California Health and Safety Code ARTICLE 5 - Standards

• Section 1367.
  A health care service plan and, if applicable, a specialized health care service plan shall meet the following requirements:(a) Facilities located in this state including, but...
• Section 1367.001.
  (a) To the extent required by federal law, every health care service plan that issues, sells, renews, or offers contracts for health care coverage in this...
• Section 1367.002.
  To the extent required by federal law, a group or individual health care service plan contract issued, amended, renewed, or delivered on or after September...
• Section 1367.003.
  (a) Every health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a...
• Section 1367.004.
  (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than...
• Section 1367.005.
  (a) An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall, at a minimum, include...
• Section 1367.006.
  (a) This section shall apply to nongrandfathered individual and group health care service plan contracts that provide coverage for essential health benefits, as defined in Section...
• Section 1367.007.
  (a) (1) For a small employer health care service plan contract offered, sold, or renewed on or after January 1, 2014, the deductible under the plan shall...
• Section 1367.008.
  (a) Levels of coverage for the nongrandfathered individual market are defined as follows:(1) Bronze level: A health care service plan contract in the bronze level shall provide...
• Section 1367.009.
  (a) Levels of coverage for the nongrandfathered small group market are defined as follows:(1) Bronze level: A health care service plan contract in the bronze level shall...
• Section 1367.01.
  (a) A health care service plan and any entity with which it contracts for services that include utilization review or utilization management functions, that prospectively, retrospectively,...
• Section 1367.010.a.
  (a) (1) A nongrandfathered health care service plan, except a health care service plan offering a specialized health care service plan contract, that offers, amends, or renews...
• Section 1367.012.
  (a) (1) A small employer health care service plan contract in effect on December 31, 2013, and still in effect as of the effective date of this...
• Section 1367.015.
  In addition to complying with subdivision (h) of Section 1367.01, in determining whether to approve, modify, or deny requests by providers prior to, retrospectively, or...
• Section 1367.02.
  (a) On or before July 1, 1999, for purposes of public disclosure, every health care service plan shall file with the department a description of any...
• Section 1367.03.
  (a) Not later than January 1, 2004, the department shall develop and adopt regulations to ensure that enrollees have access to needed health care services in...
• Section 1367.031.
  (a) A health care service plan contract that is issued, renewed, or amended on or after July 1, 2017, shall provide information to an enrollee regarding...
• Section 1367.035.
  (a) As part of the reports submitted to the department pursuant to subdivision (f) of Section 1367.03 and regulations adopted pursuant to that section, a health...
• Section 1367.04.
  (a) Not later than January 1, 2006, the department shall develop and adopt regulations establishing standards and requirements to provide health care service plan enrollees with...
• Section 1367.041.
  (a) A health care service plan that advertises or markets products in the individual or small group health care service plan markets, or allows any other...
• Section 1367.042.
  (a) A health care service plan shall notify enrollees and members of the public of all of the following information:(1) The availability of language assistance services, including...
• Section 1367.05.
  (a)  Nothing in this chapter shall prohibit a health care service plan from entering into a contract with a dental college approved by the Board...
• Section 1367.06.
  (a) A health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after January...
• Section 1367.07.
  Within one year after a health care service plan’s assessment pursuant to subdivision (b) of Section 1367.04, the health care service plan shall report to...
• Section 1367.08.
  A health care service plan shall annually disclose to the governing board of a public agency that is the subscriber of a group contract, the...
• Section 1367.09.
  (a)  An enrollee with coverage for Medicare benefits who is discharged from an acute care hospital shall be allowed to return to a skilled nursing...
• Section 1367.1.
  Subdivision (i) of Section 1367 shall apply to transitionally licensed plans only insofar as it relates to contracts entered into, amended, delivered, or renewed in...
• Section 1367.2.
  (a)  On and after January 1, 1990, every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall offer...
• Section 1367.3.
  (a) Every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall offer benefits for the comprehensive preventive care of...
• Section 1367.35.
  (a) On and after January 1, 1993, every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall provide benefits...
• Section 1367.36.
  (a)  A risk-based contract between a health care service plan and a physician or physician group that is issued, amended, delivered, or renewed in this...
• Section 1367.4.
  No plan issuing, providing, or administering any contract of individual or group coverage providing medical, surgical, or dental expense benefits applied for and issued on...
• Section 1367.41.
  (a) Commencing January 1, 2017, a health care service plan shall maintain a pharmacy and therapeutics committee that shall be responsible for developing, maintaining, and overseeing...
• Section 1367.42.
  (a) For plan years commencing on or after January 1, 2017, a plan that provides essential health benefits shall allow an enrollee to access prescription drug...
• Section 1367.43.
  Commencing January 1, 2019, a health care service plan shall prorate an enrollee’s cost sharing for a partial fill of a prescription dispensed pursuant to...
• Section 1367.45.
  (a)  Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2002, that covers hospital,...
• Section 1367.46.
  Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2009, that covers hospital, medical,...
• Section 1367.49.
  (a) A contract issued, amended, renewed, or delivered on or after January 1, 2015, by or on behalf of a health care service plan and a...
• Section 1367.5.
  No health care service plan contract that is issued, amended, renewed, or delivered on and after January 1, 2002, shall contain a provision that prohibits...
• Section 1367.50.a.
  (a) No contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health care service plan and a provider or...
• Section 1367.51.
  (a)  Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after...
• Section 1367.54.
  (a) Every group health care service plan contract that provides maternity benefits, except for a specialized health care service plan contract, that is issued, amended, renewed,...
• Section 1367.6.
  (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after January...
• Section 1367.61.
  Every health care service plan contract which provides for the surgical procedure known as a laryngectomy and which is issued, amended, delivered, or renewed in...
• Section 1367.62.
  (a)  No health care service plan contract that is issued, amended, renewed, or delivered on or after the effective date of the act adding this...
• Section 1367.63.
  (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on...
• Section 1367.635.
  (a) Every health care service plan contract that is issued, amended, renewed, or delivered on or after January 1, 1999, that provides coverage for surgical procedures...
• Section 1367.64.
  (a)  Every individual or group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, or renewed...
• Section 1367.65.
  (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered,...
• Section 1367.656.
  (a) Notwithstanding any other law, an individual or group health care service plan contract issued, amended, or renewed on or after January 1, 2015, that provides...
• Section 1367.66.
  Every individual or group health care service plan contract, except for a specialized health care service plan, that is issued, amended, or renewed on or...
• Section 1367.665.
  Every individual or group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, delivered, or renewed...
• Section 1367.67.
  Every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state on or...
• Section 1367.68.
  (a)  Any provision in a health care service plan contract entered into, amended, or renewed in this state on or after July 1, 1995, that...
• Section 1367.69.
  (a)  On or after January 1, 1995, every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered,...
• Section 1367.695.
  (a)  The Legislature finds and declares that the unique, private, and personal relationship between women patients and their obstetricians and gynecologists warrants direct access to...
• Section 1367.7.
  On and after January 1, 1980, every health care service plan contract that covers hospital, medical, or surgical expenses on a group basis, and which...
• Section 1367.71.
  (a)  Every health care service plan contract, other than a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or...
• Section 1367.8.
  No plan issuing, providing, or administering any individual or group health care service plan entered into, amended, or issued on or after January 1, 1981,...
• Section 1367.9.
  No health care service plan contract which covers hospital, medical, or surgical expenses shall be issued, amended, delivered, or renewed in this state on or...
• Section 1367.10.a.
  (a) Every health care service plan shall include within its disclosure form and within its evidence of coverage a statement clearly describing how participation in the...
• Section 1367.11.
  (a)  Every health care service plan issued, amended, or renewed on or after January 1, 1987, that offers coverage for medical transportation services, shall contain...
• Section 1367.12.
  No health care service plan that administers Medicare coverage and federal employee programs may require that more than one form be submitted per claim in...
• Section 1367.15.
  (a) This section shall apply to individual health care service plan contracts and plan contracts sold to employer groups with fewer than two eligible employees as...
• Section 1367.18.
  (a) Every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses on a group basis shall offer...
• Section 1367.19.
  On and after January 1, 1991, every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses...
• Section 1367.20.a.
  Every health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall provide to members of the public, upon...
• Section 1367.205.
  (a) In addition to the list required to be provided under Section 1367.20, a health care service plan that provides prescription drug benefits and maintains one...
• Section 1367.21.
  (a) No health care service plan contract which covers prescription drug benefits shall be issued, amended, delivered, or renewed in this state if the plan limits...
• Section 1367.215.
  (a)  Every health care service plan contract that covers prescription drug benefits shall provide coverage for appropriately prescribed pain management medications for terminally ill patients...
• Section 1367.22.
  (a)  A health care service plan contract, issued, amended, or renewed on or after July 1, 1999, that covers prescription drug benefits shall not limit...
• Section 1367.23.
  (a)  On and after January 1, 1994, every group health care service plan contract, which is issued, amended, or renewed, shall include a provision requiring...
• Section 1367.24.
  (a) Every health care service plan that provides prescription drug benefits shall maintain an expeditious process by which prescribing providers may obtain authorization for a medically...
• Section 1367.241.
  (a) Notwithstanding any other law, on and after January 1, 2013, a health care service plan that provides coverage for prescription drugs shall accept only the...
• Section 1367.243.
  (a) (1) A health care service plan that reports rate information pursuant to Section 1385.03 or 1385.045 shall report the information described in paragraph (2) to the...
• Section 1367.244.
  (a) A request for an exception to a health care service plan’s step therapy process for prescription drugs may be submitted in the same manner as...
• Section 1367.25.
  (a) A group health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or...
• Section 1367.27.
  (a) Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver...
• Section 1367.29.
  (a) On and after July 1, 2011, in accordance with the requirements of subdivision (b), every health care service plan that provides coverage for professional mental...
• Section 1367.30.a.
  Notwithstanding any other provision of law, every group health care service plan contract marketed, issued, or delivered to a resident of this state, regardless of...
• Section 1367.31.
  (a) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2017, shall be prohibited from requiring an enrollee to...
• Section 1368.
  (a) Every plan shall do all of the following:(1) Establish and maintain a grievance system approved by the department under which enrollees may submit their grievances to...
• Section 1368.01.
  (a)  The grievance system shall require the plan to resolve grievances within 30 days, except as provided in subdivision (c).(b)  The grievance system shall include...
• Section 1368.015.
  (a) Effective July 1, 2003, every plan with an Internet Web site shall provide an online form through its Internet Web site that subscribers or enrollees...
• Section 1368.016.
  (a) A health care service plan that provides coverage for professional mental health services, including a specialized health care service plan that provides coverage for professional...
• Section 1368.02.
  (a) The director shall establish and maintain a toll-free telephone number for the purpose of receiving complaints regarding health care service plans regulated by the director.(b) Every...
• Section 1368.03.
  (a) The department may require enrollees and subscribers to participate in a plan’s grievance process for up to 30 days before pursuing a grievance through the...
• Section 1368.04.
  (a) The director shall investigate and take enforcement action against plans regarding grievances reviewed and found by the department to involve noncompliance with the requirements of...
• Section 1368.05.
  (a) (1) By enacting this section, which was originally enacted by Assembly Bill 922 (Chapter 552 of the Statutes of 2011), the Legislature recognizes that, because of...
• Section 1368.1.
  (a)  A plan that denies coverage to an enrollee with a terminal illness, which for the purposes of this section refers to an incurable or...
• Section 1368.2.
  (a) On and after January 1, 2002, every group health care service plan contract, except a specialized health care service plan contract, which is issued, amended,...
• Section 1368.5.
  (a)  Every health care service plan that offers coverage for a service that is within the scope of practice of a duly licensed pharmacist may...
• Section 1369.
  Every plan shall establish procedures to permit subscribers and enrollees to participate in establishing the public policy of the plan. For purposes of this section,...
• Section 1370.
  Every plan shall establish procedures in accordance with department regulations for continuously reviewing the quality of care, performance of medical personnel, utilization of services and...
• Section 1370.1.
  Nothing in this article shall be construed to prevent a plan from utilizing subcommittees to participate in peer review activities, nor to prevent a plan...
• Section 1370.2.
  Upon an appeal to the plan of a contested claim, the plan shall refer the claim to the medical director or other appropriately licensed health...
• Section 1370.4.
  (a) Every health care service plan shall provide an external, independent review process to examine the plan’s coverage decisions regarding experimental or investigational therapies for individual...
• Section 1370.6.
  (a)  For an enrollee diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer, every...
• Section 1371.
  A health care service plan, including a specialized health care service plan, shall reimburse claims or any portion of any claim, whether in state or...
• Section 1371.1.
  (a) (1) Whenever a health care service plan, including a specialized health care service plan, determines that in reimbursing a claim for provider services an institutional or...
• Section 1371.2.
  No health care service plan, including a specialized health care service plan, shall request reimbursement for overpayment or reduce the level of payment to a...
• Section 1371.22.
  If a contract between a health care service plan and a provider requires that the provider accept, as payment from the plan, the lowest payment...
• Section 1371.25.
  A plan, any entity contracting with a plan, and providers are each responsible for their own acts or omissions, and are not liable for the...
• Section 1371.3.
  On and after January 1, 1994, every group health care service plan that provides hospital, medical, or surgical expense benefits for plan members and their...
• Section 1371.30.a.
  (a) (1)  By September 1, 2017, the department shall establish an independent dispute resolution process for the purpose of processing and resolving a claim dispute between...
• Section 1371.31.
  (a) (1) For services rendered subject to Section 1371.9, effective July 1, 2017, unless otherwise agreed to by the noncontracting individual health professional and the plan, the...
• Section 1371.35.
  (a)  A health care service plan, including a specialized health care service plan, shall reimburse each complete claim, or portion thereof, whether in state or...
• Section 1371.36.
  (a)  A health care service plan shall not deny payment of a claim on the basis that the plan, medical group, independent practice association, or...
• Section 1371.37.
  (a)  A health care service plan is prohibited from engaging in an unfair payment pattern, as defined in this section. (b)  Consistent with subdivision (a)...
• Section 1371.38.
  (a)  The department shall, on or before July 1, 2001, adopt regulations that ensure that plans have adopted a dispute resolution mechanism pursuant to subdivision...
• Section 1371.39.
  (a)  Providers may report to the department’s Office of Plan and Provider Relations, either through the toll-free provider line (877-525-1295) or e-mail address (plans-providers@dmhc.ca.gov), instances...
• Section 1371.4.
  (a) A health care service plan that covers hospital, medical, or surgical expenses, or its contracting medical providers, shall provide 24-hour access for enrollees and providers,...
• Section 1371.5.
  (a)  No health care service plan that provides basic health care services shall require prior authorization or refuse to pay for any ambulance or ambulance...
• Section 1371.8.
  A health care service plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization after the provider...
• Section 1371.9.
  (a) (1) Except as provided in subdivision (c), a health care service plan contract issued, amended, or renewed on or after July 1, 2017, shall provide that...
• Section 1372.
  Subject to the applicable provisions of this chapter, a plan may offer one or more plan contracts or specialized health care service plan contracts, except...
• Section 1373.
  (a) (1) A plan contract may not provide an exception for other coverage if the other coverage is entitlement to Medi-Cal benefits under Chapter 7 (commencing with...
• Section 1373.1.
  Every group plan entered into, amended, or renewed on or after January 1, 1977, which provides hospital, medical, or surgical expense benefits for employees or...
• Section 1373.2.
  Every group health care service plan entered into, amended, or renewed on or after January 1, 1976, which provides hospital, medical, or surgical expense benefits...
• Section 1373.3.
  An enrollee shall not be prohibited from selecting as a primary care physician any available primary care physician who contracts with the plan in the...
• Section 1373.4.
  (a) No health care service plan contract that is issued, amended, renewed, or delivered on or after July 1, 2003, that provides maternity coverage shall do...
• Section 1373.5.
  When spouses are both employed as employees, and both have enrolled themselves and their eligible family members under a group health care service plan provided...
• Section 1373.6.
  This section does not apply to a specialized health care service plan contract or to a plan contract that primarily or solely supplements Medicare. The...
• Section 1373.620.
  (a) (1) At least 60 days prior to the plan renewal date, a health care service plan that does not otherwise issue individual health care service plan...
• Section 1373.621.
  (a) Except for a specialized health care service plan, every health care service plan contract that is issued, amended, delivered, or renewed in this state on...
• Section 1373.622.
  (a) (1) After the termination of the pilot program under Section 1373.62, a health care service plan shall continue to provide coverage under the same terms and...
• Section 1373.65.
  (a) At least 75 days before the termination date of its contract with a provider group or a general acute care hospital, the health care service...
• Section 1373.7.
  A health care service plan contract, which is written or issued for delivery outside of California and which provides benefits for California residents that are...
• Section 1373.8.
  A health care service plan contract where the plan is licensed to do business in this state and the plan provides coverage that includes California...
• Section 1373.9.
  (a)   Except in the case of a specialized health care service plan, a health care service plan which negotiates and enters into a contract...
• Section 1373.95.
  (a) (1) A health care service plan, other than a specialized health care service plan that offers professional mental health services on an employer-sponsored group basis, shall...
• Section 1373.96.
  (a) A health care service plan shall, at the request of an enrollee, provide the completion of covered services as set forth in this section by...
• Section 1373.10.a.
  (a)  On and after January 1, 1985, every health care service plan, that is not a health maintenance organization or is not a plan that...
• Section 1373.11.
  A health care service plan that offers or provides one or more podiatry services, as defined in Section 2472 of the Business and Professions Code,...
• Section 1373.12.
  A health care service plan which offers or provides one or more chiropractic services, as defined in Section 7 of the Chiropractic Initiative Act, as...
• Section 1373.13.
  (a)  It is the intent of the Legislature that all persons licensed in this state to engage in the practice of dentistry shall be accorded...
• Section 1373.14.
  Except for a preexisting condition, any health care service plan, except a specialized health care service plan, which provides coverage on a group or individual...
• Section 1373.18.
  Whenever any health care service plan, except a specialized health care service plan, negotiates and enters into a contract with providers to provide services at...
• Section 1373.19.
  Any health care service plan that includes a term that requires the parties to submit to binding arbitration shall, for those cases or disputes for...
• Section 1373.20.a.
  (a)  If a plan uses arbitration to settle disputes with enrollees or subscribers, and does not use a professional dispute resolution organization independent of the...
• Section 1373.21.
  (a)  If a health care service plan uses arbitration to settle disputes with enrollees or subscribers, it shall require that an arbitration award be accompanied...
• Section 1374.
  If a health care service plan entered into, amended, or renewed in this state on or after the effective date of this section provides in...
• Section 1374.3.
  Notwithstanding any other provision of this chapter or of a health care service plan contract, every health care service plan shall comply with the requirements...
• Section 1374.5.
  A health care service plan, which is issued, renewed, or amended on or after January 1, 1988, which includes mental health services coverage in nongroup...
• Section 1374.51.
  No plan may utilize any information regarding whether an enrollee’s psychiatric inpatient admission was made on a voluntary or involuntary basis for the purpose of...
• Section 1374.55.
  (a)  On and after January 1, 1990, every health care service plan contract that is issued, amended, or renewed that covers hospital, medical, or surgical...
• Section 1374.56.
  (a)  On and after July 1, 2000, every health care service plan contract, except a specialized health care service plan contract, issued, amended, delivered, or...
• Section 1374.57.
  (a)  No group health care service plan that provides hospital, medical, or surgical expense benefits for employees or subscribers and their dependents shall exclude a...
• Section 1374.58.
  (a) A group health care service plan that provides hospital, medical, or surgical expense benefits shall provide equal coverage to employers or guaranteed associations, as defined...
• Section 1374.7.
  (a)  No plan shall refuse to enroll any person or accept any person as a subscriber or renew any person as a subscriber after appropriate...
• Section 1374.75.
  (a)  No health care service plan shall deny, refuse to enroll, refuse to renew, cancel, restrict, or otherwise terminate, exclude, or limit coverage, or charge...
• Section 1374.8.
  (a) A health care service plan shall not release any information to an employer that would directly or indirectly indicate to the employer that an employee...
• Section 1374.9.
  For violations of Section 1374.7, the director may, after appropriate notice and opportunity for hearing, by order, levy administrative penalties as follows:(a) Any health care service...
• Section 1374.10.
  (a)  Every health care service plan that covers hospital, medical or surgical expenses and which is not qualified as a health maintenance organization under Title...
• Section 1374.11.
  No health care service plan shall deny a claim for hospital, medical, surgical, dental, or optometric services for the sole reason that the individual served...
• Section 1374.12.
  No health care service plan contract issued, entered into, or renewed on or after July 1, 1984, shall be deemed to contain any provision restricting...
• Section 1374.13.
  (a) For the purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.(b) It is the intent...
• Section 1374.15.
  Any health care service plan shall, upon request by any public entity or political subdivision of the state with whom it has entered into a...
• Section 1374.16.
  (a) Every health care service plan, except a specialized health care service plan, shall establish and implement a procedure by which an enrollee may receive a...
• Section 1374.17.
  (a) A health care service plan shall not deny coverage that is otherwise available under the plan contract for the costs of solid organ or other...
• Section 1374.19.
  (a)  This section shall only apply to a health care service plan covering dental services or a specialized health care service plan contract covering dental...
• Section 1374.195.
  (a)  With respect to a contract between a health care service plan or specialized health care service plan and a dentist to provide covered dental...

Last modified: October 22, 2018