definitions
Article 2. Administration
Sections
1346 Powers of administration
1346.1. Database of health care service plans
1346.2. Coordination with Insurance Commissioner to review specified Internet portal and enhancements; Development and maintenance of electronic clearinghouse
1346.4. Legislative findings; Publication of code provisions
1346.5. Entity purporting to be exempt health care service plan
1347. [Section repealed 2006]
1347.1. [Section repealed 2005]
1347.15. Establishment of Financial Solvency Standards Board; Members; Purpose, Meetings
1347.5. Implementation of Medi-Cal program’s premium and cost-sharing payments by health care service plan
1348. Antifraud plan
1348.5. Compliance with other law
1348.6. Proscription on payment to health care practitioner to deny, limit, or delay services
1348.8. Requirements for telephone medical advice services; Forwarding of data to Department of Consumer Affairs
1348.9. Adoption of regulations establishing Consumer Participation Program; Award of advocacy and witness fees [Repealed effective January 1, 2024]
1348.95. Annual report to department
1348.96. Submission of data for risk adjustment program
Article 3. Licensing and Fees
Sections
1349. License requirement
1349.1. Exemptions
1349.2. Exemption of certain plans
1349.3. [Section repealed 2002]
1350. License requirement for sponsor of prescription drug plan
1350.1. [Section repealed 1984]
1351. Applications for licensure
1351.1. Authorization for disclosure
1351.2. Mexican prepaid health plans; Application for licensure in California; Requirements; Fees; Actions to be taken when plan ceases to operate legally in Mexico
1351.3. Effect of noncompliance
1352. Amendment for change in information
1352.1. Filings and findings prior to specified acts
1353. Applicants to satisfy provisions of chapter
1354. Denials of applications or disapprovals
1355. Duration of license
1356. Fees and reimbursements
1356.1. Excess charges or assessments
1356.2. Imposition of additional assessment
Article 3.1. Small Employer Group Access to Contracts for Health Care Services
Sections
1357. Definitions
1357.01. Compliance with article
1357.02. Application of article
1357.025. Construction of article
1357.03. Sale of contracts to small employers; Filing of employee participation and employer contribution requirements; Rejection of application; Prohibited activities
1357.035. Small employer coverage for associations with fewer than 1,000 persons
1357.04. Notification of premium charges; When coverage becomes effective; Option to change coverage
1357.05. Exclusion of employee or dependent; Limitation on exclusion of coverage
1357.06. Preexisting condition provisions
1357.07. Late enrollees
1357.08. Services to be provided
1357.09. When plan not required to offer contract
1357.10. Requirement that plan discontinue offering contracts or accepting applications
1357.11. [Section repealed 2011]
1357.12. Requirements for premiums
1357.13. Risk rates to be applied
1357.14. Disclosures required with offer of contract
1357.15. Notice of material modification; Amendments to plan; Maintenance of information; Availability of risk adjustment factor
1357.16. Provision of administrative services by qualified associations
1357.17. Regulations
1357.18. [Section repealed 2007]
1357.19. Applicability
Article 3.11. Insurance Market Reform (Inoperative)
Sections
1357.20. Contingent operative term of article (Inoperative)
1357.21. Application of requirements in Article 3.1 (Inoperative)
1357.22. Requirements of health care plan contracts for certain large and medium employers (Inoperative)
1357.23. Reasonable efforts to contract with county hospital systems and clinics (Inoperative)
Article 3.15. Preexisting Condition Provisions
Sections
1357.50. Definitions
1357.51. Preexisting condition; Waivered condition
1357.52. Exclusion criteria
1357.53. [Section repealed 2011]
1357.54. [Section repealed 2011]
1357.55. Operative date of article
Article 3.16. Nongrandfathered Small Employer Plans
Sections
1357.500. Definitions
1357.501. Applicability of article
1357.502. Health care plans subject to article
1357.502.5. Applicability of article to association, trust, or other organization acting as health care service plan
1357.503. Small employer health benefit plans; Enrollment periods; Prohibited activities; Participation requirements; Small employer eligibility; Limitations on individual eligibility rules; Single risk pool; Applicability
1357.503.035. Purchase of small employer health coverage by association meeting definition of guaranteed association
1357.504. Premium charges for small employers; Effective date of coverage; Changing coverage
1357.506. Imposition of preexisting condition provision or waiting or affiliation provision prohibited
1357.507. Restricting enrollment of late enrollees
1357.508. Provision of essential health benefits required
1357.509. Exceptions to requirement of offering health care service plan contract or accepting applications for contract; Plan of rehabilitation
1357.510. Ending of offering of contracts or accepting of applications
1357.512. Variance of premium rates (Operative term contingent)
1357.514. Disclosures in connection with offering
1357.515. Notice of material modification
1357.516. Contracts for specific administrative services
Article 3.17. Grandfathered Small Employer Plans
Sections
1357.600. Definitions
1357.601. Applicability of article
1357.602. Plans subject to this article
1357.603. Construction of article
1357.604. Sale of contracts to small employers; Filing of employee participation and employer contribution requirements; Rejection of application; Prohibited activities
1357.606. Small employer coverage for associations with fewer than 1,000 persons
1357.607. Imposition of preexisting condition provision or waiting or affiliation provision prohibited
1357.608. Late enrollees
1357.609. Services to be provided
1357.610. When plan not required to offer contract
1357.611. Requirement that plan discontinue offering contracts or accepting applications
1357.612. Requirements for premiums
1357.613. Risk rates to be applied
1357.614. Disclosures required with offer of contract
1357.615. Notice of material modification; Amendments to plan; Maintenance of information; Availability of risk adjustment factor
1357.616. Provision of administrative services by qualified associations
1357.618. Emergency regulations
Article 3.2. Additional Requirements for Medicare Supplement Contracts [Renumbered]
Article 3.5. Additional Requirements for Medicare Supplement Contracts
Sections
1358. [Section repealed 2000]
1358.1. Compliance with article
1358.2. Purpose of article
1358.3. Applicability of article
1358.4. Definitions
1358.5. Required definitions
1358.6. Prohibited provisions; Medicare supplement contract with prescription drug benefits
1358.7. Contracts prior to January 1, 2001
1358.8. General standards for contracts with effective date prior to June 1, 2010; Core benefits; Additional benefits to Medicare supplement benefit plans B to L
1358.81. General standards for contracts with an effective date on or after June 1, 2010; Core benefits; Additional benefits
1358.9. Standards applicable to contracts with effective date prior to June 1, 2010; Benefit plans that may be offered in state; Availability of contract form containing only core benefits; Innovative benefits
1358.91. Mandatory standards applicable to contracts with effective date on or after June 1, 2010; Benefit plans that may be offered in state; Innovative benefits
1358.10. Medicare Select contracts
1358.11. Discriminatory practices; Age; Time periods; Open enrollment periods; Standardized Medicare supplement benefit plan offerings
1358.12. Guaranteed issue of contract; Eligible persons; Enrollment in case of involuntary termination; Entitlement to benefit packages; Notice of rights; Refund
1358.13. Compliance with federal statutes
1358.14. Loss ratio standards; Refund or credit calculations; Prepaid or periodic charges and supporting documentation; Public hearings
1358.145. Calculation of loss ratios; Copies to department; Compliance with standards
1358.146. Format for reporting loss ratio experience
1358.15. Approval of contract by director as prerequisite to advertising or issuance; Requirements; Filing of certain changes; Time periods
1358.16. Compensation for solicitors and sales representatives
1358.17. Renewal or continuation provision; Amendments to contract; Contract limitations; Notice of right to return; Guide to health insurance; Notice of changes; Outline of coverage; Disclosure pages; Required notices
1358.18. Application form; Copy to applicant; Notice as to replacement of coverage; Buyer’s guide; Group contracts; Health information from applicant who is guaranteed coverage
1358.19. Director’s approval of advertisement
1358.20. Duties of issuer as to marketing procedures; Prohibited acts
1358.21. Appropriateness of recommended purchase or replacement; Multiple contracts; Issuance to individual enrolled in Part C
1358.22. Annual report
1358.225. Annual filing of list of contracts in state; Contents
1358.23. Waiver of time periods for preexisting conditions
1358.24. Adherence to Genetic Information Nondiscrimination Act of 2008
Article 4. Solicitation and Enrollment
Sections
1359. Standards for solicitors and solicitor firms
1360. Untrue or misleading advertising or solicitations
1360.1. Representations respecting implications of licensing
1360.5. Representing, constituting, providing services on behalf of Exchange; Unfair business practice
1361. New or revised advertisements; Filing
1361.1. Purchase of health care coverage products; Specified methods prohibited
1362. Definitions
1363. Disclosure forms or materials
1363.01. Notice regarding use of formulary by plan; Information regarding drugs on formulary
1363.02. Findings; Requirements for service plan
1363.03. Uniform prescription drug information card; Contents of card
1363.05. Statement to be included in plan’s disclosure form; Modification; Notice to enrollees
1363.06. Comparative benefit matrices (Inoperative; Operative date contingent)
1363.07. Annual update of comparative benefit matrix by health care service plan; Copies to be mailed to solicitors and employers; Availability of link to matrix on Web site (Inoperative; Operative date contingent)
1363.1. Disclosure on binding arbitration
1363.2. Use of emergency response system
1363.5. Disclosure of process used to authorize or deny services; Requirements for criteria used; Notice accompanying disclosure to public
1364. Supplemental disclosure information
1364.1. Notice of reduction in emergency service
1364.5. Filing of procedures to protect confidentiality; Statement for enrollees and subscribers; Notice of availability
1365. Cancellation and non-renewal of enrollment or subscription
1365.5. Modification of or refusal to enter contract on discriminatory basis
1366. Name of plan
1366.1. Geographic accessibility standard; Applicability; Notice of material modification of plan and public hearing
1366.2. Availability to group subscribers of termination date of health care contracts in geographic area; Definitions
1366.3. Plan ceasing to offer individual coverage; Regulations for implementation; Exceptions to applicability
1366.4. Nonphysician providers
1366.6. Sale of products by health care service plans; Levels of coverage (First of two; Operative term contingent)
1366.6. Sale of products by health care service plans; Levels of coverage (Second of two; Operative date contingent)
Article 4.5. California COBRA Program
Sections
1366.20. Citation; Intent; Adoption of emergency regulations
1366.21. Definitions governing article
1366.22. Inapplicability of requirements
1366.23. Requirement to offer continuation coverage
1366.24. Disclosures
1366.25. Notification requirements; Contract with employer or administrator to perform administrative obligation; Coverage under American Recovery and Reinvestment Act of 2009
1366.26. Rate limits
1366.27. Termination of continuation coverage
1366.28. Failures to comply
1366.29. Continuing coverage for enrollees who have exhausted continuation coverage under COBRA
Article 4.6. Coverage for Federally Eligible Defined Individuals
Sections
1366.35. Required coverage (Inoperative; Operative date contingent)
1366.50. Notice of eligibility for reduced-cost coverage through California Health Benefit Exchange or no-cost coverage through Medi-Cal
Article 5. Standards
Sections
1367. Requirements for health care service plans
1367.001. Compliance with specified federal law, rules and regulations, and state laws required; Applicability
1367.002. Compliance with provisions regarding coverage of, and cost-sharing for, preventive services and rules or regulations
1367.003. Rebate on pro rata basis; Conditions; Minimum medical loss ratios; Total amount of rebate; Adoption of regulations; Construction
1367.004. Plans covering dental services; MLR annual report requirement; Examination by director; Use of data by Legislature; Compliance guidance exempt from APA
1367.005. Individual or small group health care service plan to cover essential health benefits; Provisions
1367.006. Nongrandfathered individual and group health care service plans that cover essential health benefits; Limit on annual out-of-pocket expenses for covered essential health benefits
1367.0065. [Section repealed 2016]
1367.007. Limitation on deductible for small employer health care service plan
1367.008. Levels of coverage for nongrandfathered individual market; Determination of actuarial value for nongrandfathered individual health care service plans; Catastrophic plan
1367.009. Levels of coverage for nongrandfathered small group market; Determination of actuarial value for nongrandfathered small employer health care service plans
1367.01. Written policies and procedures for review and approval, modification, delay or denial of services; Medical director to ensure compliance; Compliance review
1367.010. Minimum value of sixty percent for large group health care service plan contract
1367.012. Renewal of small employer health care service plan contract; Notice; Exemptions; Amendments for compliance
1367.015. Decisions to deny requests by providers for authorization or claim reimbursement for mental health services
1367.02. Filing relating to any economic profiling policies or procedures; Availability to public; ‘‘Economic profiling’’
1367.03. Development of standards for timely access to health care services
1367.031. Information regarding standards for timely access to health care services
1367.035. Standards for timely access to health care services; Required inclusion of network adequacy data
1367.04. Language assistance in obtaining health care services; Adoption of regulations and standards; Considerations; Reports; Public input; Contracts
1367.041. Required non-English insurance documents
1367.042. Information made available by health care service plan
1367.05. Contract with dental college
1367.06. Service plan to cover outpatient prescription drug benefits to provide coverage for inhaler spacers, nebulizers, and peak flow meters when medically necessary for treatment of pediatric asthma
1367.07. Report by health care service plan on cultural appropriateness in specified contexts
1367.08. Compensation disclosure
1367.09. Return to skilled nursing
1367.1. Application to transitionally licensed plans
1367.2. Coverage for alcoholism; Notice of coverage
1367.3. Coverage plan for comprehensive preventive care of children
1367.35. Comprehensive preventive care of children of specified ages
1367.36. Costs of required immunization of children
1367.4. Effect of blindness on coverage
1367.41. Pharmacy and therapeutics committee
1367.42. Enrollee access to prescription drug benefits at in-network retail pharmacy; Effect on cost-sharing
1367.43. Prorated cost for partial fill of prescription
1367.45. Coverage for approved AIDS vaccine; Cost effective price
1367.46. Coverage for HIV testing required
1367.49. Information to be furnished to consumers or purchasers concerning cost range of procedure or full course of treatment, or quality of services performed by provider or supplier; Review of methodology and data; Online posting; Definitions
1367.5. Health service plan contract restrictions
1367.50. Disclosure of claims data to qualified entity
1367.51. Coverage of equipment and supplies for treatment of diabetes; Prescription items; Outpatient self-management and training
1367.54. California Prenatal Screening Program
1367.6. Coverage for breast cancer screening, diagnosis, and treatment; Denial of enrollment or coverage on grounds related to breast cancer; Prosthetic devices or reconstructive surgery
1367.61. Coverage for prosthetic devices to restore method of speaking incident to laryngectomy
1367.62. Restrictions on limiting inpatient hospital care following childbirth; Proscription on specified treatment and coverage practices; Notice of required coverage
1367.63. Reconstructive surgery
1367.635. Mastectomies and lymph node dissections
1367.64. Coverage for screening and diagnosis of prostate cancer
1367.65. Coverage for mammography for screening and diagnostic purposes
1367.656. Healthcare coverage for orally administered anticancer medication (Repealed January 1, 2019)
1367.66. Coverage for annual cervical cancer screening test
1367.665. Coverage for cancer screening tests
1367.67. Coverage for osteoporosis
1367.68. Coverage for surgical procedure for conditions affecting upper or lower jawbone
1367.69. Obstetrician-gynecologists as eligible primary care physicians
1367.695. Requirement for enrollee’s choice of obstetrical or gynecological services provider
1367.7. Coverage for prenatal diagnosis of genetic disorders of fetus
1367.71. General anesthesia and associated facility charges for dental procedures
1367.8. Coverage for handicapped persons
1367.9. Coverage for conditions attributable to diethylstilbestrol
1367.10. Disclosure of effect of participation in plan on choice of provider
1367.11. Direct reimbursement to providers of covered medical transportation services
1367.12. Number of forms to be submitted per claim for payment or reimbursement
1367.15. Closure of ‘‘block of business’’
1367.18. Coverage for orthotic and prosthetic devices and services; Benefit amount
1367.19. Coverage for special footwear for those suffering from foot disfigurement
1367.20. Provision of list of prescription drugs on plan’s formulary
1367.205. Formularies to be posted on Internet Web site; Required updates; Template
1367.21. Limitation or exclusion of coverage for drug prescribed for use different from which drug was approved
1367.215. Coverage of pain management medications for terminally ill patients
1367.22. Plan’s obligations relating to drug previously approved for enrollee’s medical condition
1367.23. Plan provision requiring notification of group contract holders and subscribers of cancellation
1367.24. Process for authorization of medically necessary nonformulary prescription drug; Required recordkeeping by plan; Review of plan’s provision of prescription drug benefits
1367.241. Prior authorization for prescription drugs
1367.243. Prescription drug reporting requirements for health service plans reporting rate information; Legislative report on drug cost impact on health care premiums
1367.244. Request for exception to plan’s step therapy process for prescription drugs
1367.25. Contraceptive coverage
1367.26. [Section repealed 2016]
1367.27. Provider directory
1367.29. Issuance of identification card to assist enrollee with accessing health benefits coverage information; Contents of identification card
1367.30. Group health care service plan contracts; Applicable law
1367.31. Referral requirement prohibited for receiving reproductive and sexual health care coverage or services
1368. Grievance systems
1368.01. Time period in which to resolve grievances; Expedited review for cases involving serious threat to patient’s health
1368.015. Online grievance procedure
1368.016. Establishment of Internet Web site; Link to specified information required; Updates; Applicability of section
1368.02. Toll-free telephone number for complaints
1368.03. Participation in plan’s grievance process before complaint with department
1368.04. Enforcement by director; Violations; Administrative penalty
1368.05. Direct consumer assistance activities by Department of Managed Health Care; Contracts with community-based consumer assistance organizations
1368.1. Information provided by plan denying coverage to enrollee with terminal illness; Conference to review information
1368.2. Hospice care
1368.5. Pharmacist coverage
1369. Participation by subscribers and enrollees
1370. Review procedures
1370.1. Review subcommittees
1370.2. Review of appeal of contested claim
1370.4. Independent external review process for coverage decisions on experimental or investigational therapies
1370.6. Coverage relating to cancer clinical trials
1371. Reimbursement of claims; Contested claims
1371.1. Notification to provider of overpayment; Reimbursement; Contested claims; Accrual of interest
1371.2. Prohibited request for reimbursement or reduction of level of payment
1371.22. Acceptance of lowest payment rate charged by provider to patient or third-party; Inapplicability of policy provision to cash payments made to provider by patient without private or public health care
1371.25. Liability
1371.3. Assignment of right to reimbursement
1371.30. Independent dispute resolution process for noncontracting individual health professional
1371.31. Reimbursement rate for noncontracting individual health professional; Reporting requirements; Exemptions
1371.35. Time limits for reimbursement, contest, or denial of certain claims; What constitutes complete claim; Claims excepted from time limits
1371.36. Denial of payment based on authorization
1371.37. Prohibition against unfair patterns
1371.38. Regulations and reports
1371.39. Instances of unfair payment patterns
1371.4. Authorization for emergency services
1371.5. Use of emergency response system
1371.8. Rescission or modification of authorization after service provided
1371.9. ‘‘In-network cost-sharing amount’’ for services provided by noncontracting individual health professional; Exemptions
1372. Contracts; Use of evidence of coverage; Exception
1373. Required or prohibited contract provisions
1373.1. Conversion provisions
1373.2. Conversion rights of dependent spouse upon change of status
1373.3. Selection of primary care physician
1373.4. Limitation on copayments and deductibles for specified maternity services
1373.5. Coverage of spouses covered under terms of same master contract; Maximum contractual benefits
1373.6. Conversion coverage
1373.62. [Section repealed 2008]
1373.620. Required notices for health care service plans
1373.621. Additional benefits for former employee meeting tenure and age requirements and for employee’s spouse or former spouse; Applicability
1373.622. Provision of coverage after termination of pilot program; Applicable rules
1373.65. Termination of contract with provider group or general acute care hospital; Written notice; Right of enrollee to keep provider for designated time period
1373.7. Out of state contracts; Psychologist licensure requirements
1373.8. Contractees’ right to select licensed professionals in California to perform contract services
1373.9. Duty to give reasonable consideration to proposals for affiliation
1373.95. Written policy on continuity of care from health care service plan
1373.96. Completion of covered services
1373.10. Acupuncture
1373.11. Affiliation with podiatrists
1373.12. Duty of health care service plan to consider affiliation with chiropractors
1373.
13. Discrimination against licensed dentists; Legislative intent
1373.14. Exclusion of victims of progressive, degenerative and dementing illnesses
1373.18. Calculation of enrollee copayments for specified contracts of health care service plan
1373.19. Selection of arbitrator
1373.20. Arbitration requirements
1373.21. Written arbitration decisions
1374. Coverage less favorable for employees than spouses
1374.3. Compliance with standards for insurance incident to support and for insurance coverage relating to Medi-Cal beneficiaries
1374.5. Unenforceability of lifetime waiver of mental health services coverage in nongroup contract
1374.51. Voluntariness of psychiatric admission not to be used when determining eligibility for reimbursement
1374.55. Coverage for treatment of infertility; ‘‘Subsidiary’’
1374.56. Coverage for testing and treatment of phenylketonuria (PKU)
1374.57. Exclusion of dependent child
1374.58. Group health care service plan to offer coverage for registered domestic partner equal to that provided to spouse
1374.7. Discrimination on basis of genetic characteristics
1374.75. Discrimination by health care service plan providers against victims of domestic violence
1374.8. Disclosure to employer that employee is receiving services
1374.9. Administrative penalties for discrimination on basis of genetic characteristics
1374.10. Inclusion of benefits for home health care
1374.11. Prisoners’ claims
1374.12. Restrictions on liability for expenses incurred while in state hospital
1374.13. Telehealth; Restrictions; Construction
1374.15. Disclosure of method used in calculating contract payment rates
1374.16. Standing referral to specialist
1374.17. Prohibition against denial of coverage for organ or tissue transplantation services based on HIV status
1374.19. Service plan or contract covering dental services; Coordination of benefits required
1374.195. Covered dental services; Contracts; Charge for services; Evidence of coverage and disclosure form; Required statement
Article 5.5. Health Care Service Plan Coverage Contract Changes
Sections
1374.20. Prohibitions on changing premium rates of health care service plan; Exemptions
1374.21. Notice of change in premium rates or coverage
1374.22. Delivery of notice; Contents
1374.23. Time of delivery of notice for specified plans
1374.24. Limitation on liability of plan
1374.25. Proof of mailing of notice
1374.255. Prohibition against changing cost-sharing design during plan year; Applicability
1374.26. Adoption of regulations
1374.27. Penalties for violation
1374.28. Suspension of authority of plan to transact business
1374.29. Purpose of article
Article 5.55. Appeals Seeking Independent Medical Reviews
Sections
1374.30. Establishment of Independent Medical Review System; Participation; Conditions for application for independent review; Forms
1374.31. Imminent threat to health; Expeditious review
1374.32. Medical review organizations
1374.33. Analysis and determination
1374.34. Prompt implementation of decision; Review and audit
1374.35. Reimbursement of costs
1374.36. Report on implementation of article
Article 5.6. Point-of-Service Health Care Service Plan Contracts
Sections
1374.60. Definitions
1374.62. Application to risk transferred through reinsurance
1374.64. Plan criteria
1374.65. Plan contract requirements
1374.66. Allowable plan provisions
1374.67. Limitations
1374.68. Requirements
1374.69. Notice of material modification
1374.70. [Section repealed 1995]
1374.71. Notice of material modification; Exemption
1374.72. Health plan to cover mental illness and emotional disturbance
1374.73. Coverage for behavioral health treatment for pervasive developmental disorder or autism
1374.74. Autism Advisory Task Force; Duties; Report
1374.76. Provision of covered mental health and substance use disorder benefits
Article 6. Operation and Renewal Requirements and Procedures
Sections
1375. [Section repealed 1978]
1375.1. Contents of plan
1375.2. Transitionally licensed plans
1375.3. Meet and confer with director prior to filing petition for bankruptcy; Information to ensure continuity of care
1375.4. Required provisions for contract between health care service plan and risk-bearing organization; Regulations; Sanctions for plan’s failure to comply with contractual requirements; Report; Exemption
1375.5. Contract provision requiring risk-bearing organization to be at financial risk for provision of health care services
1375.6. Contract provision requiring provider to accept certain rates or methods of payment
1375.7. Health Care Providers’ Bill of Rights
1375.8. Written request by provider to assume financial risk allowed when negotiating initial contract or renewing existing contract
1375.9. Health care service plans primary care physician ratio (Repealed January 1, 2019)
1376. Rules and regulations; Surety bond
1376.1. Exemption of county or city plan from deposit requirements related to financial responsibility
1377. Reserves or insurance to be maintained by certain plans for payments to subscribers or providers
1378. Administrative costs
1379. Contracts with health care providers
1379.5. Contract between plan and health care provider who provides health care services in Mexico; Requirements; Plan’s obligations
1380. Surveys of health delivery systems
1380.1. Legislative findings and declarations; Standards for uniform medical quality audit system
1380.3. Coordination of surveys
1381. Records; Location and inspection
1382. Examinations of fiscal and administrative affairs of plans
1383. Annual report to department
1383.1. Policy on second medical opinion
1383.15. Second opinion
1384. Audit reports and financial statements
1385. Books of account
Article 6.2. Review of Rate Increases
Sections
1385.01. Definitions
1385.02. Applicability of article
1385.03. Filing of rate information for individual and small group health care service plan contracts prior to implementing any rate change; Disclosure of information
1385.04. Filing of rate information for large group health care service plan contracts prior to implementing any rate change; Disclosure of information and aggregate data
1385.045. Filing of weighted average rate increase for large group health care service plan contracts; Disclosure of information and aggregate data
1385.05. Authority of department; Information that may be requested
1385.06. Submission of filing; Contents; Contract with independent actuary or actuaries
1385.07. Publication of information; Confidential information; Information to be included
1385.08. Issuance of guidance to health care service plans regarding compliance with article
1385.10. Health care service plan annual claims reporting requirements
1385.11. Review of rate filings by department; Report; Unreasonable rate increase findings
1385.13. Duties of department; Submission of information
Article 7. Discipline
Sections
1386. Suspension or revocation of license; Grounds for disciplinary action; Order to individual
1387. Civil penalties
1388. Discipline of person acting as solicitor or solicitor firm
1389. Petition to reinstate license
Article 7.5. Underwriting Practices
Sections
1389.1. Applications for coverage; HIV test prohibition
1389.2. Written statement of actuarial basis
1389.21. Proscription against rescission, cancellation, or limitation of policy, or rise in premiums after 24 months following issuance of health care service plan contract
1389.25. Written notice required for changes in premium rate or coverage for individual plan contract; Information on new coverage options in case of rejection
1389.3. Postclaims underwriting
1389.4. Written policies required; Filing; Posting (First of two; Inoperative; Operative date contingent)
1389.4. Written policies required; Filing; Exceptions (Second of two; Operative term contingent)
1389.5. Right to transfer to another individual plan (Inoperative; Operative date contingent)
1389.6. Compensation of a person or entity employed or contracted; Performance goals or quotas
1389.7. Issuance of new individual plan contract where contract rescinded; Premium rate; Preexisting condition provision; Notice; Contract effective date (First of two; Inoperative; Operative date contingent)
1389.7. Issuance of new individual plan contract where contract rescinded; Premium rate; Preexisting condition provision; Notice; Contract effective date; Applicability (Second of two; Operative term contingent)
1389.8. Duty with regard to assisting applicant for a health care service plan; Attestation; Civil penalty
Article 8. Other Enforcement Procedures
Sections
1390. Violation of chapter; Penalties
1391. Cease and desist orders
1391.5. Immediate order to discontinue unsafe practice
1392. Injunctions and other equitable relief
1393. Vesting of title to assets; Taking possession of business
1393.5. Civil penalties for violation of license provisions
1393.6. Administrative penalties for violation of provisions relating to small employer group access to contracts for health care services and preexisting condition provisions and late enrollees
1394. Penalties not exclusive
1394.1. Complaint for involuntary dissolution of plan
1394.2. Priority of claims
1394.3. Applicable law in involuntary dissolution actions
Article 8.5. Service of Process
Sections
1394.5. Methods of service
1394.7. Definitions; Insolvency of health care service plan
1394.8. Definitions; Insolvency of specialized health care service plan
Article 9. Miscellaneous
Sections
1395. Advertising; Contracts with licensed professionals; Offices; Misrepresentations by plan; Compliance by plan
1395.5. Contract to restrict health care provider’s advertising
1395.6. Disclosure relating to health care provider’s participation in network; Disclosures by contracting agent conveying its list of contracted health care providers and reimbursement rates; Election by provider to be excluded from list; Demonstration by payor of entitlement to pay contracted rate
1395.7. Staff-model dental health care service plan; Compliance with policies and procedures
1396. Misstatements or omissions in documents filed
1396.5. Privileges of nonprofit hospital corporations which indemnified subscribers
1397. Hearings; Judicial review
1397.5. Summary of complaints against plans
1397.6. Contracts with medical consultants [Section repealed 2000]
1398.5. References to prior law
1399. Surrender of license; Summary suspension or revocation of license
1399.1. Administrative actions applicable to transitionally licensed plans
1399.3. Material change to contract effective upon delivery of notice by health care service plan to solicitor
1399.5. Legislative intent; Application of chapter
Article 9.5. Claims Reviewers
Sections
1399.55. Disclosure of rationale for rejection of claim from health care provider or patient
1399.56. Compensation of person retained to review claims for health care services
1399.57. Application of
Article to Medi-Cal services or benefits
Article 10. Discontinuance and Replacement of Group Health Care Service Plan Contracts
Sections
1399.60. Application
1399.61. Definitions
1399.62. Extension of benefits
1399.63. Required coverage following discontinuance of prior contract or policy
1399.64. Compliance requirement
Article 10.5. Individual Access to Contracts for Health Care Services [Renumbered]
Article 11. Nonprofit Plans
Sections
1399.70. Submission of copy of articles of incorporation; Report
1399.71. Submission of public benefit program
1399.72. Approval for conversion from nonprofit to for-profit status
1399.73. Contents of application; Fee; Contracts for review
1399.74. Adoption of regulations; Notice; Public records; Public hearing
1399.75. Application of article
1399.76. Exceptions
Article 11.1. Consumer Operated and Oriented Plans
Sections
1399.80. Definitions
1399.81. Issuance of license
1399.83. Licensees subject to specified provisions of law
1399.84. Loan documentation
1399.86. Prohibitions in PPACA apply; Additional requirements
1399.88. Full compliance with requirements of PPACA governing CO-OPs
Article 11.5. Individual Access to Contracts for Health Care Services
Sections
1399.801. Definitions
1399.802. Compliance with chapter and
Article
1399.803. Application of
Article
1399.804. Availability of contracts to federally eligible defined individuals
1399.805. Notification of premium charges; Commencement of coverage; Changes
1399.806. Prohibited exclusions
1399.809. Discontinuation of plan
1399.810. Renewal of contracts
1399.811. Premium requirements
1399.812. Consistent application of premiums
1399.813. Disclosure
1399.814. Exemption from requirement to offer to individuals
1399.815. Notice of amendments
1399.816. [Section repealed 2013]
1399.817. Regulations
1399.818. Date of applicability of article
1399.900-1399.904. [Reserved]
Article 11.7. Child Access to Health Care Coverage
Sections
1399.825. Definitions (Inoperative; Operative date contingent)
1399.826. Child coverage; Preexisting condition; Issuance or offering of individual coverage may not be conditioned; When coverage becomes effective; Establishment of rules for eligibility; Construction (Inoperative; Operative date contingent)
1399.827. Applicability of article (Inoperative; Operative date contingent)
1399.828. Availability of plan’s health care service plan contracts to late enrollees; Prohibited activities; Compensation to solicitor prohibited (Inoperative; Operative date contingent)
1399.829. Characteristics to be considered in establishing rates; Limitations (Inoperative; Operative date contingent)
1399.832. When plan not required to offer contract or accept applications (Inoperative; Operative date contingent)
1399.833. Requirement that plan discontinue offering contracts or accepting applications (Inoperative; Operative date contingent)
1399.834. Renewal of contracts; Plan ceasing to offer individual coverage (Inoperative; Operative date contingent)
1399.835. Issuance of guidance to health plans regarding compliance with article (Inoperative; Operative date contingent)
1399.836. Operation of article (Inoperative; Operative date contingent)
Article 11.8. Individual Access to Health Care Coverage
Sections
1399.845. Definitions
1399.847. Applicability of article
1399.849. Individual health benefit plans; Preexisting condition provisions prohibited; Enrollment periods; Triggering events; Coverage effective date; Plans offered outside Exchange; Limitations on eligibility rules; Single risk pool; Applicability
1399.851. Prohibited activities for insurer, agent, or broker; Applicability; Enforcement
1399.853. Renewability; When insurer ceases offering plans
1399.855. Determination of premium rates (Operative term contingent)
1399.857. Requirements not placed on carriers
1399.858. Discontinuing of offering contracts or acceptance of applications
1399.859. Notice to applicant or subscriber of eligibility for lower cost coverage through Exchange; Applicability
1399.861. Notice to subscriber of individual grandfathered health plan of health insurance options; Inclusion of notice in renewal material and application for dependent coverage
1399.862. Implementation of article
1399.863. Adoption of emergency regulations
1399.864. Requirements of health care service plan that contracts with California Health Benefit Exchange to offer a qualified bridge plan; Medical loss ratio; Marketing and sales; Initial open enrollment (For inoperative date and repeal see subd (g))

CALIFORNIA CODE OF REGULATIONS
Title 28. Managed Health Care
Division 1. The Department of Managed Health Care
Chapter 1. Department Administration
Article 1. Conflict of Interest
1000. Conflict of Interest for the Department of Managed Health Care
Article 2. Administration
Sections
1001. Department Internet Web Page and Web Addresses
1002. Appearance and Practice Before the Department
1002.4. Public Meetings and Hearings
1003. Public Comment During Department Meetings
1004. Verification
1005. Interpretive Opinions
1006. Inspection of Public Records
1007. Request for Confidentiality
1008. Availability of Department Forms, Publications and Notices; Fees
1009. Retention of Department Records
1010. Consumer Participation Program
1011. Assessment for University of California Analysis of Proposed Mandate Legislation
Article 3. Electronic Filing
Sections
1300.41.8. Electronic Filing Chapter 2. Health Care Service Plans
Article 1. Exemptions
Sections
1300.43. Small Plans
1300.43.1. New Plans
1300.43.2. Extension for Enrollers Under Medi-Cal Program
1300.43.3. Ambulance Plans: Conditional Exemption
1300.43.4. Employee Welfare Benefit Plans [Repealed]
1300.43.5. Exemption for Licensees of Insurance Commissioner [Repealed]
1300.43.6. Moribund Plans
1300.43.7. Student Emergency Care Arrangements
1300.43.8. Public Agencies
1300.43.9. Unlicensed Solicitors and Solicitor Firms
1300.43.10. Nonprofit Retirees’ Plan
1300.43.11. Exemption for Solicitors of Nonprofit Retirees’ Plans
1300.43.12. Medi-Cal Dental Contract
1300.43.13. Mutual Benefit Plans
1300.43.14. Employee Assistance Programs
1300.43.15. Foreign Plans
Article 2. Administration
Sections
1300.44. Interpretive Opinions
1300.44.1. Application for Exemption from Rule
1300.45. Definitions
1300.46. Prohibition of Bonuses or Gratuities in Solicitations
1300.47. Advisory Committee on Managed Health Care
Article 3. Plan Applications and Amendments
Sections
1300.50. Notice of Intention to Apply for Plan License
1300.51. Application for License as a Health Care Service Plan or Specialized Health Care Service Plan
1300.51.1. Individual Information Sheet
1300.51.2. Consent to Service of Process
1300.51.3. Preparation and Amendment of Application for License As a Health Care Service Plan Under Section
1300.52. Amendments to Plan Application
1300.52.1. Notice of Material Modification
1300.52.2. Change in Plan Personnel
1300.52.3. Filings and Actions Relating to Charitable or Public Activities
1300.52.4. Standards for Amendments and Notices of Material Modification
Article 4. Solicitors
Sections
1300.57. Solicitor Application
1300.57.1. Solicitor Firm Application by Person Not Licensed by Insurance Commissioner
1300.57.2. Amendment to Solicitor Firm Application
1300.57.3. Fees Payable by Licensed Insurance Agents and Brokers
1300.57.4. Solicitor Financial Records Authorization
1300.59. Plan Assurances Prior to Solicitation
1300.59.1. Examination Fee
1300.59.2. Waiver of Examination Requirements
Article 5. Advertising and Disclosure
Sections
1300.61. Filing of Advertising and Disclosure Forms
1300.61.1. Exempt Advertising
1300.61.3. Deceptive Advertising
1300.63. Disclosure Form
1300.63.1. Evidence of Coverage
1300.63.2. Combined Evidence of Coverage and Disclosure Form
1300.63.3. Experimental Disclosure
1300.63.50. Medicare Supplement Additional Disclosure [Repealed]
1300.64.50. Medicare Supplement Application Information [Repealed]
1300.64.51. Medicare Supplement ‘‘Buyer’s Guide’’ [Repealed]
1300.64.52. Standards for Marketing Medicare Supplement Contracts [Repealed]
1300.64.53. Reporting of Multiple Coverage [Repealed]
1300.64.54. Replacement Contracts: Elimination of Waiting Periods [Repealed]
1300.64.55. Permitted Compensation Arrangements for the Sale of Medicare Supplement Contracts [Repealed]
Article 6. Appeals on Cancellation
Sections
1300.65. Cancellations and Nonrenewals, Request for Review of Cancellations, Rescissions and Nonrenewals
1300.65.1. Form to Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract
1300.65.2. Suspension of Coverage Under Federal Grace Period for Nonpayment of Premiums, Notice Requirements
1300.66. Deceptive Plan Names
Article 7. Standards
Sections
1300.67. Scope of Basic Health Care Services
1300.67.003. State Medical Loss Ratio Annual Report
1300.67.005. Essential Health Benefits
1300.67.04. Language Assistance Programs
1300.67.05. Acts of War Exclusions
1300.67.1. Continuity of Care
1300.67.1.3. Block Transfer Filings
1300.67.2. Accessibility of Services
1300.67.2.1. Geographic Accessibility Standards
1300.67.2.2. Timely Access to Non-Emergency Health Care Services
1300.67.3. Standards for Plan Organization
1300.67.4. Subscriber and Group Contracts
1300.67.8. Contracts with Providers
1300.67.10. Discrimination Prohibited [Repealed]
1300.67.11. Disclosure of Conflicts of Interest
1300.67.12. Contracts with Solicitor Firms
1300.67.13. Coordination of Benefits (‘‘COB’’)
1300.67.24. Outpatient Prescription Drug Copayments, Coinsurance, Deductibles, Limitations and Exclusions
1300.67.241. Prescription Drug Prior Authorization or Step Therapy Exception Request Form Process
1300.67.50. Certain Medicare Supplement Contracts: Presumption of Unfairness [Repealed]
1300.67.51. Medicare Supplement Contract Provisions [Repealed]
1300.67.52. Medicare Supplement Additional Benefit Requirements [Repealed]
1300.67.53. Medicare Supplement Minimum Aggregate Benefits [Repealed]
1300.67.55. Medicare Supplement Reporting Requirements [Repealed]
1300.67.56. Transitional Requirements for the Conversion of Medicare Supplement Contracts to Conform to Medicare Program Revisions [Repealed]
1300.67.57. Format For Notices of Changes in Coverage [Repealed]
1300.67.58. Participating Physician or Supplier Claims Form Requirement (Compliance with Section 4081 of the Omnibus Budget Reconciliation Act of 1987) [Repealed]
1300.67.59. Format for Reporting Loss Ratio Experience [Repealed]
Article 8. Self-Policing Procedures
Sections
1300.67.60. Standing Referral to HIV/AIDS Specialist [Renumbered]
1300.68. Grievance System
1300.68.01. Expedited Review of Grievances
1300.68.2. Hospice Services
1300.69. Public Policy Participation by Subscribers
1300.70. Health Care Service Plan Quality Assurance Program
1300.70.4. Independent Medical Reviews Experimental and Investigational Therapies
1300.71. Claims Settlement Practices
1300.71.4. Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services
1300.71.38. Fast, Fair and Cost-Effective Dispute Resolution Mechanism
1300.71.39. Unfair Billing Patterns
1300.73.21. Arbitration and Settlement Agreements
1300.74.16. Standing Referral to HIV/AIDS Specialist
1300.74.30. Independent Medical Review System
1300.74.72. Mental Health Parity
1300.74.73. Pervasive Developmental Disorder and Autism Coverage
Article 9. Financial Responsibility
Sections
1300.75. Agreements with Subsequent Providers [Repealed]
1300.75.1. Fiscal Soundness, Insurance, and Other Arrangements
1300.75.2. Plan As Subsequent Provider [Repealed]
1300.75.3. Subsequent Provider Exemption [Repealed]
1300.75.4. Definitions
1300.75.4.1. Risk Arrangement Disclosure
1300.75.4.2. Organization Information
1300.75.4.3. Plan Reporting
1300.75.4.4. Confidentiality
1300.75.4.5. Plan Compliance
1300.75.4.6. Department Costs
1300.75.4.7. Organization Evaluation
1300.75.4.8. Corrective Action
1300.76. Plan Tangible Net Equity Requirement
1300.76.1. Deposits
1300.76.2. Solicitor Firm Financial Requirement
1300.76.3. Fidelity Bond
1300.76.4. Prohibited Financial Practices
1300.77. Reimbursements
1300.77.1. Estimated Liability for Reimbursements
1300.77.2. Calculation of Estimated Liability for Reimbursements
1300.77.3. Report on Reimbursements Exceeding Ten Percent
1300.77.4. Reimbursements on a Fee-for-Services Basis: Determination of Status of Claims
1300.78. Administrative Costs
Article 10. Medical Surveys
Sections
1300.80. Medical Survey Procedure
1300.80.10. Medical Survey: Report of Correction of Deficiencies
Article 11. Examinations
1300.81. Removal of Books and Records from State
1300.82. Examination Procedure
1300.82.1. Additional or Nonroutine Examinations and Surveys
Article 12. Reports
Sections
1300.83. Annual Report [Repealed]
1300.84. Financial Statements
1300.84.05. Change of Independent Accountant
1300.84.06. Plan Annual Report
1300.84.1. Verification of Reports [Repealed]
1300.84.2. Quarterly Financial Reports
1300.84.3. Monthly Financial Reports
1300.84.4. Financial Reports by Solicitor Firms [Repealed]
1300.84.5. Public Entity Plans
1300.84.6. Plan Annual Enrollee Report
1300.84.7. Special Reports Relating to Charitable or Public Activities
Article
13. Books and Records
Sections
1300.85. Books and Records
1300.85.1. Retention of Books and Records
Article 14. Miscellaneous Provisions
Sections
1300.86. Assessment of Administrative Penalties
1300.87. Civil Penalties
1300.89. Petition for Restoration
1300.89.21. Rescissions
1300.99. Application to Surrender License
1300.99.7. Application for Conversion or Restructuring
Article 15. Charitable or Public Activities
Sections
1300.824. Requirements Relating to Charitable or Public Activity Filings
1300.824.1. Notices and Requests for Approval of Certain Transactions
1300.826. Request for Ruling on Proposed Action or
Article Amendment
Index