California Contractors License Law & Reference Book

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 [Section repealed 2007] 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 [Section repealed 2006] 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 Outpatient prescription drug coverage (First of two; Repealed January 1, 2020) 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 Outpatient prescription drug coverage [Repealed effective January 1, 2020] 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 [Section repealed 2006] 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 [Section repealed 2005] 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 contractholders 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 
1398. [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