Insurance Code

Part 2 of 23 · provisions 201–400

This section says the act is known as the Insurance Code.

Jurisdiction: United States — California
Instrument: Code
Citation: INS
Version: Undated source snapshot
Language: en
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This section defines “underwriters’ corps” for this chapter. This chapter must not impair or interfere with the powers or duties of a municipality’s regular fire department. An owner of property cannot treat an underwriters’ corps act as a justification for abandoning the property. Certain domestic insurance-underwriter corporations may maintain an underwriter’s corps at their own expense if they meet the stated fire-prevention and local-business conditions. An underwriter’s corps may enter certain burning or fire-exposed buildings and may remove or protect property from fire or water damage while a fire is happening and immediately after.

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Provisions of Insurance Code

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10115.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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If an applicant pays the full first premium and the application for non-group life insurance is approved, the insurer must pay the policy amount if the insured dies before the policy is issued and delivered, subject to the same rights, conditions, and defenses that would apply if the policy had already been issued.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10115. When a payment is made equal to the full first premium at the time an application for life insurance other than group life insurance is signed by the applicant and either (1) the applicant received at that time a receipt for said payment on a form prepared by the insurer, or (2) in the absence of such a receipt the insurer receives the said payment at its home office, branch office, or the office of one of its general agencies, and in either case the insurer, pursuant to its regular underwriting practices and standards, approves the application for the issuance by it of a policy of life insurance on the plan and for the class of risk and amount of insurance applied for, and the person to be insured dies on or after the date of the application, on or after the date of the medical examination, if any, or on or after any date specially requested in the application for the policy to take effect, whichever is later, but before such policy is issued and delivered, the insurer shall pay such amount as would have been due under the terms of the policy in the same manner and subject to the same rights, conditions and defenses as if such policy had been issued and delivered on the date the application was signed by the applicant. The provisions of this section shall not prohibit an insurer from limiting the maximum amount for which it may be liable prior to actual issuance and delivery of the policy of life insurance either to (1) an amount not less than its established maximum retention, or to (2) fifty thousand dollars ($50,000), if a statement to this effect is included in the application. (Amended by Stats. 1951, Ch. 53.)
10116.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain employer-paid group life or disability policies cannot be issued or delivered unless they include continuation of coverage during a labor-dispute work stoppage, subject to stated payment and rate conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10116. No group life insurance policy or disability insurance policy shall be issued or delivered in this State where the premiums or any part thereof is paid or is to be paid in whole or in part by an employer pursuant to the terms of a collective bargaining agreement unless the policy provides that in the event of a cessation of work by the employees covered by the policy as the result of a labor dispute the policy, upon timely payment of the premium, shall continue in effect with respect to all employees insured by the policy on the date of the cessation of work who continue to pay their individual contribution, and who assume and pay the contribution due from the employer, for the period of cessation of work, under the following conditions: (a) If the policyholder is not a trustee or the trustees of a fund established or maintained in whole or in part by the employer, the policy shall provide that the employee’s individual contribution shall be the rate in the policy, on the date cessation of work occurs, applicable to an individual in the class to which the employee belongs as set forth in the policy. If the policy does not provide for a rate applicable to individuals, the policy shall provide that the employee’s individual contribution shall be an amount equal to the amount determined by dividing (1) the total monthly premium in effect under the policy at the date of cessation of work by (2) the total number of persons insured under the policy at such date. (b) If the policyholder is a trustee or the trustees of a fund established or maintained in whole or in part by the employer, the employee’s contribution shall be the amount which he and his employer would have been required to contribute to the trust for such employee if (1) the cessation of work had not occurred and (2) the agreement requiring the employer to make contributions to the trust were in full force. (c) The policy may provide that the continuation of insurance is contingent upon the collection of individual contributions by the union or unions representing the employees for policies referred to in subdivision (a) above, and by the policyholder or the policyholder’s agent with respect to policies referred to in subdivision (b) above. (d) The policy may provide that the continuation of insurance on each employee is contingent upon timely payment of contributions by the individual and timely payment of the premium by the entity responsible for collecting the individual contributions. (e) The policy may provide that each individual premium rate shall be increased by any amount up to twenty percent (20%), or any higher percent which may be approved by the commissioner, of that otherwise shown in the policy during the period of cessation of work in order to provide sufficient compensation to the insurer to cover increased administrative costs and increased mortality and morbidity. If the policy does provide for such an increase, this shall have the effect of increasing the employee’s contribution by a like percent. (f) Nothing in this section shall be deemed to limit any right which the insurer may have in accordance with the terms of the policy to increase or decrease the premium rates before, during or after such cessation of work if, in fact, the insurer would have had the right to increase the premium rate had the cessation of work not occurred. If such a premium rate change is made, it shall be effective, notwithstanding any other provisions of this section, on such date as the insurer shall determine in accordance with the terms of the policy. (g) The policy may contain such other provisions with respect to such continuation of insurance as the commissioner may approve. (h) The policy may provide that, if a premium is unpaid at the date of cessation of work and such premium became due prior to such cessation of work, the continuation of insurance is contingent upon payment of such premium prior to the date the next premium becomes due under the terms of the policy. Nothing herein shall be deemed to require the continuation of any loss of time payments included in any such group disability policy, nor of any other coverages beyond the time that seventy-five percent (75%) of the employees continue such coverage or as to any individual employee beyond the time that he takes full-time employment with another employer; nor shall anything herein be deemed to require continuation of coverage more than six (6) months after the cessation of work. Nothing in this section shall be construed as modifying or in any way affecting the operation and effect of the provisions of Part 2 of Division 1 of the Unemployment Insurance Code. (Added by Stats. 1961, Ch. 2097.)
10116.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers must offer continuation benefits to eligible former employees and former spouses, and employers and insurers must provide related notices and information.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10116.5. (a) Every policy of disability insurance that is issued, amended, delivered, or renewed in this state on or after January 1, 1999, that provides hospital, medical, or surgical expense coverage under an employer-sponsored group plan for an employer subject to COBRA, as defined in subdivision (e), or an employer group for which the disability insurer is required to offer Cal-COBRA coverage, as defined in subdivision (f), including a carrier providing replacement coverage under Section 10128.3, shall further offer the former employee the opportunity to continue benefits as required under subdivision (b), and shall further offer the former spouse of an employee or former employee the opportunity to continue benefits as required under subdivision (c). (b) (1) If a former employee worked for the employer for at least five years prior to the date of termination of employment and is 60 years of age or older on the date employment ends is entitled to and so elects to continue benefits under COBRA or Cal-COBRA for himself or herself and for any spouse, the employee or spouse may further continue benefits beyond the date coverage under COBRA or Cal-COBRA ends, as set forth in paragraph (2). Except as otherwise specified in this section, continuation coverage shall be under the same benefit terms and conditions as if the continuation coverage under COBRA or Cal-COBRA had remained in force. For the employee or spouse, continuation coverage following the end of COBRA or Cal-COBRA is subject to payment of premiums to the insurer. Individuals ineligible for COBRA or Cal-COBRA or who are eligible but have not elected or exhausted continuation coverage under federal COBRA or Cal-COBRA are not entitled to continuation coverage under this section. Premiums for continuation coverage under this section shall be billed by, and remitted to, the insurer in accordance with subdivision (d). Failure to pay the requisite premiums may result in termination of the continuation coverage in accordance with the applicable provisions in the insurer’s group contract with the employer. (2) The employer shall notify the former employee or spouse or both, or the former spouse of the employee or former employee, of the availability of the continuation benefits under this section in accordance with Section 2800.2 of the Labor Code. To continue health care coverage pursuant to this section, the individual shall elect to do so by notifying the insurer in writing within 30 calendar days prior to the date continuation coverage under COBRA or Cal-COBRA is scheduled to end. Every disability insurer shall provide to the employer replacing a group benefit plan policy issued by the insurer, or to the employer’s agent or broker representative, within 15 days of any written request, information in possession of the insurer reasonably required to administer the requirements of Section 2800.2 of the Labor Code. (3) The continuation coverage shall end automatically on the earlier of (A) the date the individual reaches age 65, (B) the date the individual is covered under any group health plan not maintained by the employer or any other insurer or health care service plan, regardless of whether that coverage is less valuable, (C) the date the individual becomes entitled to Medicare under Title XVIII of the Social Security Act, (D) for a spouse, five years from the date on which continuation coverage under COBRA or Cal-COBRA was scheduled to end for the spouse, or (E) the date on which the employer terminates its group contract with the insurer and ceases to provide coverage for any active employees through that insurer, in which case the insurer shall notify the former employee or spouse, or both, of the right to a conversion policy. (c) (1) If a former spouse of an employee or former employee was covered as a qualified beneficiary under COBRA or Cal-COBRA, the former spouse may further continue benefits beyond the date coverage under COBRA or Cal-COBRA ends, as set forth in paragraph (2) of subdivision (b). Except as otherwise specified in this section, continuation coverage shall be under the same benefit terms and conditions as if the continuation coverage under COBRA or Cal-COBRA had remained in force. Continuation coverage following the end of COBRA or Cal-COBRA is subject to payment of premiums to the insurer. Premiums for continuation coverage under this section shall be billed by, and remitted to, the insurer in accordance with subdivision (d). Failure to pay the requisite premiums may result in termination of the continuation coverage in accordance with the applicable provisions in the insurer’s group contract with the employer or former employer. (2) The continuation coverage for the former spouse shall end automatically on the earlier of (A) the date the individual reaches 65 years of age, (B) the date the individual is covered under any group health plan not maintained by the employer or any other health care service plan or insurer, regardless of whether that coverage is less valuable, (C) the date the individual becomes entitled to Medicare under Title XVIII of the Social Security Act, (D) five years from the date on which continuation coverage under COBRA or Cal-COBRA was scheduled to end for the former spouse, or (E) the date on which the employer or former employer terminates its group contract with the insurer and ceases to provide coverage for any active employees through that insurer. (d) (1) If the premium charged to the employer for a specific employee or dependent eligible under this section is adjusted for the age of the specific employee, or eligible dependent, on other than a composite basis, the rate for continuation coverage under this section shall not exceed 102 percent of the premium charged by the insurer to the employer for an employee of the same age as the former employee electing continuation coverage in the case of an individual who was eligible for COBRA, and 110 percent in the case of an individual who was eligible for Cal-COBRA. If the coverage continued is that of a former spouse, the premium charged shall not exceed 102 percent of the premium charged by the plan to the employer for an employee of the same age as the former spouse selecting continuation coverage in the case of an individual who was eligible for COBRA, and 110 percent in the case of an individual who was eligible for Cal-COBRA. (2) If the premium charged to the employer for a specific employee or dependent eligible under this section is not adjusted for age of the specific employee, or eligible dependent, then the rate for continuation coverage under this section shall not exceed 213 percent of the applicable current group rate. For purposes of this section, the “applicable current group rate” means the total premiums charged by the insurer for coverage for the group, divided by the relevant number of covered persons. (3) However, in computing the premiums charged to the specific employer group, the insurer shall not include consideration of the specific medical care expenditures for beneficiaries receiving continuation coverage pursuant to this section. (e) For purposes of this section, “COBRA” means Section 4980B of Title 26, Section 1161 and following of Title 29, and Section 300bb of Title 42 of the United States Code, as added by the Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99-272), and as amended. (f) For purposes of this section, “Cal-COBRA” means the continuation coverage that must be offered pursuant to Article 1.7 (commencing with Section 10128.50), or Article 4.5 (commencing with Section 1366.20) of Chapter 2.2 of Division 2 of the Health and Safety Code. (g) For the purposes of this section, “former spouse” means either an individual who is divorced from an employee or former employee or an individual who was married to an employee or former employee at the time of the death of the employee or former employee. (h) Every group benefit plan evidence of coverage that is issued, amended, or renewed after January 1, 1999, shall contain a description of the provisions and eligibility requirements for the continuation coverage offered pursuant to this section. (i) This section does not apply to any individual who is not eligible for its continuation coverage prior to January 1, 2005. (Amended by Stats. 2013, Ch. 441, Sec. 13. (AB 1180) Effective October 1, 2013.)
10117.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance-related coverage may not exclude or reduce benefits because a person has Medi-Cal or Medicaid coverage or entitlement.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10117. (a) A policy of disability insurance, self-insured employee welfare benefit plan, or nonprofit hospital service plan may not provide an exception for other coverage where the other coverage is entitlement to Medi-Cal benefits under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14500) of Part 3 of Division 9 of the Welfare and Institutions Code, or medicaid benefits under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code. Each policy of disability insurance shall be interpreted not to provide an exception for those Medi-Cal or medicaid benefits. (b) A policy of disability insurance may not provide that the benefits payable thereunder are subject to reduction if the individual insured has entitlement to such Medi-Cal benefits. (c) A policy of disability insurance, self-insured employee welfare benefit plan, or nonprofit hospital service plan shall not provide an exception for enrollment for benefits because of an applicant’s entitlement to Medi-Cal benefits under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14500) of Part 3 of Division 9 of the Welfare and Institutions Code, or medicaid benefits under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code. (Amended by Stats. 1994, Ch. 147, Sec. 10. Effective July 11, 1994.)
10117.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A disability insurer contract covering hospital, medical, or surgical benefits must not include terms that block or limit health facilities’ compliance with Health and Safety Code Section 1262.5.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10117.5. No disability insurer contract that covers hospital, medical, or surgical benefits that is issued, amended, renewed, or delivered on and after January 1, 2002, shall contain a provision that prohibits or restricts any health facilities’ compliance with the requirements of Section 1262.5 of the Health and Safety Code. (Added by Stats. 2001, Ch. 691, Sec. 6. Effective January 1, 2002.)
10117.52.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance contracts may not block certain claims-data disclosures to qualified entities, and any such disclosures must follow applicable privacy and security laws.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10117.52. (a) No health insurance contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health insurer and a provider or a supplier shall prohibit, condition, or in any way restrict the disclosure of claims data related to health care services provided to a policyholder or insured of the insurer or beneficiaries of any self-insured health coverage arrangement administered by the insurer, to a qualified entity, as defined in Section 1395kk(e)(2) of Title 42 of the United States Code. All disclosures of data made under this section shall comply with all applicable state and federal laws for the protection of the privacy and security of the data, including, but not limited to, the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) and the federal Health Information Technology for Economic and Clinical Health Act, Title XIII of the federal American Recovery and Reinvestment Act of 2009 (Public Law 111-5), and implementing regulations. (b) For purposes of this section, the following definitions apply: (1) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152). (2) “Provider” means a hospital, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, a hospice, a clinic, or a rehabilitation agency. (3) “Supplier” means a physician and surgeon or other health care practitioner, or an entity that furnishes health care services other than a provider. (Added by Stats. 2012, Ch. 869, Sec. 3. (SB 1196) Effective January 1, 2013.)
10118.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies must keep dependent child coverage going past the limiting age if the child remains unable to work due to an intellectual disability or physical handicap and still depends on the insured for support, with proof given to the insurer on time.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10118. A policy of disability insurance delivered or issued for delivery in this state more than 120 days after the effective date of this section, that provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy or contract, shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of an intellectual disability or physical handicap and (b) chiefly dependent upon the insured for support and maintenance, provided proof of the incapacity and dependency is furnished to the insurer by the insured within 31 days of the child’s attainment of the limiting age and subsequently as may be required by the insurer, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age. Disability policies currently approved by the commissioner that are delivered or issued for delivery more than 120 days after the effective date of this section shall be automatically construed to be in compliance with this section and need not be refiled or reprinted. Disability policies submitted to the commissioner for approval on and after the effective date of this section shall contain provisions in compliance with this section. (Amended by Stats. 2012, Ch. 457, Sec. 36. (SB 1381) Effective January 1, 2013.)
10119.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies covering an insured’s immediate family cannot be issued or amended in California if they limit newborn or adopted-child coverage in the ways described here.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119. On and after the operative date of this section: (a) No policy of disability insurance which, in addition to covering the insured, also covers members of the insured’s immediate family, may be issued or amended in this state if it contains any disclaimer, waiver, or other limitation of coverage relative to the accident and sickness coverage or insurability of newborn infants of an insured from and after the moment of birth or of any minor child placed with an insured for adoption from and after the moment the child is placed in the physical custody of the insured for adoption. (b) Each such policy of disability insurance shall contain a provision granting immediate accident and sickness coverage to each newborn infant of, and each minor child placed for adoption with, any insured as required by subdivision (a). (c) A policy of disability insurance, self-insured care coverage, employee welfare benefit plan, or nonprofit hospital service plan, shall comply with the standards set forth in Chapter 7 (commencing with Section 3750) of Part 1 of Division 9 of the Family Code and Section 14124.94 of the Welfare and Institutions Code. (Amended by Stats. 1996, Ch. 1062, Sec. 20. Effective January 1, 1997.)
10119.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer must let eligible long-term enrollees transfer to another plan it offers, and it must give notice and maintain a plan ranking system.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.1. (a) This section shall apply to a health insurer that covers hospital, medical, or surgical expenses under an individual health benefit plan, as defined in subdivision (a) of Section 10198.6, that is issued, amended, renewed, or delivered on or after January 1, 2007. (b) At least once each year, a health insurer shall permit an individual who has been covered for at least 18 months under an individual health benefit plan to transfer, without medical underwriting, to any other individual health benefit plan offered by that same health insurer that provides equal or lesser benefits as determined by the insurer. “Without medical underwriting” means that the health insurer shall not decline to offer coverage to, or deny enrollment of, the individual or impose any preexisting condition exclusion on the individual who transfers to another individual health benefit plan pursuant to this section. (c) The insurer shall establish, for the purposes of subdivision (b), a ranking of the individual health benefit plans it offers to individual purchasers and post the ranking on its Internet Web site or make the ranking available upon request. The insurer shall update the ranking whenever a new benefit design for individual purchasers is approved. (d) The insurer shall notify in writing all insureds of the right to transfer to another individual health benefit plan pursuant to this section, at a minimum, when the insurer changes the insured’s premium rate. Posting this information on the insurer’s Internet Web site shall not constitute notice for purposes of this subdivision. The notice shall adequately inform insureds of the transfer rights provided under this section including information on the process to obtain details about the individual health benefit plans available to that insured and advising that the insured may be unable to return to his or her current individual health benefit plan if the insured transfers to another individual health benefit plan. (e) The requirements of this section shall not apply to the following: (1) A federally eligible defined individual, as defined in subdivision (e) of Section 10900, who purchases individual coverage pursuant to Section 10785. (2) An individual offered conversion coverage pursuant to Sections 12672 and 12682.1. (3) An individual enrolled in the Medi-Cal program pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code. (4) An individual enrolled in the Access for Infants and Mothers Program, pursuant to Part 6.3 (commencing with Section 12695). (5) An individual enrolled in the Healthy Families Program pursuant to Part 6.2 (commencing with Section 12693). (f) It is the intent of the Legislature that individuals shall have more choice in their health care coverage when health insurers guarantee the right of an individual to transfer to another product based on the insurer’s own ranking system. The Legislature does not intend for the department to review or verify the insurer’s ranking for actuarial or other purposes. (g) (1) This section shall become inoperative on January 1, 2014, or the 91st calendar day following the adjournment of the 2013–14 First Extraordinary Session, whichever date is later. (2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-4), this section shall become operative 12 months after the date of that repeal or amendment. (Amended by Stats. 2013, 1st Ex. Sess., Ch. 1, Sec. 3. (AB 2 1x) Effective September 30, 2013. Inoperative, by its own provisions, on January 1, 2014, subject to condition for resuming operation.)
10119.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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An agent or broker assisting a health insurance applicant must help provide accurate, complete answers and must sign the written application confirming accuracy and that the risk of inaccurate information was explained. A false, willful material statement in that attestation can lead to a civil penalty of up to $10,000, enforceable by a public prosecutor.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.3. (a) Notwithstanding any other provision of law, an agent or broker who assists an applicant in submitting an application to a health insurer has the duty to assist the applicant in providing answers to health questions accurately and completely. (b) An agent or broker who assists an applicant in submitting an application to a health insurer shall attest on the written application to both of the following: (1) That to the best of his or her knowledge, the information on the application is complete and accurate. (2) That he or she explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and that the applicant understood the explanation. (c) If, in an attestation required by subdivision (b), a declarant willfully states as true any material fact he or she knows to be false, that person shall, in addition to any applicable penalties or remedies available under current law, be subject to a civil penalty of up to ten thousand dollars ($10,000). Any public prosecutor may bring a civil action to impose that civil penalty. These penalties shall be paid to the Insurance Fund. (d) A health insurance application shall include a statement advising declarants of the civil penalty authorized under this section. (Added by Stats. 2008, Ch. 604, Sec. 4. Effective January 1, 2009.)
10119.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies with maternity coverage may not charge higher copayments or deductibles for maternity inpatient or ambulatory care than for comparable other covered services, and certain group or blanket policies with maternity benefits are restricted if they contain pregnancy-related limitations.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.5. (a) No individual or group policy of health insurance that is issued, amended, renewed, or delivered on or after July 1, 2003, that provides maternity coverage shall contain a copayment or deductible for inpatient hospital maternity services that exceeds the most common amount of the copayment or deductible contained in the policy for inpatient services provided for other covered medical conditions or contain a copayment or deductible for ambulatory care maternity services that exceeds the most common amount of the copayment or deductible contained in the policy for ambulatory care services provided for other covered medical conditions. (b) No group or blanket policy of health insurance that provides maternity benefits for a person covered continuously from conception shall be issued, amended, delivered, or renewed in this state if it contains any exclusion, reduction, or other limitations as to coverage, deductibles, or coinsurance provisions, as to involuntary complications of pregnancy, unless the provisions apply generally to all benefits paid under the policy. (c) For purposes of this section, involuntary complications of pregnancy shall include, but not be limited to, puerperal infection, eclampsia, cesarean section delivery, ectopic pregnancy, and toxemia. (d) This section shall not apply to Medicare supplement, vision-only, or Champus-supplement insurance, or to hospital indemnity, accident-only, and specified disease insurance that does not pay benefits on a fixed benefit, cash payment only basis. (e) This section shall not permit copayments or deductibles in the Medi-Cal program that are not otherwise authorized under state or federal law. (f) This section shall become operative on July 1, 2003. (Repealed (in Sec. 4) and added by Stats. 2002, Ch. 880, Sec. 5. Effective January 1, 2003. Section operative July 1, 2003, by its own provisions.)
10119.6.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies must cover or offer infertility and fertility services under specified conditions, and policies may not impose discriminatory limits or exclusions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.6. (a) (1) A large group health insurance policy that is issued, amended, or renewed on or after January 1, 2026, shall provide coverage for the diagnosis and treatment of infertility and fertility services, including a maximum of three completed oocyte retrievals with unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine (ASRM), using single embryo transfer when recommended and medically appropriate. (2) A small group health insurance policy that is issued, amended, or renewed on or after January 1, 2026, shall offer coverage for the diagnosis and treatment of infertility and fertility services. This paragraph shall not be construed to require a small group health insurance policy to provide coverage for infertility services. (3) A health insurer shall include notice of the coverage specified in this section in the insurer’s evidence of coverage. (4) This section shall not apply to Medicare supplement or specialized health insurance policies. (b) For purposes of this section, “infertility” means a condition or status characterized by any of the following: (1) A licensed physician’s findings, based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors. This definition shall not prevent testing and diagnosis before the 12-month or 6-month period to establish infertility in paragraph (3). (2) A person’s inability to reproduce either as an individual or with their partner without medical intervention. (3) The failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. For purposes of this section, “regular, unprotected sexual intercourse” means no more than 12 months of unprotected sexual intercourse for a person under 35 years of age or no more than 6 months of unprotected sexual intercourse for a person 35 years of age or older. Pregnancy resulting in miscarriage does not restart the 12-month or 6-month time period to qualify as having infertility. (c) The policy may not include any of the following: (1) Any exclusion, limitation, or other restriction on coverage of fertility medications that are different from those imposed on other prescription medications. (2) Any exclusion or denial of coverage of any fertility services based on a covered individual’s participation in fertility services provided by or to a third party. For purposes of this section, “third party” includes an oocyte, sperm, or embryo donor, gestational carrier, or surrogate that enables an intended recipient to become a parent. (3) Any deductible, copayment, coinsurance, benefit maximum, waiting period, or any other limitation on coverage for the diagnosis and treatment of infertility, except as provided in subdivision (a) that are different from those imposed upon benefits for services not related to infertility. (d) This section does not in any way deny or restrict any existing right or benefit to coverage and treatment of infertility or fertility services under an existing law, plan, or policy. (e) This section applies to every health insurance policy that is issued, amended, or renewed to residents of this state regardless of the situs of the contract. (f) Consistent with Section 10140, coverage for the treatment of infertility and fertility services shall be provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation. This subdivision shall not be construed to interfere with the clinical judgment of a physician and surgeon. (g) This section shall not apply to a religious employer, as defined in Section 10123.196. (h) This section shall not apply to a health care benefit plan or policy entered into with the Board of Administration of the Public Employees’ Retirement System pursuant to the Public Employees’ Medical and Hospital Care Act (Part 5 (commencing with Section 22750) of Division 5 of Title 2 of the Government Code) until July 1, 2027. (i) (1) Until January 1, 2027, the commissioner may issue guidance regarding compliance with this section, and that guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (2) The department shall consult with the Department of Managed Health Care and stakeholders in issuing the guidance specified in paragraph (1). (Amended by Stats. 2025, Ch. 243, Sec. 9. (SB 862) Effective January 1, 2026.)
10119.7.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies covering hospital, medical, or surgical expenses may not include exclusions or limits that apply only to conditions caused by diethylstilbestrol (DES) exposure.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.7. No group or individual policy of disability insurance which covers hospital, medical, or surgical expenses shall be issued, amended, delivered, or renewed in this state on or after January 1, 1981, if it contains any exclusion, reduction, or other limitations, as to coverage, deductibles, or coinsurance provisions applicable solely to conditions attributable to diethylstilbestrol or exposure to diethylstilbestrol. All policies subject to this section and issued, amended, delivered, or renewed in this state on or after January 1, 1981, shall be construed to be in compliance with this section, and any provision in any such policy which is in conflict with this section shall be of no force or effect. (Added by Stats. 1980, Ch. 776, Sec. 3.)
10119.8.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain insurers must offer coverage for blood lead level screening for covered children.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.8. On and after January 1, 1993, every insurer issuing, amending, or renewing a policy of individual or group disability insurance that covers hospital, medical, or surgical expenses shall offer coverage for screening for blood lead levels for covered children. This section shall not apply to specified accident, specified disease, hospital indemnity, Medicare supplement, or long-term care health insurance policies. (Added by Stats. 1991, Ch. 797, Sec. 2.)
10119.9.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must treat qualifying dental anesthesia and related facility charges as covered, but they do not have to cover the dental procedure itself.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10119.9. (a) A disability insurance policy or certificate covering hospital, surgical, or medical expenses, that meets the definition of “health benefit plan” in subdivision (a) of Section 10198.6, that is issued, amended, renewed, or delivered on or after January 1, 2000, shall be deemed to cover general anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center setting, when the clinical status or underlying medical condition of the insured requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital or surgery center setting. The disability insurance policy or certificate may require prior authorization of general anesthesia and associated charges required for dental care procedures in the same manner that prior authorization is required for other covered diseases or conditions. (b) This section shall apply only to general anesthesia and associated facility charges for only the following insureds, and only if the insureds meet the criteria in subdivision (a): (1) Insureds who are under seven years of age. (2) Insureds who are developmentally disabled, regardless of age. (3) Insureds whose health is compromised and for whom general anesthesia is medically necessary, regardless of age. (c) Nothing in this section shall require insurers to cover any charges for the dental procedure itself, including the professional fee of the dentist. Coverage for anesthesia and associated facility charges pursuant to this section shall be subject to all other terms and conditions of the policy or certificate that apply generally to other benefits. (d) Nothing in this section shall require insurers to cover anesthesia or related facility charges for dental procedures that ordinarily would require general anesthesia and that do not meet the requirements of subdivision (a), (b), or (c). (e) A disability insurance policy may include coverage specified in subdivision (a) at any time prior to January 1, 2000. (Added by Stats. 1998, Ch. 790, Sec. 2. Effective January 1, 1999.)
1012.
## Insurance Code - INS ## DIVISION 1. GENERAL RULES GOVERNING INSURANCE [100 - 1879.8] ( Division 1 enacted by Stats. 1935, Ch. 145. ) ## PART 2. THE BUSINESS OF INSURANCE [680 - 1879.8] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. General Regulations [680 - 1113] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 14. Proceedings in Cases of Insolvency and Delinquency [1010 - 1062] ( Article 14 amended by Stats. 1935, Ch. 291. )
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An order stays in effect until a court, after a full hearing, finds the basis for it no longer exists or has been removed and that the person can resume control of the property and business.

## Insurance Code - INS ## DIVISION 1. GENERAL RULES GOVERNING INSURANCE [100 - 1879.8] ( Division 1 enacted by Stats. 1935, Ch. 145. ) ## PART 2. THE BUSINESS OF INSURANCE [680 - 1879.8] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. General Regulations [680 - 1113] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 14. Proceedings in Cases of Insolvency and Delinquency [1010 - 1062] ( Article 14 amended by Stats. 1935, Ch. 291. ) ## 1012. Except in the case of an order issued based on a verified application showing the conditions in subdivision (j) of Section 1011 to exist, the order shall continue in force and effect until, on the application either of the commissioner or of that person, it shall, after a full hearing, appear to the court that the ground for the order directing the commissioner to take title and possession does not exist or has been removed and that the person can properly resume title and possession of its property and the conduct of its business. (Amended by Stats. 2013, Ch. 321, Sec. 9. (AB 1391) Effective January 1, 2014.)
10120.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies may not limit sterilization benefits because of the covered person’s reason for requesting sterilization.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120. If a policy of disability insurance issued, issued for delivery, or renewed in this state after the effective date of this section provides in any manner for payment of all or part of the cost of a “sterilization operation or procedure” any exclusion, reduction, or limitation on such a benefit based upon the reason, or reasons, of the covered persons for requesting such sterilization shall be void and of no effect. All disability policies issued, issued for delivery, or renewed in this state after effective date of this section shall be automatically construed to be in compliance with this section and need not be refiled or reprinted. As used in this code, “sterilization operations or procedures” shall include and mean any operation or procedure altering the human body which has as its purpose, or one of its purposes, the temporary or permanent prevention of procreation by either a male or a female. (Added by Stats. 1970, Ch. 1128.)
10120.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A disability insurer that issues a dental insurance policy must state its coordination-of-benefits policy in the policy or evidence of coverage, and primary and secondary dental benefit plans must pay claims as specified when coordinating benefits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.2. (a) This section shall only apply to a disability insurer that issues a dental insurance policy pursuant to this part. (b) For purposes of this section, the following terms have the following meanings: (1) “Coordination of benefits” means the method by which a disability insurer and one or more other disability insurers, health care service plans covering dental services, or specialized health care service plans, covering dental services, pay their respective reimbursements for dental benefits when an insured is covered by multiple disability insurers, or a combination of disability insurers and health care service plans or specialized health care service plans. (2) “Primary dental benefit plan” means a dental insurance policy issued by a disability insurer regulated pursuant to this part or a health care service plan or specialized health care service plan contract regulated pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code that provides an insured or enrollee with primary dental coverage. (3) “Secondary dental benefit plan” means a dental insurance policy issued by a disability insurer regulated pursuant to this part or a health care service plan or specialized health care service plan contract regulated pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code that provides an insured or enrollee with secondary dental coverage. (c) A disability insurer that issues a dental insurance policy shall declare its coordination of benefits policy prominently in its evidence of coverage or insurance policy with both insured and policyholder. (d) When a primary dental benefit plan is coordinating its benefits with one or more secondary dental benefit plans, it shall pay the maximum amount required by its policy with the insured or policyholder. (e) A disability insurer that issues a dental insurance policy, when acting as a secondary dental benefit plan or insurer, shall pay the lesser of either the amount it would have paid in the absence of any other dental benefit coverage, or the insured’s total out-of-pocket cost payable under the primary dental benefit plan for benefits covered under the secondary plan or policy. (f) Nothing in this section is intended to conflict with or modify the way in which a disability insurer that issues a dental insurance policy determines which dental benefit plan is primary and which is secondary in coordinating benefits with another insurer or plan pursuant to existing state law or regulation. (Added by Stats. 2007, Ch. 164, Sec. 3. Effective January 1, 2008.)
10120.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Rules limit how dental insurers and providers can charge for noncovered dental services and require certain disclosure language in dental coverage forms.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.3. (a) With respect to a contract between an insurer covering dental services and a dentist to provide covered dental services to insureds, the contract shall not require a dentist to accept an amount set by the insurer as payment for dental care services provided to an insured that are not covered services under the insured’s policy. This subdivision shall only apply to provider contracts issued, amended, or renewed on or after January 1, 2011. (b) A provider shall not charge more for dental services that are not covered services under a health insurance policy than his or her usual and customary rate for those services. The department shall not be required to enforce this subdivision. (c) The evidence of coverage and disclosure form, or combined evidence of coverage and disclosure form, for every health insurance policy covering dental services, or specialized health insurance policy covering dental services, that is issued, amended, or renewed on or after July 1, 2011, shall include the following statement: IMPORTANT: If you opt to receive dental services that are not covered services under this policy, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at [insert appropriate telephone number] or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document. (d) For purposes of this section, “covered services” or “covered dental services” means dental care services for which the insurer is obligated to pay pursuant to an insured’s policy, or for which the insurer would be obligated to pay pursuant to an insured’s policy but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments. (Amended by Stats. 2011, Ch. 296, Sec. 188. (AB 1023) Effective January 1, 2012.)
10120.35.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must reimburse contracting health care providers for certain business expenses tied to public health emergencies, with limits and stated exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.35. (a) Notwithstanding any other law, a health insurer, including a specialized health insurer and a health insurer that issues, sells, renews, or offers a contract covering dental services, shall reimburse its contracting health care providers for business expenses to prevent the spread of diseases causing public health emergencies declared on or after January 1, 2022. For purposes of this subdivision, “business expenses” means personal protective equipment, additional supplies, materials, and clinical staff time over and above those expenses usually included in an office visit or other nonfacility service or services if performed during a public health emergency, as defined by law, due to respiratory-transmitted infectious disease and pursuant to subdivision (b). (b) A health insurer shall reimburse a contracting health care provider pursuant to subdivision (a) for each individual patient encounter, limited to one encounter per day per insured for the duration of the public health emergency. (c) The department shall ensure a health insurer provides timely reimbursement to its contracting health care providers pursuant to subdivision (a). The department may adopt guidance to implement this section. The guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (d) For purposes of this section, “contracting health care provider” means a physician and surgeon, dentist, or doctor of podiatric medicine who is licensed by the state to deliver or furnish health care services, who owns or operates a practice, and who is contracted with the insured’s health insurer. The term “contracting health care provider” only applies to a dentist if the insured is covered by a health insurance policy or specialized health insurance policy that includes dental benefits. (e) This section does not apply to the state of emergency declared by the Governor on March 4, 2020, relating to the coronavirus 2019 (COVID-19) pandemic. (f) This section shall not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) of, Chapter 8 (commencing with Section 14200) of, or Chapter 8.75 (commencing with Section 14591) of, Part 3 of Division 9 of the Welfare and Institutions Code. (Added by Stats. 2021, Ch. 538, Sec. 2. (SB 242) Effective January 1, 2022.)
10120.4.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers and contracting entities may share provider network access for dental services only if the contract and notice requirements are met.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.4. (a) A health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized policy of health insurance covering dental services, or a contracting entity may grant a third party access to a provider network contract, or a provider’s dental services or contractual discounts provided pursuant to a provider network contract if the requirements of subdivisions (b) and (c) are met. (b) A health insurer that issues, sells, renews, or offers a policy covering dental services may grant a third party access to a provider network contract if, at the time the provider network contract is entered into, and at any time a notice is sent to a health care provider as required pursuant to Section 10133.65, the provider network contract allows a provider to choose not to participate in third-party access to the provider network contract. The third-party access provision of the provider network contract shall be clearly identified. An insurer shall not grant third-party access to the provider network contract of a provider that does not participate in third-party access to the provider network contract. (c) A contracting entity may grant a third party access to a provider network contract, or a provider’s dental services or contractual discounts provided pursuant to a provider network contract, if all of the following are met: (1) The provider network contract specifically states that the contracting entity may enter into an agreement with a third party that would allow the third party to obtain the contracting entity’s rights and responsibilities as if the third party were the contracting entity, and when the contracting entity is a health insurer, the provider chose to participate in third-party access at the time the provider network contract was entered into. (2) If the contracting entity is a health insurer, the third-party access provision of the provider network contract shall clearly identify in the contract and notice to the provider, as required pursuant to Section 10133.65, the following language conspicuously placed on the first page of the document in 12-point underlined type: This contract grants third-party access to the provider network. The provider network contracting entity has entered into an agreement with other dental insurers or third parties that allows the third party to obtain the contracting entity’s rights and responsibilities as if the third party were the contracting entity. The list of all third parties with access to this provider network can be found at (insert internet website as identified in paragraph (4)). You have the right to choose not to participate in third-party access. To exercise your right to not participate in the third-party access, submit your written or electronic request to the health insurer. (3) The contracting entity identifies prior to signing the contract, in writing or electronic format to the provider, all third parties in existence as of the date the provider network contract is entered into. (4) The contracting entity identifies all third parties in existence in a list on its internet website that is updated at least once every 90 days. (5) (A) The contracting entity requires a third party to identify the source of the discount on all written or electronic remittance advices or explanations of payment under which a discount is taken. (B) This paragraph does not apply to electronic transactions mandated by the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191). (6) A third party’s right to a provider’s discounted rate ceases as of the termination date of the provider network contract. (7) The contracting entity makes available a copy of the provider network contract relied on in the adjudication of a claim to a participating provider within 30 days of a request from the provider. (d) A provider is not bound by or required to perform dental treatment or services under a provider network contract granted to a third party in violation of this section. (e) This section does not apply if any of the following criteria are met: (1) The provider network contract is for dental services provided to a beneficiary of the federal Medicare Program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) or the federal Medicaid program pursuant to Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.). (2) Access to a provider network contract is granted to a health insurer that issues, sells, renews, or offers a policy covering dental services or a contracting entity operating under the same brand licensee program as the contracting entity. (3) Access to a provider network contract is granted to an affiliate of a contracting entity. A list of the contracting entity’s affiliates shall be made available to a provider in writing or electronic form before access is granted to a third party pursuant to subdivision (b). (f) The commissioner shall adopt regulations as are necessary to implement and enforce this section in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (g) As used in this section: (1) “Contracting entity” means a person or entity that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a health insurer or third-party administrator. (2) “Dental services” means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease. “Dental services” does not include services delivered by a provider that are billed as medical expenses under a policy of health insurance. (3) “Provider” means an individual or entity that provides dental services or supplies, as defined by the policy of health insurance or specialized policy of health insurance, including a dentist or physician, but not a physician organization that leases or rents its network to a third party. (4) “Provider network contract” means a contract between a contracting entity and a provider entered into on or after January 1, 2020, that specifies the rights and responsibilities of the contracting entity and provides for the delivery and payment of dental services to an insured. (5) “Third party” means a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the dental services or contractual discounts of a provider network contract. “Third party” does not include an employer or other group for whom the health insurer or contracting entity provides administrative services, including the payment of claims. (Added by Stats. 2019, Ch. 540, Sec. 2. (AB 954) Effective January 1, 2020.)
10120.41.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer may not, on and after January 1, 2025, issue, sell, renew, or offer policies with certain dental waiting period or preexisting condition provisions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.41. (a) For purposes of this section, the following definitions shall apply: (1) “Dental waiting period provision” means a health insurance policy provision that limits coverage for a specified period of time following an insured’s effective date of coverage. (2) “Health insurer” means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106. (3) “Preexisting condition provision” means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insured’s effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage. (b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy. (c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. (Added by Stats. 2023, Ch. 557, Sec. 4. (AB 1048) Effective January 1, 2024.)
10120.42.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers covering dental services must disclose whether the coverage is “State Regulated” and, for certain policies, include that statement on an ID card.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.42. (a) To assist a provider in determining if an insured’s dental coverage is regulated by the State of California, the health insurer shall disclose whether the insured’s dental coverage is “State Regulated” through a provider portal, if available, or otherwise upon request, on or after January 1, 2025. (b) A health insurer shall include the statement “State Regulated” if the insured’s dental coverage is subject to regulation by the department, on an electronic or physical identification card, or both if available, for policies covering dental services issued on or after January 1, 2025. (c) For purposes of this section, “health insurer” means a health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized health insurer covering dental services. (Added by Stats. 2023, Ch. 125, Sec. 2. (AB 952) Effective January 1, 2024.)
10120.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A disability insurer’s act covering hospital, medical, or surgical expenses is also a violation of this code if it violates certain Business and Professions Code sections.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10120.5. Any act by a disability insurer that covers hospital, medical, or surgical expenses that violates Section 510, Section 2056, or Section 2056.1 of the Business and Professions Code shall also be a violation of this code. (Added by Stats. 1996, Ch. 1094, Sec. 2. Effective January 1, 1997.)
10121.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Self-insured employee welfare benefit plans must not limit sterilization coverage based on the covered person’s reason, and they must provide specified newborn, adoption, pregnancy, and children’s preventive-care coverage.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10121. (a) No self-insured employee welfare benefit plan, issued or renewed on or after November 23, 1970, which contains coverage for sterilization operations or procedures, shall impose any disclaimer, restriction on, or limitation of, coverage relative to the covered individual’s reason for sterilization. All those plans entered into or renewed on or after November 23, 1970, shall be construed to be in compliance with this section, and any provision in any plan which is in conflict with this section shall be of no force or effect. (b) Every self-insured employee welfare benefit plan issued or amended on or after July 1, 1972, which provides benefits to the employee’s dependents, shall contain a provision granting immediate accident and sickness coverage, from and after the moment of birth, to each newborn infant of any family covered and to each minor child placed for adoption from and after the moment the child is placed in the physical custody of the covered family for adoption. No plan may be issued or amended if it contains any disclaimer, waiver, or other limitation of coverage relative to the coverage or insurability of newborn infants of or minor children placed for adoption with a family covered as required by this section. Coverage of minor children placed for adoption with a covered family shall be required only after January 1, 1988. (c) No self-insured employee welfare benefit plan which provides maternity benefits for a person covered continuously from conception shall be issued, amended, delivered, or renewed in this state on or after July 1, 1976, if it contains any exclusion, reduction, or other limitations as to coverage, deductibles, or coinsurance provisions as to involuntary complications of pregnancy, unless those provisions apply generally to all benefits paid under the plan. If a fixed amount is specified in the plan for surgery, the fixed amounts for surgical procedures involving involuntary complications of pregnancy shall be commensurate with other fixed amounts payable for procedures of comparable difficulty and severity. In a case where a fixed amount is payable for maternity benefits, involuntary complications of pregnancy shall be deemed an illness and entitled to benefits otherwise provided by the plan. Where the plan contains a maternity deductible, the maternity deductible shall apply only to expenses resulting from normal delivery and cesarean section delivery. However, expenses for cesarean section delivery in excess of the deductible shall be treated as expenses for any other illness under the plan. This subdivision shall apply to all self-insured employee welfare benefit plans except any plan made subject to an applicable collective bargaining agreement in effect before July 1, 1976. For purposes of this subdivision, involuntary complications of pregnancy shall include, but not be limited to, puerperal infection, eclampsia, cesarean section delivery, ectopic pregnancy, and toxemia. All plans subject to this subdivision and issued, amended, delivered, or renewed in this state on or after July 1, 1976, shall be construed to be in compliance with this section, and any provision in any plan which is in conflict with this section shall be of no force or effect. (d) Every self-insured employee welfare benefit plan issued or amended on or after January 1, 1987, which provides benefits to the employee’s dependents, shall offer a choice to all employees of coverage for comprehensive preventive health care for children. (e) For purposes of this section, benefits for the comprehensive preventive care of children shall be consistent with the Guidelines for Health Supervision of Children and Youth, as adopted by the American Academy of Pediatrics in May 1982, and provide for the following: (1) Physician service for routine physical examinations. (2) Immunizations. (3) Laboratory services in connection with routine physical examinations. (f) As used in this section, “self-insured employee welfare benefit plan” means any plan or program of benefits provided by an employer or an employee organization, or both, for the purpose of providing hospital, medical, surgical, nursing, or dental services, or indemnification for the costs incurred for those services, to the employer’s employees or their dependents. (Amended by Stats. 1988, Ch. 160, Sec. 118.)
10121.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Spouses who are both employees may claim combined maximum benefits for themselves or enrolled dependents under the same disability insurance policy or self-insured benefit plan, up to 100% of the covered charge.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10121.5. (a) When spouses are both employed as employees, and both have enrolled themselves and their eligible family members under a group policy of disability insurance provided by their respective employers, and each spouse is covered as an employee under the terms of the same master policy, each spouse may claim on his or her behalf, or on behalf of his or her enrolled dependents, the combined maximum contractual benefits to which an employee is entitled under the terms of the master policy, not to exceed in the aggregate 100 percent of the charge for the covered expense or service. (b) When spouses are both employed as employees, and both have enrolled themselves and their eligible family members under a self-insured employee welfare benefit plan provided by their respective employers, and each spouse is covered as an employee under the terms of the same master contract, each spouse may claim on his or her behalf, or on behalf of his or her enrolled dependents, the combined maximum contractual benefits to which an employee is entitled under the terms of the master contract, not to exceed in the aggregate 100 percent of the charge for the covered expense or service. (c) This section shall apply to every group disability insurance policy and self-insured employee welfare benefit plan which is entered into, issued, delivered, amended, or renewed in this state on or after January 1, 1978. (Amended by Stats. 2016, Ch. 50, Sec. 58. (SB 1005) Effective January 1, 2017.)
10121.6.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group disability insurance policies and self-insured employee welfare benefit plans cannot deny a dependent child coverage or benefits just because the child does not live with the employee, insured, or policyholder, and they must enroll certain dependent children when an application is made under the stated conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10121.6. (a) No policy of group disability insurance or self-insured employee welfare benefit plan which provides hospital, medical, or surgical expense benefits for employees, insureds, or policyholders and their dependents shall exclude a dependent child from eligibility or benefits solely because the dependent child does not reside with the employee, insured, or policyholder. (b) Each policy of group disability insurance or self-insured employee welfare benefit plan which provides hospital, medical, or surgical expense benefits for employees, insureds, or policyholders and their dependents shall enroll, upon application by the employer or group administrator, a dependent child of the noncustodial parent when that parent is the employee, insured, or policyholder at any time either the parent or the person having custody of the child as defined in Section 3751.5 of the Family Code, or the local child support agency makes an application for enrollment to the employer or group administrator when a court order for medical support exists. In the case of children who are eligible for medicaid, the State Department of Health Services may also make that application. (Amended by Stats. 2000, Ch. 808, Sec. 109. Effective September 28, 2000.)
10121.7.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group health insurance policies must give registered domestic partners coverage equal to spouses, inform employers and guaranteed associations, and in some cases enroll domestic partners and allow limited verification and notice requirements.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10121.7. (a) A policy of group health insurance that provides hospital, medical, or surgical expense benefits shall provide equal coverage to employers or guaranteed associations, as defined in Section 10700, for the registered domestic partner of an employee, insured, or policyholder to the same extent, and subject to the same terms and conditions, as provided to a spouse of the employee, insured, or policyholder, and shall inform employers and guaranteed associations of this coverage. A policy shall not offer or provide coverage for a registered domestic partner that is not equal to the coverage provided to the spouse of an employee, insured, or policyholder, and shall not discriminate in coverage between spouses or domestic partners of a different sex and spouses or domestic partners of the same sex. The prohibitions and requirements imposed by this section are in addition to any other prohibitions and requirements imposed by law. (b) If an employer or guaranteed association has purchased coverage for spouses and registered domestic partners pursuant to subdivision (a), a health insurer that provides hospital, medical, or surgical expense benefits for employees, insureds, or policyholders and their spouses shall enroll, upon application by the employer or group administrator, a registered domestic partner of the employee, insured, or policyholder in accordance with the terms and conditions of the group contract that apply generally to all spouses under the policy, including coordination of benefits. (c) For purposes of this section, the term “domestic partner” shall have the same meaning as that term is used in Section 297 of the Family Code. (d) (1) A policy of group health insurance may require that the employee, insured, or policyholder verify the status of the domestic partnership by providing to the insurer a copy of a valid Declaration of Domestic Partnership filed with the Secretary of State pursuant to Section 298 of the Family Code or an equivalent document issued by a local agency of this state, another state, or a local agency of another state under which the partnership was created. The policy may also require that the employee, insured, or policyholder notify the insurer upon the termination of the domestic partnership. (2) Notwithstanding paragraph (1), a policy may require the information described in that paragraph only if it also requests from the employee, insured, or policyholder whose spouse is provided coverage, verification of marital status and notification of dissolution of the marriage. (e) Nothing in this section shall be construed to expand the requirements of Section 4980B of Title 26 of the United States Code, Section 1161, and following, of Title 29 of the United States Code, or Section 300bb-1, and following, of Title 42 of the United States Code, as added by the Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99-272), and as those provisions may be later amended. (f) A group health insurance policy subject to this section that is issued, amended, delivered, or renewed in this state on or after January 2, 2005, shall be deemed to provide coverage for registered domestic partners that is equal to the coverage provided to a spouse of an employee, insured, or policyholder. (Amended by Stats. 2011, Ch. 722, Sec. 4. (SB 757) Effective January 1, 2012.)
10122.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group disability insurance policies covered by this section must extend dependent coverage on the same terms as the employee after employment ends, and they do not need to be refiled or reprinted.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10122. If a policy of group disability insurance issued or issued for delivery or amended in this state after the effective date of this section provides in any manner for coverage for an employee and one or more covered persons dependent upon such employee and provides for an extension of coverage for any period following a termination of employment of the employee, the policy shall provide that such extension of coverage shall apply to dependents upon the same terms and conditions precedent as applied to the covered employee, for the same period of time, subject to payment of premiums, if any, as required by the terms of the policy and subject to any applicable collective bargaining agreement. All such group disability policies issued or issued for delivery or amended in this state after the effective date of this section shall be automatically construed to be in compliance with this section and need not be refiled or reprinted. (Amended by Stats. 1972, Ch. 40.)
10122.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain group disability policies must offer coverage to physically handicapped members on the same terms as other group members, and must tell group policyholders and prospective group policyholders that the coverage is available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10122.1. On and after the effective date of this section, every policy of disability insurance which covers hospital, medical, or surgical expenses on a group basis shall offer coverage to physically handicapped individual members of the group under the same terms and conditions as are normally offered to individual members of the group without physical handicap. The availability of such coverage shall be communicated to group policyholders and to prospective group policyholders during negotiations. Group policies shall not be required to cover hospital, medical, or surgical expenses arising as a direct result of an individual member’s physical handicap. (Added by renumbering Section 10123.1 (as added by Stats. 1974, Ch. 964) by Stats. 1980, Ch. 676, Sec. 188.)
10122.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A group disability insurance policy that covers both an employee and the employee’s covered spouse must not give employees less favorable coverage conditions than the covered spouses receive.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10122.2. If a policy of group disability insurance issued, delivered, amended, or renewed in this state on or after the effective date of this section provides in any manner for coverage for an employee and a covered spouse dependent upon such employee, the policy shall not provide for coverage under conditions less favorable for employees than coverage provided for covered spouses dependent upon the employees. (Added by Stats. 1976, Ch. 59.)
10123.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Self-insured employee welfare benefit plans must extend post-employment coverage to dependents on the same terms as the covered employee, and certain plan contracts must define the confinement period used to start benefits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123. (a) No self-insured employee welfare benefit plan, issued or renewed on or after the effective date of this section, which provides coverage for an employee and one or more covered persons dependent upon such employee and provides for an extension of coverage for any period following a termination of employment of the employee, shall fail to provide that such extension of coverage shall apply to dependents upon the same terms and conditions precedent as applied to the covered employee, for the same period of time, subject to payment of premiums, if any, as required by the terms of the policy and subject to any limitations or conditions set forth in any applicable collective-bargaining agreement. All such plans entered into or renewed on or after the effective date of this section shall be construed to be in compliance with this section, and any provision in any such plan which is in conflict with this section shall be of no force or effect. (b) A plan contract which provides benefits that accrue after a certain time of confinement in a health care facility shall specify what constitutes a day of confinement or the number of consecutive hours of confinement which are requisite to the commencement of benefits. (c) As used in subdivisions (a) and (b), “self-insured employee welfare benefit plan” has the same meaning as that specified in subdivision (d) of Section 10121. (Amended by Stats. 1978, Ch. 648.)
10123.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain self-insured employee welfare benefit plans must follow Article 1.5 requirements.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1. Every self-insured employee welfare benefit plan, as defined in Section 10121, issued, amended as to benefits, or renewed after January 1, 1977, shall comply with the requirements of Article 1.5 (commencing with Section 10128) of this chapter. (Amended by Stats. 1977, Ch. 64.)
10123.10.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers and self-insured employee welfare benefit plans must offer home health care benefits in qualifying policies and plans, subject to stated rejection rights and rural-area substitution rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.10. (a) Every disability insurer transacting business in this state shall, on or after January 1, 1979, make available and offer to include in every group disability policy providing hospital, medical or surgical expense benefits payable on an expense incurred basis, to be delivered or issued for delivery in this state, benefits for home health care as set forth in this section provided by a licensed home health agency subject to the right of the group policyholder to reject the benefits or to select any alternative level of benefits as may be offered by the insurer. In rural areas where there are no licensed health agencies or in which the supply of home health agency services does not meet the needs of the community, the services of visiting nurses, if available, may be substituted for the services of the home health agency, subject to the terms and conditions set forth in subdivision (c). (b) Every self-insured employee welfare benefit plan containing hospital, medical, or surgical expense benefits or service benefits delivered on or after January 1, 1979, shall make available and offer to include benefits for home health care as set forth in this section provided by a licensed home health agency subject to the right of the employer or the employee organization to reject the benefits or accept any alternative level of benefits as may be offered by the self-insured welfare benefit plan. In rural areas where there are no licensed health agencies or in which the supply of home health agency services does not meet the needs of the community, the services of visiting nurses, if available, may be substituted for the services of the home health agency, subject to the terms and conditions set forth in subdivision (c). (c) As used in this section: (1) “Home health care” means the continued care and treatment of an insured person who is under the direct care and supervision of a physician but only if (i) continued hospitalization would have been required if home health care were not provided, (ii) the home health treatment plan is established and approved by a physician within 14 days after an inpatient hospital confinement has ended and such treatment plan is for the same or related condition for which the insured person was hospitalized, and (iii) home health care commences within 14 days after the hospital confinement has ended. “Home health services” consist of, but shall not be limited to, the following: (i) part-time or intermittent skilled nursing services provided by a registered nurse or licensed vocational nurse; (ii) part-time or intermitent home health aide services which provide supportive services in the home under the supervision of a registered nurse or a physical, speech or occupational therapist; (iii) physical, occupational or speech therapy; and (iv) medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services, and laboratory services to the extent such charges or costs would have been covered under the policy if the insured person had remained in the hospital. (2) “Home health agency” means a public or private agency or organization licensed by the State Department of Health Services in accordance with the provisions of Chapter 8 (commencing with Section 1725) of Division 2 of the Health and Safety Code. (d) The policy may contain a limitation on the number of home health visits for which benefits are payable, but the number of such visits shall not be less than 100 in any calendar year or in any continuous 12-month period for each person covered under the policy. Except for a home health aide, each visit by a representative of a home health agency shall be considered as one home health visit. A visit of four hours or less by a home health aide shall be considered as one home health visit. (e) Home health care benefits may be subject to an annual deductible of not more than fifty dollars ($50) for each person covered under a policy, and may be subject to a coinsurance provision which provides coverage of not less than 80 percent of the reasonable charges for such services. (f) Nothing in this section shall preclude an insurer or plan offering other health care benefits provided in the home. (Added by Stats. 1978, Ch. 1130.)
10123.11.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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An insurer or self-insured employee welfare benefit plan may not deny certain disability or health-service claims just because the person was in jail or juvenile detention, if the person was otherwise entitled to benefits and incurred the expense during confinement.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.11. (a) No insurer shall deny a claim under a group disability policy for hospital, medical, surgical, dental, or optometric services for the sole reason that the individual served was confined in a city or county jail as a prisoner, or was a juvenile detained in any facility if such individual is otherwise entitled to benefits under such group disability policy and incurs expense for the services so provided during confinement. This provision shall apply to any group disability policy entered into or renewed on or after July 1, 1980, whether or not such policy contains any provision terminating benefits under such policy upon an individual’s confinement in a city or county jail or juvenile detention facility. (b) No self-insured employee welfare benefit plan shall deny a claim under a plan for hospital, medical, surgical, dental, or optometric services for the reason that the individual served was confined in a city or county jail as a prisoner, or was a juvenile detained in any facility, if such individual is otherwise entitled to benefits under such plan and incurs expense for the services so provided during confinement. This provision shall apply to any self-insured employee welfare benefit plan entered into or renewed on or after July 1, 1980, whether or not such plan contains any provision terminating benefits under such plan upon an individual’s confinement in a city or county jail or juvenile detention facility. (Added by Stats. 1980, Ch. 90, Sec. 2. Effective May 9, 1980.)
10123.12.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers and certain self-insured employee welfare benefit plans must give clear notice about how coverage may affect provider choice and related financial liability.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.12. Every health insurer, including those insurers that contract for alternative rates of payment pursuant to Section 10133, and every self-insured employee welfare benefit plan that will affect the choice of physician, hospital, or other health care providers shall include within its disclosure form and within its evidence or certificate of coverage a statement clearly describing how participation in the policy or plan may affect the choice of physician, hospital, or other health care providers, and describing the nature and extent of the financial liability that is, or that may be, incurred by the insured, enrollee, or covered dependents if care is furnished by a provider that does not have a contract with the insurer or plan to provide service at alternative rates of payment pursuant to Section 10133. The form shall clearly inform prospective insureds or plan enrollees that participation in the policy or plan will affect the person’s choice in this regard by placing the following statement in a conspicuous place on all material required to be given to prospective insureds or plan enrollees including promotional and descriptive material, disclosure forms, and certificates and evidences of coverage: ## PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED It is not the intent of this section to require that the names of individual health care providers be enumerated to prospective insureds or enrollees. If a health insurer providing coverage for hospital, medical, or surgical expenses provides a list of facilities to patients or contracting providers, the insurer shall include within the provider listing a notification that insureds or enrollees may contact the insurer in order to obtain a list of the facilities with which the health insurer is contracting for subacute care and/or transitional inpatient care. (Amended by Stats. 2005, Ch. 441, Sec. 3. Effective January 1, 2006.)
10123.13.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers must pay covered health claims within 30 days, or send written contest/denial notice with reasons and copies to the insured and provider.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.13. (a) Every insurer issuing group or individual policies of health insurance that cover hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, shall reimburse a complete claim or portion thereof, whether in state or out of state, for those expenses as soon as practicable, but no later than 30 calendar days after receipt of the claim by the insurer, unless the insurer is contesting or denying the claim or a portion thereof, in which case the claimant shall be notified, in writing, that the claim is contested or denied, within 30 calendar days after receipt of the claim by the insurer. The notice that a claim is being contested or denied shall identify the portion of the claim that is contested or denied and the specific reasons including for each reason the factual and legal basis known at that time by the insurer for contesting or denying the claim. If the reason is based solely on facts or solely on law, the insurer is required to provide only the factual or the legal basis for its reason for contesting or denying the claim. The insurer shall provide a copy of the notice to each insured who received services pursuant to the claim that was contested or denied and to the insured’s health care provider that provided the services at issue. The notice shall advise the provider who submitted the claim on behalf of the insured or pursuant to a contract for alternative rates of payment and the insured that either may seek review by the department of a claim that the insurer contested or denied, and the notice shall include the address, internet website address, and telephone number of the unit within the department that performs this review function. The notice to the provider may be included on either the explanation of benefits or remittance advice and shall also contain a statement advising the provider of its right to enter into the dispute resolution process described in Section 10123.137. The notice to the insured may also be included on the explanation of benefits. (b) If an uncontested claim is not reimbursed by delivery to the claimant’s address of record within 30 calendar days after receipt, interest shall accrue at the rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period. An insurer shall automatically include in its payment of the claim all interest that has accrued pursuant to this section without requiring the claimant to submit a request for the interest amount. An insurer failing to comply with this requirement shall pay the claimant a fee of the greater of an additional fifteen dollars ($15) or 10 percent of the accrued interest. (c) (1) For purposes of this section, a claim, or portion thereof, is reasonably contested when the insurer has not received a completed claim and all information necessary to determine payer liability for the claim, or has not been granted reasonable access to information concerning provider services. Information necessary to determine liability for the claims includes, but is not limited to, reports of investigations concerning fraud and misrepresentation, and necessary consents, releases, and assignments, a claim on appeal, or other information necessary for the insurer to determine the medical necessity for the health care services provided to the claimant. An insurer may not contest a complete claim that is consistent with an approved prior authorization request if the prior authorization approval has been provided in the appropriate field on the claim. (2) If an insurer has received all of the information necessary to determine payer liability for a contested claim and has not reimbursed a claim determined to be payable within 30 calendar days of receipt of that information, interest shall accrue and be payable at a rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period. (d) The obligation of the insurer to comply with this section shall not be deemed to be waived when the insurer requires its contracting entities to pay claims for covered services. (e) (1) The department may issue guidance and regulations relating to this section. The guidance and regulations shall not be subject to the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2027. (2) After January 1, 2028, the department may issue regulations relating to this section subject to the rulemaking provisions of the Administrative Procedure Act ((Chapter 3.5 commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2030. (f) This section shall become operative on January 1, 2026. (Amended (as added by Stats. 2024, Ch. 763, Sec. 7) by Stats. 2025, Ch. 558, Sec. 19. (AB 487) Effective January 1, 2026.)
10123.131.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers must pay providers specified copying costs for records requested in a contested claim and must not request information that is not reasonably necessary to determine claim liability.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.131. (a) An insurer shall pay a provider for duplicating all information it requests in connection with a contested claim, and for patient records, as follows: (1) Except as provided in paragraph (2), the insurer shall pay the provider for copying twenty-five cents ($0.25) per page, or fifty cents ($0.50) per page for records that are copied from microfilm. (2) The insurer shall pay the provider all reasonable costs, not exceeding actual costs, incurred by the provider in providing the insurer copies of X-rays, or tracings derived from electrocardiography, electroencephalography, or electromyography. (b) No insurer subject to this section shall request information that is not reasonably necessary to determine liability for payment of a claim. (c) The obligation of the insurer to comply with this section shall not be deemed to be waived when the insurer requires its contracting entities to pay claims for covered services. (d) This section shall not apply to contractual arrangements between an insurer and its agent, an insurer and a provider, or a provider and its agent for the costs associated with the provision of duplication services. (Added by Stats. 2000, Ch. 844, Sec. 2. Effective January 1, 2001.)
10123.132.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Some disability insurers must show a telephone number on insured ID cards and send a written notice with the initial mailing.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.132. (a) Every disability insurer that covers hospital, medical, or surgical expenses and that reviews and approves the medical necessity or appropriateness of requests by providers prior to, or concurrently with, the provision of health care services to insureds, shall prominently indicate on each insured’s identification card whether a separate telephone number must be called to verify eligibility for benefits and coverage. (b) A written notice shall accompany the initial mailing of the insured’s identification card modified pursuant to subdivision (a). The notice shall indicate that the insured’s identification card includes a telephone number that may be used to verify eligibility for benefits and coverage. The notice shall also inform the insured that review and approval of a health care service based on medical necessity or appropriateness does not constitute eligibility for benefits and coverage pursuant to the policy or contract. (Added by renumbering Section 10123.135 (as added by Stats. 1999, Ch. 88) by Stats. 2000, Ch. 241, Sec. 2. Effective January 1, 2001.)
10123.135.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section requires disability insurers using medical-necessity review to follow written procedures, disclose them on request, use qualified clinical decision-makers, meet decision deadlines, and limit AI tools so they do not decide medical necessity on their own.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.135. (a) Every disability insurer, or an entity with which it contracts for services that include utilization review or utilization management functions, that covers hospital, medical, or surgical expenses and that prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based in whole or in part on medical necessity, requests by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds, or that delegates these functions to medical groups or independent practice associations or to other contracting providers, shall comply with this section. (b) A disability insurer that is subject to this section, or any entity with which an insurer contracts for services that include utilization review or utilization management functions, shall have written policies and procedures establishing the process by which the insurer prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based in whole or in part on medical necessity, requests by providers of health care services for insureds. These policies and procedures shall ensure that decisions based on the medical necessity of proposed health care services are consistent with criteria or guidelines that are supported by clinical principles and processes. These criteria and guidelines shall be developed pursuant to subdivision (f). These policies and procedures, and a description of the process by which an insurer, or an entity with which an insurer contracts for services that include utilization review or utilization management functions, reviews and approves, modifies, delays, or denies requests by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds, shall be filed with the commissioner, and shall be disclosed by the insurer to insureds and providers upon request, and by the insurer to the public upon request. (c) If the number of insureds covered under health benefit plans in this state that are issued by an insurer subject to this section constitute at least 50 percent of the number of insureds covered under health benefit plans issued nationwide by that insurer, the insurer shall employ or designate a medical director who holds an unrestricted license to practice medicine in this state issued pursuant to Section 2050 of the Business and Professions Code or the Osteopathic Initiative Act, or the insurer may employ a clinical director licensed in California whose scope of practice under California law includes the right to independently perform all those services covered by the insurer. The medical director or clinical director shall ensure that the process by which the insurer reviews and approves, modifies, delays, or denies, based in whole or in part on medical necessity, requests by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds, complies with the requirements of this section. Nothing in this subdivision shall be construed as restricting the existing authority of the Medical Board of California. (d) If an insurer subject to this section, or individuals under contract to the insurer to review requests by providers, approve the provider’s request pursuant to subdivision (b), the decision shall be communicated to the provider pursuant to subdivision (h). (e) An individual, other than a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider, may not deny or modify requests for authorization of health care services for an insured for reasons of medical necessity. The decision of the physician or other health care provider shall be communicated to the provider and the insured pursuant to subdivision (h). (f) (1) An insurer shall disclose, or provide for the disclosure, to the commissioner and to network providers, the process the insurer, its contracting provider groups, or any entity with which it contracts for services that include utilization review or utilization management functions, uses to authorize, delay, modify, or deny health care services under the benefits provided by the insurance contract, including coverage for subacute care, transitional inpatient care, or care provided in skilled nursing facilities. An insurer shall also disclose those processes to policyholders or persons designated by a policyholder, or to any other person or organization, upon request. (2) The criteria or guidelines used by an insurer, or an entity with which an insurer contracts for utilization review or utilization management functions, to determine whether to authorize, modify, delay, or deny health care services, shall comply with all of the following: (A) Be developed with involvement from actively practicing health care providers. (B) Be consistent with sound clinical principles and processes. (C) Be evaluated, and updated if necessary, at least annually. (D) If used as the basis of a decision to modify, delay, or deny services in a specified case under review, be disclosed to the provider and the policyholder in that specified case. (E) Be available to the public upon request. An insurer shall only be required to disclose the criteria or guidelines for the specific procedures or conditions requested. An insurer may charge reasonable fees to cover administrative expenses related to disclosing criteria or guidelines pursuant to this paragraph that are limited to copying and postage costs. The insurer may also make the criteria or guidelines available through electronic communication means. (3) The disclosure required by subparagraph (E) of paragraph (2) shall be accompanied by the following notice: “The materials provided to you are guidelines used by this insurer to authorize, modify, or deny health care benefits for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your insurance contract.” (g) If an insurer subject to this section requests medical information from providers in order to determine whether to approve, modify, or deny requests for authorization, the insurer shall request only the information reasonably necessary to make the determination. (h) In determining whether to approve, modify, or deny requests by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds, based in whole or in part on medical necessity, every insurer subject to this section shall meet the following requirements: (1) Decisions to approve, modify, or deny, based on medical necessity, requests by providers prior to, or concurrent with, the provision of health care services to insureds that do not meet the requirements for the time period for review required by paragraph (2), shall be made in a timely fashion appropriate for the nature of the insured’s condition, not to exceed five business days from the insurer’s receipt of the information reasonably necessary and requested by the insurer to make the determination. In cases where the review is retrospective, the decision shall be communicated to the individual who received services, or to the individual’s designee, within 30 days of the receipt of information that is reasonably necessary to make this determination, and shall be communicated to the provider in a manner that is consistent with current law. For purposes of this section, retrospective reviews shall be for care rendered on or after January 1, 2000. (2) When the insured’s condition is such that the insured faces an imminent and serious threat to the insured’s health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decisionmaking process, as described in paragraph (1), would be detrimental to the insured’s life or health or could jeopardize the insured’s ability to regain maximum function, decisions to approve, modify, or deny requests by providers prior to, or concurrent with, the provision of health care services to insureds shall be made in a timely fashion, appropriate for the nature of the insured’s condition, but not to exceed 72 hours or, if shorter, the period of time required under Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any subsequent rules or regulations issued thereunder, after the insurer’s receipt of the information reasonably necessary and requested by the insurer to make the determination. (3) Decisions to approve, modify, or deny requests by providers for authorization prior to, or concurrent with, the provision of health care services to insureds shall be communicated to the requesting provider within 24 hours of the decision. Except for concurrent review decisions pertaining to care that is underway, which shall be communicated to the insured’s treating provider within 24 hours, decisions resulting in denial, delay, or modification of all or part of the requested health care service shall be communicated to the insured in writing within two business days of the decision. In the case of concurrent review, care shall not be discontinued until the insured’s treating provider has been notified of the insurer’s decision and a care plan has been agreed upon by the treating provider that is appropriate for the medical needs of that patient. (4) Communications regarding decisions to approve requests by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds shall specify the specific health care service approved. Responses regarding decisions to deny, delay, or modify health care services requested by providers prior to, retrospectively, or concurrent with the provision of health care services to insureds shall be communicated to insureds in writing, and to providers initially by telephone or facsimile, except with regard to decisions rendered retrospectively, and then in writing, and shall include a clear and concise explanation of the reasons for the insurer’s decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity. Any written communication to a physician or other health care provider of a denial, delay, or modification or a request shall include the name and telephone number of the health care professional responsible for the denial, delay, or modification. The telephone number provided shall be a direct number or an extension, to allow the physician or health care provider easily to contact the professional responsible for the denial, delay, or modification. Responses shall also include information as to how the provider or the insured may file an appeal with the insurer or seek department review under the unfair practices provisions of Article 6.5 (commencing with Section 790) of Chapter 1 of Part 2 of Division 1 and the regulations adopted thereunder. (5) If the insurer cannot make a decision to approve, modify, or deny the request for authorization within the timeframes specified in paragraph (1) or (2) because the insurer is not in receipt of all of the information reasonably necessary and requested, or because the insurer requires consultation by an expert reviewer, or because the insurer has asked that an additional examination or test be performed upon the insured, provided that the examination or test is reasonable and consistent with good medical practice, the insurer shall, immediately upon the expiration of the timeframe specified in paragraph (1) or (2), or as soon as the insurer becomes aware that it will not meet the timeframe, whichever occurs first, notify the provider and the insured, in writing, that the insurer cannot make a decision to approve, modify, or deny the request for authorization within the required timeframe, and specify the information requested but not received, or the expert reviewer to be consulted, or the additional examinations or tests required. The insurer shall also notify the provider and enrollee of the anticipated date on which a decision may be rendered. Upon receipt of all information reasonably necessary and requested by the insurer, the insurer shall approve, modify, or deny the request for authorization within the timeframes specified in paragraph (1) or (2), whichever applies. (6) If the commissioner determines that an insurer has failed to meet any of the timeframes in this section, or has failed to meet any other requirement of this section, the commissioner may assess, by order, administrative penalties for each failure. A proceeding for the issuance of an order assessing administrative penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to, the person affected. The administrative penalties shall not be deemed an exclusive remedy for the commissioner. These penalties shall be paid to the Insurance Fund. (i) Every insurer subject to this section shall maintain telephone access for providers to request authorization for health care services. (j) (1) A disability insurer, including a specialized health insurer that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, shall comply with this section and shall ensure all of the following: (A) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An insured’s medical or other clinical history. (ii) Individual clinical circumstances as presented by the requesting provider. (iii) Other relevant clinical information contained in the insured’s medical or other clinical record. (B) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset. (C) The artificial intelligence, algorithm, or other software tool’s criteria and guidelines complies with this chapter and applicable state and federal law. (D) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decisionmaking. (E) The use of the artificial intelligence, algorithm, or other software tool does not discriminate, directly or indirectly, against insureds in violation of state or federal law. (F) The artificial intelligence, algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal Department of Health and Human Services. (G) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department pursuant to applicable state and federal law. (H) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by subdivision (b). (I) The artificial intelligence, algorithm, or other software tool’s performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability. (J) Patient data is not used beyond its intended and stated purpose, consistent with the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as applicable. (K) The artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to the insured. (2) Notwithstanding paragraph (1), the artificial intelligence, algorithm, or other software tool shall not deny, delay, or modify health care services based, in whole or in part, on medical necessity. A determination of medical necessity shall be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved in the health care services requested by the provider, as provided in subdivision (e), by reviewing and considering the requesting provider’s recommendation, the insured’s medical or other clinical history, as applicable, and individual clinical circumstances. (3) For purposes of this subdivision, “artificial intelligence” means an engineered or machine-based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments. (4) This subdivision shall apply to utilization review or utilization management functions that prospectively, retrospectively, or concurrently review requests for covered health care services. (5) A disability insurer subject to this subdivision shall comply with applicable federal rules and guidance issued by the federal Department of Health and Human Services regarding the use of artificial intelligence, algorithm, or other software tools. The department may issue guidance to implement this paragraph within one year of the adoption of federal rules or the issuance of guidance by the federal Department of Health and Human Services regarding the use of artificial intelligence, algorithm, or other software tools. Such guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (6) For purposes of implementing this subdivision, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. (k) Nothing in this section shall cause a disability insurer to be defined as a health care provider for purposes of any provision of law, including, but not limited to, Section 6146 of the Business and Professions Code, Sections 3333.1 and 3333.2 of the Civil Code, and Sections 340.5, 364, 425.13, 667.7, and 1295 of the Code of Civil Procedure. (Amended by Stats. 2024, Ch. 879, Sec. 2. (SB 1120) Effective January 1, 2025.)
10123.137.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must maintain a provider dispute resolution process, notify providers how to use it, resolve provider disputes in writing within 45 working days, and file an annual report with the department.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.137. (a) Each contract between a health insurer and a provider shall contain provisions requiring a fast, fair, and cost-effective dispute resolution mechanism under which providers may submit disputes to the insurer, and requiring the insurer to inform its providers, upon contracting with the insurer, or upon change to these provisions, of the procedures for processing and resolving disputes, including the location and telephone number where information regarding disputes may be submitted. (b) An insurer shall also ensure that a dispute resolution mechanism is accessible to noncontracting providers for the purpose of resolving billing and claims disputes. (c) Disputes are to be submitted to the insurer in writing and shall include provider name, provider tax identification number, patient name, insurer’s identification information, dates of service, description of dispute, and, if applicable, billed and paid amounts. The insurer shall resolve each provider dispute consistent with applicable law and issue a written determination within 45 working days after the date of receipt of the provider dispute. (d) On and after July 1, 2007, an insurer shall annually submit a report to the department regarding its dispute resolution mechanism. The report shall be public information and include, at a minimum, information on the number of providers that utilized the dispute resolution mechanism and a summary of the disposition of those disputes. To the extent the commissioner requires detailed information disclosing emerging or established patterns of provider disputes or corrective action by the insurer, the commissioner may maintain the confidentiality of any information found to be proprietary, upon written request of the insurer. In no event shall the commissioner find the required minimum information described in this subdivision to be proprietary. (e) If an insurer has an affiliated or subsidiary company that is licensed as a health care service plan under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, the insurer may use the same procedures relating to the provider dispute resolution process established by the affiliated or subsidiary entity pursuant to subdivision (h) of Section 1367 of the Health and Safety Code. (Added by Stats. 2005, Ch. 723, Sec. 4. Effective January 1, 2006.)
10123.14.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A self-insured employee welfare benefit plan may cover treatment for alcoholism, chemical dependency, or nicotine use.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.14. On and after January 1, 1990, every self-insured employee welfare benefit plan containing hospital, medical, or surgical expense benefits or service benefits may provide coverage for the treatment of alcoholism, chemical dependency, or nicotine use under such terms and conditions as may be agreed upon between the self-insured welfare benefit plan and the member, where the treatment may take place in facilities licensed to provide alcoholism or chemical dependency services under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code. Treatment for nicotine use may be subject to separate deductibles, copayments, and overall cost limitations as determined by the plan. (Added by Stats. 1989, Ch. 688, Sec. 3.)
10123.141.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group hospital, medical, or surgical insurance policies must offer special footwear coverage as an option for people with foot disfigurement, unless the policy only covers specified diseases or other limited benefits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.141. (a) Every policy of expense incurred hospital, medical, or surgical insurance issued, amended, or renewed on or after January 1, 1991, on a group basis, except for policies that only provide coverage for specified diseases or other limited benefit coverage, shall offer coverage as an option for special footwear needed by persons who suffer from foot disfigurement under the terms and conditions agreed upon between the group contract holder and the insurer. (b) As used in this section, foot disfigurement shall include, but not be limited to, disfigurement from cerebral palsy, arthritis, polio, spina bifida, and diabetes, and foot disfigurement caused by accident or developmental disability. (Amended by Stats. 2006, Ch. 538, Sec. 463. Effective January 1, 2007.)
10123.145.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Providers must repay insurer overpayments within 30 working days unless they contest the overpayment in writing.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.145. (a) (1) Whenever an insurer issuing group or individual policies of disability insurance which covers hospital, medical, or surgical expenses determines that in reimbursing a claim for provider services an institutional or professional provider has been overpaid, and then notifies the provider in writing through a separate notice identifying the overpayment and the amount of the overpayment, the provider shall reimburse the insurer within 30 working days of receipt by the provider of the notice of overpayment unless the overpayment or portion thereof is contested by the provider in which case the insurer shall be notified, in writing, within 30 working days. The notice that an overpayment is being contested shall identify the portion of the overpayment that is contested and the specific reasons for contesting the overpayment. (2) If the provider does not make reimbursement for an uncontested overpayment within 30 working days after receipt, interest shall accrue at the rate of 10 percent per annum beginning with the first calendar day after the 30-working-day period. (3) A prorated cost-sharing payment, or any portion thereof, made to a pharmacist for the dispensing of a partial fill pursuant to Section 4052.10 of the Business and Professions Code shall not be considered to be an overpayment pursuant to this section. (b) (1) This subdivision shall only apply to a health insurance policy covering dental services or a specialized health insurance policy covering dental services. (2) The insurer’s notice of overpayment shall inform the provider how to access the insurer’s dispute resolution mechanism offered pursuant to subdivision (a) of Section 10123.137. The notice shall include the name and address to which the dispute should be submitted and a statement that Section 10123.145 of the Insurance Code requires a provider to reimburse the insurer for an overpayment within 30 working days of receipt by the provider of the notice of overpayment unless the provider contests the overpayment within 30 working days. The notice shall also include information clearly identifying the claim, the name of the patient, the date of service, and a clear explanation of the basis upon which the insurer believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim. The notice shall also include a statement that if the provider does not make reimbursement of an uncontested overpayment within 30 working days after receipt of the notice, interest shall accrue at a rate of 10 percent per annum. (Amended by Stats. 2017, Ch. 615, Sec. 5. (AB 1048) Effective January 1, 2018.)
10123.146.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers using direct or vendor-based payment to dental providers must offer a non-fee-based default payment method and follow consent and notice rules before using fee-based payment methods.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.146. (a) The following definitions shall apply for purposes of this section: (1) (A) “Affirmative consent” means a dental provider’s express consent to opt in or opt out of receiving fee-based payment. Affirmative consent requires a dental provider’s signature. The terms of the affirmative consent shall be clear and readily understandable. (B) Affirmative consent may be given through email. (C) A provider accessing funds does not constitute affirmative consent to receive a fee-based payment. (2) “Contracted vendor” means a third party facilitating payment processing on behalf of the health insurer. (3) “Dental provider” means an individual or group of individuals licensed under Chapter 4 (commencing with Section 1600) of Division 2 of the Business and Professions Code. (4) “Fee-based payment” refers to any payment type that requires the dental provider to incur a fee from the health insurer or its contracted vendor to access payment from a plan or its contracted vendor. (5) “Health insurer” has the same meaning as defined in paragraph (2) of subdivision (a) of Section 10120.41. (6) “Signature” includes an electronic or digital signature if the form of the signature is recognized as a valid signature under applicable federal or state law, including, but not limited to, checking a box indicating affirmative consent. (b) (1) A health insurer that provides payment directly, or through a contracted vendor, to a dental provider shall have a non-fee-based default method of payment. (2) The health insurer shall remit or associate with each payment the claims and claim details associated with payment. (c) (1) A health insurer or its contracted vendor shall obtain affirmative consent from a dental provider who opts in to a fee-based payment method before the insurer or vendor provides a fee-based payment method to the provider. (2) At the time a dental provider opts in to a fee-based payment method, the health insurer or its contracted vendor shall provide information on the payment method, including a notice of the fees charged by the health insurer or contracted vendor, alternative methods of payment, instructions on how to opt out of the fee-based payment method, and a notice of the dental provider’s ability to opt out of the fee-based payment method at any time. (3) Upon receipt of the dental provider’s affirmative consent, the health insurer or its contracted vendor subsequently may issue payments to the dental provider using a fee-based payment method. (4) The health insurer also shall notify the dental provider if its contracted vendor is sharing a part of the profit, fee arrangement, or board composition with the health insurer. (d) (1) A dental provider may opt out of a fee-based payment method and opt in to a non-fee-based payment method at any time by providing affirmative consent to the health insurer or its contracted vendor. (2) If a dental provider opts in or opts out of a method of payment pursuant to this subdivision, the provider’s payment method decision shall remain in effect until the provider informs the health insurer or contracted vendor of another preferred method of payment, including fee-based or non-fee-based methods. (e) A health insurer or its contracted vendor that obtains a dental provider’s affirmative consent to opt in or opt out of a fee-based payment method shall apply the decision to include both of the following: (1) The dental provider’s entire practice. (2) To all products or services covered by the health insurer pursuant to a contract with the dental provider, including network provider contracts, as described in Section 10120.4. (f) This section does not apply if a health insurer has a direct contract with a provider that allows the provider to choose payment methods, including a non-fee-based payment method for services rendered. (g) This section shall become operative on April 1, 2026, and apply to all health insurance policies issued, amended, or renewed on or after that date. (Added by Stats. 2025, Ch. 219, Sec. 2. (SB 386) Effective January 1, 2026. Operative April 1, 2026, by its own provisions.)
10123.147.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers must pay complete covered health claims within 30 calendar days, and if they contest or deny a claim they must give written notice with required details.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.147. (a) Every insurer issuing group or individual policies of health insurance that cover hospital, medical, or surgical expenses, including those telehealth services covered by the insurer as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, shall reimburse a complete claim or portion thereof, whether in state or out of state, as soon as practicable, but no later than 30 calendar days after receipt of the complete claim by the insurer. However, an insurer may contest or deny a claim, or portion thereof, by notifying the claimant, in writing, that the claim is contested or denied, within 30 calendar days after receipt of the claim by the insurer. The notice that a claim, or portion thereof, is contested shall identify the portion of the claim that is contested, by procedure or revenue code, and the specific information needed from the provider to reconsider the claim. The notice that a claim, or portion thereof, is denied shall identify the portion of the claim that is denied, by procedure or revenue code, and the specific reasons for the denial, including the factual and legal basis known at that time by the insurer for each reason. If the reason is based solely on facts or solely on law, the insurer is required to provide only the factual or legal basis for its reason to deny the claim. The insurer shall provide a copy of the notice required by this subdivision to each insured who received services pursuant to the claim that was contested or denied and to the insured’s health care provider that provided the services at issue. The notice required by this subdivision shall include a statement advising the provider who submitted the claim on behalf of the insured or pursuant to a contract for alternative rates of payment and the insured that either may seek review by the department of a claim that was contested or denied by the insurer and the address, internet website address, and telephone number of the unit within the department that performs this review function. The notice to the provider may be included on either the explanation of benefits or remittance advice and shall also contain a statement advising the provider of its right to enter into the dispute resolution process described in Section 10123.137. An insurer may delay payment of an uncontested portion of a complete claim for reconsideration of a contested portion of that claim so long as the insurer pays those charges specified in subdivision (b). (b) If a complete claim or portion thereof that is neither contested nor denied is not reimbursed by delivery to the claimant’s address of record within the 30 calendar days after receipt, the insurer shall pay the greater of fifteen dollars ($15) per year or a rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period. An insurer shall automatically include the fifteen dollars ($15) per year or interest due in the payment made to the claimant, without requiring a request therefor. An insurer failing to comply with this requirement shall pay the claimant the greater of an additional fifteen dollars ($15) or a fee of 10 percent of the accrued interest. (c) For the purposes of this section, a claim or portion thereof, is reasonably contested if the insurer has not received the completed claim. A paper claim from an institutional provider shall be deemed complete upon submission of a legible emergency department report and a completed UB 92 or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the insurer within 30 calendar days of receipt of the claim. An electronic claim from an institutional provider shall be deemed complete upon submission of an electronic equivalent to the UB 92 or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the insurer within 30 calendar days of receipt of the claim. However, if the insurer requests a copy of the emergency department report within the 30 calendar days after receipt of the electronic claim from the institutional provider, the insurer may also request additional reasonable relevant information within 30 calendar days of receipt of the emergency department report, at which time the claim shall be deemed complete. A claim from a professional provider shall be deemed complete upon submission of a completed HCFA 1500 or its electronic equivalent or other format adopted by the National Uniform Billing Committee, and reasonable relevant information requested by the insurer within 30 calendar days of receipt of the claim. The provider shall provide the insurer reasonable relevant information within 10 working days of receipt of a written request that is clear and specific regarding the information sought. If, as a result of reviewing the reasonable relevant information, the insurer requires further information, the insurer shall have an additional 15 calendar days after receipt of the reasonable relevant information to request the further information, notwithstanding any time limit to the contrary in this section, at which time the claim shall be deemed complete. (d) This section shall not apply to claims about which there is evidence of fraud and misrepresentation, to eligibility determinations, or in instances where the plan has not been granted reasonable access to information under the provider’s control. An insurer shall specify, in a written notice to the provider within 30 calendar days of receipt of the claim, which, if any, of these exceptions applies to a claim. (e) If a claim or portion thereof is contested on the basis that the insurer has not received information reasonably necessary to determine payer liability for the claim or portion thereof, then the insurer shall have 30 calendar days after receipt of this additional information to complete reconsideration of the claim. If a claim, or portion thereof, undergoing reconsideration is not reimbursed by delivery to the claimant’s address of record within the 30 calendar days after receipt of the additional information, the insurer shall pay interest at the rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period. An insurer shall automatically include interest due in the payment made to the claimant, without requiring a request therefor. (f) An insurer shall not delay payment on a claim from a physician or other provider to await the submission of a claim from a hospital or other provider, without citing specific rationale as to why the delay was necessary and providing a monthly update regarding the status of the claim and the insurer’s actions to resolve the claim, to the provider that submitted the claim. (g) An insurer shall not request or require that a provider waive its rights pursuant to this section. (h) This section shall apply only to claims for services rendered to a patient who was provided emergency services and care as defined in Section 1317.1 of the Health and Safety Code in the United States on or after September 1, 1999. (i) This section shall not be construed to affect the rights or obligations of any person pursuant to Section 10123.13. (j) This section shall not be construed to affect a written agreement, if any, of a provider to submit bills within a specified time period. (k) (1) The department may issue guidance and regulations relating to this section. The guidance and regulations shall not be subject to the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2027. (2) After January 1, 2028, the department may issue regulations relating to this section subject to the rulemaking provisions of the Administrative Procedure Act ((Chapter 3.5 commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2030. (l) This section shall become operative on January 1, 2026. (Repealed (in Sec. 8) and added by Stats. 2024, Ch. 763, Sec. 9. (AB 3275) Effective January 1, 2025. Operative January 1, 2026, by its own provisions.)
10123.15.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group disability insurers that cover hospital, medical, and surgical expenses and cover brain disorders must also cover specified severe mental disorders in the same manner.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.15. Every group policy of disability insurance which covers hospital, medical, and surgical expenses on a group basis, and which offers coverage for disorders of the brain shall also offer coverage in the same manner for the treatment of the following biologically based severe mental disorders: schizophrenia, schizo-affective disorder, bipolar disorders and delusional depressions, and pervasive developmental disorder. Coverage for these mental disorders shall be subject to the same terms and conditions applied to the treatment of other disorders of the brain; however, an insurer may reserve the right to confirm diagnoses and to review the appropriateness of specific treatment plans as necessary to ensure that coverage under this section is provided for only those diagnostic and treatment services which are medically necessary. Nothing in this section shall be construed to affect the scope of licensure of any health care professional nor to impair rights to reimbursement guaranteed health care providers pursuant to Section 10176. (Amended by Stats. 1992, Ch. 462, Sec. 1. Effective January 1, 1993.)
10123.16.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A disability insurer may not exclude covered persons from long-term care facility or home-based care benefits because they have certain brain-related conditions, except for a preexisting condition.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.16. Except for a preexisting condition, every disability insurer issuing policies of individual or group disability insurance in this state that offers group or individual coverage for long-term care facility services or home-based care shall not exclude persons covered by the plan from receiving these benefits, if they are diagnosed as having any significant destruction of brain tissue with resultant loss of brain function, including, but not limited to, progressive, degenerative, and dementing illnesses, including, but not limited to, Alzheimer’s disease, from the coverage offered for long-term care facility services or home-based care. For purposes of this section, where a particular disease can be determined only with an autopsy, “diagnosed” means clinical diagnosis not dependent on pathological confirmation, but employing nationally accepted criteria. (Amended by Stats. 1988, Ch. 1049, Sec. 2.)
10123.17.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A self-insured employee welfare benefit plan offering long-term care facility or home-based care coverage may not exclude covered persons with certain diagnosed brain-destruction conditions, except for a preexisting condition.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.17. Except for a preexisting condition, every self-insured employee welfare benefit plan in this state that offers group coverage for long-term care facility services or home-based care shall not exclude persons covered by the plan from receiving these benefits, if they are diagnosed as having any significant destruction of brain tissue with resultant loss of brain function, including, but not limited to, progressive, degenerative, and dementing illnesses, including, but not limited to, Alzheimer’s disease, from the coverage offered for long-term care facility services or home-based care. For purposes of this section, where a particular disease can be determined only with an autopsy, “diagnosed” means clinical diagnosis not dependent on pathological confirmation, but employing nationally accepted criteria. (Amended by Stats. 1988, Ch. 1049, Sec. 3.)
10123.18.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover annual cervical cancer screening tests and the HPV vaccine, with no cost-sharing for the vaccine coverage.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.18. (a) A disability insurance policy issued, amended, or renewed on or after January 1, 2024, and that provides coverage for hospital, medical, or surgical benefits shall provide coverage, upon the referral of a patient’s physician and surgeon, a nurse practitioner, or a certified nurse-midwife, providing care to the patient and operating within the scope of practice otherwise permitted for the licensee, for an annual cervical cancer screening test. (1) The coverage for an annual cervical cancer screening test provided pursuant to this section shall include the conventional Pap test, a human papillomavirus screening test that is approved by the United States Food and Drug Administration (FDA) and the option of any cervical cancer screening test approved by the FDA, upon the referral of the patient’s health care provider. (2) This subdivision does not require an individual or group policy to cover treatment or surgery for cervical cancer or to prevent application of deductible or copayment provisions contained in the policy or certificate, and does not require that coverage under an individual or group policy be extended to any other procedures. (b) A disability insurance policy issued, amended, or renewed on or after January 1, 2024, that provides coverage for hospital, medical, or surgical benefits shall provide coverage for the human papillomavirus vaccine for insureds for whom the vaccine is approved by the FDA. The policy shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided pursuant to this subdivision. (c) This section shall not apply to vision-only, dental-only, accident-only, specified disease, hospital indemnity, Medicare supplement, CHAMPUS supplement, long-term care, or disability income insurance. For accident-only, hospital indemnity, or specified disease insurance, coverage for benefits under this section shall apply only to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or certificate. This section does not impose a new benefit mandate on accident-only, hospital indemnity, or specified disease insurance. (Amended by Stats. 2023, Ch. 809, Sec. 7. (AB 659) Effective January 1, 2024.)
10123.184.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies with maternity benefits must cover California Prenatal Screening Program participation, and that coverage cannot be made subject to cost sharing or used as a prerequisite for other services.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.184. (a) Every group policy of disability insurance that covers hospital, medical, or surgical expenses, and that provides maternity benefits, that is issued, amended, renewed, or delivered on or after January 1, 1999, and every individual policy of disability insurance that covers hospital, medical, or surgical expenses, and that provides maternity benefits, that is of a type and form first offered for sale on or after January 1, 1999, shall provide coverage for participation in the California Prenatal Screening Program, which is a statewide prenatal testing program administered by the State Department of Public Health, pursuant to Section 124977 of the Health and Safety Code. Notwithstanding any other law, a disability insurer that provides coverage for maternity benefits shall not require participation in the statewide prenatal testing program administered by the State Department of Public Health as a prerequisite to eligibility for, or receipt of, any other service. (b) Coverage required under this section shall not be subject to copayment, coinsurance, deductible, or any other form of cost sharing. (c) Reimbursement for services covered pursuant to this section shall be paid at the amount set pursuant to Section 124977 of the Health and Safety Code and regulations adopted thereunder. (Amended by Stats. 2015, Ch. 18, Sec. 24. (SB 75) Effective June 24, 2015.)
10123.185.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must include coverage for osteoporosis-related services, subject to stated conditions and exclusions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.185. (a) Every policy of disability insurance that covers hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed in this state and certificate of group disability insurance issued, amended, delivered, or renewed in this state pursuant to a master group policy issued, amended, delivered, or renewed in another state on or after January 1, 1994, shall be deemed to include coverage for services related to diagnosis, treatment, and appropriate management of osteoporosis. The services may include, but need not be limited to, all Food and Drug Administration approved technologies, including bone mass measurement technologies as deemed medically appropriate. (b) This section shall not apply to specified accident, specified disease, hospital indemnity, Medicare supplement, or long-term care health insurance policies. (Added by Stats. 1993, Ch. 1208, Sec. 3. Effective January 1, 1994.)
10123.19.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies with binding-arbitration and jury-trial-waiver terms must include a clear disclosure and meet specific formatting and arbitration rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.19. (a) Any disability insurance policy that includes terms that require binding arbitration to settle disputes and that restrict, or provide for a waiver of, the right to a jury trial shall include, in clear and understandable language, a disclosure that meets all of the following conditions: (1) The disclosure shall clearly state whether the plan uses binding arbitration to settle disputes, including specifically whether the plan uses binding arbitration to settle claims of medical malpractice. (2) The disclosure shall appear as a separate article in the agreement issued to the employer group or individual subscriber and shall be prominently displayed on the enrollment form signed by each subscriber or enrollee. (3) In any disability insurance policy, the disclosure required by this section shall be displayed immediately before the signature line provided for the representative of the group contracting with a disability insurer and immediately before the signature line provided for the individual enrolling in the policy. (b) Any disability insurance policy that includes a term that requires the parties to submit to binding arbitration in case of a medical malpractice claim or dispute shall, for those cases or disputes for which the total amount of damages claimed is fifty thousand dollars ($50,000) or less, provide for selection by the parties of a single neutral arbitrator who shall have no jurisdiction to award more than fifty thousand dollars ($50,000). If the parties are unable to agree on the selection of a single neutral arbitrator, the method provided in Section 1281.6 of the Code of Civil Procedure shall be utilized. The provision shall not be subject to waiver by the policy. (Added by Stats. 1994, Ch. 653, Sec. 5. Effective January 1, 1995.)
10123.191.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers covering prescription drugs must use and accept only the required prior authorization form or an approved electronic process, and several parties must follow notice, approval, and review timelines.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.191. (a) Notwithstanding any other law, on and after January 1, 2013, a health insurer that provides coverage for prescription drugs shall utilize and accept only the prior authorization form developed pursuant to subdivision (c), or an electronic prior authorization process described in subdivision (e), when requiring prior authorization for prescription drugs. (b) (1) If a health insurer, contracted physician group, or utilization review organization fails to notify a prescribing provider of its coverage determination within 72 hours for nonurgent requests, or within 24 hours if exigent circumstances exist, upon receipt of a completed prior authorization or step therapy exception request, the prior authorization or step therapy exception request shall be deemed approved for the duration of the prescription, including refills. (2) If a request for prior authorization or a step therapy exception is incomplete or clinically relevant material information necessary to make a coverage determination is not included, the insurer, contracted physician group, or utilization review organization shall notify the prescribing provider within 72 hours of receipt, or within 24 hours of receipt if exigent circumstances exist, what additional or clinically relevant material information is needed to approve or deny the prior authorization or step therapy exception request, or to appeal the denial thereof. Once the requested information is received, the applicable time period to approve or deny a prior authorization or step therapy exception request, or to appeal, shall begin to elapse. If a coverage determination or request for additional or clinically relevant material information by an insurer, contracted physician group, or utilization review organization is not received by the prescribing provider within the time allotted, the prior authorization or step therapy exception request, or appeal of a denial thereof, shall be deemed approved for the duration of the prescription, including refills. In the event of a denial, the insurer, contracted physician group, or utilization review organization shall inform the prescribing provider and insured of the external appeal process under subdivision (h) of this section, which shall also apply to a denial of a prior authorization or step therapy exception request. (3) A health insurer, contracted physician group, utilization review organization, or external independent review organization shall approve a step therapy exception request, or internal or external appeal of a denial thereof, if any of the criteria in subdivision (c) of Section 10123.201 are satisfied. (c) On or before January 1, 2017, the department and the Department of Managed Health Care shall jointly develop a uniform prior authorization form. Notwithstanding any other law, on and after July 1, 2017, or six months after the form is completed pursuant to this section, whichever is later, every prescribing provider shall use that uniform prior authorization form, or an electronic prior authorization process described in subdivision (e), to request prior authorization for coverage of prescription drugs and every health insurer shall accept that form or electronic process as sufficient to request prior authorization for prescription drugs. (d) The prior authorization form developed pursuant to subdivision (c) shall meet the following criteria: (1) The form shall not exceed two pages. (2) The form shall be made electronically available by the department and the health insurer. (3) The completed form may also be electronically submitted from the prescribing provider to the health insurer. (4) The department and the Department of Managed Health Care shall develop the form with input from interested parties from at least one public meeting. (5) The department and the Department of Managed Health Care, in development of the standardized form, shall take into consideration the following: (A) Existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services. (B) National standards pertaining to electronic prior authorization. (e) A prescribing provider may use an electronic prior authorization system utilizing the standardized form described in subdivision (c) or an electronic process developed specifically for transmitting prior authorization information that meets the National Council for Prescription Drug Programs’ SCRIPT standard for electronic prior authorization transactions. (f) Subdivision (a) does not apply if any of the following occurs: (1) A contracted physician group is delegated the financial risk for the pharmacy or medical drug benefit by a health insurer. (2) A contracted physician group uses its own internal prior authorization process rather than the health insurer’s prior authorization process for the health insurer’s insureds. (3) A contracted physician group is delegated a utilization management function by the health insurer concerning any prescription drug, regardless of the delegation of financial risk. (g) For prescription drugs, prior authorization requirements described in subdivisions (c) and (e) apply regardless of how that benefit is classified under the terms of the health insurer’s group or individual policy. (h) A health insurer shall maintain a process for an external exception request review that complies with subdivision (c) of Section 156.122 of Title 45 of the Code of Federal Regulations. The external appeal process for exception requests shall also apply to a denial of a prior authorization or step therapy exception request. An independent review organization’s reversal of a health insurer’s denial of a request for an exception, prior authorization, or a step therapy exception shall be binding on the insurer and shall apply for the duration of the prescription, including refills. An insurer shall notify the insured and prescribing provider of the independent review organization’s coverage determination, or request for additional or clinically relevant material information necessary to make a coverage determination, within the time limits required by paragraph (2) of subdivision (b). This subdivision shall not affect or limit an insured’s eligibility for independent medical review under Section 10169 or to file an internal appeal with the insurer. (i) For an individual, small group, or large group health insurance policy, a health insurer that provides coverage for prescription drugs shall comply with subdivision (c) of Section 156.122 of Title 45 of the Code of Federal Regulations. (j) For purposes of this section: (1) “Prescribing provider” shall include a provider authorized to write a prescription, pursuant to subdivision (a) of Section 4040 of the Business and Professions Code, to treat a medical condition of an insured. (2) “Exigent circumstances” exist when an insured is suffering from a health condition that may seriously jeopardize the insured’s life, health, or ability to regain maximum function or when an insured is undergoing a current course of treatment using a nonformulary drug. (3) “Completed prior authorization request” means a completed uniform prior authorization form developed pursuant to subdivision (c), or a completed request submitted using an electronic prior authorization system described in subdivision (e), or, for contracted physician groups described in subdivision (f), the process used by the contracted physician group. (4) “Step therapy exception” means a decision to override a generally applicable step therapy protocol in favor of coverage of the prescription drug prescribed by a health care provider for an individual insured. (Amended by Stats. 2021, Ch. 742, Sec. 4. (AB 347) Effective January 1, 2022.)
10123.192.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers with prescription drug benefits and drug formularies must post, update, and format formulary information on their website, and state agencies must develop a standard formulary template.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.192. (a) A health insurer that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following: (1) Post the formulary or formularies for each product offered by the insurer on the insurer’s Internet Web site in a manner that is accessible and searchable by potential insureds, insureds, providers, the general public, the department, and federal agencies as required by federal law or regulations. (2) Update the formularies posted pursuant to paragraph (1) with any change to those formularies on a monthly basis. (3) No later than six months after the date that a standard formulary template is developed under subdivision (b), use that template to display the formulary or formularies for each product offered by the insurer. (b) (1) By January 1, 2017, the department and the Department of Managed Health Care shall jointly, and with input from interested parties from at least one public meeting, develop a standard formulary template for purposes of paragraph (3) of subdivision (a). In developing the template, the department and Department of Managed Health Care shall take into consideration existing requirements for reporting of formulary information established by the federal Centers for Medicare and Medicaid Services. To the extent feasible, in developing the template, the department and the Department of Managed Health Care shall evaluate a way to include on the template, in addition to the information required to be included under paragraph (2), cost-sharing information for drugs subject to coinsurance. (2) The standard formulary template shall include a notification that the presence of a drug on the insurer’s formulary does not guarantee that an insured will be prescribed that drug by his or her prescribing provider for a particular medical condition. As applied to a particular formulary for a product offered by an insurer, the standard formulary template shall do all of the following: (A) Include information on cost-sharing tiers and utilization controls, including prior authorization or step therapy requirements, for each drug covered by the product. (B) Indicate any drugs on the formulary that are preferred over other drugs on the formulary. (C) Include information to educate insureds about the differences between drugs administered or provided under a health insurer’s medical benefit and drugs prescribed under a health insurer’s prescription drug benefit and about how to obtain coverage information about drugs that are not covered under the health insurer’s prescription drug benefit. (D) Include information to educate insureds that health insurers that provide prescription drug benefits are required to have a method for insureds to obtain prescription drugs not listed in the health insurer’s drug formulary if the drugs are deemed to be medically necessary by a clinician pursuant to Section 1367.24 of the Health and Safety Code, as required by clause (iv) of subparagraph (A) of paragraph (2) of subdivision (a) of Section 10112.27. (E) Include information on which medications are covered, including both generic and brand name. (F) Include information on what tier of the health insurer’s drug formulary each medication is in. (c) The commissioner may adopt regulations as may be necessary to carry out the purposes of this section. In adopting regulations, the commissioner shall comply with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (d) For purposes of this section, “formulary” means the complete list of drugs preferred for use and eligible for coverage under a health insurance product and includes the drugs covered under the pharmacy benefit of the product. (Amended by Stats. 2015, Ch. 619, Sec. 6. (AB 339) Effective January 1, 2016.)
10123.193.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies that cover outpatient prescription drugs must cover medically necessary drugs, keep cost sharing reasonable, and avoid formulary practices that discourage enrollment or unfairly reduce benefits for people with health conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.193. (a) The Legislature hereby finds and declares all of the following: (1) The federal Patient Protection and Affordable Care Act, its implementing regulations and guidance, and related state law prohibit discrimination based on a person’s expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions, including benefit designs that have the effect of discouraging the enrollment of individuals with significant health needs. (2) The Legislature intends to build on the existing state and federal law to ensure that health coverage benefit designs do not have an unreasonable discriminatory impact on chronically ill individuals, and to ensure affordability of outpatient prescription drugs. (3) Assignment of all or most prescription medications that treat a specific medical condition to the highest cost tiers of a formulary may effectively discourage enrollment by chronically ill individuals, and may result in lower adherence to a prescription drug treatment regimen. (b) A nongrandfathered policy of health insurance that is offered, amended, or renewed on or after January 1, 2017, shall comply with this section. The cost-sharing limits established by this section apply only to outpatient prescription drugs covered by the policy that constitute essential health benefits, as defined by Section 10112.27. (c) A policy of health insurance that provides coverage for outpatient prescription drugs shall cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary consistent with this part. (d) Copayments, coinsurance, and other cost sharing for outpatient prescription drugs shall be reasonable so as to allow access to medically necessary outpatient prescription drugs. (e) (1) Consistent with federal law and guidance, the formulary or formularies for outpatient prescription drugs maintained by the health insurer shall not discourage the enrollment of individuals with health conditions and shall not reduce the generosity of the benefit for insureds with a particular condition in a manner that is not based on a clinical indication or reasonable medical management practices. Section 1342.7 of the Health and Safety Code and any regulations adopted pursuant to that section shall be interpreted in a manner that is consistent with this section. (2) For combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS/HIV, a policy of health insurance shall cover a single-tablet drug regimen that is as effective as a multitablet regimen unless, consistent with clinical guidelines and peer-reviewed scientific and medical literature, the multitablet regimen is clinically equally or more effective and more likely to result in adherence to a drug regimen. (3) Any limitation or utilization management shall be consistent with and based on clinical guidelines and peer-reviewed scientific and medical literature. (f) (1) This section shall not be construed to require a health insurer to impose cost sharing. (2) This section shall not be construed to require cost sharing for prescription drugs that state or federal law otherwise requires to be provided without cost sharing. (3) A prescription drug benefit shall provide that if the pharmacy’s retail price for a prescription drug is less than the applicable copayment or coinsurance amount, the insured shall not be required to pay more than the retail price. The payment rendered shall constitute the applicable cost sharing and shall apply to the deductible, if any, and also to the maximum out-of-pocket limit in the same manner as if the enrollee had purchased the prescription medication by paying the cost-sharing amount. (g) A policy of health insurance shall ensure that the placement of prescription drugs on formulary tiers is based on clinically indicated, reasonable medical management practices. (h) In the provision of outpatient prescription drug coverage, a health insurer may utilize formulary, prior authorization, step therapy, or other reasonable medical management practices consistent with this part. (Amended (as amended by Stats. 2016, Ch. 86, Sec. 204) by Stats. 2018, Ch. 787, Sec. 5. (SB 1021) Effective January 1, 2019.)
10123.1932.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance cost sharing for covered outpatient prescription drugs is capped, and certain drug formularies are limited to four tiers.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1932. (a) (1) With respect to an individual or group policy of health insurance subject to Section 10112.28, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed two hundred fifty dollars ($250), except as provided in paragraphs (2) and (3). (2) With respect to products with actuarial value at or equivalent to the bronze level, cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed five hundred dollars ($500), except as provided in paragraph (3). (3) For a policy of health insurance that is a “high deductible health plan” under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code, paragraphs (1) and (2) of this subdivision shall apply only once an insured’s deductible has been satisfied for the year. (4) For a nongrandfathered individual or small group policy of health insurance, the annual deductible for outpatient drugs, if any, shall not exceed twice the amount specified in paragraph (1) or (2), respectively. (5) For purposes of paragraphs (1) and (2), “any other form of cost sharing” shall not include a deductible. (6) A copayment or percentage coinsurance shall not exceed 50 percent of the cost to the insurer, as described in Section 1300.67.24 of Title 28 of the California Code of Regulations. (7) If there is a generic equivalent to a brand name drug, an insurer shall ensure that the insured is subject to the lowest cost sharing that would be applied, whether or not both the generic equivalent and the brand name drug are on the formulary. This paragraph shall not be construed to require both the generic equivalent and the brand name drug to be on the formulary. (b) (1) If a policy of health insurance offered, sold, or renewed in the nongrandfathered individual or small group market maintains a drug formulary grouped into tiers that includes a fourth tier, a policy of health insurance shall use the following definitions for each tier of the drug formulary: (A) Tier one shall consist of most generic drugs and low-cost preferred brand name drugs. (B) Tier two shall consist of nonpreferred generic drugs, preferred brand name drugs, and any other drugs recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost. (C) Tier three shall consist of nonpreferred brand name drugs or drugs that are recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost, or that generally have a preferred and often less costly therapeutic alternative at a lower tier. (D) Tier four shall consist of drugs that the Food and Drug Administration of the United States Department of Health and Human Services or the manufacturer requires to be distributed through a specialty pharmacy, drugs that require the insured to have special training or clinical monitoring for self-administration, or drugs that cost the health insurer more than six hundred dollars ($600) net of rebates for a one-month supply. (2) In placing specific drugs on specific tiers, or choosing to place a drug on the formulary, the insurer shall comply with the other provisions of this section and this part. (3) A policy of health insurance may maintain a drug formulary with fewer than four tiers. A policy of health insurance shall not maintain a drug formulary with more than four tiers. (4) This section shall not be construed to limit a health insurer from placing any drug in a lower tier. (Amended by Stats. 2023, Ch. 820, Sec. 2. (AB 948) Effective January 1, 2024.)
10123.1933.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must not impose prior authorization or step therapy on medically necessary HIV/AIDS prevention antiretroviral drugs, and must cover pharmacist-furnished PrEP/PEP and related services.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1933. (a) (1) Notwithstanding Section 10123.201, a health insurer shall not subject antiretroviral drugs that are medically necessary for the prevention of AIDS/HIV, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy, except as provided in paragraph (2). (2) If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a drug, device, or product for the prevention of AIDS/HIV, this section does not require a health insurer to cover all of the therapeutically equivalent versions without prior authorization or step therapy, if at least one therapeutically equivalent version is covered without prior authorization or step therapy. (b) Notwithstanding any other law, a health insurer shall not prohibit, or permit a contracted pharmacy benefit manager to prohibit, a pharmacist from dispensing preexposure prophylaxis or postexposure prophylaxis. (c) A health insurer shall cover preexposure prophylaxis and postexposure prophylaxis that has been furnished by a pharmacist, as authorized in Sections 4052.02 and 4052.03 of the Business and Professions Code, including the pharmacist’s services and related testing ordered by the pharmacist. A health insurer shall pay or reimburse, consistent with the requirements of this chapter, for the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the health insurer has an out-of-network pharmacy benefit. (Amended by Stats. 2024, Ch. 1, Sec. 3. (SB 339) Effective February 6, 2024.)
10123.1935.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers offering outpatient prescription drug benefits must cover at least one FDA-approved medication in each listed category, without prior authorization, step therapy, or utilization review.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1935. (a) Notwithstanding any other law, a group or individual health insurer offering an outpatient prescription drug benefit shall provide coverage for at least one medication approved by the United States Food and Drug Administration in each of the following categories without prior authorization, step therapy, or utilization review: (1) Medication for the reversal of opioid overdose, including a naloxone product or another opioid antagonist. (2) Medication for the detoxification or maintenance treatment of a substance use disorder, including a daily oral buprenorphine product. (3) A long-acting buprenorphine product. (4) A long-acting injectable naltrexone product. (b) This section does not prohibit a health insurer from selecting an AB-rated generic equivalent, biosimilar, as defined in Section 262(i)(2) of Title 42 of the United States Code, or interchangeable biological product, as defined in Section 262(i)(3) of Title 42 of the United States Code, to meet the requirements of subdivision (a). (Added by Stats. 2024, Ch. 633, Sec. 2. (AB 1842) Effective January 1, 2025.)
10123.194.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers must give insureds a uniform prescription drug information card and include specified information on it.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.194. (a) Every disability insurer that covers hospital, medical, or surgical expenses, and, as part of that coverage, also covers prescription drug benefits, and that issues a card to insureds for claims processing purposes, shall issue to each of its insureds a uniform card containing uniform prescription drug information. The uniform prescription drug information card shall, at a minimum, include the following information: (1) The name or logo of the benefit administrator or disability insurer issuing the card, which shall be displayed on the front side of the card. (2) The insured’s identification number, or the policyholder’s identification number when the insured is a dependent who accesses services using the policy holder’s identification number, which shall be displayed on the front side of the card. (3) A telephone number that pharmacy providers may call for assistance. (4) Information required by the benefit administrator or disability insurer that is necessary to commence processing the pharmacy claim, except as provided for in paragraph (5). (5) A disability insurer shall not be required to print any of the following information on an insured’s card: (A) Any number that is the same for all of its insured, provided that the disability insurer provides this number to the pharmacy on an annual basis. (B) Any information that may result in fraudulent use of the card. (C) Any information that is otherwise prohibited from being included on the card. (b) Beginning July 1, 2002, the new uniform prescription drug information card required by subdivision (a) shall be issued by an insurer to an insured upon enrollment or upon any change in the insured’s coverage that impacts the data content or format of the card. (c) Nothing in this section requires an insurer to issue a separate card for prescription drug coverage if the insurer issues a card for health care coverage in general and the card is able to accommodate the information required by subdivision (a). (d) “Card” as used in this section includes other technology that performs substantially the same function as a card. (e) For purposes of this section, if a disability insurer delegates responsibility for issuing the uniform prescription drug information card to a contractor or agent, then the contract between the disability insurer and its contractor or agent shall require compliance with this section. (Added by Stats. 2001, Ch. 622, Sec. 2. Effective January 1, 2002.)
10123.1945.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies generally cannot charge cost sharing or add delays for vasectomy services and procedures, with limited exceptions for certain plans and religious-employer arrangements.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1945. (a) (1) A disability insurance policy issued, amended, renewed, or delivered on or after January 1, 2024, except for a grandfathered health plan or a qualifying health plan for a health savings account, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on vasectomy services or procedures. For a qualifying health plan for a health savings account, an insurer shall establish the plan’s cost sharing for vasectomy services and procedures at the minimum level necessary to preserve the insured’s ability to claim tax-exempt contributions and withdrawals from the insured’s health savings account under Internal Revenue Service laws, regulations, and guidance. (2) An insurer shall not impose any restrictions or delays, including, but not limited to, prior authorization, on vasectomy services and procedures. (3) Coverage with respect to an insured under this section shall be identical for an insured’s covered spouse and covered nonspouse dependents. (b) This section shall not be construed to deny or restrict in any way an existing right or benefit provided under law or by contract. (c) This section shall not be construed to require an individual or group disability insurance policy to cover experimental or investigational treatments. (d) Notwithstanding any other provision of this section, a religious employer may request a disability insurance policy without coverage for contraceptive methods that are contrary to the religious employer’s religious tenets. If so requested, a disability insurance policy shall be provided without coverage for vasectomy services and procedures. The exclusion from coverage under this provision shall not apply to vasectomy services or procedures for purposes other than contraception. (1) An insurer that contracts with a religious employer to provide a disability insurance policy that does not include coverage and benefits for vasectomy services and procedures shall notify, in writing, upon initial enrollment and annually thereafter upon renewal, each enrollee that vasectomy services and procedures are not included in the insured’s disability insurance policy. (2) For purposes of this section, a “religious employer” is an entity for which each of the following is true: (A) The inculcation of religious values is the purpose of the entity. (B) The entity primarily employs persons who share the religious tenets of the entity. (C) The entity serves primarily persons who share the religious tenets of the entity. (D) The entity is a nonprofit organization pursuant to Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended. (e) This section only applies to disability insurance policies or contracts that are defined as health benefit plans pursuant to subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity coverage, coverage for benefits under this section applies to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or contract. This section shall not be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance. (f) For purposes of this section, the following definitions apply: (1) “Grandfathered health plan” has the meaning set forth in Section 1251 of PPACA. (2) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued thereunder. (Added by Stats. 2022, Ch. 630, Sec. 16. (SB 523) Effective January 1, 2023.)
10123.195.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section limits insurers from denying or restricting prescription-drug coverage for off-label use, and requires coverage for mifepristone in specified circumstances.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.195. (a) A group or individual disability insurance policy issued, delivered, or renewed in this state or certificate of group disability insurance issued, delivered, or renewed in this state pursuant to a master group policy issued, delivered, or renewed in another state that, as a provision of hospital, medical, or surgical services, directly or indirectly covers prescription drugs shall not limit or exclude coverage for a drug on the basis that the drug is prescribed for a use that is different from the use for which that drug has been approved for marketing by the United States Food and Drug Administration (FDA), provided that all of the following conditions have been met: (1) The drug is approved by the FDA. (2) (A) The drug is prescribed by a contracting licensed health care professional for the treatment of a life-threatening condition; or (B) The drug is prescribed by a contracting licensed health care professional for the treatment of a chronic and seriously debilitating condition, the drug is medically necessary to treat that condition, and the drug is on the insurer’s formulary, if any. (3) The drug has been recognized for treatment of that condition by any of the following: (A) The American Hospital Formulary Service’s Drug Information. (B) One of the following compendia, if recognized by the federal Centers for Medicare and Medicaid Services as part of an anticancer chemotherapeutic regimen: (i) The Elsevier Gold Standard’s Clinical Pharmacology. (ii) The National Comprehensive Cancer Network Drug and Biologics Compendium. (iii) The Thomson Micromedex DrugDex. (C) Two articles from major peer reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective unless there is clear and convincing contradictory evidence presented in a major peer reviewed medical journal. (b) (1) A group or individual health insurance policy issued, delivered, or renewed in this state or certificate of group health insurance issued, delivered, or renewed in this state pursuant to a master group policy issued, delivered, or renewed in another state that, as a provision of hospital, medical, or surgical services, directly or indirectly covers prescription drugs shall not limit or exclude coverage for brand name or generic mifepristone solely on the basis that the drug is prescribed for a use that is different from the use for which that drug has been approved for marketing by the FDA or that varies from an approved risk evaluation and mitigation strategy pursuant to Section 355-1 of Title 21 of the United States Code, except if the state deems it necessary to address an imminent health or safety concern regarding brand name or generic mifepristone. (2) A group or individual health insurance policy issued, delivered, or renewed in this state or certificate of group health insurance issued, delivered, or renewed in this state pursuant to a master group policy issued, delivered, or renewed in another state that, as a provision of hospital, medical, or surgical services, directly or indirectly covers prescription drugs shall include coverage for brand name or generic mifepristone, even if the drug has not been approved by the FDA for abortion if the requirements of paragraph (3) have been met, except if the state deems it necessary to address an imminent health or safety concern regarding brand name or generic mifepristone. (3) If name brand or generic mifepristone has not been approved by the FDA for abortion, coverage is required pursuant to paragraph (2) if the drug is a recognized medication for abortion by the World Health Organization (WHO) Model List of Essential Medicines, the WHO abortion care guideline, or the National Academies of Science, Engineering, and Medicine Consensus Study Report, or if the state approves its use based on peer-reviewed studies and prior approval of the drug that is no longer in effect. (c) It shall be the responsibility of the contracting prescriber to submit to the insurer documentation supporting compliance with the requirements of subdivision (a), if requested by the insurer. (d) Any coverage required by this section shall also include medically necessary services associated with the administration of a drug subject to the conditions of the policy. (e) For purposes of this section, “life-threatening” means either or both of the following: (1) Diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted. (2) Diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival. (f) For purposes of this section, “chronic and seriously debilitating” means diseases or conditions that require ongoing treatment to maintain remission or prevent deterioration and cause significant long-term morbidity. (g) The provision of drugs and services when required by this section shall not, in itself, give rise to liability on the part of the insurer. (h) This section shall not apply to a policy of disability insurance that covers hospital, medical, or surgical expenses that is issued outside of California to an employer whose principal place of business is located outside of California. (i) This section does not prohibit the use of a formulary, copayment, technology assessment panel, or similar mechanism as a means for appropriately controlling the utilization of a drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the FDA. (j) If an insurer denies coverage pursuant to this section on the basis that its use is experimental or investigational, that decision is subject to review under the Independent Medical Review System of Article 3.5 (commencing with Section 10169). (k) This section is not applicable to vision-only, dental-only, Medicare or Champus supplement, disability income, long-term care, accident-only, specified disease or hospital confinement indemnity insurance. (Amended by Stats. 2025, Ch. 136, Sec. 19. (AB 260) Effective September 26, 2025.)
10123.196.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section requires certain disability insurance policies to cover specified contraceptive drugs, devices, services, and supplies, and limits cost sharing and coverage restrictions, subject to listed exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.196. (a) An individual or group policy of disability insurance issued, amended, renewed, or delivered on or after January 1, 2000, through December 31, 2015, inclusive, that provides coverage for hospital, medical, or surgical expenses, shall provide coverage for the following, under the same terms and conditions as applicable to all benefits: (1) A disability insurance policy that provides coverage for outpatient prescription drug benefits shall include coverage for a variety of federal Food and Drug Administration (FDA)-approved prescription contraceptive methods, as designated by the insurer. If an insured’s health care provider determines that none of the methods designated by the disability insurer is medically appropriate for the insured’s medical or personal history, the insurer shall, in the alternative, provide coverage for some other FDA-approved prescription contraceptive method prescribed by the patient’s health care provider. (2) Coverage with respect to an insured under this subdivision shall be identical for an insured’s covered spouse and covered nonspouse dependents. (b) (1) A group or individual policy of disability insurance, except for a specialized health insurance policy, that is issued, amended, renewed, or delivered on or after January 1, 2016, shall provide coverage for all of the following services and contraceptive methods for all policyholders and insureds: (A) (i) Except as provided in clause (ii) and in subparagraphs (B) and (C) of paragraph (2), all FDA-approved, contraceptive drugs, devices, and other products, including all FDA-approved, contraceptive drugs, devices, and products available over the counter, as prescribed by the insured’s provider. (ii) For any policy described in paragraph (1) that is issued, amended, renewed, or delivered on or after January 1, 2024, both of the following conditions shall apply: (I) A prescription shall not be required to trigger coverage of over-the-counter FDA-approved contraceptive drugs, devices, and products. (II) Point-of-sale coverage for over-the-counter FDA-approved contraceptive drugs, devices, and products shall be provided at in-network pharmacies without cost sharing or medical management restrictions. (B) Voluntary tubal ligation and other similar sterilization procedures. (C) Clinical services related to the provision or use of contraception, including consultations, examinations, procedures, device insertion, ultrasound, anesthesia, patient education, referrals, and counseling. (D) Followup services related to the drugs, devices, products, and procedures covered under this subdivision, including, but not limited to, management of side effects, counseling for continued adherence, and device removal. (2) (A) Except for a grandfathered health plan, a disability insurer subject to this subdivision shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided pursuant to this subdivision. (B) If the FDA has approved one or more therapeutic equivalents, as that term is defined by the FDA, of a contraceptive drug, device, or product, a disability insurer is not required to cover all of those therapeutically equivalent versions in accordance with this subdivision, as long as at least one is covered without cost sharing in accordance with this subdivision. If there is no therapeutically equivalent generic substitute available in the market, an insurer shall provide coverage without cost sharing for the original, brand name contraceptive. (C) If a covered therapeutic equivalent of a drug, device, or product is deemed medically inadvisable by the insured’s provider, a disability insurer shall defer to the determination and judgment of the provider and provide coverage for the alternative prescribed contraceptive drug, device, product, or service without imposing any cost-sharing requirements. Medical inadvisability may include considerations such as severity of side effects, differences in permanence or reversibility of contraceptives, and ability to adhere to the appropriate use of the drug or item, as determined by the provider. The department may promulgate regulations establishing an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome, including timeframes, for an insured, an insured’s designee, or an insured’s provider to request coverage of an alternative prescribed contraceptive. A request for coverage under this subparagraph that is submitted by an insured, an insured’s designee, or a provider shall be approved by the disability insurer in compliance with the time limits in Section 10123.191. (3) Except as otherwise authorized under this section, an insurer shall not infringe upon an insured’s choice of contraceptive drug, device, or product and shall not impose any restrictions or delays on the coverage required under this subdivision, including prior authorization, step therapy, or other utilization control techniques. (4) Coverage with respect to an insured under this subdivision shall be identical for an insured’s covered spouse and covered nonspouse dependents. (c) This section shall not be construed to deny or restrict in any way any existing right or benefit provided under law or by contract. (d) This section shall not be construed to require an individual or group disability insurance policy to cover experimental or investigational treatments. (e) (1) Notwithstanding any other provision of this section, a religious employer may request a disability insurance policy without coverage for contraceptive methods that are contrary to the religious employer’s religious tenets. If so requested, a disability insurance policy shall be provided without coverage for contraceptive methods. The exclusion from coverage under this provision shall not apply to a contraceptive drug, device, procedure, or other product that is used for purposes other than contraception. (2) For purposes of this section, a “religious employer” is an entity for which each of the following is true: (A) The inculcation of religious values is the purpose of the entity. (B) The entity primarily employs persons who share the religious tenets of the entity. (C) The entity serves primarily persons who share the religious tenets of the entity. (D) The entity is a nonprofit organization pursuant to Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended. (f) (1) A group or individual policy of disability insurance, except for a specialized health insurance policy, that is issued, amended, renewed, or delivered on or after January 1, 2017, shall cover up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives when dispensed or furnished at one time for an insured by a provider, pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. (2) This subdivision shall not be construed to require a policy to cover contraceptives provided by an out-of-network provider, pharmacy, or location licensed or otherwise authorized to dispense drugs or supplies, except as may be otherwise authorized by state or federal law or by the insurer’s policies governing out-of-network coverage. (3) This subdivision shall not be construed to require a provider to prescribe, furnish, or dispense 12 months of self-administered hormonal contraceptives at one time. (4) An insurer subject to this subdivision shall not impose utilization controls or other forms of medical management limiting the supply of FDA-approved, self-administered hormonal contraceptives that may be dispensed or furnished by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies to an amount that is less than a 12-month supply, and shall not require an insured to make any formal request for such coverage other than a pharmacy claim. (g) This section shall not be construed to exclude coverage for contraceptive supplies as prescribed by a provider, acting within the provider’s scope of practice, for reasons other than contraceptive purposes, such as decreasing the risk of ovarian cancer or eliminating symptoms of menopause, or for contraception that is necessary to preserve the life or health of an insured. (h) This section only applies to disability insurance policies or contracts that are defined as health benefit plans pursuant to subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity coverage, coverage for benefits under this section applies to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or contract. This section shall not be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance. (i) For purposes of this section, the following definitions apply: (1) “Grandfathered health plan” has the meaning set forth in Section 1251 of PPACA. (2) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued thereunder. (3) With respect to policies of disability insurance issued, amended, or renewed on or after January 1, 2016, “health care provider” means an individual who is certified or licensed to furnish family planning services within their scope of practice pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, including a pharmacist authorized pursuant to Section 4052 or 4052.3 of the Business and Professions Code, or an initiative act referred to in that division, or Division 2.5 (commencing with Section 1797) of the Health and Safety Code. (4) For purposes of this section, “over-the-counter FDA-approved contraceptive drugs, devices, and products” and “over-the-counter birth control methods” are limited to those included as essential health benefits pursuant to Section 10112.27. (Amended by Stats. 2022, Ch. 630, Sec. 17. (SB 523) Effective January 1, 2023.)
10123.1961.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurance policies cannot charge cost-sharing or use utilization review for outpatient abortion services, and the department must adopt implementing regulations by January 1, 2026.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1961. (a) (1) The requirements of this section shall apply to a group or individual policy or certificate of health insurance or student blanket disability insurance that provides coverage for hospital, medical, or surgical expenses that is issued, amended, renewed, or delivered on or after January 1, 2023. This section does not apply to a specialized health insurance policy. A policy or certificate subject to the requirements of this section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement on coverage for all abortion and abortion-related services, including preabortion and followup services. (2) Except as otherwise authorized by this section, an insurer shall not impose any utilization management or utilization review, including prior authorization and annual or lifetime limits consistent with Sections 10112.1 and 10112.27, on the coverage for outpatient abortion services. (b) This section does not deny or restrict in any way the department's authority to ensure an insurer’s compliance with this chapter when the insurer provides coverage for abortion services. (c) This section does not require an individual or group disability insurance policy to cover an experimental or investigational treatment. (d) For purposes of this section, “abortion” means any medical treatment intended to induce the termination of a pregnancy except for the purpose of producing a live birth. (e) For a group or individual policy or certificate of health insurance or student blanket disability insurance that is a high deductible health plan, as defined in Section 223(c)(2) of Title 26 of the United States Code, the cost-sharing limits in paragraph (1) of subdivision (a) shall apply once an insured’s deductible has been satisfied for the benefit year. (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the commissioner may interpret and implement this section by issuing guidance without taking any further regulatory action. The commissioner shall consult with the Department of Managed Health Care in issuing guidance under this section. The department shall adopt regulations on or before January 1, 2026, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (Added by Stats. 2022, Ch. 11, Sec. 2. (SB 245) Effective January 1, 2023.)
10123.197.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Step therapy exception requests may be submitted and must be handled like prior authorization requests; regulators must include them on the uniform prior authorization form.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.197. (a) A request for an exception to a health insurer’s step therapy process for prescription drugs may be submitted in the same manner as a request for prior authorization for prescription drugs pursuant to Section 10123.191, and shall be treated in the same manner, and shall be responded to by the health insurer in the same manner, as a request for prior authorization for prescription drugs. (b) The department and the Department of Managed Health Care shall include a provision for step therapy exception requests in the uniform prior authorization form developed pursuant to subdivision (c) of Section 10123.191. (c) “Step therapy exception” means a decision to override a generally applicable step therapy protocol in favor of coverage of the prescription drug prescribed by a health care provider for an individual insured. (Amended by Stats. 2021, Ch. 742, Sec. 5. (AB 347) Effective January 1, 2022.)
10123.198.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer covering professional mental health services must issue an ID card to the insured, and the card must include specified information.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.198. (a) On and after July 1, 2011, in accordance with the requirements of subdivision (b), a health insurer that provides coverage for professional mental health services shall issue an identification card to an insured in order to assist the insured with accessing health benefits coverage information, including, but not limited to, in-network provider access information, and claims processing purposes. The identification card, at a minimum, shall include all of the following information: (1) The name of the health insurer issuing the identification card. (2) The insured’s identification number. (3) A telephone number that insureds or providers may call for assistance with health benefits coverage information, in-network provider access information, and claims processing information, and if assessment services are provided by the health insurer, access to assessment services for the purpose of referral to an appropriate level of care or an appropriate health care provider. (4) The health insurer’s Internet Web site address. (b) The identification card required by this section shall be issued by a health insurer to an insured upon commencement of coverage or upon a change in the insured’s coverage that impacts the data content or format of the card. (c) This section does not require a health insurer to issue a separate identification card for professional mental health coverage if the insurer issues a card for health care coverage in general and the card provides the information required by this section. (d) If a health insurer, as described in subdivision (a), delegates responsibility for issuing the card to a contractor or agent, the contractor or agent shall be required to comply with this section. (e) This section does not prohibit a health insurer from meeting the standards of the Workgroup for Electronic Data Interchange (WEDI) or other national uniform standards with respect to identification cards, and a health insurer shall be deemed compliant with this section if the insurer conforms with these standards, as long as the minimum requirements described in subdivision (a) have been met. (f) For the purposes of this section, “identification card” includes other technology that performs substantially the same function as an identification card. (g) (1) This section shall not apply to Medicare supplement insurance, employee assistance programs, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, and specified disease insurance. This section shall also not apply to specialized health insurance policies, except behavioral health-only policies. (2) Notwithstanding paragraph (1), this section shall not apply to a behavioral health-only policy that provides coverage for professional mental health services pursuant to a contract with a health care service plan or insurer if that plan or insurer issues an identification card to its subscribers or insureds pursuant to this section or Section 1367.29 of the Health and Safety Code. (Amended by Stats. 2018, Ch. 687, Sec. 9. (SB 910) Effective January 1, 2019.)
10123.199.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurers must post required mental health coverage information on a website and update it at least quarterly.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.199. (a) A health insurer that provides coverage for professional mental health services shall establish an Internet Web site. Each Internet Web site shall include, or provide a link to, the following information: (1) A telephone number that the insured or provider can call, during normal business hours, for assistance obtaining mental health benefits coverage information, including the extent to which benefits have been exhausted, in-network provider access information, and claims processing information. (2) A link to prescription drug formularies posted pursuant to Section 10123.192, or instructions on how to obtain formulary information. (3) A detailed summary description of the process by which the insurer reviews and approves, modifies, or denies requests for health care services as described in Section 10123.135. (4) Lists of providers or instructions on how to obtain a provider list as required by Section 10133.1. (5) A detailed summary of the health insurer’s grievance process. (6) A detailed description of how the insured may request continuity of care as described in Section 10133.55. (7) Information concerning the right, and applicable procedure, of the insured to request an independent medical review pursuant to Section 10169. (b) Except as otherwise specified, the material described in subdivision (a) shall be updated at least quarterly. (c) The information described in subdivision (a) may be made available through a secured Internet Web site that is only accessible to the insured. (d) The material described in subdivision (a) shall also be made available to insureds in hard copy upon request. (e) This article does not preclude an insurer from including additional information on its Internet Web site for applicants or insureds, including, but not limited to, the cost of procedures or services by health care providers in an insurer’s network. (f) The department shall include on the department’s Internet Web site, a link to the Internet Web site of each health insurer described in subdivision (a). (g) This section shall not apply to Medicare supplement insurance, employee assistance programs, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, and specified disease insurance. This section shall also not apply to specialized health insurance policies, except behavioral health-only policies. (h) This section shall not apply to a health insurer that contracts with a specialized health care service plan, insurer, or other entity to cover professional mental health services for its insureds, provided that the health insurer provides a link on its Internet Web site to an Internet Web site operated by the specialized health care service plan, insurer, or other entity with which it contracts, and that plan, insurer, or other entity complies with this section or Section 1368.016 of the Health and Safety Code. (Amended by Stats. 2018, Ch. 687, Sec. 10. (SB 910) Effective January 1, 2019.)
10123.1991.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer must give insureds a written or electronic notice about the benefits of behavioral health and wellness screening for children and adolescents ages 8 to 18.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.1991. (a) (1) A health insurer shall provide to insureds a written or electronic notice regarding the benefits of a behavioral health and wellness screening for children and adolescents 8 to 18 years of age. (2) “Behavioral health and wellness screening” means a screening, test, or assessment to identify indicators or symptoms of behavioral health issues in an individual, including, but not limited to, depression or anxiety. (b) The notice shall provide information regarding the benefits of behavioral health and wellness screenings for both depression and anxiety. (c) A health insurer shall provide notice pursuant to this section annually. (d) This section does not apply to Medi-Cal managed care that contracts with the State Department of Health Care Services entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code. (Amended by Stats. 2025, Ch. 243, Sec. 10. (SB 862) Effective January 1, 2026.)
10123.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Self-insured employee welfare benefit plans that cover hospital, medical, or surgical expenses must offer that coverage to physically handicapped persons and tell members and prospective members that the coverage is available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.2. On and after the effective date of this section, every self-insured employee welfare benefit plan which provides coverage for hospital, medical, or surgical expenses shall offer coverage to physically handicapped persons for such expenses incurred, under such terms and conditions as are normally provided by the self-insured welfare benefit plan and a member without physical handicap. Every self-insured welfare benefit plan shall communicate the availability of such coverage to all members and prospective members. The self-insured welfare benefit plan shall not be required to cover hospital, medical, or surgical expenses arising as a direct result of a physically disabled person’s handicap. (Added by Stats. 1974, Ch. 964.)
10123.20.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies must cover generally medically accepted cancer screening tests, and they generally cannot require prior authorization for biomarker testing in insureds with advanced or metastatic stage 3 or 4 cancer.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.20. (a) A health insurance policy that is issued, amended, delivered, or renewed on or after July 1, 2000, shall be deemed to provide coverage for all generally medically accepted cancer screening tests, subject to all other terms and conditions that would otherwise apply. (b) A health insurance policy that is issued, amended, delivered, or renewed on or after July 1, 2022, shall not require prior authorization for either of the following: (1) Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer. (2) Biomarker testing of cancer progression or recurrence in the insured with advanced or metastatic stage 3 or 4 cancer. (c) For purposes of this section, “biomarker test” means a diagnostic test, such as single or multigene, of the cancer patient’s biospecimen, such as tissue, blood, or other bodily fluids, for DNA or RNA alterations, including phenotypic characteristics of a malignancy, to identify an individual with a subtype of cancer, in order to guide patient treatment. (d) This section shall not apply to vision-only, dental-only, accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, or disability income insurance, except that for accident-only, specified disease, or hospital indemnity insurance, coverage for benefits under this section shall apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or contract. This section shall not be construed as imposing a new benefit mandate on accident-only, specified disease, or hospital indemnity insurance. (e) Notwithstanding subdivision (b), this section does not prohibit a health insurer from requiring prior authorization on biomarker testing that is not for an FDA-approved therapy for advanced or metastatic stage 3 or 4 cancer. (f) This section does not limit, prohibit, or modify an insured’s rights to biomarker testing as part of an approved clinical trial under Section 10145.4. (Amended by Stats. 2021, Ch. 605, Sec. 2. (SB 535) Effective January 1, 2022.)
10123.201.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers covering outpatient prescription drugs must cover medically necessary drugs and certain related drug benefits, while allowing some prior authorization and step therapy rules within stated limits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.201. (a) A policy of health insurance that covers outpatient prescription drugs shall cover medically necessary drugs. The policy may provide for step therapy and prior authorization consistent with Section 1342.7 of the Health and Safety Code and any regulations adopted pursuant to that section. (b) (1) Commencing January 1, 2017, an insurer shall maintain a pharmacy and therapeutics committee that shall be responsible for developing, maintaining, and overseeing any drug formulary list. If the insurer delegates responsibility for the formulary to any entity, the obligation of the insurer to comply with this part shall not be waived. (2) The pharmacy and therapeutics committee board membership shall conform with both of the following: (A) Represent a sufficient number of clinical specialties to adequately meet the needs of insureds. (B) Consist of a majority of individuals who are practicing physicians, practicing pharmacists, and other practicing health professionals who are licensed to prescribe drugs. (3) Members of the board shall abstain from voting on any issue in which the member has a conflict of interest with respect to the issuer or a pharmaceutical manufacturer. (4) At least 20 percent of the board membership shall not have a conflict of interest with respect to the issuer or any pharmaceutical manufacturer. (5) The pharmacy and therapeutics committee shall meet at least quarterly and shall maintain written documentation of the rationale for its decisions regarding the development of, or revisions to, the formulary drug list. (6) The pharmacy and therapeutics committee shall do all of the following: (A) Develop and document procedures to ensure appropriate drug review and inclusion. (B) Base clinical decisions on the strength of the scientific evidence and standards of practice, including assessing peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other related information. (C) Consider the therapeutic advantages of drugs in terms of safety and efficacy when selecting formulary drugs. (D) Review policies that guide exceptions and other utilization management processes, including drug utilization review, quantity limits, and therapeutic interchange. (E) Evaluate and analyze treatment protocols and procedures related to the insurer’s formulary at least annually. (F) Review and approve all clinical prior authorization criteria, step therapy protocols, and quantity limit restrictions applied to each covered drug. (G) Review new United States Food and Drug Administration-approved drugs and new uses for existing drugs. (H) Ensure the insurer’s formulary drug list or lists cover a range of drugs across a broad distribution of therapeutic categories and classes and recommended drug treatment regimens that treat all disease states and does not discourage enrollment by any group of insureds. (I) Ensure the insurer’s formulary drug list or lists provide appropriate access to drugs that are included in broadly accepted treatment guidelines and that are indicative of general best practices at the time. (7) This subdivision shall be interpreted consistent with federal guidance issued under paragraph (3) of subdivision (a) of Section 156.122 of Title 45 of the Code of Federal Regulations. This subdivision shall apply to the individual, small group, and large group markets. (c) (1) A health insurer may impose prior authorization requirements on prescription drug benefits, consistent with the requirements of this part. (2) (A) If there is more than one drug that is clinically appropriate for the treatment of a medical condition, a health insurer may require step therapy. (B) A health insurer shall expeditiously grant a request for a step therapy exception within the applicable time limit required by Section 10123.191 if a prescribing provider submits necessary justification and supporting clinical documentation supporting the provider’s determination that the required prescription drug is inconsistent with good professional practice for provision of medically necessary covered services to the insured, taking into consideration the insured’s needs and medical history, along with the professional judgment of the insured’s provider. The basis of the provider’s determination may include, but is not limited to, any of the following criteria: (i) The required prescription drug is contraindicated or is likely, or expected, to cause an adverse reaction or physical or mental harm to the insured in comparison to the requested prescription drug, based on the known clinical characteristics of the insured and the known characteristics and history of the insured’s prescription drug regimen. (ii) The required prescription drug is expected to be ineffective based on the known clinical characteristics of the insured and the known characteristics and history of the insured’s prescription drug regimen. (iii) The insured has tried the required prescription drug while covered by their current or previous health coverage or Medicaid, and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse reaction. The health insurer may require the submission of documentation demonstrating that the insured tried the required prescription drug before it was discontinued. (iv) The required prescription drug is not clinically appropriate for the insured because the required drug is expected to do any of the following, as determined by the insured’s prescribing provider: (I) Worsen a comorbid condition. (II) Decrease the capacity to maintain a reasonable functional ability in performing daily activities. (III) Pose a significant barrier to adherence to, or compliance with, the insured’s drug regimen or plan of care. (v) The insured is stable on a prescription drug selected by the insured’s prescribing provider for the medical condition under consideration while covered by their current or previous health coverage or Medicaid. (C) (i) This section does not prohibit a health care provider from prescribing a prescription drug that is clinically appropriate. (ii) This section does not prohibit an insurer or utilization review organization from requiring an insured to try an AB-rated generic equivalent, biosimilar, as defined in Section 262(i)(2) of Title 42 of the United States Code, or interchangeable biological product, as defined in Section 262(i)(3) of Title 42 of the United States Code, before providing coverage for the equivalent branded prescription drug. (iii) Clause (ii) does not prohibit or supersede a step therapy exception request as described in subparagraph (B) of paragraph (2) of subdivision (c). (3) An insurer shall provide coverage for the medically necessary dosage and quantity of the drug prescribed for the treatment of a medical condition consistent with professionally recognized standards of practice. (4) For plan years commencing on or after January 1, 2017, an insurer that provides essential health benefits shall allow an insured to access prescription drug benefits at an in-network retail pharmacy unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy. A nongrandfathered individual or small group health insurer may charge an insured a different cost sharing for obtaining a covered drug at a retail pharmacy, but all cost sharing shall count toward the policy’s annual limitation on cost sharing consistent with Section 10112.28. (d) A health care provider or prescribing provider may file an internal appeal of a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request consistent with the health insurer’s current utilization management processes. (e) An insured or the insured’s designee or guardian may appeal a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request by filing an internal appeal with the health insurer pursuant to Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any subsequent rules or regulations issued thereunder. (f) Every health insurer that provides prescription drug benefits shall maintain all of the following information, which shall be made available to the commissioner upon request: (1) The complete drug formulary or formularies of the insurer, if the insurer maintains a formulary, including a list of the prescription drugs on the formulary of the insurer by major therapeutic category with an indication of whether any drugs are preferred over other drugs. (2) Records developed by the pharmacy and therapeutics committee of the insurer, or by others responsible for developing, modifying, and overseeing formularies, including medical groups, individual practice associations, and contracting pharmaceutical benefit management companies, used to guide the drugs prescribed for the insureds of the insurer, that fully describe the reasoning behind formulary decisions. (3) Any insurer arrangements with prescribing providers, medical groups, individual practice associations, pharmacists, contracting pharmaceutical benefit management companies, or other entities that are associated with activities of the insurer to encourage formulary compliance or otherwise manage prescription drug benefits. (g) If an insurer provides prescription drug benefits, the commissioner shall, as part of its market conduct examination, review the performance of the insurer in providing those benefits, including, but not limited to, a review of the procedures and information maintained pursuant to this section, and describe the performance of the insurer as part of its report issued as part of its market conduct examination. (h) The commissioner shall not publicly disclose any information reviewed pursuant to this section that is determined by the commissioner to be confidential pursuant to state law. (i) For purposes of this section, the following definitions shall apply: (1) “Authorization” means approval by the health insurer to provide payment for the prescription drug. (2) “Step therapy” means a type of protocol that specifies the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are to be prescribed. (3) “Step therapy exception” means a decision to override a generally applicable step therapy protocol in favor of coverage of the prescription drug prescribed by a health care provider for an individual insured. (4) “Utilization review organization” means an entity that conducts utilization review, other than a health insurer performing its own utilization review. (j) Nonformulary prescription drugs shall include any drug for which an insured’s copayment or out-of-pocket costs are different than the copayment for a formulary prescription drug, except as otherwise provided by law or regulation. (k) This section does not affect an insured’s or policyholder’s eligibility to submit a complaint to the department for review or to apply to the department for an independent medical review under Article 3.5 (commencing with Section 10169). (l) This section does not restrict or impair the application of any other provision of this part. (m) This section and Section 10123.191 apply to both the health insurer and a utilization review organization that performs utilization review or utilization management functions on the insurer’s behalf. Commencing January 1, 2022, a contract between a health insurer and a utilization review organization that performs utilization review or utilization management functions on the insurer’s behalf shall include terms that require the utilization review organization to comply with this section and Section 10123.191. (Amended by Stats. 2023, Ch. 495, Sec. 2. (SB 621) Effective January 1, 2024.)
10123.202.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurance policies may not require referrals for reproductive and sexual health care, and health insurers may not add extra contraceptive utilization protocols beyond Section 10123.196.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.202. (a) A health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, excluding specialized health insurance policies, shall be prohibited from requiring an insured to receive a referral before receiving coverage or services for reproductive and sexual health care. (b) (1) For the purposes of this section, “reproductive and sexual health care services” are all reproductive and sexual health services described in Sections 6925, 6926, 6927, and 6928 of the Family Code, or Section 121020 of the Health and Safety Code, obtained by a patient. (2) This section applies whether or not the patient is a minor. (c) In implementing this section, a health insurer may establish reasonable provisions governing utilization protocols for obtaining reproductive and sexual health care services, as provided for in subdivision (a), if these provisions are consistent with the intent of this section and are those customarily applied to other health care providers, such as primary care physicians and surgeons, to whom the insured has direct access, and are not more restrictive for reproductive and sexual health care services. An insured shall not be required to obtain prior approval from another physician, another provider, or the insurer before obtaining direct access to reproductive and sexual health care services. An insurer may establish reasonable provisions governing communication with the insured’s primary care physician and surgeon regarding the insured’s condition, treatment, and a need for followup care. (d) This section shall not apply to a health insurance policy that does not require insureds to obtain a referral from their primary care physician before seeking covered health care services from a specialist. (e) A health insurer shall not impose utilization protocols related to contraceptive drugs, supplies, and devices beyond those in Section 10123.196. (f) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRICARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (Amended by Stats. 2018, Ch. 687, Sec. 11. (SB 910) Effective January 1, 2019.)
10123.203.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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An insurer must prorate an insured’s cost sharing for a partial prescription fill, starting January 1, 2019.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.203. Commencing January 1, 2019, an insurer shall prorate an insured’s cost sharing for a partial fill of a prescription dispensed pursuant to Section 4052.10 of the Business and Professions Code. This section shall only apply to oral, solid dosage forms of prescription drugs. (Added by Stats. 2017, Ch. 615, Sec. 6. (AB 1048) Effective January 1, 2018.)
10123.204.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurance policies must provide prescription drug information on request and in real time, and health insurers may not block or penalize related disclosures.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.204. (a) A health insurance policy issued, amended, delivered, or renewed on or after July 1, 2023, that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following: (1) Upon request of an insured or an insured’s prescribing provider, furnish all of the following information regarding a prescription drug to the insured or the insured’s prescribing health care provider: (A) The insured’s eligibility for the prescription drug. (B) The most current formulary or formularies. (C) Cost-sharing information for the prescription drug and other formulary alternatives, consistent with cost-sharing requirements as set forth in the policy and accurate at the time it is provided, including any variance in cost sharing based on the patient’s preferred dispensing pharmacy, whether retail or mail order, or the health care provider. (D) Applicable utilization management requirements for the prescription drug and other formulary alternatives. (2) Respond in real time to a request made pursuant to paragraph (1) through a standard API. (3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1). (4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time. (5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code. (b) A health insurer shall not do any of the following: (1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a). (2) Restrict, prohibit, or otherwise hinder a prescribing provider from communicating or sharing to an insured any of the following: (A) The information provided pursuant to subdivision (a). (B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the insured’s health insurance policy. (C) Information about the cash price of the drug. (3) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a). “Interfere with, prevent, or materially discourage access, exchange, or use of the information” includes charging fees for access to the information, not responding to a request at the time made consistent with this section, or instituting insured consent requirements. (4) Penalize a prescribing provider for disclosing the information provided pursuant to subdivision (a). For purposes of this paragraph, “penalize” includes an action intended to punish a provider for disclosing the information set forth in subdivision (a) or intended to discourage a provider from disclosing this information in the future. (5) Penalize a prescribing provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug. For purposes of this paragraph, “penalize” includes an action intended to punish a provider who has prescribed, administered, or ordered a lower cost or clinically appropriate alternative drug, or intended to discourage a provider from prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug in the future. (c) For purposes of this section: (1) “Cost sharing” includes applicable copayments, coinsurances, or deductibles. (2) “Cost-sharing information” means the actual out-of-pocket amount an insured would be required to pay a dispensing pharmacy or prescribing provider for a prescription drug under the terms of the insured’s health insurance policy. (3) “Formulary” has the same meaning as in Section 10123.192. (4) “Interoperability element” means integrated technologies or services necessary to provide a response to an insured or an insured’s prescribing provider. (5) “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition, including prescriptions to treat mental health and substance use disorders, for an insured. (6) “Standard API” means an application interface that is standardized for vendors to conform to in order to access the information pursuant to Section 170.215 of Title 45 of the Code of Federal Regulations. (d) (1) This section does not authorize further disclosure inconsistent with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code). (2) This section does not alter or interfere with requirements that a health insurer cover prescription drugs consistent with this chapter and regulations promulgated thereunder. (3) This section does not alter or interfere with a health insurer’s other obligations under this article, including requirements to disclose or explain its prescription drug benefit. (Added by Stats. 2022, Ch. 590, Sec. 2. (AB 2352) Effective January 1, 2023.)
10123.2045.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies covering prescription drugs cannot make an insured pay more than the insurer’s actual drug cost, and certain PBM-related contracts cannot authorize spread pricing after the stated date.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.2045. (a) A health insurance policy issued, amended, or renewed on or after January 1, 2026, that provides prescription drug coverage shall not calculate an insured’s cost sharing at an amount that exceeds the actual rate paid by the insurer for the prescription drug. Cost sharing shall include deductibles and coinsurance. (b) To the extent that a health insurance policy with a pharmacy benefit manager issued, amended, or renewed on or after January 1, 2026, includes disclosure of the net price paid by the pharmacy benefit manager or group purchasing organization, then an insured’s cost sharing shall not be calculated at an amount that exceeds that net price paid. (c) (1) Commencing January 1, 2026, if a preexisting contract between a pharmacy benefit manager licensed pursuant to Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code and a health insurer authorizes spread pricing, as that term is defined by Section 1385.001 of the Health and Safety Code, any subsequent amendment or renewal of that contract shall not authorize spread pricing. (2) A contract that is executed on or after January 1, 2026, between a pharmacy benefit manager licensed pursuant to Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code and a health insurer shall not authorize spread pricing, as that term is defined by Section 1385.001 of the Health and Safety Code. (Added by Stats. 2025, Ch. 605, Sec. 16. (SB 41) Effective January 1, 2026.)
10123.205.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers covered by the section must report specified drug-cost information to the department each year, and the department must compile, publish, and keep most of the information confidential.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.205. (a) (1) A health insurer that reports rate information pursuant to Section 10181.3 or 10181.45 shall report the information described in paragraph (2) to the department no later than October 1 of each year, beginning October 1, 2018. (2) For all covered prescription drugs, including generic drugs, brand name drugs, and specialty drugs dispensed at a plan pharmacy, network pharmacy, or mail order pharmacy for outpatient use, all of the following shall be reported: (A) The 25 most frequently prescribed drugs. (B) The 25 most costly drugs by total annual plan spending. (C) The 25 drugs with the highest year-over-year increase in total annual plan spending. (b) The department shall compile the information reported pursuant to subdivision (a) into a report for the public and legislators that demonstrates the overall impact of drug costs on health care premiums. The data in the report shall be aggregated and shall not reveal information specific to individual health insurers. (c) For the purposes of this section, a “specialty drug” is one that exceeds the threshold for a specialty drug under the Medicare Part D program (Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173)). (d) By January 1 of each year, beginning January 1, 2018, the department shall publish on its Internet Web site the report required pursuant to subdivision (b). (e) After the report required in subdivision (b) is released, the department shall include the report as part of the public meeting required pursuant to subdivision (b) of Section 10181.45. (f) Except for the report required pursuant to subdivision (b), the department shall keep confidential all of the information provided to the department pursuant to this section, and the information shall be protected from public disclosure. (Added by Stats. 2017, Ch. 603, Sec. 5. (SB 17) Effective January 1, 2018.)
10123.206.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies covering prescribed oral anticancer drugs must cap patient copayments and coinsurance at $250 per prescription, with a special rule for high-deductible plans and an exception for certain dental, vision, and Medicare-related coverage.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.206. (a) Notwithstanding any other law, an individual or group health insurance policy issued, amended, or renewed on or after January 1, 2015, that provides coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall comply with all of the following: (1) Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred fifty dollars ($250) for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication covered by the policy. (2) For a health insurance policy that meets the definition of a “high deductible health plan” set forth in Section 223(c)(2) of Title 26 of the United States Code, paragraph (1) shall only apply once an insured’s deductible has been satisfied for the year. (3) An orally administered anticancer medication shall be provided consistent with the appropriate standard of care for that medication. (b) This section shall not apply to a specialized health insurance policy that covers only dental or vision benefits or any coverage under a health insurance policy for the Medicare Program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.). (Amended by Stats. 2023, Ch. 607, Sec. 2. (SB 421) Effective January 1, 2024.)
10123.207.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Most health insurance policies must cover certain colorectal cancer screening tests, and related colonoscopies, without cost sharing, subject to an out-of-network provider exception.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.207. (a) Every health insurance policy, except a specialized health insurance policy, that is issued, amended, or renewed on or after January 1, 2022, shall provide coverage without cost sharing for a colorectal cancer screening test assigned either a grade of A or a grade of B by the United States Preventive Services Task Force. The required colonoscopy for a positive result on a test or procedure, other than a colonoscopy, that is a colorectal cancer screening examination or laboratory test identified assigned either a grade of A or a grade of B by the United States Preventive Services Task Force shall also be provided without any cost sharing. (b) This section does not preclude a health insurer that has a network of providers from imposing cost-sharing requirements for the items or services described in this section that are delivered by an out-of-network provider. (Added by Stats. 2021, Ch. 436, Sec. 2. (AB 342) Effective January 1, 2022.)
10123.208.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies issued, amended, renewed, or delivered on or after January 1, 2022 must cover medically necessary or appropriate home test kits for STDs, including lab processing costs, unless the policy is specialized health insurance.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.208. (a) A health insurance policy issued, amended, renewed, or delivered on or after January 1, 2022, excluding specialized health insurance policies, shall provide coverage for home test kits for sexually transmitted diseases (STD), including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an in-network clinician, or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs. (b) For purposes of this section, “home test kit” means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting. (Added by Stats. 2021, Ch. 486, Sec. 7. (SB 306) Effective January 1, 2022.)
10123.209.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies in scope must cover medically necessary biomarker testing, and insurers must use a specified process to decide medical necessity.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.209. (a) A health insurance policy that is issued, amended, delivered, or renewed on or after July 1, 2024, shall include coverage for medically necessary biomarker testing, subject to utilization review management, pursuant to this section. Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an insured’s disease or condition to guide treatment decisions. Coverage shall include biomarker tests that meet any of the following: (1) A labeled indication for a test that has been approved or cleared by the United States Food and Drug Administration (FDA) or is an indicated test for an FDA-approved drug. (2) A national coverage determination made by the federal Centers for Medicare and Medicaid Services. (3) A local coverage determination made by a Medicare Administrative Contractor for California. (4) Evidence-based clinical practice guidelines, supported by peer-reviewed literature and peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff. (5) Standards set by the National Academy of Medicine. (b) A health insurer shall use the process described in subdivision (f) of Section 10123.135 to determine whether biomarker testing is medically necessary for purposes of this section. (c) A health insurance policy that is subject to this section shall ensure that biomarker testing is provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples. This section shall not be construed to require coverage of biomarker testing for screening purposes unless otherwise required by this part. (d) Restricted or denied use of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is subject to grievance and appeal processes under state and federal law, including Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any regulations subsequently adopted thereunder, and the Independent Medical Review System under Article 3.5 (commencing with Section 10169). (e) For purposes of this section, the following definitions apply: (1) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a specific therapeutic intervention. A biomarker includes, but is not limited to, gene mutations or protein expression. (2) “Biomarker testing” means the analysis of an individual’s tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker testing includes, but is not limited to, single-analyte tests, multiplex panel tests, and whole genome sequencing. (f) This section is subject to the provisions of Section 10123.20 as amended by Chapter 605 of the Statutes of 2021 for an insured with advanced or metastatic stage III or IV cancer. (Added by Stats. 2023, Ch. 401, Sec. 2. (SB 496) Effective January 1, 2024.)
10123.21.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies meeting the stated conditions must cover certain medically necessary jawbone-related surgery, unless dental services are specifically excluded.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.21. On or after July 1, 1995, every individual or group policy of disability insurance that provides hospital, medical, or surgical coverage entered into, amended, or renewed in this state shall, subject to other terms and conditions as may be agreed upon between the group or individual policyholder and the insurer, provide coverage for the surgical procedure for those covered conditions directly affecting the upper or lower jawbone, or associated bone joints, if each procedure being considered for reimbursement is deemed medically-necessary by the insurer pursuant to the policy’s definition of medical necessity. Nothing in this section shall be construed to require the provision of dental services if dental services are specifically excluded from coverage under the terms and conditions of the contract between the group or individual policyholder and insurer. (Added by Stats. 1994, Ch. 1282, Sec. 2. Effective January 1, 1995.)
10123.210.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer covering employees of a religious employer must give each insured written information at enrollment and each renewal about abortion and contraception benefits or services not included in the policy, and about any no-cost options through the California Reproductive Health Equity Program.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.210. (a) A health insurer that provides health coverage to the employees of a religious employer that does not include coverage and benefits for both abortion and contraception shall provide, in writing upon initial enrollment and annually thereafter upon renewal, each insured with information regarding both of the following: (1) Abortion and contraception benefits or services that are not included in the insured’s health insurance policy. (2) Abortion and contraception benefits or services that may be available at no cost through the California Reproductive Health Equity Program. (b) For purposes of this section: (1) “Abortion” has the same meaning as defined in Section 123464 of the Health and Safety Code. (2) “California Reproductive Health Equity Program” means the program established pursuant to Section 127632 of the Health and Safety Code. (3) “Contraception” means the services and contraceptive methods described in paragraph (1) of subdivision (b) of Section 10123.196. (4) “Religious employer” has the same meaning as described in Section 10123.196. (c) This section does not alter the applicability of any other requirement of this chapter. (Added by Stats. 2022, Ch. 562, Sec. 3. (AB 2134) Effective January 1, 2023.)
10123.211.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurance policies must cover emergency room care and followup treatment for rape or sexual assault, with no cost sharing for the first nine months after treatment starts, subject to stated exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.211. (a) (1) A health insurance policy that is issued, amended, or renewed on or after July 1, 2025, excluding a specialized health insurance policy, shall provide coverage for emergency room medical care and followup health care treatment for an insured who is treated following a rape or sexual assault, as defined in Sections 261, 261.6, 263, 263.1, 286, 287, and 288.7 of the Penal Code, without imposing cost sharing, including copayments, coinsurance, or deductibles, for the first nine months after the enrollee initiates treatment. (2) For the purposes of this section, “followup health care treatment” includes medical or surgical services for the diagnosis, prevention, or treatment of medical conditions arising from an instance of rape or sexual assault. (3) The waiver of the imposition of cost sharing pursuant to paragraph (1) shall only apply if the enrollee’s treating provider submits all requests for claims payments using accurate diagnosis codes specific to rape or sexual assault. (b) A health insurer shall not require any of the following to provide coverage under this section: (1) An insured to file a police report on the rape or sexual assault. (2) Charges to be brought against an assailant. (3) An assailant to be convicted of an offense listed in subdivision (a). (c) (1) This section does not authorize an insured to receive followup health care treatment required to be covered by this section if treatment is furnished by a nonparticipating provider, except as specified in paragraphs (2) and (3). (2) A health insurer shall arrange for the provision of followup health care treatment required by this section from providers outside the insurer’s network if those services are unavailable within the network to ensure timely access to covered health care services consistent with Section 10133.54. (3) A health insurer shall cover followup health care treatment if those services are for emergency services and care as defined in Section 1317.1 of the Health and Safety Code. (d) For a health insurance policy that meets the definition of a “high deductible health plan” set forth in Section 223(c)(2) of Title 26 of the United States Code, this section shall only apply once an enrollee’s deductible has been satisfied for the year. (e) “Cost sharing” includes any copayment, coinsurance, or deductible, or any other form of cost sharing paid by the insured other than premium or share of premium. (f) This section does not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (g) Coverage provided under this section is coverage of sensitive services provided to a protected individual as those terms are defined in Section 791.02 and pursuant to Section 791.29. (Added by Stats. 2024, Ch. 971, Sec. 3. (AB 2843) Effective January 1, 2025.)
10123.22.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer may not deny otherwise available transplant coverage because the insured or policyholder has HIV.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.22. (a) A health insurer shall not deny coverage that is otherwise available under the health insurance policy for the costs of solid organ or other tissue transplantation services based upon the insured or policyholder being infected with the human immunodeficiency virus. (b) Notwithstanding any other provision of law, in the provision of benefits required by this section, a health insurer may utilize case management, managed care, or utilization review, subject to the terms and conditions of the policy and consistent with sound clinical processes and guidelines. (Added by renumbering Section 10123.21 (as added by Stats. 2005, Ch. 419, Sec. 2) by Stats. 2015, Ch. 303, Sec. 370. (AB 731) Effective January 1, 2016.)
10123.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Self-insured employee welfare benefit plans may not discriminate based on genetic characteristics, ask for genetic information for nontherapeutic purposes, or treat solicitors differently on that basis.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.3. (a) No self-insured employee welfare benefit plan shall refuse to enroll any person or accept any person as a subscriber or renew any person as a subscriber after appropriate application on the basis of a person’s genetic characteristics that may, under some circumstances, be associated with disability in that person or that person’s offspring. No plan shall require a higher rate or charge, or offer or provide different terms, conditions, or benefits, on the basis of a person’s genetic characteristics that may, under some circumstances, be associated with disability in that person or that person’s offspring than is at the time required of any other individual in an otherwise identical classification, nor shall any plan make or require any rebate, discrimination, or discount upon the amount to be paid or the service to be rendered under the plan because the person carries those traits. (b) No self-insured employee welfare benefit plan shall seek information about a person’s genetic characteristics for any nontherapeutic purpose. (c) No discrimination shall be made in the fees or commissions of a solicitor or solicitor firm for an enrollment or a subscription or the renewal of an enrollment or subscription of any person on the basis of a person’s genetic characteristics that may, under some circumstances, be associated with disability in that person or that person’s offspring. (d) “Genetic characteristics” as used in this section means either of the following: (1) Any scientifically or medically identifiable gene or chromosome, or combination or alteration thereof, that is known to be a cause of a disease or disorder in a person or his or her offspring, or that is determined to be associated with a statistically increased risk of development of a disease or disorder, and that is presently not associated with any symptoms of any disease or disorder. (2) Inherited characteristics that may derive from the individual or family member, that are known to be a cause of a disease or disorder in a person or his or her offspring, or that are determined to be associated with a statistically increased risk of development of a disease or disorder, and that are presently not associated with any symptoms of any disease or disorder. (Amended by Stats. 1999, Ch. 311, Sec. 4. Effective January 1, 2000.)
10123.31.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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The commissioner may assess administrative penalties against self-insured employee welfare benefit plans in the health insurance business for violating Section 10123.3.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.31. (a) In addition to any other remedy permitted by law, the commissioner shall have the administrative authority to assess penalties specified in this section against self-insured employee welfare benefit plans engaged in the business of health insurance for violations of Section 10123.3. (b) Any plan that violates Section 10123.3 is liable for administrative penalties of not more than two thousand five hundred dollars ($2,500) for the first violation and not more than five thousand dollars ($5,000) for each subsequent violation. (c) Any plan that violates Section 10123.3 with a frequency that indicates a general business practice or commits a knowing violation of that section, is liable for administrative penalties of not less than fifteen thousand dollars ($15,000) and not more than one hundred thousand dollars ($100,000) for each violation. (d) An act or omission that is inadvertent and that results in incorrect rates being charged to more than one subscriber shall be a single violation for the purpose of this section. (Added by Stats. 1995, Ch. 695, Sec. 5. Effective January 1, 1996.)
10123.35.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section restricts disclosure of genetic test results by self-insured welfare benefit plans and other persons, unless there is a written authorization, and it provides civil and criminal penalties for violations.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.35. (a) This section shall apply to the disclosure of genetic test results contained in an applicant or enrollee’s medical records by a self-insured welfare benefit plan. (b) Any person who negligently discloses results of a test for a genetic characteristic to any third party in a manner that identifies or provides identifying characteristics of the person to whom the test results apply, except pursuant to a written authorization as described in subdivision (g), shall be assessed a civil penalty in an amount not to exceed one thousand dollars ($1,000) plus court costs, as determined by the court, which penalty and costs shall be paid to the subject of the test. (c) Any person who willfully discloses the results of a test for a genetic characteristic to any third party in a manner that identifies or provides identifying characteristics of the person to whom the test results apply, except pursuant to a written authorization as described in subdivision (g), shall be assessed a civil penalty in an amount not less than one thousand dollars ($1,000) and no more than five thousand dollars ($5,000) plus court costs, as determined by the court, which penalty and costs shall be paid to the subject of the test. (d) Any person who willfully or negligently discloses the results of a test for a genetic characteristic to a third party in a manner that identifies or provides identifying characteristics of the person to whom the test results apply, except pursuant to a written authorization as described in subdivision (g), that results in economic, bodily, or emotional harm to the subject of the test, is guilty of a misdemeanor punishable by a fine not to exceed ten thousand dollars ($10,000). (e) In addition to the penalties listed in subdivisions (b) and (c), any person who commits any act described in subdivision (b) or (c) shall be liable to the subject for all actual damages, including damages for economic, bodily, or emotional harm which is proximately caused by the act. (f) Each disclosure made in violation of this section is a separate and actionable offense. (g) The applicant’s “written authorization,” as used in this section, shall satisfy the following requirements: (1) Is written in plain language. (2) Is dated and signed by the individual or a person authorized to act on behalf of the individual. (3) Specifies the types of persons authorized to disclose information about the individual. (4) Specifies the nature of the information authorized to be disclosed. (5) States the name or functions of the persons or entities authorized to receive the information. (6) Specifies the purposes for which the information is collected. (7) Specifies the length of time the authorization shall remain valid. (8) Advises the person signing the authorization of the right to receive a copy of the authorization. Written authorization is required for each separate disclosure of the test results, and the authorization shall set forth the person or entity to whom the disclosure would be made. (h) This section shall not apply to disclosures required by the Department of Health Services necessary to monitor compliance with Chapter 1 (commencing with Section 124975) of Part 5 of Division 106 of the Health and Safety Code, nor to disclosures required by the Department of Managed Health Care necessary to administer and enforce compliance with Section 1374.7 of the Health and Safety Code. (Amended by Stats. 2000, Ch. 857, Sec. 59. Effective January 1, 2001.)
10123.36.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers using economic profiling must file related policies and procedures with the department, and the commissioner must make filings public on request unless confidential by state law.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.36. (a) On or before July 1, 1999, for purposes of public disclosure, every disability insurer that covers hospital, medical, or surgical expenses, and authorizes insureds to select providers who have contracted with the insurer for alternative rates of payment as described in Section 10133, and the disability insurer or any of its contracting providers or provider groups utilize economic profiling related to services provided to insureds, shall file with the department a description of any policies and procedures related to economic profiling utilized by the insurer and any of its contracting providers and provider groups. The filing shall describe how these policies and procedures are used in utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions. The filing shall also indicate in what manner, if any, the economic profiling system being used takes into consideration risk adjustments that reflect case mix, type and severity of patient illness, age of patients, and other policyholder characteristics that may account for higher or lower than expected costs or utilization of services. Any changes to the policies and procedures shall be filed expeditiously with the commissioner. Nothing in this section shall be construed to restrict or impair the department, in its discretion, from utilizing the information filed pursuant to this section for purposes of ensuring compliance with this chapter. (b) The commissioner shall make each disability insurer filing available to the public upon request. The commissioner shall not publicly disclose any information submitted pursuant to this section that is determined by the commissioner to be confidential pursuant to state law. (c) Each disability insurer that uses economic profiling shall, upon request, provide a copy of economic profiling information related to a contracting provider or provider group to the profiled provider or group. In addition, each disability insurer shall require as a condition of contract that its contracting provider groups that maintain economic profiles of individual providers who may be selected by insureds shall, upon request, provide a copy of individual economic profiling information to individual providers who are profiled. The economic profiling information provided pursuant to this section shall be provided upon request until 60 days after the date upon which the contract between the insurer and the individual provider or provider group terminates, or until 60 days after the date the contract between the provider group and the individual provider terminates, whichever is applicable. (d) For the purposes of this section, “economic profiling” shall mean any evaluation of a particular physician, provider, or provider group based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, or provider group. (Added by Stats. 1998, Ch. 893, Sec. 2. Effective January 1, 1999.)
10123.38.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies covered by this section must cover medically necessary PANDAS and PANS care, and insurers may not deny, delay, or limit that coverage for the reasons stated here.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.38. (a) A health insurance policy issued, amended, or renewed on or after January 1, 2025, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by the treating physician and surgeon and is medically necessary, as defined by current nationally recognized clinical practice guidelines by expert treating physicians published in peer-reviewed medical literature. Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy. (b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance, deductible, or other cost sharing that is greater than that applied to other benefits provided by the policy. (c) (1) A required authorization for PANDAS and PANS prophylaxis, diagnosis, or treatment shall be provided in a timely manner that is appropriate for the severity of an insured’s condition pursuant to Section 10133.54. (2) A health insurer shall not deny or delay coverage for PANDAS or PANS therapies because the insured previously received treatment, including the same or similar treatment, for PANDAS or PANS, or because the insured was diagnosed with or received treatment for their condition under a different diagnostic name, including autoimmune encephalopathy. (3) A health insurer shall not limit coverage of immunomodulating therapies for PANDAS or PANS in a manner that is inconsistent with the treatment recommendations pursuant to subdivision (d), and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies pursuant to this section. (d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations delineated in current clinical practice guidelines published in peer-reviewed medical literature or put forth by organizations composed of expert treating clinicians. (e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune encephalitis until the American Medical Association and the federal Centers for Medicare and Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future, it may be coded under that name and this section shall apply to that disorder or syndrome. (f) This section does not apply to a specialized health insurance policy that covers dental or vision benefits or a Medicare supplement policy. (Added by Stats. 2024, Ch. 822, Sec. 2. (AB 2105) Effective January 1, 2025.)
10123.4.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A self-insured employee welfare benefit plan covered by this section cannot offer employee/spouse-dependent coverage on terms less favorable to employees than to covered spouses.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.4. If a self-insured employee welfare benefit plan issued, amended, or renewed in this state on or after the effective date of this section provides in any manner for coverage for an employee and a covered spouse dependent upon such employee, the plan shall not provide for coverage under conditions less favorable for employees than coverage provided for covered spouses dependent upon the employees. As used in this section, “self-insured employee welfare benefit plan” has the same meaning as that specified in subdivision (b) of Section 10121. (Added by Stats. 1976, Ch. 59.)
10123.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers offering group disability insurance for hospital, medical, or surgical expenses must cover comprehensive preventive care for children 16 or younger and tell group policyholders and prospective policyholders that the benefits are available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.5. (a) On or after January 1, 1993, every insurer issuing group disability insurance that covers hospital, medical, or surgical expenses shall provide benefits for the comprehensive preventive care of children 16 years of age or younger under those terms and conditions as may be agreed upon between the group policyholder and the insurer. Every insurer shall communicate the availability of these benefits to all group policyholders and to all prospective group policyholders with whom they are negotiating. (b) For purposes of this section, benefits for the comprehensive preventive care of children shall comply with both of the following: (1) Be consistent with both of the following: (A) The most recent Recommendations for Preventive Pediatric Health Care, as adopted by the American Academy of Pediatrics. (B) The Recommended Childhood Immunization Schedule/United States, jointly adopted as of January 1, 2025, by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians. Immunizations subject to this subparagraph may be modified or supplemented by the State Department of Public Health pursuant to Section 120164. (2) Provide for the following: (A) Periodic health evaluations. (B) Immunizations. (C) Laboratory services in connection with periodic health evaluations. (D) Screening for blood lead levels in children who are at risk for lead poisoning, as determined by a health care provider in accordance with the applicable California regulations. (c) For purposes of this section, a health care provider is any of the following: (1) A person licensed to practice medicine pursuant to Article 3 (commencing with Section 2050) of Chapter 5 of Division 2 of the Business and Professions Code. (2) A nurse practitioner licensed to practice pursuant to Article 8 (commencing with Section 2834) of Chapter 6 of Division 2 of the Business and Professions Code. (3) A physician assistant licensed to practice pursuant to Article 3 (commencing with Section 3513) of Chapter 7.7 of Division 2 of the Business and Professions Code. (Amended by Stats. 2025, Ch. 105, Sec. 46. (AB 144) Effective September 17, 2025.)
10123.51.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies in scope must add coverage for ACEs screenings, and the department may issue implementation guidance.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.51. (a) A health insurance policy issued, amended, or renewed on or after January 1, 2022, that provides coverage for pediatric services and preventive care, as required by this chapter, including Sections 10112.2 and 10112.27, shall additionally include coverage for adverse childhood experiences screenings. This section does not prohibit a health insurer from applying cost-sharing requirements as authorized by law. (b) For purposes of this section, “adverse childhood experiences,” or “ACEs,” means an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. (c) The department may adopt guidance to health insurers to implement this section. The guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The departmental guidance shall apply the rules and regulations for screening for trauma as set forth in the Medi-Cal program as the minimum ACEs coverage requirements for health insurers. This section does not prohibit a health insurer from exceeding the Medi-Cal program’s rules and regulations for trauma screening. (Added by Stats. 2021, Ch. 641, Sec. 2. (SB 428) Effective January 1, 2022.)
10123.55.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers issuing certain group disability insurance must offer preventive care benefits for children age 17 and 18 and tell group policyholders and prospective policyholders that the benefits are available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.55. (a) On or after January 1, 1993, every insurer issuing group disability insurance that covers hospital, medical, or surgical expenses shall offer benefits for the comprehensive preventive care of children 17 and 18 years of age under those terms and conditions as may be agreed upon between the group policyholder and the insurer. Every insurer shall communicate the availability of these benefits to all group policyholders and to all prospective group policyholders with whom they are negotiating. (b) For purposes of this section, benefits for the comprehensive preventive care of children shall comply with both of the following: (1) Be consistent with both of the following: (A) The most recent Recommendations for Preventive Pediatric Health Care, as adopted by the American Academy of Pediatrics. (B) The Recommended Childhood Immunization Schedule/United States, jointly adopted as of January 1, 2025, by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians. Immunizations subject to this subparagraph may be modified or supplemented by the State Department of Public Health pursuant to Section 120164. (2) Provide for the following: (A) Periodic health evaluations. (B) Immunizations. (C) Laboratory services in connection with periodic health evaluations. (D) Screening for blood lead levels in children who are at risk for lead poisoning, as determined by a health care provider in accordance with the applicable California regulations. (c) For purposes of this section, a health care provider is any of the following: (1) A person licensed to practice medicine pursuant to Article 3 (commencing with Section 2050) of Chapter 5 of Division 2 of the Business and Professions Code. (2) A nurse practitioner licensed to practice pursuant to Article 8 (commencing with Section 2834) of Chapter 6 of Division 2 of the Business and Professions Code. (3) A physician assistant licensed to practice pursuant to Article 3 (commencing with Section 3513) of Chapter 7.7 of Division 2 of the Business and Professions Code. (Amended by Stats. 2025, Ch. 105, Sec. 47. (AB 144) Effective September 17, 2025.)
10123.6.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers offering group disability insurance that covers hospital, medical, or surgical expenses must offer alcoholism treatment coverage and tell policyholders and prospective policyholders that the coverage is available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.6. On and after January 1, 1990, every insurer issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer coverage for the treatment of alcoholism under such terms and conditions as may be agreed upon between the group policyholder and the insurer. Every insurer shall communicate the availability of such coverage to all group policyholders and to all prospective group policyholders with whom they are negotiating. If the group subscriber or policyholder agrees to such coverage or to coverage for treatment of chemical dependency, or nicotine use, the treatment may take place in facilities licensed to provide alcoholism or chemical dependency services under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code. Treatment for nicotine use may be subject to separate deductibles, copayments, and overall cost limitations as determined by the policy. (Amended by Stats. 1989, Ch. 688, Sec. 2.)
10123.61.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer may not issue, amend, sell, renew, or offer short-term limited duration health insurance in this state starting January 1, 2019.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.61. (a) Commencing January 1, 2019, a health insurer shall not issue, amend, sell, renew, or offer a policy of short-term limited duration health insurance in this state. (b) For purposes of this section, “short-term limited duration health insurance” means health insurance coverage provided pursuant to a health insurance policy that has an expiration date specified in the policy that is less than 12 months after the original effective date of the coverage. (Added by Stats. 2018, Ch. 687, Sec. 4. (SB 910) Effective January 1, 2019.)
10123.65.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer may not make an insured pay more than the lesser of the drug’s cost-sharing amount and its retail price at the point of sale, and may not require a pharmacist or pharmacy to collect more than the drug’s total retail price.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.65. (a) The maximum amount a health insurer may require an insured to pay at the point of sale for a covered prescription drug is the lesser of the following: (1) The applicable cost-sharing amount for the prescription drug. (2) The retail price. (b) A health insurer shall not require a pharmacist or pharmacy to charge or collect from an insured a cost-sharing amount that exceeds the total retail price for the prescription drug. (c) The payment rendered shall constitute the applicable cost sharing and shall apply to the deductible, if any, and also to the maximum out-of-pocket limit in the same manner as if the insured had purchased the prescription drug by paying the cost-sharing amount. (Added by Stats. 2018, Ch. 770, Sec. 3. (AB 2863) Effective January 1, 2019.)
10123.67.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers must file a written second-medical-opinion policy with the department by July 1, 1997, give notice to insureds, and explain how requests are reviewed.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.67. (a) On or before July 1, 1997, every disability insurer that covers hospital, medical, or surgical expenses, as described in subdivision (b), shall file with the department a written policy, which is not subject to approval or disapproval by the department, describing the manner in which the insurer determines if a second medical opinion is medically necessary and appropriate. Notice of the policy and information regarding the manner in which an insured may receive a second medical opinion shall be provided to all insureds in the insurer’s evidence of coverage. The written policy shall describe the manner in which requests for a second medical opinion are reviewed by the insurer. (b) This section shall only apply to disability insurers covering hospital, medical, or surgical expenses that contract with providers for alternative rates pursuant to Section 10133 or 11512 and that limit payments under those policies to services secured by insureds from providers charging alternative rates pursuant to the contracts. (c) Nothing in this section shall require the disability insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract, nor to provide services through providers who are not under contract with the plan. (Added by Stats. 1996, Ch. 1091, Sec. 2. Effective January 1, 1997.)
10123.68.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Some disability insurers must authorize and process second-opinion requests for covered insureds, with prompt handling and specific network/cost rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.68. (a) When requested by an insured or contracting health professional who is treating an insured, a disability insurer that covers hospital, medical, or surgical expenses shall authorize a second opinion by an appropriately qualified health care professional. Reasons for a second opinion to be provided or authorized shall include, but are not limited to, the following: (1) If the insured questions the reasonableness or necessity of recommended surgical procedures. (2) If the insured questions a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a serious chronic condition. (3) If clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating health professional is unable to diagnose the condition and the insured requests an additional diagnosis. (4) If the treatment plan in progress is not improving the medical condition of the insured within an appropriate period of time given the diagnosis and plan of care, and the insured requests a second opinion regarding the diagnosis or continuance of the treatment. (5) If the insured has attempted to follow the plan of care or consulted with the initial provider concerning serious concerns about the diagnosis or plan of care. (b) For purposes of this section, an appropriately qualified health care professional is a primary care physician or a specialist who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to the particular illness, disease, condition or conditions associated with the request for a second opinion. (c) If an insured or participating health professional who is treating an insured requests a second opinion pursuant to this section, an authorization or denial shall be provided in an expeditious manner. When the insured’s condition is such that the insured faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or lack of timeliness that would be detrimental to the insured’s life or health or could jeopardize the insured’s ability to regain maximum function, the second opinion shall be rendered in a timely fashion appropriate to the nature of the insured’s condition, not to exceed 72 hours after the insurer’s receipt of the request, whenever possible. Each insurer shall file with the Department of Insurance timelines for responding to requests for second opinions for cases involving emergency needs, urgent care, and other requests by July 1, 2000, and within 30 days of any amendment to the timelines. The timelines shall be made available to the public upon request. (d) If an insurer approves a request by an insured for a second opinion, the insured shall be responsible only for the costs of applicable copayments that the insurer requires for similar referrals. (e) If the insured is requesting a second opinion about care from his or her primary care physician, the second opinion shall be provided by an appropriately qualified health care professional of the insured’s choice who is contracted with the insurer. (f) If the insured is requesting a second opinion about care from a specialist, the second opinion shall be provided by any provider of the same or equivalent specialty, of the insured’s choice, within the insurer’s provider network, if the insurance contract limits second opinions to within a network. (g) The insurer may limit second opinions to its network of providers if the insurance contract limits the benefit to within a network of providers and there is a participating provider who meets the standard specified in subdivision (b). If there is no participating provider who meets this standard, then the insurer shall authorize a second opinion by an appropriately qualified health professional outside of the insurer’s provider network. In approving a second opinion either inside or outside of the insurer’s provider network, the insurer shall take into account the ability of the insured to travel to the provider. (h) The insurer shall require the second opinion health professional to provide the insured and the initial health professional with a consultation report, including any recommended procedures or tests that the second opinion health professional believes appropriate. Nothing in this section shall be construed to prevent the insurer from authorizing, based on its independent determination, additional medical opinions concerning the medical condition of an insured. (i) If the insurer denies a request by an insured for a second opinion, it shall notify the insured in writing of the reasons for the denial and shall inform the insured of the right to dispute the denial, and the procedures for exercising that right. (j) If the insurance contract limits health care services to within a network of providers, in order for coverage to be in force, the insured shall obtain services only from a provider who is participating in, or under contract with, the insurer pursuant to the specific insurance contract under which the insured is entitled to health care service benefits. (k) This section shall not apply to any policy or contract of disability insurance that covers hospital, medical, or surgical expenses and that does not limit second opinions, subject to all other terms and conditions of the contract. (l) This section shall not apply to accident-only, specified disease, or hospital indemnity health insurance policies. (Amended by Stats. 2000, Ch. 135, Sec. 113. Effective January 1, 2001. Note: Amendment by Stats. 2000, Ch. 857, was nullified because of Ch. 857's prevailing deferral clause.)
10123.7.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group health insurers must offer and disclose coverage for orthotic and prosthetic devices and services, and the benefit/cost-sharing terms cannot fall below the stated minimums. The section also excludes several kinds of insurance.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.7. (a) On or after January 1, 1986, an insurer issuing group health insurance shall offer coverage for orthotic and prosthetic devices and services under the terms and conditions that may be agreed upon between the group policyholder and the insurer. An insurer shall communicate the availability of that coverage to all group policyholders and to all prospective group policyholders with whom the insurer is negotiating. Coverage for prosthetic devices shall include original and replacement devices, as prescribed by a physician and surgeon or doctor of podiatric medicine acting within the scope of his or her license. Coverage for orthotic devices shall provide for coverage if the device, including original and replacement devices, is prescribed by a physician and surgeon or doctor of podiatric medicine acting within the scope of his or her license, or is ordered by a licensed health care provider acting within the scope of his or her license. An insurer shall have the right to conduct a utilization review to determine medical necessity before authorizing these services. (b) Notwithstanding subdivision (a), on and after July 1, 2007, the amount of the benefit for orthotic and prosthetic devices and services shall be no less than the annual and lifetime benefit maximums applicable to all benefits in the policy. A copayment, coinsurance, deductible, and maximum out-of-pocket amount applied to the benefit for orthotic and prosthetic devices and services shall be no more than the most common amounts contained in the policy. (c) This section shall not apply to Medicare supplement, vision-only, dental-only, or CHAMPUS supplement insurance, or to hospital indemnity, hospital-only, accident-only, or specified disease insurance that does not pay benefits on a fixed benefit, cash payment only basis. (Amended by Stats. 2018, Ch. 687, Sec. 5. (SB 910) Effective January 1, 2019.)
10123.8.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover breast cancer screening, diagnosis, and treatment, and they cannot deny coverage just because of a family history of breast cancer or prior breast disease testing.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.8. (a) Every policy of disability insurance that provides coverage for hospital, medical, or surgical expenses, that is issued, amended, delivered, or renewed on or after January 1, 2000, shall provide coverage for screening for, diagnosis of, and treatment for, breast cancer. (b) No policy of disability insurance that provides coverage for hospital, medical, or surgical expenses shall deny enrollment or coverage to an individual solely due to a family history of breast cancer, or who has had one or more diagnostic procedures for breast disease but has not developed or been diagnosed with breast cancer. (c) Every policy of disability insurance shall cover screening and diagnosis of breast cancer, consistent with generally accepted medical practice and scientific evidence, upon the referral of the insured’s participating physician. (d) Treatment for breast cancer under this section shall include coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits. (e) As used in this section, “mastectomy” means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Partial removal of a breast includes, but is not limited to, lumpectomy, which includes surgical removal of the tumor with clear margins. (f) As used in this section, “prosthetic devices” means the provision of initial and subsequent devices pursuant to an order of the patient’s physician and surgeon. (g) For purposes of this section, disability insurance does not include accident only, credit, disability income, specified disease and hospital confinement indemnity, coverage of Medicare services pursuant to contracts with the United States government, Medicare supplement, long-term care insurance, dental, vision, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance. (Amended by Stats. 2012, Ch. 449, Sec. 4. (SB 255) Effective January 1, 2013.)
10123.81.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies and self-insured employee welfare benefit plans must cover mammography screening or diagnostic services when there is a qualifying referral.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law. (b) This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care. (c) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (Amended by Stats. 2018, Ch. 687, Sec. 6. (SB 910) Effective January 1, 2019.)
10123.82.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies covering laryngectomy must include coverage for prosthetic devices to help the patient speak, subject to the laryngectomy’s deductible, coinsurance, and other benefit terms.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.82. Every policy of disability insurance which provides for the surgical procedure known as a laryngectomy and which is issued, amended, delivered, or renewed in this state on or after January 1, 1993, shall include coverage for prosthetic devices to restore a method of speaking for the patient incident to the laryngectomy. Coverage for prosthetic devices shall be subject to the deductible and coinsurance conditions applied to the laryngectomy, and all other terms and conditions applicable to other benefits. As used in this section, “laryngectomy” means the removal of the larynx for medically necessary reasons, as determined by a licensed physician and surgeon. Any provision in any policy issued, amended, delivered, or renewed in this state on or after January 1, 1993, which is in conflict with this section shall be of no force or effect. As used in this section, “prosthetic devices” means and includes the provision of initial and subsequent prosthetic devices, including installation accessories, pursuant to an order of the patient’s physician and surgeon. “Prosthetic devices” does not include electronic voice producing machines. (Added by Stats. 1992, Ch. 808, Sec. 2. Effective January 1, 1993.)
10123.83.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies covering hospital, medical, or surgical expenses must include obstetrician-gynecologists as eligible primary care physicians if they meet the insurer’s written eligibility criteria.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.83. (a) On or after January 1, 1995, every policy of disability insurance that covers hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed in this state shall include obstetrician-gynecologists as eligible primary care physicians provided they meet the insurer’s written eligibility criteria for all specialists seeking primary care physician status. (b) For purposes of this section, the term “primary care physician” means a physician, as defined in Section 14254 of the Welfare and Institutions Code, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. (Amended by Stats. 1995, Ch. 353, Sec. 1. Effective January 1, 1996.)
10123.835.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover prostate cancer screening and diagnosis when medically necessary.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.835. (a) Every individual or group policy of disability insurance that covers hospital, medical, or surgical benefits that is issued, amended, or renewed on or after January 1, 1999, shall be deemed to provide coverage for the screening and diagnosis of prostate cancer, including, but not limited to, prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice. (b) Nothing in this section shall be construed to require an individual or group policy to cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, and combined hormonal therapy, or to prevent application of deductible or copayment provisions contained in the policy, nor shall this section be construed to require that coverage under an individual or group policy be extended to any other procedures. (c) This section shall not apply to specified accident, specified disease, hospital indemnity, Medicare supplement, or long-term care health insurance policies. (Added by renumbering Section 10123.83 (as added by Stats. 1998, Ch. 839) by Stats. 2009, Ch. 234, Sec. 11. (AB 299) Effective January 1, 2010.)
10123.84.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must let policyholders directly access obstetrical and gynecological physician services, and policyholders cannot be required to get prior approval first.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.84. (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 obstetrical and gynecological physician services. (b) Each policy of disability insurance that covers hospital, medical, or surgical expenses, and that is issued, amended, delivered, or renewed in this state, shall allow a policyholder the option to seek obstetrical and gynecological physician services directly from an obstetrician and gynecologist or directly from a participating family physician and surgeon designated by the plan as providing obstetrical and gynecological services. (c) In implementing this section, a disability insurer may establish reasonable requirements governing utilization protocols and the use of obstetricians and gynecologists or family physicians and surgeons, as provided for in subdivision (b), if those requirements are consistent with the intent of this section, are customarily applied to other physicians and surgeons, including primary care physicians and surgeons, to whom the policyholder has direct access, and are no more restrictive for the provision of obstetrical and gynecological physician services. A policyholder shall not be required to obtain prior approval from another physician, another provider, or the insurer prior to obtaining direct access to obstetrical and gynecological physician services, but the insurer may establish reasonable requirements for the participating obstetrician and gynecologist or the family physician and surgeon, as provided in subdivision (b), to communicate with the policyholder’s primary care physician regarding the policyholder’s condition, treatment, and any need for followup care. (d) This section does not diminish the requirements of Section 10123.83. (Amended by Stats. 2019, Ch. 632, Sec. 13. (AB 1622) Effective January 1, 2020.)
10123.85.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer may not require in-person contact before paying for telehealth-covered services, and may not restrict the setting where those services are provided, subject to contract terms and Section 10123.855.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.85. (a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code apply. (b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the health care provider. (c) A health insurer shall not require that in-person contact occur between a health care provider and a patient before payment is made for the services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the policyholder or contractholder and the insurer, and between the insurer and its participating providers or provider groups, and pursuant to Section 10123.855. (d) A health insurer shall not limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided by telehealth, subject to the terms and conditions of the contract between the policyholder or contractholder and the insurer, and between the insurer and its participating providers or provider groups, and pursuant to Section 10123.855. (e) Notwithstanding any other law, this section does not authorize a health insurer to require the use of telehealth if the health care provider has determined that it is not appropriate. (Amended by Stats. 2019, Ch. 867, Sec. 4. (AB 744) Effective January 1, 2020.)
10123.855.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must treat telehealth services the same as in-person services for reimbursement, coverage, and cost-sharing limits, with some exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.855. (a) (1) A contract between a health insurer and a health care provider for an alternative rate of payment pursuant to Section 10133 shall specify that the health insurer shall reimburse the treating or consulting health care provider for the diagnosis, consultation, or treatment of an insured or policyholder appropriately delivered through telehealth services on the same basis and to the same extent that the health insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment. (2) This section does not limit the ability of a health insurer and a health care provider to negotiate the rate of reimbursement for a health care service provided pursuant to a contract subject to this section. Services that are the same, as determined by the provider’s description of the service on the claim, shall be reimbursed at the same rate whether provided in person or through telehealth. When negotiating a rate of reimbursement for telehealth services for which no in-person equivalent exists, a health insurer and the provider shall ensure the rate is consistent with subdivision (a) of Section 10123.137. (b) (1) A policy of health insurance that provides benefits through contracts with providers at alternative rates of payment shall specify that the health insurer shall provide coverage for health care services appropriately delivered through telehealth services on the same basis and to the same extent that the health insurer is responsible for coverage for the same service through in-person diagnosis, consultation, or treatment. Coverage shall not be limited only to services delivered by select third-party corporate telehealth providers. (2) This section does not alter the existing statutory or regulatory obligations of a health insurer to ensure that insureds have access to all covered services through an adequate network of contracted providers, as required by Sections 10133 and 10133.5 and the regulations promulgated thereunder. (3) This section does not require a health insurer to deliver health care services through telehealth services. (4) This section does not require a health insurer to cover telehealth services provided by an out-of-network provider, unless coverage is required under other provisions of law. (c) A health insurer may offer a policy containing a copayment or coinsurance requirement for a health care service delivered through telehealth services, provided that the copayment or coinsurance does not exceed the copayment or coinsurance applicable if the same services were delivered through in-person diagnosis, consultation, or treatment. This subdivision does not require cost sharing for services provided through telehealth. (d) Services provided through telehealth and covered pursuant to this chapter shall be subject to the same deductible and annual or lifetime dollar maximum as equivalent services that are not provided through telehealth. (e) The definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code apply to this section. (f) The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application. (Amended by Stats. 2021, Ch. 439, Sec. 6. (AB 457) Effective January 1, 2022.)
10123.856.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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If a health insurer offers telehealth through a third-party corporate telehealth provider, it must give the insured certain disclosures, record-sharing notices, and reporting-related information; the insured must consent and may be given an option to continue specialty telehealth with contracted providers in some cases.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.856. (a) If a health insurer offers a service via telehealth to an insured through a third-party corporate telehealth provider, all of the following conditions shall be met: (1) The health insurer shall disclose to the insured in any promotion or coordination of the service both of the following: (A) The availability of receiving the service on an in-person basis or via telehealth, if available, from the insured’s primary care provider, treating specialist, or from another contracting individual health professional, a contracting clinic, or a contracting health facility consistent with the service and existing timeliness and geographic access standards in Section 10133.5 and regulations promulgated thereunder. (B) If the insured has coverage for out-of-network benefits, a reminder of the availability of receiving the service either via telehealth or on an in-person basis using the insured’s out-of-network benefits, and the cost sharing obligation for out-of-network benefits compared to in-network benefits and balance billing protections for services received from contracted providers. (2) After being notified pursuant to paragraph (1), the insured chooses to receive the service via telehealth through a third-party corporate telehealth provider. (3) The insured consents to the service consistent with Section 2290.5 of the Business and Professions Code. (4) If the insured is currently receiving specialty telehealth services for a mental or behavioral health condition, the insured is given the option of continuing to receive that service with the contracting individual health professional, a contracting clinic, or a contracting health facility. (b) For purposes of this section, the following definitions shall apply: (1) “Contracting individual health professional” means a physician and surgeon or other professional who is licensed by the state to deliver or furnish health care services, including mental or behavioral health services, and who is contracted with the insured’s health insurer. A “contracting individual health professional” shall not include a dentist licensed pursuant to the Dental Practice Act (Chapter 4 (commencing with Section 1600) of Division 2 of the Business and Professions Code). Application of this definition is not precluded by a contracting individual health professional’s affiliation with a group. (2) “Contracting clinic” means a clinic, as defined in Section 1200 of the Health and Safety Code, that is contracted with the insured’s health insurer. (3) “Contracting health facility” mean a health facility, as defined in Section 1250 of the Health and Safety Code, that is contracted with the insured’s health insurer. (4) “Third-party corporate telehealth provider” means a corporation directly contracted with a health insurer that provides health care services exclusively through a telehealth technology platform and has no physical location at which a patient can receive services. (c) If services are provided to an insured through a third-party corporate telehealth provider, a health insurer shall comply with all of the following: (1) Notify the insured of the insured’s right to access the insured’s medical records pursuant to, and consistent with, Chapter 1 (commencing with Section 123100) of Part 1 of Division 106 of the Health and Safety Code. (2) Notify the insured that the record of any services provided to the insured through a third-party corporate telehealth provider shall be shared with the insured’s primary care provider, unless the insured objects. (3) Ensure that the records are entered into a patient record system shared with the insured’s primary care provider or are otherwise provided to the insured’s primary care provider, unless the insured objects, in a manner consistent with state and federal law. (4) Notify the insured that all services received through the third-party corporate telehealth provider are considered to be in network available at in-network cost-sharing and out-of-pocket costs shall accrue to any applicable deductible or out-of-pocket maximum. (d) A health insurer shall include in its reports submitted to the department pursuant to Section 10133.5 and regulations adopted pursuant to that section, in a manner specified by the commissioner, all of the following for each product type: (1) By specialty, the total number of services delivered via telehealth provided by third-party corporate telehealth providers. (2) The names of each third-party corporate telehealth provider contracted with the insurer and, for each, the number of services provided by specialty. (3) For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party corporate telehealth provider’s contracted providers available to the insurer’s insured that are also contracting individual health professionals. (4) For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by insureds, including frequency of use, gender, age, and any other information as determined by the department. (5) For each enrollee that has accessed services for a third-party corporate telehealth provider, enrollee demographic data, including gender and age, and any other information as determined by the department. (e) The commissioner shall investigate and take enforcement action, as appropriate, against a health insurer that fails to comply with these requirements and shall periodically evaluate contracts between health insurers and third-party corporate telehealth providers to determine if any audit, evaluation, or enforcement actions should be undertaken by the commissioner. (f) This section shall not apply when an insured seeks services directly from a third-party corporate telehealth provider. (Added by Stats. 2021, Ch. 439, Sec. 7. (AB 457) Effective January 1, 2022.)
10123.857.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers offering dental coverage with telehealth services must report specified telehealth data to the department and disclose telehealth impacts on benefit limits to the insured.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.857. (a) A health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized health insurance policy covering dental services that offers a service via telehealth to an insured through a third-party corporate telehealth provider shall report to the department, in a manner specified by the department, all of the following for each product type: (1) The total number of services delivered via telehealth by a third-party corporate telehealth provider. (2) For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party telehealth provider’s contracted providers available to the insurer’s insured that are also network providers. (3) For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by insureds, including information on the gender and age of the insured, and any other information as determined by the department. (b) A health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized health care policy covering dental services that offers a service via telehealth to an insured through a third-party corporate telehealth provider, shall disclose to the insured the impact of third-party telehealth visits on the insured’s benefit limitations, including frequency limitations and the insured’s annual maximum. (c) Section 10123.856 shall not apply to specialized health insurance policies covering dental services. (d) For the purposes of this section, “third-party corporate telehealth provider” means a corporation that provides dental services exclusively through a telehealth technology platform and has no physical location at which a patient can receive services, and is directly contracted with a health insurer that issues, sells, renews, or offers a policy, including a specialized health insurance policy, that covers dental services. (Amended by Stats. 2024, Ch. 444, Sec. 5. (SB 577) Effective January 1, 2025.)
10123.86.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover mastectomy-related hospital stay decisions, reconstructive and prosthetic care, and all mastectomy complications.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.86. (a) Every policy of disability insurance covering hospital, surgical, or medical expenses that is issued, amended, renewed, or delivered on or after January 1, 1999, that provides coverage for surgical procedures known as mastectomies and lymph node dissections, shall do all of the following: (1) Allow the length of a hospital stay associated with those procedures to be determined by the attending physician and surgeon in consultation with the patient, postsurgery, consistent with sound clinical principles and processes. No disability insurer shall require a treating physician and surgeon to receive prior approval in determining the length of hospital stay following those procedures. (2) Cover prosthetic devices or reconstructive surgery, including devices or surgery to restore and achieve symmetry for the patient incident to the mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applicable to other benefits. (3) Cover all complications from a mastectomy, including lymphedema. (b) As used in this section, all of the following definitions apply: (1) “Coverage for prosthetic devices or reconstructive surgery” means any initial and subsequent reconstructive surgeries or prosthetic devices, and followup care deemed necessary by the attending physician and surgeon. (2) “Prosthetic devices” means and includes the provision of initial and subsequent prosthetic devices pursuant to an order of the patient’s physician and surgeon. (3) “Mastectomy” means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Partial removal of a breast includes, but is not limited to, lumpectomy, which includes surgical removal of the tumor with clear margins. (4) “To restore and achieve symmetry” means that, in addition to coverage of prosthetic devices and reconstructive surgery for the diseased breast on which the mastectomy was performed, prosthetic devices and reconstructive surgery for a healthy breast is also covered if, in the opinion of the attending physician and surgeon, this surgery is necessary to achieve normal symmetrical appearance. (c) No individual, other than a licensed physician and surgeon competent to evaluate the specific clinical issues involved in the care requested, may deny requests for authorization of health care services pursuant to this section. (d) No insurer shall do any of the following in providing the coverage described in subdivision (a): (1) Reduce or limit the reimbursement of the attending provider for providing care to an insured in accordance with the coverage requirements. (2) Provide monetary or other incentives to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with the coverage requirements. (3) Provide monetary payments or rebates to an insured to encourage acceptance of less than the coverage requirements. (e) On or after July 1, 1999, every insurer shall include notice of the coverage required by this section in the insurer’s evidence of coverage or certificate of insurance. (f) Nothing in this section shall be construed to limit retrospective utilization review and quality assurance activities by the insurer. (g) This section shall only apply to health benefit plans, as defined in subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity insurance, coverage for benefits under this section shall apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy. Nothing in this section shall be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance. (Amended by Stats. 2012, Ch. 449, Sec. 5. (SB 255) Effective January 1, 2013.)
10123.861.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies with outpatient prescription drug benefits must cover medically necessary FDA-approved menopause treatments and, for later-issued policies, add menopause information and access programs.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.861. (a) A health insurance policy that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date of this section shall include coverage for United States Food and Drug Administration-approved treatments used to treat menopausal symptoms, as medically necessary, including, but not limited to, all of the following: (1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss. (2) Low-dose antidepressants. (3) Anticonvulsants. (4) Medications to prevent or treat osteoporosis. (5) Nonhormonal medications for vasomotor-related symptoms. (b) A health insurance policy that is issued, amended, or renewed on or after January 1, 2027, shall include a program to ensure insured individuals have access to current menopause information and covered items and services. (c) For the program to satisfy subdivision (b), the insurer shall do all of the following: (1) Provide, no later than July 1, 2027, and biannually thereafter, all contracted providers delivering primary care with information about current clinical care recommendations for menopause care, including hormone therapy, from the Menopause Society or other nationally recognized professional association. The insurer shall encourage providers delivering primary care to review the information. (2) Establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall identify the Current Procedural Terminology (CPT) codes for services commonly used to evaluate, diagnose, and treat symptoms resulting from menopause. (3) Establish and maintain a policy to provide insured individuals who may experience menopause and who are 40 years of age and older with an annual menopause assessment during primary care and obstetrician-gynecologist appointments. Insured individuals may opt out of receiving the assessments. The policy shall include a copy of the assessment tool and information on how it was developed or chosen. (4) Provide insured individuals who may experience menopause and who are 40 years of age and older with a notice that includes a definition of menopause and that lists the covered items and services used to evaluate and treat symptoms resulting from menopause. The first notice shall be sent within 60 days of the insured individual’s 40th birthday and shall be sent biannually thereafter. Insured individuals may opt out of receiving the notices. The notice shall include a description of at least all of the following types of federal Food and Drug Administration-approved items and services: (A) Hormone therapy in the full range of formulations and methods of administration. (B) Low-dose antidepressants. (C) Anticonvulsants. (D) Medications to prevent or treat osteoporosis. (E) Nonhormonal medications for vasomotor-related symptoms. (5) Establish and maintain a policy to contract with providers delivering primary care, including advanced practice providers such as licensed nurse practitioners and certified nurse-midwives, who hold a certification or credential in menopause care from a nationally recognized organization, such as the Menopause Society or other similar organization. The policy shall state what steps the insurer will take to incentivize providers to receive and maintain the certification or credential. (d) The health insurer shall file with the commissioner within six months of the operative date of this statute the policies and notices specified in subdivision (c). The insurer shall also disclose the policies to network providers, provider groups, and delegated entities that may be impacted by the policies and notices and shall attest to that disclosure to the commissioner. (e) Coverage for the treatment options pursuant to this section shall be provided without discrimination on the basis of gender expression or identity. (f) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause. (g) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause. (Added by Stats. 2026, Ch. 27, Sec. 56. (SB 164) Effective June 29, 2026.)
10123.862.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must base menopause-related medical necessity and utilization review on accepted menopause-care standards, follow specified menopause professional guidelines from 2027, and avoid stricter conflicting review criteria within that scope.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.862. (a) A health insurer shall base a medical necessity determination or the utilization review criteria that the insurer, and an entity acting on the insurer’s behalf, applies to determine the medical necessity of health care services and benefits for the treatment of symptoms resulting from menopause on current generally accepted standards of menopause care. (b) Beginning January 1, 2027, when conducting utilization review of all covered health care services and benefits for the treatment of symptoms resulting from menopause, a health insurer shall apply criteria and guidelines developed by the Menopause Society or another nationally recognized professional association, as specified by the commissioner. (c) In conducting utilization review involving patient care decisions that are within the scope of the sources specified in subdivision (b), a health insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in those sources. This subdivision does not prohibit an insurer from applying utilization review criteria to health care services and benefits for menopause care that meet either of the following criteria: (1) Are outside the scope of the criteria and guidelines set forth in the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a). (2) Relate to advancements in technology or types of care that are not covered in the most recent versions of the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a). (d) If a health insurer purchases or licenses utilization review criteria pursuant to paragraph (1) or (2) of subdivision (c), the insurer shall verify and document before use that the criteria were developed in accordance with subdivision (a). (e) A health insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with this section. (f) For purposes of this section, the following definitions apply: (1) “Generally accepted standards of menopause care” means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties, including gynecology, endocrinology, and family practice. Valid, evidence-based sources establishing generally accepted standards of menopause care include peer reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit health care provider professional associations, specialty societies, and federal government agencies, and drug labeling approved by the United States Food and Drug Administration. (2) “Menopause” includes perimenopause, menopause, and postmenopause. (3) “Utilization review” means either of the following: (A) Prospectively, retrospectively, or concurrently reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests by health care providers, insured individuals, or their authorized representatives for coverage of health care services prior to, retrospectively, or concurrent with the provision of health care services to insured individuals. (B) Evaluating the medical necessity, appropriateness, or efficacy of health care services, benefits, or procedures, under any circumstances, to determine if a health care service or benefit subject to a medical necessity coverage requirement in a health insurance policy is covered as medically necessary for an insured individual. (4) “Utilization review criteria” means criteria, standards, protocols, or guidelines used by a health insurer to conduct utilization review. (g) (1) This section applies to all health care services and benefits for the treatment of symptoms resulting from menopause covered by a health insurance policy, including prescription drugs. (2) This section applies to a health insurer that conducts utilization review and an entity or contracting provider that performs utilization review or utilization management functions on an insurer’s behalf. (3) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause. (h) If the commissioner determines that a health insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and Section 10123.861 through guidance or similar instructions, without taking regulatory action, until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care and interested stakeholders in developing guidance. (Added by Stats. 2026, Ch. 27, Sec. 57. (SB 164) Effective June 29, 2026.)
10123.864.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Medically necessary pasteurized donor human milk from a licensed tissue bank is treated as a basic health care service.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.864. The provision of medically necessary pasteurized donor human milk obtained from a tissue bank licensed pursuant to Chapter 4.1 (commencing with Section 1635) of Division 2 of the Health and Safety Code is a basic health care service, as described in Sections 10112.27 and 10112.281 and any regulations adopted thereunder. (Added by Stats. 2024, Ch. 975, Sec. 4. (AB 3059) Effective January 1, 2025.)
10123.865.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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An individual health insurance policy must cover maternity services for covered insureds, starting no later than July 1, 2012.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.865. (a) Commencing no later than July 1, 2012, an individual health insurance policy shall provide coverage for maternity services for all insureds covered under the policy. (b) For purposes of this section, “maternity services” include prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and postpartum care. This definition of “maternity services” shall remain in effect until the time as federal regulations and guidance issued pursuant to the federal Patient Protection and Affordable Care Act (Public Law 111-148) define the scope of benefits to be provided under the maternity benefit requirement of that act, after which time the definition of that term under the federal act and associated regulations and guidance shall apply for purposes of this section. (c) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (Amended by Stats. 2018, Ch. 687, Sec. 7. (SB 910) Effective January 1, 2019.)
10123.866.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A group health insurance policy must cover maternity services for all insureds, starting no later than July 1, 2012.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.866. (a) Commencing no later than July 1, 2012, a group health insurance policy shall provide coverage for maternity services for all insureds covered under the policy. (b) For purposes of this section, “maternity services” include prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and postpartum care. This definition of “maternity services” shall remain in effect until the time as federal regulations and guidance issued pursuant to the federal Patient Protection and Affordable Care Act (Public Law 111-148) define the scope of benefits to be provided under the maternity benefit requirement of that act, after which time the definition of that term under the federal act and associated regulations and guidance shall apply for purposes of this section. (c) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (Amended by Stats. 2018, Ch. 687, Sec. 8. (SB 910) Effective January 1, 2019.)
10123.867.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer must create a maternal mental health program with required screenings, quality measures, and provider guidance.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.867. (a) A health insurer shall develop a maternal mental health program designed to promote quality and cost-effective outcomes. The program shall consist of at least one maternal mental health screening to be conducted during pregnancy, at least one additional screening to be conducted during the first six weeks of the postpartum period, and additional postpartum screenings, if determined to be medically necessary and clinically appropriate in the judgment of the treating provider. The program shall be developed consistent with sound clinical principles and processes, and shall include quality measures to encourage screening, diagnosis, treatment, and referral. The program guidelines and criteria shall be provided to relevant medical providers, including all contracting obstetric providers. As part of the maternal mental health program, a health insurer is encouraged to improve screening, treatment, and referral to maternal mental health services, include coverage for doulas, incentivize training opportunities for contracting obstetric providers, and educate insureds about the program. (b) For the purposes of this section: (1) “Contracting obstetric provider” means an individual who is certified or licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or an initiative act referred to in that division, and who is contracted with the insured’s health insurer to provide services under the insured’s health insurance policy. (2) “Maternal mental health” means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression. (c) This section does not apply to specialized health insurers, except behavioral health-only insurers that provide coverage for professional mental health services. (Amended by Stats. 2024, Ch. 815, Sec. 2. (AB 1936) Effective January 1, 2025.)
10123.868.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer must develop a maternal and infant health equity program by January 1, 2025.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.868. On or before January 1, 2025, a health insurer shall develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas. This may be achieved by integrating the program into existing maternal mental health programs, including those encouraging the coverage of doula care, or by expanding existing doula programs. (Added by Stats. 2023, Ch. 349, Sec. 3. (AB 904) Effective January 1, 2024.)
10123.869.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurer contracts issued, amended, or renewed on or after January 1, 2025 must let providers separately bill for certain immediate postpartum contraception services and items when the birth occurs in a general acute care hospital or licensed birth center.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.869. (a) A contract between a health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, shall authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a general acute care hospital or licensed birth center. The provider contract shall not consider those devices, implants, or services to be part of a payment for a general obstetric procedure. (b) For purposes of this section, “immediate postpartum contraception” means the postpartum insertion of intrauterine devices or contraceptive implants performed before the insured is discharged from the general acute care hospital or licensed birth center and includes the devices or implants themselves. (c) This section does not affect an insured’s right to directly access women’s health care services, including contraceptive services, and informed consent. (Added by Stats. 2024, Ch. 950, Sec. 2. (AB 2129) Effective January 1, 2025.)
10123.87.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies with maternity coverage must not limit inpatient hospital stays below 48 hours after a normal delivery or 96 hours after a caesarean, unless the stated exception conditions are met.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.87. (a) No individual or group policy of disability insurance that provides coverage for hospital, medical, and surgical benefits that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that provides maternity coverage, shall do any of the following: (1) Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section. However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if both of the following conditions are met: (A) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother. (B) The policy covers a postdischarge followup visit for the mother and newborn within 48 hours of discharge, when prescribed by the treating physician. The visit shall be provided by a licensed health care provider whose scope of practice includes postpartum care and newborn care. The visit shall include, at a minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments. The treating physician shall disclose to the mother the availability of a postdischarge visit, including an in-home visit, physician office visit, or a visit to a facility under contract with the insurer. The treating physician, in consultation with the mother, shall determine whether the postdischarge visit shall occur at home, the contracted facility, or the treating physician’s office after assessment of certain factors. These factors shall include, but not be limited to, the transportation needs of the family, and environmental and social risks. (2) Reduce or limit the reimbursement of the attending provider for providing care to an individual insured in accordance with the coverage requirements. (3) Provide monetary or other incentives to an attending provider to induce the provider to provide care to an individual insured in a manner inconsistent with the coverage requirements. (4) Deny a mother or her newborn eligibility, or continued eligibility, to enroll or to renew coverage solely to avoid the coverage requirements. (5) Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum coverage requirements. (6) Restrict inpatient benefits for the second day of hospital care in a manner that is less than favorable to the mother or her newborn than those provided during the preceding portion of the hospital stay. (7) Require the treating physician to obtain authorization from the insurer prior to prescribing any services covered by this section. (b) (1) Every individual or group policy of disability insurance that provides coverage for hospital, medical, and surgical benefits shall include notice of the coverage specified in subdivision (a) in the insurer’s evidence of coverage or certificate of insurance for evidences of coverage or certificates of insurance issued on or after January 1, 1998. (2) Every insurer that issues a policy of disability insurance under paragraph (1) shall provide additional written notice to all females between the ages of 10 and 50 who are covered under those policies of the coverage under subdivision (a) within 60 days of the effective date of this act. The insurer shall provide additional written notice of the coverage specified in subdivision (a) during the course of prenatal care if both of the following conditions are met: (A) The insurer previously notified policyholders that hospital stays for delivery would be inconsistent with the requirement in subparagraph (A) of paragraph (1) of subdivision (a). (B) The insurer received notice, whether by receipt of a claim, a request for preauthorization for pregnancy-related services, or other actual notice that the insured is pregnant. (c) Nothing in this section shall be construed to prohibit an insurer from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section. (Amended by Stats. 1997, Ch. 798, Sec. 3. Effective October 9, 1997.)
10123.88.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies must cover reconstructive surgery for eligible policies, and only certain licensed physicians may deny initial coverage authorization requests.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.88. (a) Every policy of health insurance covering hospital, medical, or surgical expenses that is issued, amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in subparagraph (A) or (B) of paragraph (1) of subdivision (c). Nothing in this section shall be construed to require a policy to provide coverage for cosmetic surgery, as defined in subdivision (d). This section shall only apply to health benefit plans, as defined in subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity insurance, coverage for benefits under this section shall apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy. Nothing in this section shall be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance. (b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested. (c) (1) “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (A) To improve function. (B) To create a normal appearance, to the extent possible. (2) As of July 1, 2010, “reconstructive surgery” shall include medically necessary dental or orthodontic services that are an integral part of reconstructive surgery, as defined in paragraph (1), for cleft palate procedures. (3) For purposes of this section, “cleft palate” means a condition that may include cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate. (d) Nothing in this section shall be construed to require an insurer to provide coverage for cosmetic surgery. “Cosmetic surgery” means surgery that is performed to alter or reshape normal structures of the body in order to improve the patient’s appearance. (e) In interpreting the definition of reconstructive surgery, an insurer may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following: (1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee. (2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee. (3) Denial of payment for procedures performed without prior authorization. (Amended by Stats. 2009, Ch. 604, Sec. 2. (SB 630) Effective January 1, 2010.)
10123.89.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover PKU testing and treatment, including prescribed formulas and special food products, subject to specified limits and exclusions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.89. (a) On and after July 1, 2000, every policy of disability insurance issued, amended, delivered, or renewed in this state that provides coverage for hospital, medical, or surgical expenses shall provide coverage for the testing and treatment of phenylketonuria (PKU) under the terms and conditions of the policy. (b) Coverage for treatment of phenylketonuria (PKU) shall include those formulas and special food products that are part of a diet prescribed by a licensed physician and managed by a health care professional in consultation with a physician who specializes in the treatment of metabolic disease and who participates in or is authorized by the insurer, provided that the diet is deemed medically necessary to avert the development of serious physical or mental disabilities or to promote normal development or function as a consequence of phenylketonuria (PKU). (c) Coverage pursuant to this section is not required except to the extent that the cost of necessary formulas and special food products exceeds the cost of a normal diet. (d) For purposes of this section, the following definitions shall apply: (1) “Formula” means an enteral product or enteral products for use at home that are prescribed by a physician or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments, as medically necessary for the treatment of phenylketonuria (PKU). (2) “Special food product” means a food product that is both of the following: (A) Prescribed by a physician or nurse practitioner for the treatment of phenylketonuria (PKU) and is consistent with the recommendations and best practices of qualified health professionals with expertise germane to, and experience in the treatment and care of, phenylketonuria (PKU). It does not include a food that is naturally low in protein, but may include a food product that is specially formulated to have less than one gram of protein per serving. (B) Used in place of normal food products, such as grocery store foods, used by the general population. (e) This section shall not apply to vision-only, dental-only, accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, or disability income insurance, except that for accident only, specified disease, or hospital indemnity coverage, coverage for benefits under this section shall apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or contract. Nothing in this section shall be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance. (Added by Stats. 1999, Ch. 541, Sec. 2. Effective January 1, 2000.)
10123.9.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain group disability insurance policies must add prenatal genetic-disorder diagnosis coverage and tell policyholders and negotiating groups that the coverage is available.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.9. On and after January 1, 1980, every group policy of disability insurance which covers hospital, medical, or surgical expenses on a group basis, and which offers maternity coverage in such groups, shall also offer coverage for prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy. Such coverage shall be offered under such terms and conditions as may be agreed upon between the insurer and the group policyholder. Every group policy of disability insurance shall communicate the availability of such coverage to all group policyholders and to all groups with whom they are negotiating. (Added by Stats. 1979, Ch. 629.)
10123.91.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain health insurers must cover HIV testing for applicable health policies, and the insurer keeps discretion over the testing provider.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10123.91. (a) On or after January 1, 2009, every insurer that issues, amends, or renews an individual or group policy of health insurance that covers hospital, medical, or surgical expenses shall provide coverage for human immunodeficiency virus (HIV) testing, regardless of whether the testing is related to a primary diagnosis. (b) It shall remain within the sole discretion of the health insurer as to the provider of the testing with which it chooses to contract. Reimbursement shall be provided according to the respective principles and policies of the health insurer. (Added by Stats. 2008, Ch. 631, Sec. 2. Effective January 1, 2009.)
10124.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A self-insured employee welfare benefit plan must keep a dependent child covered after the limiting age if the child has a qualifying disability and remains mainly dependent on the employee, and proof must be provided on time.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10124. (a) A self-insured employee welfare benefit plan delivered or issued for delivery in this state more than 120 days after the effective date of this section, which provides that coverage of a dependent child of an employee shall terminate upon attainment of the limiting age for dependent children specified in the policy or contract, shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to be both (1) incapable of self-sustaining employment by reason of an intellectual disability or physical handicap and (2) chiefly dependent upon the employee for support and maintenance, provided proof of the incapacity and dependency is furnished to the employer or employee organization providing the plan or program of benefits by the employee within 31 days of the child’s attainment of the limiting age and subsequently as may be required by the employer or employee organization, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age. (b) As used in this section, “self-insured employee welfare benefit plan” means a plan or program of benefits provided by an employer or an employee organization, or both, for the purpose of providing hospital, medical, surgical, nursing, or dental services, or indemnification for the costs incurred for these services, to the employer’s employees or their dependents. (Amended by Stats. 2013, Ch. 76, Sec. 138. (AB 383) Effective January 1, 2014.)
10124.7.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Self-insured employee benefit plans issued or renewed on or after the effective date must, where feasible, provide benefits for confinement in an extended care facility under terms agreed by the employer and the employee or employee organization.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10124.7. Each self-insured employee benefit plan issued or renewed on or after the effective date of this section shall provide, where feasible, that benefits for confinement in an extended care facility, as defined in subsection (j) of Section 1395x of Title 42 of the United States Code, may be provided under such terms and conditions as may be agreed upon between the employer and the employee or employee organization. Nothing in this section shall preclude a self-insured employee benefit plan from providing benefits for confinement in institutions other than extended care facilities as defined in this section. (Added by renumbering Section 10124 (as added by Stats. 1972, Ch. 522) by Stats. 1977, Ch. 579.)
10125.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers offering group disability insurance must offer mental or nervous disorder coverage and tell group policyholders about outpatient coverage availability.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10125. (a) On and after January 1, 1974, every insurer issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer coverage for expenses incurred as a result of mental or nervous disorders, under the terms and conditions which may be agreed upon between the group policyholder and the insurer. If the terms and conditions include coverage for inpatient care for nervous or mental disorders, the coverage shall extend to treatment provided at all of the following facilities: (1) A general acute care hospital as defined in subdivision (a) of Section 1250 of the Health and Safety Code. (2) An acute psychiatric hospital as defined in subdivision (b) of Section 1250 of the Health and Safety Code. (3) A psychiatric health facility as defined by Section 1250.2 of the Health and Safety Code operating pursuant to licensure by the State Department of Health Care Services. Nothing in this subdivision prohibits an insurer that negotiates and enters into a contract with a professional or institutional provider for alternative rates of payment pursuant to Section 10133 from restricting or modifying the choice of providers. (b) Every insurer shall communicate to prospective group policyholders as to the availability of outpatient coverage for the treatment of mental or nervous disorders. Every insurer shall communicate the availability of that coverage to all group policyholders and to all prospective group policyholders with whom they are negotiating. This coverage may include community residential treatment services, as described in former Section 5458 of the Welfare and Institutions Code, that are alternatives to institutional care. (Amended by Stats. 2013, Ch. 23, Sec. 21. (AB 82) Effective June 27, 2013.)
10125.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurers must pay or reimburse pharmacists for covered services, subject to scope-of-practice and coverage conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10125.1. (a) Every insurer issuing disability insurance that covers hospital, medical, or surgical expenses that offers coverage for a service that is within the scope of practice of a duly licensed pharmacist shall pay or reimburse the cost of the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the insurer has an out-of-network pharmacy benefit. (b) Payment or reimbursement may be made pursuant to this section for a service performed by a duly licensed pharmacist only when all of the following conditions are met: (1) The service performed is within the lawful scope of practice of the pharmacist. (2) The coverage otherwise provides reimbursement for identical services performed by other licensed health care providers. (c) Nothing in this section shall require the insurer to pay a claim to more than one provider for duplicate service or be interpreted to limit physician reimbursement. (Amended by Stats. 2023, Ch. 322, Sec. 2. (AB 317) Effective January 1, 2024.)
10125.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A pharmacy benefit manager that contracts with a health insurer must follow specified Health and Safety Code provisions, and health insurers remain responsible when they delegate functions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10125.2. (a) A pharmacy benefit manager that contracts with a health insurer shall comply with Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code, including Sections 1385.004 and 1385.006 of the Health and Safety Code. (b) A complaint made by an insured that includes potential violations by a pharmacy benefit manager of the terms of Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code may be considered by the department to be a complaint against the health insurer. (c) If a health insurer delegates functions to a pharmacy benefit manager, the pharmacy benefits manager shall comply with this code, as applicable. A health insurer shall specify by contract the pharmacy benefits manager’s responsibilities and shall monitor the pharmacy benefit manager to ensure compliance with this code. Notwithstanding delegation pursuant to this subdivision, the health insurer shall remain responsible for compliance with this code. (d) A contract between a health insurer and a pharmacy benefit manager issued, amended, or renewed on or after January 1, 2027, or the date on which the Department of Managed Health Care has established the pharmacy benefit manager licensure process, whichever is later, shall require the pharmacy benefit manager to be licensed and in good standing with the Department of Managed Health Care. A contract term that violates Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code shall be void on and after January 1, 2029. (e) The department may issue guidance regarding implementation of, and compliance with, this section and Sections 10125.2, 10123.2045, and 10123.205. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 1340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2030. The department shall consult with stakeholders in developing guidance pursuant to this subdivision. (Amended by Stats. 2025, Ch. 605, Sec. 17. (SB 41) Effective January 1, 2026.)
10126.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Group disability insurance policies meeting the stated conditions must give a covered dependent spouse the same conversion rights and conditions, and those rights cannot require a physical exam or statement of health.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126. Every policy of group disability insurance issued, amended, or renewed on or after January 1, 1977, which provides hospital, medical, or surgical expense benefits for employees or members and their dependents and which contains provisions granting the employee or member the right to convert the insurance coverage in the event of termination of employment or membership, shall include in such conversion provisions the same conversion rights and conditions to a covered dependent spouse of the employee or member in the event the covered dependent spouse ceases to be a qualified family member by reason of termination of marriage or death of the employee or member. Such conversion rights shall not require a physical examination or a statement of health. (Amended by Stats. 1976, Ch. 1173.)
10126.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section says a disability insurance policy rule about using the provider’s lowest payment rate does not include certain cash payments from uninsured individual patients.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126.5. If a disability insurance policy between an insurer that covers hospital, medical, or surgical expenses and a provider requires that the provider accept, as payment from the insurer, the lowest payment rate charged by the provider to any patient or third party, this policy provision shall not be deemed to apply to, or take into consideration, any cash payments made to the provider by individual patients who do not have any private or public form of health care coverage for the service rendered by the provider, as described in subdivision (c) of Section 657 of the Business and Professions Code. This section shall apply to a provider contract that is issued, amended, or renewed on or after the effective date of this section. (Added by Stats. 1998, Ch. 20, Sec. 3. Effective April 14, 1998.)
10126.6.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies must cover emergency medical transportation services.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126.6. (a) Every policy of disability insurance that provides hospital, medical, or surgical coverage under a health benefit plan, defined in subdivision (a) of Section 10198.6, that provides coverage for emergency health care services, that is issued, amended, delivered, or renewed in this state on or after January 1, 1999, shall include coverage for emergency medical transportation services, as defined in subdivision (b). This coverage shall be provided without regard to whether the emergency provider has a contractual arrangement with the insurer or whether there was prior authorization, subject to the terms and conditions of the policy. (b) For purposes of this section, “emergency medical transportation services” means ambulance services provided through the “911” emergency response system. (Added by Stats. 1998, Ch. 979, Sec. 5. Effective January 1, 1999.)
10126.61.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance policies issued, amended, or renewed on or after July 1, 2025 must set up reimbursement for certain ambulance-style health programs and limit enrollee cost-sharing for covered services from noncontracting providers.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126.61. (a) A health insurance policy issued, amended, or renewed on or after July 1, 2025, shall establish a process to reimburse for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program. (b) (1) A health insurance policy issued, amended, or renewed on or after July 1, 2025, shall require an insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternate destination program, or mobile integrated health program. (2) Notwithstanding any other law, reimbursement rates adopted pursuant to this subdivision shall not exceed the health insurer’s usual and customary charges for services rendered. (c) For purposes of this section, the following definitions apply: (1) “Community paramedicine program” means a program defined in Section 1815 of the Health and Safety Code. (2) “Mobile integrated health program” means a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the emergency medical services system. (3) “Triage to alternate destination program” means a program defined in Section 1819 of the Health and Safety Code. (Added by Stats. 2024, Ch. 884, Sec. 2. (SB 1180) Effective January 1, 2025.)
10126.65.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurance coverage must limit what the insured or subscriber pays for noncontracting air ambulance services to the in-network cost-sharing amount.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126.65. (a) (1) Notwithstanding Section 10352, a health insurance policy issued, amended, or renewed on or after January 1, 2020, shall provide that if an insured or subscriber receives covered services from a noncontracting air ambulance provider, the insured or subscriber shall pay no more than the same cost sharing that the insured or subscriber would pay for the same covered services received from a contracting air ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.” (2) A subscriber or insured shall not owe the noncontracting provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured or subscriber and the noncontracting provider of the in-network cost-sharing amount owed by the insured or subscriber. (b) The following shall apply for purposes of this section: (1) Any cost sharing paid by the insured or subscriber for the services subject to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28. (2) Cost sharing arising from services subject to this section shall be counted toward any deductible in the same manner as cost sharing would be attributed to a contracting provider. (3) The cost sharing paid by the insured or subscriber pursuant to this section shall satisfy the insured’s or subscriber’s obligation to pay cost sharing for the health service. (c) A noncontracting provider may advance to collections only the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured or subscriber failed to pay. (d) A health insurer or a provider may seek relief in any court for the purpose of resolving a payment dispute. A provider is not prohibited from using a health insurer’s existing dispute resolution processes. (Added by Stats. 2019, Ch. 537, Sec. 3. (AB 651) Effective January 1, 2020.)
10126.66.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers must cap insured cost-sharing for noncontracting ground ambulance services and separately reimburse the provider; providers cannot over-collect or use certain debt-collection methods.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.” (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insured’s coverage is regulated by the department or if the coverage is not state-regulated. (b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28. (2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider. (3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insured’s obligation to pay cost sharing for the health service. (c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay. (1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not do either of the following: (A) Report adverse information to a consumer credit reporting agency. (B) Commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a). (2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section. (d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows: (A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code. (B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following: (i) The ambulance provider’s training, qualifications, and length of time in practice. (ii) The nature of the services provided. (iii) The fees usually charged by the ambulance provider. (iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered. (v) Other aspects of the economics of the ambulance provider’s practice that are relevant. (vi) Any unusual circumstances in the case. (2) A local government has jurisdiction over the ground ambulance transport if either of the following applies: (A) The ground ambulance transport is initiated within the boundaries of the local government’s regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based. (3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered. (4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider. (e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurer’s existing dispute resolution process under Section 10123.137. (f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. (Amended by Stats. 2024, Ch. 520, Sec. 13. (SB 1061) Effective January 1, 2025.)
10127.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain self-insured employee welfare benefit plans must cover mental or nervous disorder expenses and tell members about that coverage.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127. On and after January 1, 1974, every self-insured employee welfare benefit plan that provides coverage for hospital, medical, or surgical expenses shall offer coverage for expenses incurred as a result of mental or nervous disorders, under the terms and conditions which may be agreed upon between the self-insured welfare benefit plan and the member. If the terms and conditions include coverage for services provided in a general acute care hospital, or an acute psychiatric hospital as defined in Section 1250 of the Health and Safety Code, and do not restrict or modify the choice of providers, the coverage shall extend to care provided by a psychiatric health facility, as defined by Section 1250.2 of the Health and Safety Code, operating pursuant to licensure by the State Department of Health Care Services. Every plan shall communicate to prospective members as to the availability of outpatient coverage for the treatment of mental or nervous disorders. Every self-insured welfare benefit plan shall communicate the availability of this coverage to all members and prospective members. This coverage may include community residential treatment services, as described in former Section 5458 of the Welfare and Institutions Code, that are alternatives to institutional care. (Amended by Stats. 2013, Ch. 23, Sec. 22. (AB 82) Effective June 27, 2013.)
10127.09.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain disability insurance policies for higher education institutions must follow specific coverage requirements.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.09. Notwithstanding any other law, a disability insurance policy that provides hospital, medical, surgical, prescription drug, or nursing benefits, except a policy providing only dental or vision benefits, that is issued, amended, renewed, or delivered, on or after January 1, 2024, and that is issued to a bona fide public or private institution of higher learning and provides coverage to its students and their dependents, or to its faculty, staff, administration, and their respective dependents, shall comply with the coverage requirements of Sections 10123.1945 and 10123.196. (Added by Stats. 2022, Ch. 630, Sec. 18. (SB 523) Effective January 1, 2023.)
10127.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance and self-insured employee welfare benefit plans with loss of time benefits may not reduce those benefits because Social Security benefits increase.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.1. (a) No policy of disability insurance providing loss of time benefits shall contain any provision for a reduction of such benefits during a benefit period because of an increase in benefits payable under the Federal Social Security Act, as amended. (b) No self-insured employee welfare benefit plan providing loss of time benefits shall contain any provision for a reduction of such benefits during a benefit period because of an increase in benefits payable under the Federal Social Security Act, as amended. (c) This section shall apply to all disability insurance policies issued, delivered, amended, or renewed in this state on or after January 1, 1977, and shall apply to group disability insurance policies and self-insured employee welfare benefit plans which are entered into, amended, or renewed on or after such date or upon the expiration of any applicable collective-bargaining agreement, whichever occurs later. (Added by Stats. 1976, Ch. 68.)
10127.10.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section requires certain life insurance and annuity policies sold to senior citizens to include cancellation notices, and it gives buyers a 30-day return right with refund rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.10. (a) Every policy of individual life insurance and every individual annuity contract that is initially delivered or issued for delivery to a senior citizen in this state on and after July 1, 2004, shall have printed on the front of the policy jacket or on the cover page a notice stating that, after receipt of the policy by the owner, the policy may be returned by the owner for cancellation by mail or other delivery method to the insurer or agent from whom it was purchased. The period of time set forth by the insurer for return of the policy by the owner shall be clearly stated in the notice and this period shall be not less than 30 days. The owner may return the policy to the insurer by mail or other delivery method at any time during the period specified in the notice. During the 30-day cancellation period, the premium for an individual variable life insurance policy or an individual variable annuity contract may be invested only in fixed-income investments and money-market funds, unless the owner specifically directs that the premium be invested in the mutual funds underlying the variable life insurance policy or variable annuity contract. Return of the policy within the 30-day cancellation period shall have one of the following effects: (1) In the case of individual variable life insurance policies and individual variable annuity contracts for which the owner has not directed that the premium be invested in the mutual funds underlying the policy during the cancellation period, return of the policy during the cancellation period shall have the effect of voiding the policy from the beginning, and the parties shall be in the same position as if no policy had been issued. All premiums paid and any policy fee paid for the policy shall be refunded by the insurer to the owner within 30 days from the date that the insurer is notified that the owner has canceled the policy. (2) In the case of individual variable life insurance policies and individual variable annuity contracts for which the owner has directed that the premium be invested in the mutual funds underlying the policy during the 30-day cancellation period, cancellation shall entitle the owner to a refund of the account value and any policy fee paid for the policy. The account value shall be refunded by the insurer to the owner within 30 days from the date that the insurer is notified that the owner has canceled the policy. (b) This section applies to all individual life insurance policies and all individual annuity contracts issued or delivered to senior citizens in this state on or after January 1, 2004. All policies subject to this section which are in effect on January 1, 2003, shall be construed to be in compliance with this section, and any provision in any policy which is in conflict with this section shall be of no force or effect. (c) Every individual nonvariable life insurance policy and every individual nonvariable annuity contract, including modified guaranteed annuity contracts, subject to this section, that is delivered or issued for delivery in this state shall have the following notice printed on the front of the policy jacket or on the cover page in 12-point bold print with one inch of space on all sides, using the exact language in quotation marks below, with whichever one of the three bracketed product descriptions that applies to the product on which the notice appears: ## “IMPORTANT! You have purchased a [life insurance policy], [annuity contract], [modified guaranteed annuity contract], referred to below as a “policy.” Carefully review it for limitations. This policy may be returned within 30 days from the date you received it for a full refund by returning it to the insurance company or agent who sold you this policy. After 30 days, cancellation may result in a substantial penalty, known as a surrender charge.” The sentence “After 30 days, cancellation may result in a substantial penalty, known as a surrender charge” may be deleted if the policy does not contain a surrender charge. The phrase “known as a surrender charge” may be deleted if the policy contains a penalty but no surrender charge. If the policy contains both a penalty, or penalties, and a surrender charge, the sentence shall state that cancellation may result in “substantial penalties, including a surrender charge.” Whether a charge constitutes a surrender charge or a penalty shall be determined by the nature of the charge and not the name given to the charge by the insurer. If the surrender charge is called a “withdrawal charge” in the policy, the insurer shall add the following sentence at the end of the notice: “In this policy the surrender charge is called a ‘withdrawal charge.’” (d) Every individual variable life insurance policy and every individual variable annuity contract subject to this section, that is delivered or issued for delivery in this state, shall have the following notice printed on the front of the policy jacket or on the cover page in 12-point bold print with one inch of space on all sides, using the exact language in quotation marks below, with whichever one of the two bracketed product descriptions that applies to the product on which the notice appears: ## “IMPORTANT! You have purchased a [variable life insurance policy], [variable annuity contract], referred to below as a “policy.” Carefully review it for limitations. This policy may be returned within 30 days from the date you received it. During that 30-day period, your money will be placed in a fixed account or money-market fund, unless you direct that the premium be invested in a stock or bond portfolio underlying the policy during the 30-day period. If you do not direct that the premium be invested in a stock or bond portfolio, and if you return the policy within the 30-day period, you will be entitled to a refund of the premium and any policy fee paid. If you direct that the premium be invested in a stock or bond portfolio during the 30-day period, and if you return the policy during that period, you will be entitled to a refund of the policy’s account value on the day the policy is received by the insurance company or agent who sold you this policy, which could be less than the premium you paid for the policy, plus any policy fee paid. A return of the policy after 30 days may result in a substantial penalty, known as a surrender charge.” The sentence “A return of the policy after 30 days may result in a substantial penalty, known as a surrender charge” may be deleted if the policy does not contain a surrender charge. If the policy contains both a penalty, or penalties, and a surrender charge, the sentence shall state that cancellation may result in “substantial penalties, including a surrender charge.” The phrase “known as a surrender charge” may be deleted if the policy contains a penalty but no surrender charge. Whether or not a charge constitutes a surrender charge or a penalty will be determined by the nature of the charge and not the name given to the charge by the insurer. If the surrender charge is called a “withdrawal charge” in the policy, the insurer shall add the following sentence at the end of the notice: “In this policy the surrender charge is called a ‘withdrawal charge.’” (e) If the individual annuity contract is an immediate annuity contract, the following sentence, using the exact language in quotation marks below, in 12-point bold print, shall be added at the end of the right to examine language required by this section and before the one inch of space: “After the 30-day period has expired, you may not be able to get your purchase payment money back in any manner, or in any manner other than in annuity payments made according to the terms of your contract. The insurance company or agent who sold you this contract can explain if your contract has these restrictions.” (f) This section does not apply to life insurance policies issued in connection with a credit transaction or issued under a contractual policy-change or conversion privilege provision contained in a policy. (g) For purposes of this chapter, a senior citizen means an individual who is 60 years of age or older on the date of purchase of the policy. (h) General references to “policy” or “policies” in this section refer to both life insurance policies and annuity contracts. (i) This section shall become operative on July 1, 2015. (Repealed (in Sec. 5 ) and added by Stats. 2014, Ch. 166, Sec. 6. (AB 2347) Effective January 1, 2015. Section operative July 1, 2015, by its own provisions.)
10127.11.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Insurers and life agents must give a prominent warning on certain life insurance and annuity illustrations for senior citizens, and preprinted illustrations must use specified formatting for notices and guaranteed-value columns.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.11. Every insurer and life agent offering for sale individual life insurance policies or individual annuity contracts that are initially delivered or issued for delivery to senior citizens in this state on and after January 1, 1995, with the use of nonpreprinted illustrations of nonguaranteed values shall disclose on those illustrations or on an attached cover sheet, in bold or underlined capitalized print, or in the form of a contrasting color sticker, bright highlighter pen, or in any manner that makes it more prominent than the surrounding material, with at least one-half inch space on all four sides, the following statement: “THIS IS AN ILLUSTRATION ONLY. AN ILLUSTRATION IS NOT INTENDED TO PREDICT ACTUAL PERFORMANCE. INTEREST RATES, DIVIDENDS, OR VALUES THAT ARE SET FORTH IN THE ILLUSTRATION ARE NOT GUARANTEED, EXCEPT FOR THOSE ITEMS CLEARLY LABELED AS GUARANTEED.” All preprinted policy illustrations shall contain this notice in 12-point bold print with at least one-half inch space on all four sides and shall be printed on the illustration form itself or on an attached cover sheet, or in the form of a contrasting color sticker placed on the front of the illustration. All preprinted illustrations containing nonguaranteed values shall show the columns of guaranteed values in bold print. All other columns used in the illustration shall be in standard print. “Values” as used here includes cash value, surrender value, and death benefit. (Amended by Stats. 1998, Ch. 379, Sec. 1. Effective January 1, 1999.)
10127.12.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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If an insurer sends an annual statement to a senior citizen policyowner for a qualifying individual life insurance policy or individual annuity contract, it must also include the current accumulation value and current cash surrender value.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.12. Whenever an insurer provides an annual statement to a senior citizen policyowner of an individual life insurance policy or an individual annuity contract issued after January 1, 1995, the insurer shall also provide the current accumulation value and the current cash surrender value. (Amended by Stats. 1994, Ch. 984, Sec. 3. Effective September 29, 1994.)
10127.13.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Senior-citizen individual life insurance policies and annuity contracts with surrender-related charges must include a disclosure notice, and the notice must be printed in bold 12-point type on the policy jacket front or cover page.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.13. (a) All individual life insurance policies and individual annuity contracts for senior citizens that contain a charge upon surrender, partial surrender, excess withdrawal, or penalties upon surrender shall contain a notice disclosing the location of all of the following: the charge, the charge time period, the charge information, and any associated penalty information. The notice shall be in bold 12-point type on the front of the policy jacket or on the cover page of the policy. (b) A policy shall have just one cover page. If the notice required by this section and the statutorily required right to examine notice are both on the cover page, as opposed to the front cover of the policy jacket, they shall appear on the same page. (c) General references to “policy” in this section refer to both life insurance policies and annuity contracts. (d) This section shall become operative on July 1, 2015. (Amended (as added by Stats. 2014, Ch. 166, Sec. 8) by Stats. 2015, Ch. 348, Sec. 17. (AB 1515) Effective January 1, 2016.)
10127.14.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section requires the department and the Department of Managed Health Care to compile comparative benefit matrices, and requires health insurers to submit specified benefit information and annual updates.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.14. (a) The department and the Department of Managed Health Care shall compile information required by this section and Section 1363.06 of the Health and Safety Code into two comparative benefit matrices. The first matrix shall compare benefit packages offered pursuant to Section 1373.62 of the Health and Safety Code and Section 10127.15. The second matrix shall compare benefit packages offered pursuant to Sections 1366.35, 1373.6, and 1399.804 of the Health and Safety Code and Sections 10785, 10901.2, and 12682.1. (b) The comparative benefit matrix shall include: (1) Benefit information submitted by health care service plans pursuant to Section 1363.06 of the Health and Safety Code and by health insurers pursuant to subdivision (d). (2) The following statements in at least 12-point type at the top of the matrix: (A) “This benefit summary is intended to help you compare coverage and benefits and is a summary only. For a more detailed description of coverage, benefits, and limitations, please contact the health care service plan or health insurer.” (B) “The comparative benefit summary is updated annually, or more often if necessary to be accurate.” (C) “The most current version of this comparative benefit summary is available on (address of the plan’s or insurer’s site).” This subparagraph applies only to those health insurers that maintain an Internet Web site. (3) The telephone number or numbers that may be used by an applicant to contact either the department or the Department of Managed Health Care, as appropriate, for further assistance. (c) The department and the Department of Managed Health Care shall jointly prepare two standardized templates for use by health care service plans and health insurers in submitting the information required pursuant to subdivision (d) of Section 1363.06 and subdivision (d). The templates shall be exempt from the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (d) Health insurers shall submit the following to the department by January 31, 2003, and annually thereafter: (1) A summary explanation of the following for each product described in subdivision (a): (A) Eligibility requirements. (B) The full premium cost of each benefit package in the service area in which the individual and eligible dependents work or reside. (C) When and under what circumstances benefits cease. (D) The terms under which coverage may be renewed. (E) Other coverage that may be available if benefits under the described benefit package cease. (F) The circumstances under which choice in the selection of physicians and providers is permitted. (G) Lifetime and annual maximums. (H) Deductibles. (2) A summary explanation of the following coverages, together with the corresponding copayments and limitations, for each product described in subdivision (a): (A) Professional services. (B) Outpatient services. (C) Hospitalization services. (D) Emergency health coverage. (E) Ambulance services. (F) Prescription drug coverage. (G) Durable medical equipment. (H) Mental health services. (I) Residential treatment. (J) Chemical dependency services. (K) Home health services. (L) Custodial care and skilled nursing facilities. (3) The telephone number or numbers that may be used by an applicant to access a health insurer customer service representative and to request additional information about the insurance policy. (4) Any other information specified by the department in the template. (e) Each health insurer shall provide the department with updates to the information required by subdivision (d) at least annually, or more often if necessary to maintain the accuracy of the information. (f) The department and the Department of Managed Health Care shall make the comparative benefit matrices available on their respective Internet Web sites and to the health care service plans and health insurers for dissemination as required by Section 1373.6 of the Health and Safety Code and Section 12682.1, after confirming the accuracy of the description of the matrices with the health insurers and health care service plans. (g) As used in this section, “benefit matrix” shall have the same meaning as benefit summary. (h) This section shall not apply to accident-only, specified disease, hospital indemnity, CHAMPUS supplement, long-term care, Medicare supplement, dental-only, or vision-only insurance policies. (i) (1) This section shall be inoperative on January 1, 2014. (2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300g-91), this section shall become operative on the date of that repeal or amendment. (3) For purposes of this subdivision, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law. (Amended by Stats. 2013, Ch. 441, Sec. 14. (AB 1180) Effective October 1, 2013. Inoperative, by its own provisions, on January 1, 2014, subject to condition for resuming operation.)
10127.15.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A disability insurance policy or self-insured employee welfare benefit plan cannot reduce loss-of-time benefits during a benefit period just because Social Security benefits increase.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.15. Any provision contained in a policy of disability insurance or a self-insured employee welfare benefit plan for a reduction of loss of time benefits during a benefit period because of an increase in benefits payable under the federal Social Security Act, as amended, shall be null and void with respect to any such increase which occurs on or after the effective date of this section. (Added by Stats. 1977, Ch. 272.)
10127.16.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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After the pilot program ends, health insurers must keep providing coverage to certain eligible people under the same terms, and the state health services department must keep paying the stated amount. The provision also requires notices, reconciliation reports, and sets cutoff dates after which some obligations stop.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.16. (a) (1) After the termination of the pilot program under Section 10127.15, a health insurer shall continue to provide coverage under the same terms and conditions specified in Section 10127.15 as it existed on January 1, 2007, including the terms of the standard benefit plan and the subscriber payment amount, to each individual who was terminated from the program, pursuant to subdivision (f) of Section 12725 of the Insurance Code during the term of the pilot program and who enrolled or applied to enroll in a standard benefit plan within 63 days of termination. The State Department of Health Care Services shall continue to pay the amount described in Section 10127.15 for each of those individuals. A health insurer shall not be required to offer the coverage described in Section 10127.15 after the termination of the pilot program to individuals not already enrolled in the program. (2) Notwithstanding paragraph (1) of this subdivision or Section 10127.15 as it existed on January 1, 2007, the following rules shall apply: (A) (i) A health insurer shall not be obligated to provide coverage to any individual pursuant to this section on or after January 1, 2014. (ii) The State Department of Health Care Services shall not be obligated to provide any payment to any health insurer under this section for (I) health care expenses incurred on or after January 1, 2014, or (II) the standard monthly administrative fee, as defined in Section 10127.15 as it existed on January 1, 2007, for any month after December 2013. (B) Each health insurer providing coverage pursuant to this section shall, on or before October 1, 2013, send a notice to each individual enrolled in a standard benefit plan that is in at least 12-point type and with, at minimum, the following information: (i) Notice as to whether or not the plan will terminate as of January 1, 2014. (ii) The availability of individual health coverage, including through Covered California, including at least all of the following: (I) That, beginning on January 1, 2014, individuals seeking coverage may not be denied coverage based on health status. (II) That the premium rates for coverage offered by a health care service plan or a health insurer cannot be based on an individual’s health status. (III) That individuals obtaining coverage through Covered California may, depending upon income, be eligible for premium subsidies and cost-sharing subsidies. (IV) That individuals seeking coverage must obtain this coverage during an open or special enrollment period, and a description of the open and special enrollment periods that may apply. (C) As a condition of receiving payment for a reporting period pursuant to this section, a health insurer shall provide the State Department of Health Care Services with a complete, final annual reconciliation report by the earlier of December 31, 2014, or an earlier date as prescribed by Section 10127.15, as it existed on January 1, 2007, for that reporting period. To the extent that it receives a complete, final reconciliation report for a reporting period by the date required pursuant to this subparagraph, the State Department of Health Care Services shall complete reconciliation with the health insurer for that reporting period within 18 months after receiving the report. (b) If the state fails to expend, pursuant to this section, sufficient funds for the state’s contribution amount to any health insurer, the health insurer may increase the monthly payments that its subscribers are required to pay for any standard benefit plan to the amount that the State Department of Health Care Services would charge without a state subsidy for the same insurance product issued to the same individual within the program. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. (Amended by Stats. 2015, Ch. 18, Sec. 25. (SB 75) Effective June 24, 2015.)
10127.17.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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The section creates a fund, requires insurers to pay and remit a fee for each covered policy or annuity product, and requires the commissioner and recipient district attorneys to handle, report on, and audit the funds under set conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.17. (a) The Life and Annuity Consumer Protection Fund is hereby created as a special account within the Insurance Fund. Each insurer admitted to transact insurance in this state shall pay a fee to be determined by the commissioner, not to exceed one dollar ($1), for each individual life insurance policy and each individual annuity product that it issues to a resident of this state. If an insurer elects to charge the purchaser of a life insurance policy or annuity product this fee, the fee shall be set forth as a separate charge in the contract schedule or premium notice. Life insurance or annuity forms are not required to be filed again for review as a consequence of this provision. The revenue from this fee shall be deposited into the Life and Annuity Consumer Protection Fund. (b) Moneys in the Life and Annuity Consumer Protection Fund shall be distributed by the commissioner, upon appropriation by the Legislature, to fund the reasonable costs incurred in regulating entities transacting life insurance and annuity products in this state. Moneys in the fund shall not be used for any other purpose. (c) Fifty percent of these funds shall be distributed within the department for functions related to individual life insurance and annuity products, including, but not limited to: (1) Investigating and prosecuting financial abuse by insurance licensees, or persons holding themselves out to be insurance licensees, or any person purporting to be engaged in the business of insurance. (2) Responding to consumer inquiries and complaints related to life insurance or annuity products. (3) Disseminating information to insurers, insureds, and others regarding the applicable regulation of life insurance and annuity products, including consumer protection, purchasing and using insurance and annuity products, claim filing, benefit delivery, and dispute resolution. (4) Regulating and overseeing life insurance and annuity products and advertising for these products directed toward consumers. (d) Fifty percent of the funds shall be distributed to district attorneys for investigating and prosecuting individual life insurance and annuity product financial abuse cases involving insurance licensees, or persons holding themselves out to be insurance licensees, or any person purporting to be engaged in the business of insurance, and for other projects beneficial to insurance consumers. (1) The commissioner shall distribute funds to district attorneys who are able to show a likely positive outcome that will benefit consumers in the local jurisdiction based on specific criteria promulgated by the commissioner. Each local district attorney desiring a portion of those funds shall submit to the commissioner an application, including, at a minimum all of the following: (A) The proposed use of the moneys and the anticipated outcome. (B) A list of all prior relevant cases or projects and a copy of the final accounting for each. If cases or projects are ongoing, the most recent accounting shall be provided. (C) A detailed budget, including salaries and general expenses, and specifically identifying the cost of purchase or rental of equipment or supplies. (2) Each district attorney that receives funds pursuant to this section shall submit a final detailed accounting at the conclusion or closure of each case or project. For cases or projects that continue longer than six months, interim accountings shall be submitted every six months, or as otherwise directed by the commissioner. (3) Each district attorney that receives funds pursuant to this section shall submit a final report to the commissioner, which may be made public, as to the success of the case or project conducted. The report shall provide information and statistics on the number of active investigations, arrests, indictments, and convictions. The applications for moneys, the distribution of moneys, and the annual reports shall be public documents. (4) Notwithstanding any other provision of this section, information submitted to the commissioner pursuant to this section concerning criminal investigations, whether active or inactive, shall be confidential. (5) The commissioner may conduct a fiscal audit of the programs administered under this subdivision. This fiscal audit shall be conducted by an internal audit unit of the department. The cost of any fiscal audits shall be paid for from the Life and Annuity Consumer Protection Fund established by this section. (6) If the commissioner determines that a district attorney is unable or unwilling to investigate or prosecute a relevant financial abuse case, the commissioner may discontinue distribution of funds allocated for that matter and may redistribute those funds to other eligible district attorneys. (e) If, as of June 30 of any calendar year, the total amount in the Life and Annuity Consumer Protection Fund exceeds five million dollars ($5,000,000), the commissioner shall reduce the amount of the assessment accordingly for the following year to eliminate that excess. An insurer, upon receipt of an invoice, shall transmit payment to the department for deposit in the Life and Annuity Consumer Protection Fund. Any balance remaining in the Life and Annuity Consumer Protection Fund at the end of the fiscal year shall be retained in the account, to be available in the next fiscal year. (f) The commissioner may develop guidelines for implementing or clarifying these provisions, including guidelines for the allocation, distribution, and potential return of unused funds. The commissioner may, from time to time, issue regulations for implementing or clarifying these provisions. (g) The commissioner shall provide a consolidated report annually on the department’s Internet Web site, which shall include, but is not limited to, the following information: (1) The number of opened consumer complaints related to life insurance or annuity products. (2) The number of opened investigations related to life insurance or annuity products. (3) The number of investigations related to life insurance or annuity products referred to and reported by prosecuting agencies. (4) The number of administrative or regulatory cases related to life insurance or annuity products referred to the department’s legal division. (5) The number of administrative or regulatory enforcement actions taken in cases related to life insurance or annuity products. (6) Descriptions of efforts by the department to disseminate information to insurers and others regarding the applicable regulation of life insurance and annuity products, including consumer protection, purchasing and using insurance and annuity products, claim filing, benefit delivery, and dispute resolution. (Repealed and added by Stats. 2013, Ch. 347, Sec. 7. (SB 476) Effective January 1, 2014.)
10127.18.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer that stops offering individual health coverage in California must offer coverage to affected policyholders under specified terms, unless an exception applies.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.18. (a) On and after January 1, 2005, a health insurer issuing individual policies of health insurance that ceases to offer individual coverage in this state shall offer coverage to the policyholders who had been covered by those policies at the time of withdrawal under the same terms and conditions as provided in paragraph (3) of subdivision (a), paragraphs (2) to (4), inclusive, of subdivision (b), subdivisions (c) to (e), inclusive, and subdivision (h) of Section 12682.1. (b) The department may adopt regulations to implement this section. (c) This section shall not apply when a plan participating in Medi-Cal, Healthy Families, Access for Infants and Mothers, or any other contract between the plan and a government entity no longer contracts with the government entity to provide health coverage in the state, or a specified area of the state, nor shall this section apply when a plan ceases entirely to market, offer, and issue any and all forms of coverage in any part of this state after the effective date of this section. (d) (1) This section shall be inoperative on January 1, 2014. (2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91), this section shall become operative on the date of that repeal or amendment. (3) For purposes of this subdivision, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law. (Amended by Stats. 2013, Ch. 441, Sec. 16. (AB 1180) Effective October 1, 2013. Inoperative, by its own provisions, on January 1, 2014, subject to condition for resuming operation.)
10127.19.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Health insurers and certain MEWAs must give yearly enrollment and covered-person data to the department, and the department must publicly report the data by April 15 each year.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.19. (a) Commencing March 1, 2013, and at least annually thereafter, a health insurer, not including a health insurer offering specialized health insurance policies, shall provide to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, the number of covered lives, by product type, as of December 31 of the prior year, that receive health care coverage under a health insurance policy that covers individuals and small groups inside and outside of the California Health Benefit Exchange, large groups, administrative services only business lines, and any other business lines. Health insurers shall include the unduplicated enrollment data in specific product types as determined by the department, including, but not limited to, HMO, point-of-service, PPO, grandfathered, and Medi-Cal managed care. Data reported pursuant to this subdivision shall specify the covered persons that are being reported pursuant to subdivision (b). (b) Commencing March 1, 2020, and at least annually thereafter, information specific to a multiple employer welfare arrangement (MEWA) shall be provided to the department, in a form and manner determined by the department in consultation with the Department of Managed Health Care, as follows: (1) A health insurer that provides coverage through a MEWA that is not subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the name of each MEWA and the number of covered persons in each MEWA as of December 31 of the prior year, divided by market segment and product type. Data reported pursuant to this subdivision shall be identified and separately reported under subdivision (a). (2) A MEWA that is subject to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall provide the number of covered persons in the MEWA as of December 31 of the prior year, divided by product type. Compliance with a data call issued pursuant to this section satisfies the requirements of this subdivision. (c) The department shall publicly report the data provided by each health insurer and MEWA pursuant to this section, including, but not limited to, posting the data on the department’s internet website. The department shall consult with the Department of Managed Health Care to ensure that the data reported is comparable and consistent, does not duplicate existing reporting requirements, and utilizes existing reporting formats. The data for the previous calendar year shall be made available no later than April 15 of each calendar year. (Amended by Stats. 2020, Ch. 370, Sec. 217. (SB 1371) Effective January 1, 2021.)
10127.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurance policies covered by this section must state what counts as a day or number of consecutive hours of confinement needed to start benefits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.2. Each policy of disability insurance issued or renewed on or after the effective date of this section, which policy provides benefits that accrue after a certain time of confinement in a health care facility, shall specify what constitutes a day of confinement or the number of consecutive hours of confinement which are requisite to the commencement of benefits. With respect to renewal of individual policies of disability insurance, insurers shall not be required to issue notification to the insured of the provisions of this section unless notice of policy renewal is delivered to the insured. (Added by Stats. 1978, Ch. 648.)
10127.20.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer offering a qualified health plan through the Exchange must file an annual report with the commissioner starting July 1, 2023.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.20. (a) Beginning on July 1, 2023, and annually thereafter, a health insurer offering a qualified health plan through the Exchange shall report to the commissioner the total amount of funds maintained in a segregated account pursuant to subdivision (a) of Section 1303 of the federal Patient Protection and Affordable Care Act (Public Law 111-148). This annual report shall contain the ending balance of the account and the total dollar amount of claims paid during the reporting year. (b) For purposes of this section: (1) “Exchange” means the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code. (2) “Qualified health plan” has the same meaning as defined in Section 1301 of the federal Patient Protection and Affordable Care Act (Public Law 111-148). (Added by Stats. 2022, Ch. 563, Sec. 2. (AB 2205) Effective January 1, 2023.)
10127.21.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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A health insurer must send the same risk-adjustment data to the department at the same time it is submitted to federal health officials, in the same format.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.21. Any data submitted by a health insurer to the United States Secretary of Health and Human Services, or his or her designee, for purposes of the risk adjustment program described in Section 1343 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18063) shall be concurrently submitted to the department and in the same format. The department shall use the information to monitor federal implementation of risk adjustment in the state and to ensure that insurers are in compliance with federal requirements related to risk adjustment. (Added by Stats. 2013, 1st Ex. Sess., Ch. 1, Sec. 6. (AB 2 1x) Effective September 30, 2013.)
10127.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Some group disability insurers must offer coverage for treatment-related expenses for certificate holders under Section 4938, starting January 1, 1985.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.3. On and after January 1, 1985, every insurer issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer coverage for expenses incurred as a result of treatment by holders of certificates under Section 4938 of the Business and Professions Code, under such terms and conditions as may be agreed upon between the group policyholder and the insurer. An insurer is not required to offer the coverage provided by this section as part of any policy covering employees of a public entity. (Added by Stats. 1984, Ch. 1067, Sec. 2.)
10127.4.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Disability insurer contracts with health care providers cannot include terms that bar or limit provider advertising, subject to stated exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.4. (a) Except as provided in subdivisions (b) and (c), no contract that is issued, amended, renewed, or delivered on or after January 1, 1999, between a disability insurer that provides coverage for hospital, medical, or surgical benefits and a health care provider shall contain provisions that prohibit, restrict, or limit the health care provider from advertising. (b) Nothing in this section shall be construed to prohibit disability insurers from establishing reasonable guidelines in connection with the activities regulated pursuant to this part, including those to prevent advertising that is, in whole or in part, untrue, misleading, deceptive, or otherwise inconsistent with this part or the rules and regulations promulgated thereunder. For advertisements mentioning a provider’s participation in a plan or product line of a disability insurer, nothing in this section shall be construed to prohibit disability insurers from requiring each advertisement to contain a disclaimer to the effect that the provider’s services may be covered for some, but not all, plans or product lines of the disability insurer, or that the disability insurer may cover some, but not all, provider services. (c) Nothing in this section is intended to prohibit provisions or agreements intended to protect service marks, trademarks, trade secrets, or other confidential information or property. If a health care provider participates in a provider panel or network as a result of a direct contractual agreement with a disability insurer that, in turn, has entered into a direct contractual agreement with another person or entity, pursuant to which insureds and other beneficiaries of that other person or entity may receive covered services from the health care provider, then nothing in this section is intended to prohibit reasonable provisions or agreements in the direct contractual arrangement between the health care provider and the disability insurer that protect the name or trade name of the other person or entity or requires that the health care provider obtain the consent of the disability insurer prior to the use of the name or trade name of the other person or entity in any advertising by the health care provider. (d) Nothing in this section shall be construed to impair or impede the authority of the commissioner to regulate advertising, disclosure, or solicitation pursuant to this part. (Added by Stats. 1998, Ch. 523, Sec. 4. Effective January 1, 1999.)
10127.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Applications, certificates, and policies for credit life or credit disability insurance must include a bold-capital-letter statement warning that a preexisting health condition may void coverage if that applies.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.5. Every application for, certificate of, and policy of credit life or credit disability insurance shall set forth a statement in bold capital letters indicating that any preexisting health condition of the applicant may render the coverage void, if that is the case. For the purpose of this section, “credit life or credit disability insurance” means insurance on the life or health of any borrower sold by any creditor to provide for the repayment of the amount of a loan or other extension of credit in the event of the debtor’s death or disability as defined in the policy. (Amended by Stats. 1984, Ch. 1200, Sec. 6. Effective September 17, 1984.)
10127.7.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Certain individual life insurance policies must include a cancellation notice, allow return within a stated period, and refund premiums and fees after cancellation.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.7. Every policy of individual life insurance with a face value of less than ten thousand dollars ($10,000) which is delivered or issued for delivery in this state on and after July 1, 1974, shall have printed thereon or attached thereto a notice stating that, after receipt of the policy by the owner, the policy may be returned by the owner for cancellation by delivering it or mailing it to the insurer or to the agent through whom it was purchased. The period of time set forth by the insurer for return of the policy by the insured shall be clearly stated on the notice and this period shall be not less than 10 days nor more than 30 days. The insured may return the policy to the insurer at any time during the period specified in the notice. This delivery or mailing of the policy by the owner shall void the policy from the beginning, and the parties shall be in the same position as if no policy or contract had been issued. All premiums paid and any policy fee paid for the policy shall be refunded to the owner within 30 days from the date that the insurer is notified that the insured has canceled the policy. This section applies to all policies issued, amended, or delivered in this state on or after January 1, 2011, and applies to any renewal thereof. All policies subject to this section that are in effect on January 1, 2011, shall be construed to be in compliance with this section, and any provision in such a policy that is in conflict with this section shall be of no force or effect. This section does not apply to individual life insurance policies issued in connection with a credit transaction or issued under a contractual policy change or conversion privilege provision contained in a policy. (Amended by Stats. 2010, Ch. 184, Sec. 1. (SB 1405) Effective January 1, 2011.)
10127.8.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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Term life insurance ads aimed at people 55 or older must make several prominent disclosures, and the commissioner has rulemaking and enforcement powers.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.8. (a) The purpose of this section is to assure truthful and adequate disclosure of all material and relevant information in the advertising of term life insurance which the commissioner, on the basis of an assessment of the total advertisement, determines is directed to individuals 55 years of age or older. (b) Advertisements for term life insurance directed to individuals 55 years of age or older shall: (1) Clearly and prominently distinguish basic life insurance benefits from suppplemental benefits such as accidental death benefits. (2) Prominently disclose any limitations, exceptions, or reductions affecting each benefit. (3) Prominently disclose any condition affecting the policy or certificate holder’s continued insurability. If term coverage terminates at a stated age, or at the end of any designated period, that fact and the specified age or designated period shall be disclosed. (4) Prominently disclose any change in benefits resulting from the aging of the insured, policy duration, or any other factor. (5) Prominently disclose any change in premium resulting from the aging of the insured, policy duration, or any other factor. If the insurer retains any right to modify premiums in the future, that fact shall be disclosed. (c) If the benefits of the advertised policy or certificate decrease with the insured’s age or with policy or certificate duration, while the premium remains approximately constant, that fact shall, in a print or broadcast advertisement, be disclosed, in the same form and with prominence or visible duration, or both, equal to that given any positive description of benefits or the telephone number or address provided for further information or application, whichever is the most prominent. (d) A television or radio advertisement for term life insurance directed to individuals 55 years of age or older shall in the spoken text contain the statement “policy (or certificate) benefits and limitations should be carefully examined prior to purchase.” (e) The commissioner may, by regulation, adopt a term life insurance monetary value index, similar to the Life Insurance Surrender Cost Index of Article 12.5 (commencing with Section 2545) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, to be disclosed in all advertisements of term life insurance for individuals 55 years of age or older, and on all policies and certificates of that insurance. In developing a term life insurance monetary value index, the commissioner shall consider actual premiums and policy and certificate benefits and the manner in which they are affected with the passage of time. Any term life insurance monetary value index developed pursuant to this section shall assume an insured’s desire to retain coverage for at least 10 years. (f) This section does not supersede or repeal any regulation of the commissioner which governs life insurance advertising and such regulation shall continue to be in force in addition to this section. (g) The commissioner shall adopt regulations that are necessary to carry out this section. (h) This section applies to the advertisement of individual policies of insurance and any group policies or certificates delivered or issued for delivery in this state, regardless of the situs of the contract. (i) In addition to any other penalty provided by law or the availability of any administrative procedure, if an insurer, after notice and hearing, is found to have violated this section, or regulations adopted pursuant to this section, or knowingly permits any person to do so, the commissioner, in accordance with the procedures provided in Section 704, may suspend the insurer’s certificate of authority to transact life insurance. Section 704.7 shall apply in any proceeding conducted pursuant to this section. (Added by Stats. 1988, Ch. 1473, Sec. 1.)
10127.9.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. )
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This section requires a cancellation notice for certain individual life insurance policies and annuity contracts, gives owners a return right during the stated period, and requires insurers to refund amounts within 30 days after cancellation notice.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1. General Provisions [10110 - 10127.20] ( Article 1 enacted by Stats. 1935, Ch. 145. ) ## 10127.9. (a) (1) Every individual life insurance policy and every individual annuity contract that is initially delivered or issued for delivery in this state on and after January 1, 1990, shall have printed on the front of the policy jacket or on the cover page a notice stating that, after receipt of the policy by the owner, the policy may be returned by the owner for cancellation by mail or other delivery method to the insurer or to the agent through whom it was purchased. The period of time set forth by the insurer for return of the policy by the owner shall be clearly stated and this period shall be not less than 10 days nor more than 30 days. (2) The owner may return the policy to the insurer by mail or other delivery method at any time during the period specified in the notice. In the case of individual nonvariable life insurance policies and individual nonvariable annuity contracts, including modified guaranteed contracts, by delivering or mailing the policy pursuant to this section during the cancellation period, the owner shall void the policy from the beginning, and the parties shall be in the same position as if no policy had been issued. All premiums paid and any policy fee paid for the policy shall be refunded by the insurer to the owner within 30 days from the date that the insurer is notified that the owner has canceled the policy. In the case of individual variable annuity contracts and individual variable life insurance policies, return of the policy during the cancellation period shall entitle the owner to a refund of the account value and any policy fee paid for the policy. The account value and policy fee shall be refunded by the insurer to the owner within 30 days from the date that the insurer is notified that the owner has canceled the policy. (b) This section applies to all individual policies issued or delivered in this state on or after January 1, 1990, but does not apply to any policy subject to Section 10127.7. All policies subject to this section which are in effect on January 1, 1990, shall be construed to be in compliance with this section, and any provision in any policy which is in conflict with this section shall be of no force or effect. (c) This section does not apply to individual life insurance policies issued in connection with a credit transaction or issued under a contractual policy-change or conversion privilege provision contained in a policy. (d) General references to “policy” or “policies” in this section refer to both life insurance policies and annuity contracts. (e) This section shall become operative on July 1, 2015. (Repealed (in Sec. 3 ) and added by Stats. 2014, Ch. 166, Sec. 4. (AB 2347) Effective January 1, 2015. Section operative July 1, 2015, by its own provisions.)
10128.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. )
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This section says the article applies to certain group life insurance, group disability, nonprofit hospital service, and self-insured welfare benefit plan policies issued in this state.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. ) ## 10128. The provisions of this article shall apply to all policies of group life insurance issued in this state pursuant to the provisions of Sections 10202, 10202.7, 10202.8, 10203 and 10203.7, to all group disability policies issued in this state pursuant to the provisions of Section 10270.5, to any group nonprofit hospital service contract issued in this state pursuant to the provisions of Section 11512.2, and to any self-insured welfare benefit plan issued in this state as defined in Section 10121. (Amended by Stats. 1977, Ch. 64.)
10128.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. )
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This section defines terms used in Article 1.5, including carrier, discontinuance, employee, policy, policyholder, premium, replacement coverage, and totally disabled.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. ) ## 10128.1. In this article, unless the context otherwise requires: (a) “Carrier” means the insurance company, nonprofit hospital service corporation, or other entity responsible for the payment of benefits or provision of services under a policy. (b) “Dependent” shall have the meaning set forth in a policy. (c) “Discontinuance” shall mean the termination of a policy or the termination of coverage between an entire employer unit under a group disability policy, group nonprofit hospital service contract or self-insured welfare benefit plan, and does not refer to the termination of any agreement between any individual member under a contract and the disability insurer, nonprofit hospital service contract or self-insured welfare benefit plan. (d) “Employee” means all agents, employees, and members of unions or associations to whom benefits are provided under a policy. (e) “Extension of benefits” means the continuation of coverage under a particular benefit provided under a policy following discontinuance with respect to an employee or dependent who is totally disabled on the date of discontinuance. (f) “Policy” means any group insurance policy, group hospital service contract or other plan, contract or policy subject to the provisions of this article. (g) “Policyholder” means the entity to which a policy or contract specified in Section 10128 is issued. (h) “Premium” means the consideration payable to the carrier. (i) “Replacement coverage” means the benefits provided by a succeeding carrier. (j) “Totally disabled” shall have the meaning set forth in a policy. (Amended by Stats. 1983, Ch. 126, Sec. 2.)
10128.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. )
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Certain group life and related disability or medical benefit policies must keep extending coverage after discontinuance, subject to disability, timing, and replacement-coverage conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. ) ## 10128.2. Every policy containing a life insurance benefit shall contain a reasonable extension of such benefit upon discontinuance of the policy with respect to employees who become totally disabled while insured under the policy on or after the date this article becomes applicable to such policy and who continue to be totally disabled at the date of discontinuance of the policy. Every policy containing a loss of time benefit, a specific indemnity during hospital confinement, or a hospital, medical, or surgical expense benefit shall contain a reasonable extension of such benefits upon discontinuance of the policy with respect to employees or dependents who become totally disabled while insured under the policy on or after the date this article becomes applicable to such policy and who continue to be totally disabled at the date of discontinuance of the policy. (a) Every policy containing a life insurance benefit which does not contain a disability benefit provision of any type (e.g. premium waiver extension, extended death benefit in event of total disability, or payment of income for a specified period during total disability), shall be deemed to include a reasonable extension of benefits upon discontinuance of the policy if it provides the totally disabled employee the same rights of conversion to an individual life insurance policy at the time of discontinuance of the policy that such employee would have had if his employment or association membership had terminated on the same date. The rights of conversion specified above need not be provided with regard to any amount of insurance for which the employee becomes insured under any replacement coverage. (b) Every policy containing a life insurance benefit which contains a disability benefit provision of any type shall be deemed to include a reasonable extension of benefits upon discontinuance of the policy if it provides: (1) Such discontinuance does not affect the disability benefit; and (2) The rights of conversion described in (a) above shall apply to the amount the individual is insured for at the termination of the disability benefit unless the disability benefit is a payment of income for a specified period, in which event the rights of conversion would apply to the amount of life insurance, if any, remaining after the payment of income; and (3) With respect to any amounts of life insurance provided under the policy to which no disability benefit provision applies, the rights of conversion described in (a) above shall apply. No extension of life insurance under either a disability benefit or the rights of conversion specified above need be provided with regard to any amount of insurance for which the employee becomes insured under any replacement coverage. (c) Every policy providing benefits for loss of time or a specific indemnity during hospital confinement, shall be deemed to include a reasonable extension of such benefits upon discontinuance of the policy if such discontinuance does not affect the benefit provided. (d) Every policy providing hospital, medical or surgical benefits on an expense-incurred or service basis shall be deemed to include a reasonable extension of such benefits upon discontinuance of the policy if it provides benefits for covered expenses directly relating to the condition causing total disability existing at the time premium payments for the employee or dependent cease and incurred during a period of not less than 12 months thereafter, which period shall not be interrupted by discontinuance of the policy. That extension of benefits may be terminated at such time as the employee or dependent is no longer totally disabled or at such time as a succeeding carrier may elect to provide replacement coverage to that employee or dependent without limitation as to the disabling condition. (e) The benefits payable during any extension of benefits may be subject to all limitations or restrictions contained in the policy. (Amended by Stats. 1983, Ch. 888, Sec. 3.)
10128.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. )
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A succeeding carrier replacing group health coverage must promptly cover people covered under the prior policy, with limited exceptions for certain disability-related services and fraud-related denials.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. ) ## 10128.3. (a) Any carrier providing replacement coverage with respect to hospital, medical or surgical benefits on an expense-incurred or service basis within a period of 60 days from the date of discontinuance of a prior policy providing that hospital, medical or surgical benefits shall immediately cover all employees and dependents who were validly covered under the previous policy at the date of discontinuance, including all former employees entitled to continuation coverage under Section 10116.5, who are within the definitions of eligibility under the succeeding carrier’s policy, and who would otherwise be eligible for coverage under the succeeding carrier’s policy, regardless of any provisions of the policy relating to active full-time employment or hospital confinement or pregnancy. However, with respect to employees or dependents who are totally disabled on the date of discontinuance of the prior carrier’s contract or policy and entitled to an extension of benefits pursuant to subdivision (b) of Section 1399.62 of the Health and Safety Code, or pursuant to subdivision (d) of Section 10128.2, the succeeding carrier is not required to provide benefits for services or expenses directly related to any conditions which caused the total disability. (b) Except as otherwise provided in subdivision (a), until an employee or dependent entitled to coverage under a succeeding carrier’s policy pursuant to subdivision (a) of this section qualifies for full benefits by meeting all effective date requirements of the succeeding carrier’s policy, the level of benefits shall not be lower than the benefits provided under the prior carrier’s policy reduced by the amount of benefits paid by the prior carrier. The employee or dependent shall continue to be covered by the succeeding carrier until the earlier of the following dates: (1) The date coverage would terminate for an employee or dependent in accordance with the provisions of the succeeding carrier’s policy. (2) In the case of an employee or dependent who was totally disabled on the date of discontinuance of the prior carrier’s policy and entitled to an extension of benefits pursuant to subdivision (b) of Section 1399.62 of the Health and Safety Code, or subdivision (d) of Section 10128.2, the date the period of extension of benefits terminates, or, if the prior carrier’s policy is not subject to this article, the date to which benefits would have been extended had the prior carrier’s policy been subject to this article. (c) Except as otherwise provided in this section, and except to the extent that benefits for the condition would have been reduced or excluded under the prior carrier’s policy, no provision in a succeeding carrier’s policy of replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier’s policy shall be applied with respect to those employees, former employees entitled to continuation coverage under Section 10116.5, and dependents validly insured under the prior carrier’s policy on the date of discontinuance. (d) In a situation where a determination of the prior carrier’s benefit is required by the succeeding carrier, at the succeeding carrier’s request, the prior carrier shall furnish a statement of benefits available or pertinent information, sufficient to permit verification of the benefit determination by the succeeding carrier. (e) For purposes of subdivision (a), a succeeding carrier’s policy shall not exclude coverage of a dependent child who was covered by the previous carrier solely because the insured does not provide primary support for that dependent child. (f) The fraudulent failure or refusal of an employee or dependent to disclose a preexisting condition to the succeeding carrier shall not be ascribed to the entire group and shall not alleviate the duty of a succeeding carrier under subdivision (a) to immediately cover all employees, former employees entitled to continuation coverage under Section 10116.5, and dependents who were validly covered under the previous policy on the date of discontinuance. Any denial of benefits on the basis of fraud shall be limited to the employee or dependent who committed the fraud. (g) Except to the extent that benefits for the condition would have been reduced or excluded under the prior carrier’s contract or policy, no provision in the succeeding carrier’s contract, where an employee changes carriers due to a change in employment or other circumstances, that would operate to reduce or exclude benefits for the following congenital craniofacial anomalies: cleft lip and palate (as defined in ICD-9-CM Diagnosis Code 749, International Classification of Diseases, 9th Revision, Clinical Modification, Volume 1, Second Edition, September, 1980), acrocephalosyndactyly (as defined in ICD-9-CM Diagnosis Code 755.55, cranio only), and other congenital musculoskeletal anomalies (as defined in ICD-9-CM Diagnosis Code 756.0), on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier’s contract, shall be applied to those employees, former employees entitled to continuation coverage under Section 10116.5, and dependents validly covered under the prior carrier’s contract or policy on the date the prior contract or policy terminated when payment or services had been commenced by the previous carrier. That succeeding coverage shall otherwise be subject to all other provisions of the contract between the insured and the succeeding carrier. (Amended by Stats. 1995, Ch. 489, Sec. 4. Effective January 1, 1996.)
10128.4.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. )
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This article applies to certain group life and disability insurance policies issued, delivered, amended, or renewed in California after January 1, 1977.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.5. Discontinuance of Group Life Insurance and Discontinuance and Replacement of Group Disability Insurance [10128 - 10128.4] ( Heading of Article 1.5 amended by Stats. 1977, Ch. 64. ) ## 10128.4. This article shall apply to all policies issued, delivered, amended, or renewed in this state after January 1, 1977. A policy subject to the provisions of this article which is issued, delivered, amended as to benefits, or renewed in this state on or after the effective date of amendments to this article made at the 1977–1978 Regular Session of the Legislature shall be construed to be in compliance with the provisions of this article and such amendments to this article. (Amended by Stats. 1977, Ch. 64.)
10128.50.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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This section names the Cal-COBRA article and says the commissioner may adopt emergency regulations to implement it if federal assistance becomes available to qualified beneficiaries.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.50. (a) This article shall be known as the California Continuation Benefits Replacement Act, or “Cal-COBRA.” (b) It is the intent of the Legislature that continued access to health insurance coverage is provided to employees, and their dependents, of employers with 2 to 19 eligible employees who are not currently offered continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985. (c) It is the intent of the Legislature that any federal assistance that is or may become available to qualified beneficiaries under this article be effectively and promptly implemented by the department. (d) The commissioner, in consultation with the Director of the Department of Managed Health Care, may adopt emergency regulations to implement this article in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code by making a finding of emergency and demonstrating the need for immediate action in the event that any federal assistance is or becomes available to qualified beneficiaries under this article. The adoption of these regulations shall be considered by the Office of Administrative Law to be necessary to avoid serious harm to the public peace, health, safety, or general welfare. Any regulations adopted pursuant to this subdivision shall be substantially similar to those adopted by the Director of the Department of Managed Health Care under subdivision (d) of Section 1366.20 of the Health and Safety Code. (Amended by Stats. 2009, Ch. 3, Sec. 5. Effective May 12, 2009.)
10128.51.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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This section defines key terms used for California Cobra continuation coverage in group benefit plans.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.51. (a) “Continuation coverage” means extended coverage under the group benefit plan under which an eligible employee or eligible dependent is currently covered, or, in the case of a termination of the group benefit plan or an employer open enrollment period, extended coverage under the group benefit plan currently offered by the employer. (b) “Group benefit plan” has the same meaning as “health benefit plan” defined in Section 10700, including group policies of vision-only and dental-only coverage, provided pursuant to Chapter 8 (commencing with Section 10700) to an employer with 2 to 19 eligible employees, as defined in Section 10700. (c) (1) “Qualified beneficiary” means any individual who, on the day before the qualifying event, is covered under a group benefit plan offered by a disability insurer pursuant to Article 1 (commencing with Section 10700) of Chapter 8, and has a qualifying event, as defined in subdivision (d). (2) “Qualified beneficiary eligible for premium assistance under ARRA” means a qualified beneficiary, as defined in paragraph (1), who (A) was or is eligible for continuation coverage as a result of the involuntary termination of the covered employee’s employment during the period specified in subparagraph (A) of paragraph (3) of subdivision (a) of Section 3001 of ARRA, (B) elects continuation coverage, and (C) meets the definition of “qualified beneficiary” set forth in paragraph (3) of Section 1167 of Title 29 of the United States Code, as used in subparagraph (E) of paragraph (10) of subdivision (a) of Section 3001 of ARRA or any subsequent rules or regulations issued pursuant to that law. (3) “ARRA” means Title III of Division B of the federal American Recovery and Reinvestment Act of 2009 or any amendment to that federal law extending federal premium assistance to qualified beneficiaries. (d) “Qualifying event” means any of the following events that, but for the election of continuation coverage under this article, would result in a loss of coverage under the group benefit plan to a qualified beneficiary: (1) The death of the covered employee. (2) The termination of employment or reduction in hours of the covered employee’s employment, except that termination for gross misconduct does not constitute a qualifying event. (3) The divorce or legal separation of the covered employee from the covered employee’s spouse. (4) The loss of dependent status by a dependent enrolled in the group benefit plan. (5) With respect to a covered dependent only, the covered employee’s entitlement to benefits under Title XVIII of the United States Social Security Act (Medicare). (e) “Employer” means any employer that meets the definition of “small employer” as set forth in Section 10700 and (1) employed 2 to 19 eligible employees on at least 50 percent of its working days during the preceding calendar year, or, if the employer was not in business during any part of the preceding calendar year, employed 2 to 19 eligible employees on at least 50 percent of its working days during the preceding calendar quarter, (2) has contracted for health care coverage through a group benefit plan offered by a disability insurer, and (3) is not subject to Section 4980B of the United States Internal Revenue Code or Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. Section 1161 et seq. (f) “Core coverage” means coverage for hospital, medical, or surgical benefits provided under the group benefit plan that a qualified beneficiary was receiving immediately prior to the qualifying event, other than noncore coverage. (g) “Noncore coverage” means coverage for vision and dental care. (Amended by Stats. 2010, Ch. 24, Sec. 6. (SB 838) Effective June 3, 2010.)
10128.52.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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This section lists people who are exempt from the article’s continuation coverage requirements.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.52. The continuation coverage requirements of this article do not apply to the following individuals: (a) Individuals who are entitled to Medicare benefits or become entitled to Medicare benefits pursuant to Title XVIII of the United States Social Security Act, as amended or superseded. Entitlement to Medicare Part A only constitutes entitlement to benefits under Medicare. (b) Individuals who have other hospital, medical, or surgical coverage, or who are covered or become covered under another group benefit plan, including a self-insured employee welfare benefit plan, that provides coverage for individuals and that does not impose any exclusion or limitation with respect to any preexisting condition of the individual, other than a preexisting condition limitation or exclusion that does not apply to or is satisfied by the qualified beneficiary pursuant to Sections 10198.6 and 10198.7. A group conversion option under any group benefit plan shall not be considered as an arrangement under which an individual is or becomes covered. (c) Individuals who are covered, become covered, or are eligible for federal COBRA coverage pursuant to Section 4980B of the United States Internal Revenue Code or Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. Section 1161 et seq. (d) Individuals who are covered, become covered, or are eligible for coverage pursuant to Chapter 6A of the Public Health Service Act, 42 U.S.C. Section 300bb-1 et seq. (e) Qualified beneficiaries who fail to meet the requirements of subdivision (b) of Section 10128.54 or subdivision (h) of Section 10128.55 regarding notification of a qualifying event or election of continuation coverage within the specified time limits. (f) Except as provided in Section 3001 of ARRA, qualified beneficiaries who fail to submit the correct premium amount required by subdivision (b) of Section 10128.55 and Section 10128.57, in accordance with the terms and conditions of the policy or contract, or fail to satisfy other terms and conditions of the policy or contract. (Amended by Stats. 2010, Ch. 24, Sec. 7. (SB 838) Effective June 3, 2010.)
10128.53.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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Disability insurers covered by this section must offer continuation coverage to qualified beneficiaries, and qualified beneficiaries may continue coverage if they elect it and meet the section’s conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.53. (a) Every disability insurer, that provides coverage under a group benefit plan to an employer, including those policies and contracts that provide vision-only and dental-only benefits, as defined in Section 10128.51, shall offer continuation coverage, pursuant to this section, to a qualified beneficiary under the contract upon a qualifying event without evidence of insurability. The qualified beneficiary shall, upon election, be able to continue his or her coverage under the group benefit plan, subject to the contract’s terms and conditions, and subject to the requirements of this section. Except as otherwise provided in this section, continuation coverage shall be provided under the same terms and conditions that apply to similarly situated individuals under the group benefit plan. (b) Every disability insurer shall also offer the continuation coverage to a qualified beneficiary who (1) elects continuation coverage under a group benefit plan as defined in this article or in Section 1366.21 of the Health and Safety Code, but whose continuation coverage is terminated under the group benefit plan pursuant to subdivision (b) of Section 10128.57, prior to any other termination date specified in Section 10128.57, or (2) who elects coverage through the disability insurer during any employer open enrollment, and the employer has contracted with the disability insurer to provide coverage to the employer’s active employees. This continuation coverage shall be provided only for the balance of the period that the qualified beneficiary would have remained covered under the prior group benefit plan had the employer not terminated the contract with the previous insurer or health care service plan. (c) Every disability insurer shall offer a qualified beneficiary the ability to elect the same core, noncore, or core and noncore coverage that the qualified beneficiary had immediately prior to the qualifying event. (d) Any child who is born to a former employee who is a qualified beneficiary who has elected continuation coverage pursuant to this section, or a child who is placed for adoption with a former employee who is a qualified beneficiary who has elected continuation coverage pursuant to this article during the period of continuation coverage provided by this article shall be considered a qualified beneficiary entitled to receive benefits pursuant to this article for the remainder of the period that the former employee is covered pursuant to this article, if the child is enrolled under a group benefit plan as a dependent of that former employee who is a qualified beneficiary within 30 days of the child’s birth or placement for adoption. (e) An individual who becomes a qualified beneficiary pursuant to this article shall continue to receive coverage pursuant to this article until continuation coverage is terminated at the qualified beneficiary’s election or pursuant to Section 10128.57, whichever comes first, even if the employer that sponsored the group benefit plan that is continued subsequently becomes subject to Section 4980B of the United States Internal Revenue Code of Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. Sec. 1161 et seq. (f) A qualified beneficiary electing coverage pursuant to this section shall be considered part of the group benefit plan and treated as similarly situated employees for contract purposes, unless otherwise specified in this article. (Amended by Stats. 1998, Ch. 107, Sec. 17. Effective July 6, 1998.)
10128.54.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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Insurers must give covered employees and policyholders notices explaining continuation coverage rights, required deadlines, and premium-payment rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.54. (a) Every insurer’s evidence of coverage for group benefit plans subject to this article, that is issued, amended, or renewed on or after January 1, 1999, shall disclose to covered employees of group benefit plans subject to this article the ability to continue coverage pursuant to this article, as required by this section. (b) This disclosure shall state that all insureds who are eligible to be qualified beneficiaries, as defined in subdivision (c) of Section 10128.51, shall be required, as a condition of receiving benefits pursuant to this article, to notify, in writing, the insurer, or the employer if the employer contracts to perform the administrative services as provided for in Section 10128.55, of all qualifying events as specified in paragraphs (1), (3), (4), and (5) of subdivision (d) of Section 10128.51 within 60 days of the date of the qualifying event. This disclosure shall inform insureds that failure to make the notification to the insurer, or to the employer when under contract to provide the administrative services, within the required 60 days will disqualify the qualified beneficiary from receiving continuation coverage pursuant to this article. The disclosure shall further state that a qualified beneficiary who wishes to continue coverage under the group benefit plan pursuant to this article must request the continuation in writing and deliver the written request, by first-class mail, or other reliable means of delivery, including personal delivery, express mail, or private courier company, to the disability insurer, or to the employer if the plan has contracted with the employer for administrative services pursuant to subdivision (d) of Section 10128.55, within the 60-day period following the later of (1) the date that the insured’s coverage under the group benefit plan terminated or will terminate by reason of a qualifying event, or (2) the date the insured was sent notice pursuant to subdivision (e) of Section 10128.55 of the ability to continue coverage under the group benefit plan. The disclosure required by this section shall also state that a qualified beneficiary electing continuation shall pay to the disability insurer, in accordance with the terms and conditions of the policy or contract, which shall be set forth in the notice to the qualified beneficiary pursuant to subdivision (d) of Section 10128.55, the amount of the required premium payment, as set forth in Section 10128.56. The disclosure shall further require that the qualified beneficiary’s first premium payment required to establish premium payment be delivered by first-class mail, certified mail, or other reliable means of delivery, including personal delivery, express mail, or private courier company, to the disability insurer, or to the employer if the employer has contracted with the insurer to perform the administrative services pursuant to subdivision (d) of Section 10128.55, within 45 days of the date the qualified beneficiary provided written notice to the insurer or the employer, if the employer has contracted to perform the administrative services, of the election to continue coverage in order for coverage to be continued under this article. This disclosure shall also state that the first premium payment must equal an amount sufficient to pay all required premiums and all premiums due, and that failure to submit the correct premium amount within the 45-day period will disqualify the qualified beneficiary from receiving continuation coverage pursuant to this article. (c) The disclosure required by this section shall also describe separately how qualified beneficiaries whose continuation coverage terminates under a prior group benefit plan pursuant to Section 10128.57 may continue their coverage for the balance of the period that the qualified beneficiary would have remained covered under the prior group benefit plan, including the requirements for election and payment. The disclosure shall clearly state that continuation coverage shall terminate if the qualified beneficiary fails to comply with the requirements pertaining to enrollment in, and payment of premiums to, the new group benefit plan within 30 days of receiving notice of the termination of the prior group benefit plan. (d) Prior to August 1, 1998, every insurer shall provide to all covered employees of employers subject to this article written notice containing the disclosures required by this section, or shall provide to all covered employees of employers subject to this article a new or amended evidence of coverage that includes the disclosures required by this section. Any insurer that, in the ordinary course of business, maintains only the addresses of employer group purchasers of benefits, and does not maintain addresses of covered employees, may comply with the notice requirements of this section through the provision of the notices to its employer group purchases of benefits. (e) Every disclosure form issued, amended, or renewed on and after January 1, 1999, for a group benefit plan subject to this article shall provide a notice that, under state law, an insured may be entitled to continuation of group coverage and that additional information regarding eligibility for this coverage may be found in the evidence of coverage. (f) Every disclosure form issued, amended, or renewed on and after July 1, 2006, for a group benefit plan subject to this article shall include the following notice: “Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.” (Amended by Stats. 2005, Ch. 526, Sec. 7. Effective January 1, 2006.)
10128.55.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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This section requires disability insurers and employers to send several COBRA-related notices about continuation coverage, premium assistance, and termination of coverage, and it gives qualified beneficiaries election rights.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.55. (a) Every group benefit plan contract between a disability insurer and an employer subject to this article that is issued, amended, or renewed on or after July 1, 1998, shall require the employer to notify the insurer in writing of any employee who has had a qualifying event, as defined in paragraph (2) of subdivision (d) of Section 10128.51, within 30 days of the qualifying event. The group contract shall also require the employer to notify the insurer, in writing, within 30 days of the date when the employer becomes subject to Section 4980B of the United States Internal Revenue Code or Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. Sec. 1161 et seq. (b) Every group benefit plan contract between a disability insurer and an employer subject to this article that is issued, amended, or renewed after July 1, 1998, shall require the employer to notify qualified beneficiaries currently receiving continuation coverage, whose continuation coverage will terminate under one group benefit plan prior to the end of the period the qualified beneficiary would have remained covered, as specified in Section 10128.57, of the qualified beneficiary’s ability to continue coverage under a new group benefit plan for the balance of the period the qualified beneficiary would have remained covered under the prior group benefit plan. This notice shall be provided either 30 days prior to the termination or when all enrolled employees are notified, whichever is later. Every disability insurer shall provide to the employer replacing a group benefit plan policy issued by the insurer, or to the employer’s agent or broker representative, within 15 days of any written request, information in possession of the insurer reasonably required to administer the notification requirements of this subdivision and subdivision (c). (c) Notwithstanding subdivision (a), the group benefit plan contract between the insurer and the employer shall require the employer to notify the successor plan in writing of the qualified beneficiaries currently receiving continuation coverage so that the successor plan, or contracting employer or administrator, may provide those qualified beneficiaries with the necessary premium information, enrollment forms, and instructions consistent with the disclosure required by subdivision (c) of Section 10128.54 and subdivision (e) of this section to allow the qualified beneficiary to continue coverage. This information shall be sent to all qualified beneficiaries who are enrolled in the group benefit plan and those qualified beneficiaries who have been notified, pursuant to Section 10128.54 of their ability to continue their coverage and may still elect coverage within the specified 60-day period. This information shall be sent to the qualified beneficiary’s last known address, as provided to the employer by the health care service plan or, disability insurer currently providing continuation coverage to the qualified beneficiary. The successor insurer shall not be obligated to provide this information to qualified beneficiaries if the employer or prior insurer or health care service plan fails to comply with this section. (d) A disability insurer may contract with an employer, or an administrator, to perform the administrative obligations of the plan as required by this article, including required notifications and collecting and forwarding premiums to the insurer. Except for the requirements of subdivisions (a), (b), and (c), this subdivision shall not be construed to permit an insurer to require an employer to perform the administrative obligations of the insurer as required by this article as a condition of the issuance or renewal of coverage. (e) Every insurer, or employer or administrator that contracts to perform the notice and administrative services pursuant to this section, shall, within 14 days of receiving a notice of a qualifying event, provide to the qualified beneficiary the necessary premium information, enrollment forms, and disclosures consistent with the notice requirements contained in subdivisions (b) and (c) of Section 10128.54 to allow the qualified beneficiary to formally elect continuation coverage. This information shall be sent to the qualified beneficiary’s last known address. (f) Every insurer, or employer or administrator that contracts to perform the notice and administrative services pursuant to this section, shall, during the 180-day period ending on the date that continuation coverage is terminated pursuant to paragraphs (1), (3), and (5) of subdivision (a) of Section 10128.57, notify a qualified beneficiary who has elected continuation coverage pursuant to this article of the date that his or her coverage will terminate, and shall notify the qualified beneficiary of any conversion coverage available to that qualified beneficiary. This requirement shall not apply when the continuation coverage is terminated because the group contract between the insurer and the employer is being terminated. (g) (1) An insurer shall provide to a qualified beneficiary who has a qualifying event during the period specified in subparagraph (A) of paragraph (3) of subdivision (a) of Section 3001 of ARRA, a written notice containing information on the availability of premium assistance under ARRA. This notice shall be sent to the qualified beneficiary’s last known address. The notice shall include clear and easily understandable language to inform the qualified beneficiary that changes in federal law provide a new opportunity to elect continuation coverage with a 65-percent premium subsidy and shall include all of the following: (A) The amount of the premium the person will pay. For qualified beneficiaries who had a qualifying event between September 1, 2008, and May 12, 2009, inclusive, if an insurer is unable to provide the correct premium amount in the notice, the notice may contain the last known premium amount and an opportunity for the qualified beneficiary to request, through a toll-free telephone number, the correct premium that would apply to the beneficiary. (B) Enrollment forms and any other information required to be included pursuant to subdivision (e) to allow the qualified beneficiary to elect continuation coverage. This information shall not be included in notices sent to qualified beneficiaries currently enrolled in continuation coverage. (C) A description of the option to enroll in different coverage as provided in subparagraph (B) of paragraph (1) of subdivision (a) of Section 3001 of ARRA. This description shall advise the qualified beneficiary to contact the covered employee’s former employer for prior approval to choose this option. (D) The eligibility requirements for premium assistance in the amount of 65 percent of the premium under Section 3001 of ARRA. (E) The duration of premium assistance available under ARRA. (F) A statement that a qualified beneficiary eligible for premium assistance under ARRA may elect continuation coverage no later than 60 days of the date of the notice. (G) A statement that a qualified beneficiary eligible for premium assistance under ARRA who rejected or discontinued continuation coverage prior to receiving the notice required by this subdivision has the right to withdraw that rejection and elect continuation coverage with the premium assistance. (H) A statement that reads as follows: “IF YOU ARE HAVING ANY DIFFICULTIES READING OR UNDERSTANDING THIS NOTICE, PLEASE CONTACT [name of insurer] at [insert appropriate telephone number].” (2) With respect to qualified beneficiaries who had a qualifying event between September 1, 2008, and May 12, 2009, inclusive, the notice described in this subdivision shall be provided by the later of May 26, 2009, or seven business days after the date the insurer receives notice of the qualifying event. (3) With respect to qualified beneficiaries who had or have a qualifying event between May 13, 2009, and the later date specified in subparagraph (A) of paragraph (3) of subdivision (a) of Section 3001 of ARRA, inclusive, the notice described in this subdivision shall be provided within the period of time specified in subdivision (e). (4) Nothing in this section shall be construed to require an insurer to provide the insurer’s evidence of coverage as a part of the notice required by this subdivision, and nothing in this section shall be construed to require an insurer to amend its existing evidence of coverage to comply with the changes made to this section by the enactment of Assembly Bill 23 of the 2009–10 Regular Session or by the act amending this section during the second year of the 2009–10 Regular Session. (5) The requirement under this subdivision to provide a written notice to a qualified beneficiary and the requirement under paragraph (1) of subdivision (h) to provide a new opportunity to a qualified beneficiary to elect continuation coverage shall be deemed satisfied if an insurer previously provided a written notice and additional election opportunity under Section 3001 of ARRA to that qualified beneficiary prior to the effective date of the act adding this paragraph. (h) (1) Notwithstanding any other provision of law, a qualified beneficiary eligible for premium assistance under ARRA may elect continuation coverage no later than 60 days after the date of the notice required by subdivision (g). (2) For a qualified beneficiary who elects to continue coverage pursuant to this subdivision, the period beginning on the date of the qualifying event and ending on the effective date of the continuation coverage shall be disregarded for purposes of calculating a break in coverage in determining whether a preexisting condition provision applies under subdivision (e) of Section 10198.7 or subdivision (c) of Section 10708. (3) For a qualified beneficiary who had a qualifying event between September 1, 2008, and February 16, 2009, inclusive, and who elects continuation coverage pursuant to paragraph (1), the continuation coverage shall commence on the first day of the month following the election. (4) For a qualified beneficiary who had a qualifying event between February 17, 2009, and May 12, 2009, inclusive, and who elects continuation coverage pursuant to paragraph (1), the effective date of the continuation coverage shall be either of the following, at the option of the beneficiary, provided that the beneficiary pays the applicable premiums: (A) The date of the qualifying event. (B) The first day of the month following the election. (5) Notwithstanding any other provision of law, a qualified beneficiary who is eligible for the special election period described in paragraph (17) of subdivision (a) of Section 3001 of ARRA may elect continuation coverage no later than 60 days after the date of the notice required under subdivision (j). For a qualified beneficiary who elects coverage pursuant to this paragraph, the continuation coverage shall be effective as of the first day of the first period of coverage after the date of termination of employment, except, if federal law permits, coverage shall take effect on the first day of the month following the election. However, for purposes of calculating the duration of continuation coverage pursuant to Section 10128.57, the period of that coverage shall be determined as though the qualifying event was a reduction of hours of the employee. (6) Notwithstanding any other provision of law, a qualified beneficiary who is eligible for any other special election period under ARRA may elect continuation coverage no later than 60 days after the date of the special election notice required under ARRA. (i) An insurer shall provide a qualified beneficiary eligible for premium assistance under ARRA written notice of the extension of that premium assistance as required under Section 3001 of ARRA. (j) A health insurer, or an administrator or employer if administrative obligations have been assumed by those entities pursuant to subdivision (d), shall give the qualified beneficiaries described in subparagraph (C) of paragraph (17) of subdivision (a) of Section 3001 of ARRA the written notice required by that paragraph by implementing the following procedures: (1) The insurer shall, within 14 days of the effective date of the act adding this subdivision, send a notice to employers currently contracting with the insurer for a group benefit plan subject to this article. The notice shall do all of the following: (A) Advise the employer that employees whose employment is terminated on or after March 2, 2010, who were previously enrolled in any group health care service plan or health insurance policy offered by the employer may be entitled to special health coverage rights, including a subsidy paid by the federal government for a portion of the premium. (B) Ask the employer to provide the insurer with the name, address, and date of termination of employment for any employee whose employment is terminated on or after March 2, 2010, and who was at any time covered by any health care service plan or health insurance policy offered to their employees on or after September 1, 2008. (C) Provide employers with a format and instructions for submitting the information to the insurer, or their administrator or employer who has assumed administrative obligations pursuant to subdivision (d), by telephone, fax, electronic mail, or mail. (2) Within 14 days of receipt of the information specified in paragraph (1) from the employer, the insurer shall send the written notice specified in paragraph (17) of subdivision (a) of Section 3001 of ARRA to those individuals. (3) If an individual contacts his or her health insurer and indicates that he or she experienced a qualifying event that entitles him or her to the special election period described in paragraph (17) of subdivision (a) of Section 3001 of ARRA or any other special election provision of ARRA, the insurer shall provide the individual with the notice required under paragraph (17) of subdivision (a) of Section 3001 of ARRA or any other applicable provision of ARRA, regardless of whether the insurer receives or received information from the individual’s previous employer regarding that individual pursuant to Section 24100 of the Health and Safety Code. The insurer shall review the individual’s application for coverage under this special election notice to determine if the individual qualifies for the special election period and the premium assistance under ARRA. The insurer shall comply with paragraph (5) if the individual does not qualify for either the special election period or premium assistance under ARRA. (4) The requirement under this subdivision to provide the written notice described in paragraph (17) of subdivision (a) of Section 3001 of ARRA to a qualified beneficiary and the requirement under paragraph (5) of subdivision (h) to provide a new opportunity to a qualified beneficiary to elect continuation coverage shall be deemed satisfied if a health insurer previously provided the written notice and additional election opportunity described in paragraph (17) of subdivision (a) of Section 3001 of ARRA to that qualified beneficiary prior to the effective date of the act adding this paragraph. (5) If an individual does not qualify for either a special election period or the subsidy under ARRA, the insurer shall provide a written notice to that individual that shall include information on the right to appeal as set forth in Section 3001 of ARRA. (6) A health insurer shall provide information on its publicly accessible Internet Web site regarding the premium assistance made available under ARRA and any special election period provided under that law. An insurer may fulfill this requirement by linking or otherwise directing consumers to the information regarding COBRA continuation coverage premium assistance located on the Internet Web site of the United States Department of Labor. The information required by this paragraph shall be located in a section of the insurer’s Internet Web site that is readily accessible to consumers, such as the Web site’s Frequently Asked Questions section. (k) Notwithstanding any other provision of law, a qualified beneficiary eligible for premium assistance under ARRA may elect to enroll in different coverage subject to the criteria provided under subparagraph (B) of paragraph (1) of subdivision (a) of Section 3001 of ARRA. (l) A qualified beneficiary enrolled in continuation coverage as of February 17, 2009, who is eligible for premium assistance under ARRA may request application of the premium assistance as of March 1, 2009, or later, consistent with ARRA. (m) An insurer that receives an election notice from a qualified beneficiary eligible for premium assistance under ARRA, pursuant to subdivision (h), shall be considered a person entitled to reimbursement, as defined in Section 6432(b)(3) of the Internal Revenue Code, as amended by paragraph (12) of subdivision (a) of Section 3001 of ARRA. (n) (1) For purposes of compliance with ARRA, in the absence of guidance from, or if specifically required for state-only continuation coverage by, the United States Department of Labor, the Internal Revenue Service, or the Centers for Medicare and Medicaid Services, an insurer may request verification of the involuntary termination of a covered employee’s employment from the covered employee’s former employer or the qualified beneficiary seeking premium assistance under ARRA. (2) An insurer that requests verification pursuant to paragraph (1) directly from a covered employee’s former employer shall do so by providing a written notice to the employer. This written notice shall be sent by mail or facsimile to the covered employee’s former employer within seven business days from the date the insurer receives the qualified beneficiary’s election notice pursuant to subdivision (h). Within 10 calendar days of receipt of written notice required by this paragraph, the former employer shall furnish to the insurer written verification as to whether the covered employee’s employment was involuntarily terminated. (3) A qualified beneficiary requesting premium assistance under ARRA may furnish to the insurer a written document or other information from the covered employee’s former employer indicating that the covered employee’s employment was involuntarily terminated. This document or information shall be deemed sufficient by the insurer to establish that the covered employee’s employment was involuntarily terminated for purposes of ARRA, unless the insurer makes a reasonable and timely determination that the documents or information provided by the qualified beneficiary are legally insufficient to establish involuntary termination of employment. (4) If an insurer requests verification pursuant to this subdivision and cannot verify involuntary termination of employment within 14 business days from the date the employer receives the verification request or from the date the insurer receives documentation or other information from the qualified beneficiary pursuant to paragraph (3), the insurer shall either provide continuation coverage with the federal premium assistance to the qualified beneficiary or send the qualified beneficiary a denial letter which shall include notice of his or her right to appeal that determination pursuant to ARRA. (5) No person shall intentionally delay verification of involuntary termination of employment under this subdivision. (Amended by Stats. 2010, Ch. 24, Sec. 8. (SB 838) Effective June 3, 2010.)
10128.56.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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A qualified beneficiary who elects continuation coverage must pay the insurer monthly by the due date, generally capped at 110% of the applicable rate; certain disabled beneficiaries may be charged up to 150% after 18 months. Insurers may not charge employers extra Cal-COBRA administration fees except as included in the risk-adjusted employee risk rate.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.56. A qualified beneficiary electing continuation coverage shall pay to the disability insurer, on or before the due date of each payment but not more frequently than on a monthly basis, not more than 110 percent of the applicable rate charged for a covered employee or, in the case of dependent coverage, not more than 110 percent of the applicable rate charged to a similarly situated individual under the group benefit plan being continued under the group contract. In the case of a qualified beneficiary who is determined to be disabled pursuant to Title II or Title XVI of the United States Social Security Act, the qualified beneficiary shall be required to pay to the insurer an amount no greater than 150 percent of the group rate after the first 18 months of continuation coverage provided pursuant to this section. In no case shall an insurer charge an employer an additional fee for administering Cal-COBRA other than those incorporated in the risk adjusted employee risk rate as provided for in subdivision (t) of Section 10700. (Amended by Stats. 1998, Ch. 107, Sec. 20. Effective July 6, 1998.)
10128.57.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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Continuation coverage ends when one of several listed events happens, and a qualified beneficiary must give the required notices within stated time limits to keep disability-based coverage.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.57. (a) The continuation coverage provided pursuant to this article shall terminate at the first to occur of the following: (1) In the case of a qualified beneficiary who is eligible for continuation coverage pursuant to paragraph (2) of subdivision (d) of Section 10128.51, the date 36 months after the date the qualified beneficiary’s benefits under the contract would otherwise have terminated because of a qualifying event. (2) Except as provided in Section 3001 of ARRA, the end of the period for which premium payments were made, if the qualified beneficiary ceases to make payments or fails to make timely payments of a required premium, in accordance with the terms and conditions of the policy or contract. In the case of nonpayment of premiums, reinstatement shall be governed by the terms and conditions of the policy or contract and by Section 3001 of ARRA, if applicable. (3) In the case of a qualified beneficiary who is eligible to continuation coverage pursuant to paragraph (1), (3), (4), or (5) of subdivision (d) of Section 10116.51, the date 36 months after the date the qualified beneficiary’s benefits under the contract would otherwise have terminated by reason of a qualifying event. (4) The requirements of this article no longer apply to the qualified beneficiary pursuant to the provisions of Section 10128.52. (5) In the case of a qualified beneficiary who is eligible for continuation coverage pursuant to paragraph (2) of subdivision (d) of Section 10128.51, and determined, under Title II or Title XVI of the Social Security Act, to be disabled any time during the first 60 days of continuation coverage, and the spouse or dependent who has elected coverage pursuant to this article, the date 36 months after the date the qualified beneficiary’s benefits under the contract would otherwise have terminated because of a qualifying event. The qualified beneficiary shall notify the insurer, or the employer or administrator that contracts to perform administrative services, of the social security determination within 60 days of the date of the determination letter and prior to the end of the original 36-month continuation coverage period in order to be eligible for coverage pursuant to this subdivision. If the qualified beneficiary is no longer disabled under Title II or Title XVI of the Social Security Act, the benefits provided in this paragraph shall terminate on the later of the date provided by paragraph (1), or the month that begins more than 31 days after the date of the final determination under Title II or Title XVI of the United States Social Security Act that the qualified beneficiary is no longer disabled. A qualified beneficiary eligible for 36 months of continuation coverage as a result of a disability shall notify the insurer, or the employer or administrator that contracts to perform the notice and administrative services, within 30 days of a determination that the qualified beneficiary is no longer disabled. (6) In the case of a qualified beneficiary who is initially eligible for and elects continuation coverage pursuant to paragraph (2) of subdivision (d) of Section 10128.51, but who has another qualifying event, as described in paragraph (1), (3), (4), or (5) of subdivision (d) of Section 10128.51, within 36 months of the date of the first qualifying event, and has notified the insurer, or employer or administrator under contract to provide administrative services, of the second qualifying event within 60 days of the date of the second qualifying event, the date 36 months after the date of the first qualifying event. (7) The employer, or any successor employer or purchaser of the employer, ceases to provide any group benefit plan to his or her employees. (8) The qualified beneficiary moves out of the insurer’s service area, or the qualified beneficiary commits fraud or deception in the use of benefits. (b) If the group benefits contracts between the insurer and the employer is terminated prior to the date the qualified beneficiary’s continuation coverage would terminate pursuant to this section, coverage under the prior plan shall terminate and the qualified beneficiary may elect continuation coverage under the subsequent group benefit plan, if any, pursuant to the requirements of subdivision (b) of Section 10128.53 and subdivision (c) of Section 10128.54. (c) The amendments made to this section by Assembly Bill 1401 of the 2001–02 Regular Session shall apply to individuals who begin receiving continuation coverage under this article on or after January 1, 2003. (Amended by Stats. 2010, Ch. 24, Sec. 9. (SB 838) Effective June 3, 2010.)
10128.58.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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A disability insurer under this article does not have to provide continuation coverage if the insured fails to give the required notice or the employer fails to comply with Section 10128.55.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.58. A disability insurer subject to this article shall not be obligated to provide continuation coverage to a qualified beneficiary pursuant to this article if an insured fails to make the notification required by Section 10128.54, or if the employer of the insured fails to comply with Section 10128.55. (Amended by Stats. 1998, Ch. 107, Sec. 22. Effective July 6, 1998.)
10128.59.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. )
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Health insurers must offer qualifying insureds an opportunity to continue coverage for up to 36 months, subject to the article’s terms and rate limits.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 1.7. California Cobra Program [10128.50 - 10128.59] ( Article 1.7 added by Stats. 1997, Ch. 665, Sec. 6. ) ## 10128.59. (a) A health insurer that provides coverage under a group benefit plan to an employer shall offer an insured who has exhausted continuation coverage under COBRA the opportunity to continue coverage for up to 36 months from the date the insured’s continuation coverage began if the insured is entitled to less than 36 months of continuation coverage under COBRA. The health insurer shall offer coverage pursuant to terms of this article, including the rate limitations contained in Section 10128.56. (b) Notification of the coverage available under this section shall be included in the notice of the pending termination of COBRA coverage that is required to be provided to COBRA beneficiaries and that is required to be provided under Section 10128.54. (c) For purposes of this section, “COBRA” means Section 4980B of Title 26 of the United States Code, Sections 1161 et seq. of Title 29 of the United States Code, and Section 300bb of Title 42 of the United States Code. (d) This section shall not apply to accident-only, specified disease, hospital indemnity, CHAMPUS supplement, long-term care, Medicare supplement, dental-only, or vision-only insurance policies. (e) This section shall become operative on September 1, 2003, and shall apply to individuals who begin receiving COBRA coverage on or after January 1, 2003. (Added by Stats. 2002, Ch. 794, Sec. 13. Effective January 1, 2003. Section operative September 1, 2003, by its own provisions.)
10129.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Sections 10130 and 10131 do not apply to certain group or long-term individual disability policies if the policy says benefits are not assignable.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10129. Sections 10130 and 10131 do not apply to group life policies, to group disability policies, or to individual disability policies providing a benefit for loss of time and which are noncancellable and guaranteed renewable for not less than five years, when any of such group life policies, group disability policies or individual disability policies expressly provide that benefits payable thereunder are not assignable, and in such case the benefits shall be paid only as provided in the policy. (Amended by Stats. 1947, Ch. 904.)
10129.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Sections 10130 and 10131 do not apply to certain annuity contracts.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10129.5. Sections 10130 and 10131 do not apply to annuity contracts which are within the scope of Section 401(g) of the Internal Revenue Code of the United States. (Added by Stats. 1963, Ch. 2061.)
1013.
## Insurance Code - INS ## DIVISION 1. GENERAL RULES GOVERNING INSURANCE [100 - 1879.8] ( Division 1 enacted by Stats. 1935, Ch. 145. ) ## PART 2. THE BUSINESS OF INSURANCE [680 - 1879.8] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. General Regulations [680 - 1113] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 14. Proceedings in Cases of Insolvency and Delinquency [1010 - 1062] ( Article 14 amended by Stats. 1935, Ch. 291. )
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If specified insolvency or loss conditions exist, the commissioner must immediately take possession of the person’s property and business records; anyone who refuses to hand over seized books, records, or assets can be charged with a misdemeanor.

## Insurance Code - INS ## DIVISION 1. GENERAL RULES GOVERNING INSURANCE [100 - 1879.8] ( Division 1 enacted by Stats. 1935, Ch. 145. ) ## PART 2. THE BUSINESS OF INSURANCE [680 - 1879.8] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. General Regulations [680 - 1113] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 14. Proceedings in Cases of Insolvency and Delinquency [1010 - 1062] ( Article 14 amended by Stats. 1935, Ch. 291. ) ## 1013. Whenever it appears to the commissioner that any of the conditions set forth in section 1011 exist or that irreparable loss and injury to the property and business of a person specified in section 1010 has occurred or may occur unless the commissioner so act immediately, the commissioner, without notice and before applying to the court for any order, forthwith shall take possession of the property, business, books, records and accounts of such person, and of the offices and premises occupied by it for the transaction of its business, and retain possession subject to the order of the court. Any person having possession of and refusing to deliver any of the books, records or assets of a person against whom a seizure order has been issued by the commissioner, shall be guilty of a misdemeanor and punishable by fine not exceeding one thousand dollars or imprisonment not exceeding one year, or both such fine and imprisonment. (Amended by Stats. 1935, Ch. 291.)
10130.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A life or disability policy may be transferred, passed by will, or pass by succession to any person, even if the transferee has no insurable interest.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10130. A life or disability policy may pass by transfer, will or succession to any person, whether or not the transferee has an insurable interest. Such transferee may recover upon it whatever the insured might have recovered. (Enacted by Stats. 1935, Ch. 145.)
10131.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Notice to the insurer of a transfer of a life or disability policy is generally not required to keep the policy valid, unless the policy itself expressly requires notice.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10131. Notice to an insurer of a transfer of a life or disability policy is not necessary to preserve the validity of the policy unless expressly required by the policy. (Enacted by Stats. 1935, Ch. 145.)
10132.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A life insurance policy that pays proceeds in installments may include a term that stops the beneficiary from selling or borrowing against an installment before it is due.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10132. The beneficiary under a life policy which provides for the payment of its proceeds in periodical installments, may be restrained by its provisions from disposing of or incumbering his interest in any such installment prior to the date when it becomes due and payable by the insurer. (Enacted by Stats. 1935, Ch. 145.)
10133.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A disability insurer must pay certain covered hospital or medical/surgical benefits only after the insured gives written consent for the claim, and the payment limits in the section apply.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133. (a) Upon written consent of the insured first obtained with respect to a particular claim, any disability insurer shall pay group insurance benefits contingent upon, or for expenses incurred on account of, hospitalization or medical or surgical aid to the person or persons furnishing the hospitalization or medical or surgical aid, or, on and after January 1, 1994, to the person or persons having paid for the hospitalization or medical or surgical aid, but the amount of any such payment shall not exceed the amount of benefit provided by the policy with respect to the service or billing of the provider of aid, and the amount of the payments pursuant to one or more assignments shall not exceed the amount of expenses incurred on account of the hospitalization or medical or surgical aid. Payments so made shall discharge the insurer’s obligation with respect to the amount so paid. (b) Nothing in this section shall be construed to authorize an insurer to furnish or directly provide services of hospitals, or psychiatric health facilities, as defined in Section 1250.2 of the Health and Safety Code, or physicians and surgeons, or psychologists or in any manner to direct, participate in, or control the selection of the hospital or health facility or physician and surgeon or psychologist from whom the insured secures services or exercise medical or dental or psychological professional judgment, except that an insurer may negotiate and enter into contracts for alternative rates of payment with institutional providers, and offer the benefit of these alternative rates to insureds who select those providers. (c) Alternatively, insurers may, by agreement with group policyholders, limit payments under a policy to services secured by insureds from institutional providers, and after July 1, 1983, from professional providers, charging alternative rates pursuant to contract with the insurer. (d) Pursuant to subdivision (c), when alternate rates of payment to providers are applicable to contracts with group policyholders, the contracts shall include programs for the continuous review of the quality of care, performance of medical or psychological personnel included in the plan, utilization of services and facilities, and costs, by professionally recognized unrelated third parties utilizing in the case of professional providers similarly licensed providers for each medical, psychological, or dental service covered under the plan and utilizing in the case of institutional providers appropriate professional providers. All provisions of the laws of the state relating to immunity from liability and discovery privileges for medical, psychological, and dental peer review shall apply to the licensed providers performing the foregoing activities. (e) On or after July 1, 1983, the amendments made to this section during the 1982 portion of the 1981–82 Regular Session, shall also be applicable with respect to both professional and institutional providers. (Amended by Stats. 1993, Ch. 744, Sec. 2. Effective January 1, 1994.)
10133.1.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Insurers must give group policyholders a current roster of contracted institutional and professional providers that offer alternative rates, and they must make the list available for public inspection at the insurer’s or plan’s principal office in the state during regular business hours.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.1. Insurers shall provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates under their group policy and shall also make such lists available for public inspection during regular business hours at the insurer’s or plan’s principal office within the state. (Added by Stats. 1982, Ch. 1594, Sec. 10.5. Effective September 30, 1982. Operative January 1, 1983, by Sec. 82 of Ch. 1594.)
10133.10.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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An insurer with non-English health insurance marketing materials in the individual or small group market must provide specified documents in the same non-English language and use trained, qualified translators.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.10. (a) An insurer that markets, advertises, or produces educational materials for a health insurance policy, as defined in Section 106, in the individual or small group health insurance markets, or allows any other person or business to market or advertise on its behalf in the individual or small group health insurance markets, in a non-English language that does not meet the requirements set forth in Sections 10133.8 and 10133.9, shall provide the following documents in the same non-English language: (1) Welcome letters or notices of initial coverage, if applicable. (2) Applications for health insurance and any information pertinent to eligibility or participation. (3) Notices advising limited-English-proficient persons of the availability of no-cost translation and interpretation services. (4) Notices pertaining to the right and instructions on how an insured may file a grievance. (5) The uniform summary of benefits and coverage required pursuant to paragraph (2) of subdivision (a) of Section 10603. (b) An insurer shall use trained and qualified translators for the translation of all marketing and advertising materials relating to health insurance products and for all of the documents specified in subdivision (a). (c) This section shall not apply to a specialized health insurance policy that does not offer an essential health benefit as defined in Section 10112.27. (Added by Stats. 2013, Ch. 447, Sec. 2. (SB 353) Effective January 1, 2014.)
10133.11.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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An insurer must tell insureds and the public about language assistance, disability aids, nondiscrimination, and complaint-filing information, and provide it at specified times and places. The department must not grant certain waivers, and a specialized health insurance policy may request a waiver if it meets stated conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.11. (a) An insurer shall notify insureds and members of the public of all of the following information: (1) The availability of language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner pursuant to Section 10133.8, and how to access these services. This information shall be available in the top 15 languages spoken by limited-English-proficient individuals in California as determined by the State Department of Health Care Services. (2) The availability of appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities. (3) An insurer does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. (4) How to file a complaint, including the name of the health insurer representative and the telephone number, address, and email address of the health insurer representative who may be contacted about the complaint, and how to submit the complaint to the department for review. (5) How to file a discrimination complaint with the United States Department of Health and Human Services Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. (b) The information required to be provided pursuant to this section shall be provided to an insured with individual coverage upon initial enrollment and annually thereafter upon renewal, and to insureds with group coverage upon initial enrollment and annually thereafter upon renewal. An insurer may include this information with other materials sent to the insured. The information shall also be provided in the following manner: (1) In a conspicuously visible location in the evidence of coverage. (2) At least annually, in or with newsletters, outreach, or other materials that are routinely disseminated to the health insurer’s insureds. (3) On the Internet Web site published and maintained by the health insurer, in a manner that allows insureds, prospective insureds, and members of the public to easily locate the information. (c) (1) A specialized health insurance policy that is not a covered entity, as defined in Section 92.4 of Title 45 of the Code of Federal Regulations, subject to Section 1557 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18116) may request a waiver from the requirements under this section. (2) The department shall not grant a waiver under this subdivision to a specialized health insurance policy that arranges for mental health or behavioral health benefits. (3) The department shall provide information on its Internet Web site about any waivers granted under this subdivision. (Amended by Stats. 2018, Ch. 92, Sec. 156. (SB 1289) Effective January 1, 2019.)
10133.12.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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The department must require health insurers to establish and maintain specified APIs, and the commissioner may issue compliance guidance until January 1, 2027.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.12. (a) Commencing January 1, 2027, or when final federal rules are implemented, whichever occurs later, the department shall require a health insurer to establish and maintain the following application programming interfaces (API) for the benefit of all insureds and contracted providers, as applicable: (1) Patient access API. (2) Provider access API. (3) Payer-to-payer API. (4) Prior authorization API. (b) API described in subdivision (a) shall be in accordance with standards published in a final rule issued by the federal Centers for Medicare and Medicaid Services and published in the Federal Register, and shall align with federal effective dates, including enforcement delays and suspensions, issued by the federal Centers for Medicare and Medicaid Services. (c) Until January 1, 2027, the commissioner may issue guidance to health insurers regarding compliance with this section and that guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (d) This section does not limit existing requirements under this chapter, including, but not limited to, Section 10133.15. (Amended by Stats. 2024, Ch. 386, Sec. 2. (AB 2198) Effective January 1, 2025.)
10133.13.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurers covered by this section must train direct-contact staff on evidence-based cultural competency for trans-inclusive health care, and the department and commissioner have compliance and enforcement duties.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.13. (a) (1) Within six months after the department issues guidance pursuant to paragraph (1) of subdivision (d), and no later than March 1, 2025, a health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health insurance policy, but not including specialized health insurance policies that provide only dental or vision services, shall require all of its health insurer staff who are in direct contact with insureds in the delivery of care or insured services to complete evidence-based cultural competency training for the purpose of providing trans-inclusive health care for individuals who identify as transgender, gender diverse, or intersex (TGI). (2) An evidence-based cultural competency training implemented pursuant to paragraph (1) shall include all of the following: (A) Information about the effects, including, but not limited to, ongoing personal effects, of historical and contemporary exclusion and oppression of TGI communities. (B) Information about communicating more effectively across gender identities, including TGI-inclusive terminology, using people’s correct names and pronouns, even when they are not reflected in records or legal documents; avoiding language, whether verbal or nonverbal, that demeans, ridicules, or condemns TGI individuals; and avoiding making assumptions about gender identity by using gender-neutral language and avoiding language that presumes all individuals are heterosexual, cisgender or gender conforming, or nonintersex. (C) Discussion on health inequities within the TGI community, including family and community acceptance. (D) Perspectives of diverse, local constituency groups and TGI-serving organizations, including, but not limited to, the California Transgender Advisory Council. (E) Recognition of the difference between personal values and professional responsibilities with regard to serving TGI people. (F) Facilitation by TGI-serving organizations. (3) Use of any training curricula for purposes of implementing paragraph (1) shall be subject to approval by the department, following stakeholder engagement with local constituency groups and TGI-serving organizations, including, but not limited to, the California Transgender Advisory Council. (4) After first-time completion of the evidence-based cultural competency training, in the form of initial basic training, an individual described in paragraph (1) shall complete a refresher course if a complaint has been filed, and a decision has been made in favor of the complainant, against that individual for not providing trans-inclusive health care, or on a more frequent basis if deemed necessary by the health insurer or the department for purposes of providing trans-inclusive health care. (b) (1) No later than September 1, 2024, the department shall develop and implement procedures, and may impose sanctions pursuant to any applicable enforcement provisions, to ensure that a health insurer is compliant with the requirements described in subdivision (a). (2) Within six months after the department issues guidance pursuant to paragraph (1) of subdivision (d), the department shall track and monitor complaints received by the department related to trans-inclusive health care and publicly report this data with other complaint data on its website or with other public reports containing complaint data. (c) For purposes of this section, the following definitions apply: (1) “TGI” means transgender, gender diverse, or intersex. (2) “TGI-serving organization” has the same meaning as set forth in paragraph (2) of subdivision (f) of Section 150900 of the Health and Safety Code. (3) “Trans-inclusive health care” means comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect. (d) (1) Within six months of development of the quality standard and recommendations for curriculum pursuant to Section 150950 of the Health and Safety Code and no later than September 1, 2024, the department shall develop guidance and procedures for compliance with this section. In developing guidance pursuant to this subdivision, the department shall consider the recommendations made by the working group pursuant to Section 150950 of the Health and Safety Code. (2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of guidance or similar instructions, until regulations are adopted. (3) The department shall adopt regulations for purposes of this section by July 1, 2027, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations are adopted. In developing the regulations, the department shall consider the recommendations made by the working group pursuant to Section 150950 of the Health and Safety Code. (e) If a health insurer delegates duties under this section to a contracted entity, including, but not limited to, a medical group or independent practice association, then the entity to which those duties are delegated shall comply with this section. (f) The commissioner may take enforcement action, including, but not limited to, imposing penalties for noncompliance with the requirements of this section or regulations promulgated thereunder. If the commissioner determines that a health insurer, or an entity contracted with the health insurer, has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. (Added by Stats. 2022, Ch. 822, Sec. 5. (SB 923) Effective January 1, 2023.)
10133.14.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A health insurer covered by Section 10133.13 must list, in its provider directory and call center access, which in-network providers offer and have provided gender-affirming services, and update that information when a provider asks to be included or excluded.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.14. No later than March 1, 2025, a health insurer subject to Section 10133.13 shall include information within or accessible from the insurer’s provider directory, and accessible through the insurer’s call center, that identifies which of an insurer’s in-network providers have affirmed that they offer and have provided gender-affirming services, including, but not limited to, feminizing mammoplasty, male chest reconstruction, mastectomy, gender-confirming facial surgery, hysterectomy, oophorectomy, penectomy, orchiectomy, feminizing genitoplasty, metoidioplasty, phalloplasty, scrotoplasty, voice masculinization or feminization, hormone therapy related to gender dysphoria or intersex conditions, gender-affirming gynecological care, or voice therapy related to gender dysphoria or intersex conditions. This information shall be updated when an in-network provider requests its inclusion or exclusion as a provider that offers and provides gender-affirming services. Nothing in this act alters any business establishment’s obligation to provide full and equal services to customers or patients regardless of their sex and other protected characteristics, pursuant to the Unruh Civil Rights Act (Section 51 of the Civil Code) and other applicable law. (Added by Stats. 2022, Ch. 822, Sec. 6. (SB 923) Effective January 1, 2023.)
10133.15.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurers must publish and keep current provider directories, make them publicly accessible, and update provider information on set schedules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.15. (a) Commencing July 1, 2016, a health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain provider directory or directories with information on contracting providers that deliver health care services to the insurer’s insureds, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the insurer. (b) An insurer shall provide the online directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, insureds, potential insureds, the department, and other state or federal agencies can easily identify the networks and insurer products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, an insurer shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (c) (1) An online provider directory or directories shall be available on the insurer’s internet website to the public, potential insureds, insureds, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the insurer, indicate interest in obtaining coverage with the insurer, provide a member identification or policy number, provide any other identifying information, or create or access an account. (2) The online provider directory or directories shall be accessible on the insurer’s public internet website through an identifiable link or tab and in a manner that is accessible and searchable by insureds, potential insureds, the public, and providers. By July 1, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the insurer’s public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate. (d) (1) An insurer shall allow insureds, potential insureds, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the insurer through the insurer’s toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work. (2) An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. (e) (1) The insurer shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the insurer of any of the following: (A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (B) A contracted provider is no longer under contract for a particular product. (C) A provider’s practice location or other information required under subdivision (h) or (i) has changed. (D) Upon the completion of the investigation described in subdivision (o), a change is necessary based on an insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (E) Any other information that affects the content or accuracy of the provider directory or directories. (2) Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when: (A) A provider has retired or otherwise has ceased to practice. (B) A provider or provider group is no longer under contract with the insurer for any reason. (C) The contracting provider group has informed the insurer that the provider is no longer associated with the provider group and is no longer under contract with the insurer. (f) The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurer’s internet website. (g) The provider directory or directories shall include the following disclosures informing insureds that they are entitled to both of the following: (1) Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8. (2) Full and equal access to covered services, including insureds with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973. (h) The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories: (1) The provider’s name, practice location or locations, and contact information. (2) Type of practitioner. (3) National Provider Identifier number. (4) California license number and type of license. (5) The area of specialty, including board certification, if any. (6) The provider’s office email address, if available. (7) The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds. (8) A listing for each of the following providers that are under contract with the insurer: (A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer. (B) Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 4999.200 of the Business and Professions Code, nurse midwives, and dentists. (C) For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic. (D) For a provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the insurer, the name of the provider, and the name of the federally qualified health center or clinic. (E) Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities. (F) Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services. (9) The provider directory or directories may note that authorization or referral may be required to access some providers. (10) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the provider’s staff. (11) Identification of providers who no longer accept new patients for some or all of the insurer’s products. (12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this section shall be construed to require the use of network tiers other than contract and noncontracting tiers. (13) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (i) A vision, dental, or other specialized insurer, except for a specialized mental health insurer, shall include all of the following information for each provider directory or directories used by the insurer for its networks: (1) The provider’s name, practice location or locations, and contact information. (2) Type of practitioner. (3) National Provider Identifier number. (4) California license number and type of license, if applicable. (5) The area of specialty, including board certification, or other accreditation, if any. (6) The provider’s office email address, if available. (7) The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds. (8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer. (9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the provider’s staff. (10) Identification of providers who no longer accept new patients for some or all of the insurer’s products. (11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j) (1) The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following occurs: (A) The provider is not accepting new patients. (B) If the provider had previously not accepted new patients, the provider is currently accepting new patients. (2) If a provider who is not accepting new patients is contacted by an insured or potential insured seeking to become a new patient, the provider shall direct the insurer or potential insured to both the insurer for additional assistance in finding a provider and to the department to report any inaccuracy with the insurer’s directory or directories. (3) If an insured or potential insured informs an insurer of a possible inaccuracy in the provider directory or directories, the insurer shall promptly investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories. (k) (1) On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision. (2) In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services. (3) By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards developed by the department for each product offered by the insurer. (l) (1) An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurer’s provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the insurer shall notify all contracted providers described in subdivisions (h) and (i) as follows: (A) For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the insurer shall notify each provider at least once every six months. (B) For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the insurer shall notify its contracted providers to ensure that all of the providers are contacted by the insurer at least once annually. (2) The notification shall include all of the following: (A) The information the insurer has in its directory or directories regarding the provider or provider group, including a list of networks and products that include the contracted provider or provider group. (B) A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p). (C) Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m). (3) The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider group is accepting new patients for each product. (4) If the insurer does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the insurer shall take no more than 15 business days to verify whether the provider’s information is correct or requires updates. The insurer shall document the receipt and outcome of each attempt to verify the information. If the insurer is unable to verify whether the provider’s information is correct or requires updates, the insurer shall notify the provider 10 business days in advance of removal that the provider will be removed from the directory or directories. The provider shall be removed from the directory or directories at the next required update of the provider directory or directories after the 10-business day notice period. A provider shall not be removed from the provider directory or directories if they respond before the end of the 10-business day notice period. (5) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). (m) An insurer shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance. (1) The policies and procedures described under this subdivision shall be submitted by an insurer annually to the department for approval and in a format described by the department. (2) Every insurer shall ensure processes are in place to allow providers to promptly verify or submit changes to the information required to be in the directory or directories pursuant to this section. Those processes shall, at a minimum, include an online interface for providers to submit verification or changes electronically and shall generate an acknowledgment of receipt from the insurer. Providers shall verify or submit changes to information required to be in the directory or directories pursuant to this section using the process required by the insurer. (3) The insurer shall establish and maintain a process for insureds, potential insureds, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the insurer’s provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the insurer will accept these reports, as well as a hyperlink on the insurer’s provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website. (n) (1) This section does not prohibit an insurer from requiring its provider groups or contracting specialized health insurers to provide information to the insurer that is required by the insurer to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health insurer. This responsibility shall be specifically documented in a written contract between the insurer and the provider group or contracting specialized health insurer. (2) If an insurer requires its contracting provider groups or contracting specialized health insurers to provide the insurer with information described in paragraph (1), the insurer shall continue to retain responsibility for ensuring that the requirements of this section are satisfied. (3) A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section. (4) A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs: (A) A provider does not respond to the provider group’s attempt to verify the provider’s information. As used in this paragraph, “verify” means to contact the provider in writing, electronically, and by telephone to confirm whether the provider’s information is correct or requires updates. (B) The provider group documents its efforts to verify the provider’s information. (C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurer’s provider directory or directories. (5) Section 10133.65, known as the Health Care Providers’ Bill of Rights, applies to any material change to a provider contract pursuant to this section. (o) (1) Whenever an insurer receives a report indicating that information listed in its provider directory or directories is inaccurate, the insurer shall promptly investigate the reported inaccuracy and, no later than 30 business days following receipt of the report, either verify the accuracy of the information or update the information in its provider directory or directories, as applicable. (2) When investigating a report regarding its provider directory or directories, the insurer shall, at a minimum, do the following: (A) Contact the affected provider no later than five business days following receipt of the report. (B) Document the receipt and outcome of each report. The documentation shall include the provider’s name, location, and a description of the insurer’s investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories. (C) If changes to an insurer’s provider directory or directories are required as a result of the insurer’s investigation, the changes to the online provider directory or directories shall be made no later than the next scheduled weekly update, or the update immediately following that update, or sooner if required by federal law or regulations. For printed provider directories, the change shall be made no later than the next required update, or sooner if required by federal law or regulations. (p) (1) Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the insurer’s attempts to verify the provider’s information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the provider’s or provider group’s information. As used in this subdivision, “verify” means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the provider’s or provider group’s information is correct or requires updates. An insurer may seek to delay payment or reimbursement owed to a provider or provider group only after the 10-business day notice period described in paragraph (4) of subdivision (l) has lapsed. (2) An insurer shall notify the provider or provider group 10 days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the insurer delays a payment or reimbursement pursuant to this subdivision, the insurer shall reimburse the full amount of any payment or reimbursement subject to delay to the provider or provider group according to either of the following timelines, as applicable: (A) No later than three business days following the date on which the insurer receives the information required to be submitted by the provider or provider group pursuant to subdivision (l). (B) At the end of the one-calendar-month delay described in paragraph (1), if the provider or provider group fails to provide the information required to be submitted to the insurer pursuant to subdivision (l). (3) An insurer may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the insurer to a change in the information required to be in the directory or directories pursuant to this section. (4) An insurer that delays payment or reimbursement under this subdivision shall document each instance a payment or reimbursement was delayed and report this information to the department in a format described by the department. This information shall be submitted along with the policies and procedures required to be submitted annually to the department pursuant to paragraph (1) of subdivision (m). (q) In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurer’s provider directory or directories, the department may require the insurer to provide coverage for all covered health care services provided to the insured and to reimburse the insured for any amount beyond what the insured would have paid, had the services been delivered by an in-network provider under the insured’s health insurance policy. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insured’s health insurance policy. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the insured. (r) Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner. (s) An insurer that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet the requirements of this section. (t) This section shall not be construed to alter a provider’s obligation to provide health care services to an insured pursuant to the provider’s contract with the insurer. (u) As part of the department’s routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurer’s compliance with subdivision (p). (v) For purposes of this section, “provider group” means a medical group, independent practice association, or other similar group of providers. (Amended by Stats. 2025, Ch. 413, Sec. 6. (SB 402) Effective January 1, 2026.)
10133.2.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A disability insurer that contracts for alternative provider rates must calculate patient copayment only from the negotiated alternative rate.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.2. When any disability insurer negotiates and enters into a contract with professional or institutional providers to provide services at alternative rates of payment of the type described in Sections 10133 and 11512 of the Insurance Code, the amount of patient copayment shall be calculated exclusively from the negotiated alternative rate for the service rendered. No disability insurer or professional or institutional provider, negotiating and entering into a contract pursuant to this section, shall charge or collect copayment amounts greater than those calculated in accordance with this section. This section shall become operative on January 1, 1993. (Added by Stats. 1991, Ch. 827, Sec. 1.5.)
10133.3.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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If a self-insured governmental plan contracts for alternative provider rates, patient copayments must be based only on that negotiated rate, and the plan or provider may not charge or collect higher copayments.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.3. When any self-insured governmental plan, as defined in Section 12671, negotiates and enters into a contract with professional or institutional providers to provide services at alternative rates of payment of the type described in Sections 10133 and 11512 of the Insurance Code, the amount of patient copayment shall be calculated exclusively from the negotiated alternative rate for the service rendered. No self-insured governmental plan or professional or institutional provider, negotiating and entering into a contract pursuant to this section, shall charge or collect copayment amounts greater than those calculated in accordance with this section. This section shall become operative on January 1, 1993. (Added by Stats. 1991, Ch. 827, Sec. 2.)
10133.4.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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For insurers using alternate-rate provider contracts under Section 10133, a primary care provider includes certain physician assistants and nurse practitioners. The section also says it does not require a primary care provider to accept more insureds than good-health-care standards allow.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.4. (a) For purposes of insurers that contract with providers for alternate rates pursuant to Section 10133, a primary care provider includes a “nonphysician medical practitioner,” which is defined as a physician assistant performing services under the supervision of a primary care physician in compliance with Chapter 7.7 (commencing with Section 3500) of Division 2 of the Business and Professions Code or a nurse practitioner performing services in collaboration with a physician pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of the Business and Professions Code. (b) This section shall not require a primary care provider to accept the assignment of a number of insureds that would exceed standards of good health care as provided in Section 10133.5. (c) This section shall not be interpreted to modify subdivision (e) of Section 2836.1 of the Business and Professions Code or subdivision (b) of Section 3516 of the Business and Professions Code. (Amended by Stats. 2014, Ch. 71, Sec. 100. (SB 1304) Effective January 1, 2015.)
10133.5.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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The commissioner must issue regulations for certain health insurers to help insureds get needed care in a timely way.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.5. (a) The commissioner shall, on or before January 1, 2004, promulgate regulations applicable to health insurers which contract with providers for alternative rates pursuant to Section 10133 to ensure that insureds have the opportunity to access needed health care services in a timely manner. (b) These regulations shall be designed to assure accessibility of provider services in a timely manner to individuals comprising the insured or contracted group, pursuant to benefits covered under the policy or contract. The regulations shall insure: 1.Adequacy of number and locations of institutional facilities and professional providers, and consultants in relationship to the size and location of the insured group and that the services offered are available at reasonable times. 2.Adequacy of number of professional providers, and license classifications of such providers, in relationship to the projected demands for services covered under the group policy or plan. The department shall consider the nature of the specialty in determining the adequacy of professional providers. 3.The policy or contract is not inconsistent with standards of good health care and clinically appropriate care. 4. All contracts including contracts with providers, and other persons furnishing services, or facilities shall be fair and reasonable. (c) In developing standards under subdivision (a), the department shall also consider requirements under federal law; requirements under other state programs and law, including utilization review; and standards adopted by other states, national accrediting organizations and professional associations. The department shall further consider the accessability to provider services in rural areas. (d) In designing the regulations the commissioner shall consider the regulations in Title 28, of the California Administrative Code of Regulations, commencing with Section 1300.67.2, which are applicable to Knox-Keene plans, and all other relevant guidelines in an effort to accomplish maximum accessibility within a cost efficient system of indemnification. The department shall consult with the Department of Managed Health Care concerning regulations developed by that department pursuant to Section 1367.03 of the Health and Safety Code and shall seek public input from a wide range of interested parties. (e) Health insurers that contract for alternative rates of payment with providers shall report annually on complaints received by the insurer regarding timely access to care. The department shall review these complaints and any complaints received by the department regarding timeliness of care and shall make public this information. (f) The department shall report to the Assembly Committee on Health and the Senate Committee on Insurance of the Legislature on March 1, 2003, and on March 1, 2004, regarding the progress towards the implementation of this section. (g) Every three years, the commissioner shall review the latest version of the regulations adopted pursuant to subdivision (a) and shall determine if the regulations should be updated to further the intent of this section. (Amended by Stats. 2002, Ch. 797, Sec. 5. Effective January 1, 2003.)
10133.52.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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This section requires the department to set reporting instructions and deadlines for health insurers about prior authorization, and it eventually bars prior authorization for services on a published list unless an exception applies.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.52. (a) On or before July 1, 2026, the department shall issue instructions to health insurers to report all covered health care services subject to prior authorization, the percentage rate at which they are approved or modified by the health insurer or its delegated entity, and other statistics regarding prior authorization determinations as determined by the department. These instructions shall include a standard reporting template. (b) (1) On or before December 31, 2026, a health insurer shall report to the department, in accordance with the instructions issued pursuant to subdivision (a), the covered health care services subject to prior authorization, the percentage rate at which they are approved or modified by the health insurer or its delegated entity, data regarding requested or authorized duration, frequency, or level of care of the health care services, and other statistics regarding prior authorization determinations pursuant to subdivision (a). Data regarding modifications shall be reported separately from approvals in accordance with the instructions issued pursuant to subdivision (a). (2) If a health insurer delegates responsibility for decisions regarding prior authorization requests to another entity, the health insurer shall obtain information required to be reported by this section from each delegated entity and include that information in the health insurer’s report to the department. A health insurer shall require a delegated entity to comply with a request made pursuant to this paragraph. (c) (1) The department shall evaluate the reports received pursuant to this section and identify the health care services approved by health insurers or their delegated entities at a rate that meets or exceeds the threshold rate of 90 percent. For purposes of this paragraph, “approved” may also include modified requests for the purpose of calculating the threshold rate as the department determines appropriate. (2) The department may consider all of the following factors when determining the appropriateness of removing prior authorization for a specific covered health care service, regardless of its approval percentage rate: (A) Utilization of a health care service in a manner inconsistent with current clinical practice guidelines published in peer-reviewed medical literature or United States Food and Drug Administration-approved indications, as applicable. (B) The potential for fraud, waste, and abuse. (C) The potential for cost savings from eliminating prior authorization, including out-of-pocket cost savings to the insured. (D) The potential for improvements in quality of care, health care outcomes, and timely access to care for insureds from eliminating prior authorization. (E) Other factors deemed appropriate by the department. (3) Before finalizing the list of covered health care services pursuant to this section, the department shall consult interested stakeholders. (4) On or before July 1, 2027, the department shall publish the list of covered health care services identified pursuant to paragraph (1). As of the date specified in subparagraph (A) of paragraph (5), a health insurer shall not impose prior authorization on a covered health care service included on the list published by the department pursuant to this paragraph. (5) The department shall issue instructions to health insurers regarding all of the following: (A) The date, which shall be no later than January 1, 2028, by which the health insurer and its delegated entities shall cease requiring prior authorization for the covered health care services identified pursuant to this subdivision. When issuing the date by which a health insurer and its delegated entities shall cease requiring prior authorization pursuant to this section, the department shall take into consideration the time necessary for insurers to update their policies. (B) Requirements for notifying providers of the change in prior authorization requirements. (C) The process by which a health insurer may petition the department to reinstate the ability of the health insurer to use prior authorization for a particular covered health care service upon a showing of good cause that a lack of prior authorization for the covered health care service has resulted in a demonstrable increase in the cost of care or decrease in the quality of care for the health insurer’s insureds, including fraud, waste, or abuse. The department determination on a petition pursuant to this subparagraph shall be made within 60 days of receipt of all information necessary for the department to issue a decision on the petition. A health insurer shall not reinstate prior authorization for a covered health care service subject to this section until authorized by the department and in accordance with any other law, as applicable. (6) The department may issue other instructions it deems necessary and appropriate to implement this section. (d) Notwithstanding subdivision (c), a health insurer may impose prior authorization on any of the following: (1) Outpatient prescription drugs in tier three or four of a health insurer’s formulary, as those tiers are defined in Section 10123.1932. (2) A drug or medical device prescribed or recommended for a use that is different from the use for which the drug or medical device has been cleared or approved for marketing by the United States Food and Drug Administration. (3) A covered health care service that is experimental or investigational, excluding services for which there is medical or scientific evidence, as defined in Section 10145.3. (4) A covered health care service that is prescribed or recommended for a use that is a novel application of an existing therapy or technology, excluding uses for which there is medical or scientific evidence, as defined in Section 10145.3. (5) A covered health care service requested, ordered, prescribed, delivered, furnished, or dispensed by an out-of-network or noncontracting provider. (e) A covered health care service that is exempted from prior authorization pursuant to this section constitutes a service authorized by the health insurer for purposes of Section 796.04. A health insurer or its delegated entity shall not deny or reduce the contracted or agreed upon payment, or the applicable rate or reimbursement methodology specified in a policy, for a covered health care service exempted from a prior authorization requirement pursuant to this section unless the provider failed to substantially perform or supply the covered health care service. (f) Notwithstanding subdivision (c), a health insurer may, in accordance with any other applicable law, reinstate prior authorization for a specific health care provider on a covered health care service for which prior authorization is otherwise prohibited pursuant to subdivision (c) only if the health insurer has determined, based on clear and convincing evidence, that the health care provider has engaged in either of the following: (1) Fraudulent activity related to the provision or billing of health care services. (2) Pattern or practice of repeatedly providing care that is clinically inappropriate or inconsistent with generally accepted standards of care, and that results in either potential harm to patients or excessive utilization of health care resources inconsistent with generally accepted standards of care. (g) (1) The department may contract with a consultant or consultants with expertise in this subject area to assist the department in implementing this section, including developing instructions described in subdivision (a), evaluating the reports received by the department pursuant to subdivision (b), developing and publishing a list pursuant to subdivision (c), developing other implementation instructions, and drafting the report required pursuant to this section. (2) The department’s contract with a consultant shall include conflict-of-interest provisions to prohibit a person from participating in a report in which the person knows or has reason to know they have a material financial interest, including a person who has a consulting or other agreement with a person or organization that would be affected by the results of the report. (3) Contracts entered into pursuant to this subdivision are exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. (h) No later than four years after the date determined by the department for cessation of prior authorization requirements pursuant to subparagraph (A) of paragraph (5) of subdivision (c), the department shall publish a report regarding the impacts of the cessation of prior authorization requirements. A health insurer shall report information and data regarding the impacts of implementing this section, including effects on the volume of covered health care services subjected to prior authorization, statistics on prior authorization requests and determinations, administrative costs, timely access to care, insured health outcomes, and data on reinstatements of prior authorization pursuant to subdivision (f), to be included in this report. (i) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of bulletins, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until this section is repealed. (2) The department shall consult with the Department of Managed Health Care before issuing instructions and the list of covered health care services for which prior authorization is prohibited, pursuant to this section, to ensure consistency to the extent practical. (j) This section does not apply to a specialized health insurer, except to the extent the insurer provides or administers essential health benefits pursuant to health insurance policies or certificates subject to Section 10112.27. (k) For purposes of this section: (1) “Covered health care service” means a health care item, product, drug, supply, procedure, treatment, or service covered by a health insurance policy or certificate. (2) “Prior authorization” means the process by which utilization review determines the medical necessity or medical appropriateness of otherwise covered health care services prior to or concurrent with the rendering of those health care services. “Prior authorization” also includes an insurer’s or its delegated entity’s requirement that an insured or health care provider notify the health insurer before providing a health care service, including preauthorization, precertification, and prior approval. (l) This section shall remain in effect only until January 1, 2034, and as of that date is repealed. (Added by Stats. 2025, Ch. 408, Sec. 2. (SB 306) Effective January 1, 2026. Repealed as of January 1, 2034, by its own provisions.)
10133.53.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurers in these plans must give insureds and contracting providers periodic information about timely access to care, appointment wait times, and interpreter services.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.53. (a) (1) A health insurance policy that is issued, renewed, or amended on or after July 1, 2017, that provides benefits through contracts with providers for alternative rates pursuant to Section 10133 shall provide information to an insured regarding the standards for timely access to care adopted pursuant to Section 10133.5 and the information required by this section, including information related to receipt of interpreter services in a timely manner, no less than annually. (2) A health insurance policy that is issued, renewed, or amended on or after July 1, 2022, that provides benefits through contracts with providers for alternative rates pursuant to Section 10133 shall provide information to an insured regarding the standards for timely access to care required by Section 10133.54, adopted pursuant to Section 10133.5, and the information required by this section, including information related to receipt of interpreter services in a timely manner, no less than annually. (b) A health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall, at a minimum, provide information regarding appointment wait times for urgent care, nonurgent primary care, nonurgent specialty care, and telephone screening established in Section 10133.54 or pursuant to Section 10133.5 to insureds and contracting providers. The information shall also include notice of the availability of interpreter services at the time of the appointment pursuant to Section 10133.8. A health insurer may indicate that exceptions to appointment wait times may apply if the department has found exceptions to be permissible. (c) The information required to be provided pursuant to this section shall be provided to an insured with individual coverage upon initial enrollment and annually thereafter upon renewal, and to insureds and group policyholders with group coverage upon initial enrollment and annually thereafter upon renewal. An insurer may include this information with other materials sent to the insured. The information shall also be provided in the following manner: (1) In a separate section of the evidence of coverage titled “Timely Access to Care.” (2) At least annually, in or with newsletters, outreach, or other materials that are routinely disseminated to the policy’s insureds. (3) Commencing January 1, 2018, in a separate section of the provider directory published and maintained by the insurer pursuant to Section 10133.15. The separate section shall be titled “Timely Access to Care.” (4) On the internet website published and maintained by the insurer, in a manner that allows insureds and prospective insureds to easily locate the information. (d) (1) A health insurer shall provide the information required by this section to contracting providers on no less than an annual basis. (2) A health insurer shall also inform a contracting provider of all of the following: (A) Information about a health insurer’s obligation under California law to provide or arrange for timely access to care. (B) How a contracting provider or insured can contact the health insurer to obtain assistance if a patient is unable to obtain a timely referral to an appropriate provider. (C) The toll-free telephone number for the Department of Insurance where providers and insureds can file a complaint if they are unable to obtain a timely referral to an appropriate provider. (3) A health insurer may comply with this subdivision by including the information with an existing communication with a contracting provider. (Amended by Stats. 2021, Ch. 724, Sec. 4. (SB 221) Effective January 1, 2022.)
10133.54.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurers must provide timely access to covered health care services and meet specified appointment and phone-response time limits, subject to stated exceptions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.54. (a) This section applies to policies of health insurance, as defined by subdivision (b) of Section 106. The requirements of this section apply to all health care services covered by a health insurance policy. (b) Notwithstanding Section 10133.5, a health insurer shall comply with the timely access requirements in this section, but a specialized health insurance policy as defined in subdivision (c) of Section 106, other than a specialized mental health insurance policy, is exempt from the provisions of this section, except as specified in paragraph (6) and subdivision (c). (1) A health insurer shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the insured’s condition, consistent with good professional practice. An insurer shall establish and maintain provider networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. An insurer that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier. (2) A health insurer shall ensure that all insurer and provider processes necessary to obtain covered health care services, including, but not limited to, prior authorization processes, are completed in a manner that assures the provision of covered health care services to an insured in a timely manner appropriate for the insured’s condition and in compliance with this section. (3) If it is necessary for a provider or an insured to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the insured’s health care needs, and ensures continuity of care consistent with good professional practice, and consistent with the objectives of Section 10133.5, the regulations adopted pursuant to Section 10133.5, and this section. (4) Interpreter services required by Section 10133.8 of this code and Article 12.1 (commencing with Section 2538.1) of Title 10 of the California Code of Regulations shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment, consistent with Section 2538.6 of Title 10 of the California Code of Regulations, without imposing delay on the scheduling of the appointment. This subdivision does not modify the requirements established in Sections 10133.8 and 10133.9 of this code and Section 2538.6 of Title 10 of the California Code of Regulations, or approved by the department pursuant to Section 2538.6 of Title 10 of the California Code of Regulations for an insurer’s language assistance program. (5) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), a health insurer shall ensure that its contracted provider network has adequate capacity and availability of licensed health care providers to offer insureds appointments that meet the following timeframes: (A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subparagraph (H). (B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subparagraph (H). (C) Nonurgent appointments for primary care: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I). (D) Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I). (E) Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I). (F) Commencing July 1, 2022, nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subparagraph (H). This subparagraph does not limit coverage for nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days. (G) Nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I). (H) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the insured. (I) Preventive care services, as defined in subdivision (e), and periodic follow up care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice. (J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subparagraph (A), (B) or (D), unless the requirements in subparagraph (H) or (I) are met, and shall be subject to the other provisions of this section. (6) (A) The following types of health insurance policies shall be subject to the requirements in subparagraph (B): (i) A health insurance policy covering the pediatric oral or vision essential health benefit. (ii) A specialized health insurance policy that provides coverage for the pediatric oral essential health benefit, as defined in paragraph (5) of subdivision (a) of Section 10112.27. (iii) A specialized health insurance policy that covers dental benefits only, as defined in subdivision (c) of Section 106. (B) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), each health insurance policy specified in subparagraph (A) shall ensure that contracted oral or vision provider networks have adequate capacity and availability of licensed health care providers, including generalist and specialist dentists, ophthalmologists, optometrists, and opticians, to offer insureds appointments for covered oral or vision services in accordance with the following requirements: (i) Urgent appointments within the plan network shall be offered within 72 hours of the time of request for appointment, if consistent with the insured’s individual needs and as required by professionally recognized standards of dental practice. (ii) Nonurgent appointments shall be offered within 36 business days of the request for appointment, except as provided in clause (iii). (iii) Preventive care appointments shall be offered within 40 business days of the request for appointment. (iv) The applicable waiting time for a particular appointment in this paragraph may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the provider’s practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the insured. (7) An insurer shall ensure it has sufficient numbers of contracted providers to maintain compliance with the standards established by this section. (A) This section does not modify the requirements regarding accessibility established by Article 6 (commencing with Section 2240) of Title 10 of the California Code of Regulations. (B) An insurer shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by assisting an insured to locate available and accessible contracted providers in a timely manner appropriate for the insured’s health needs. An insurer shall arrange for the provision of services outside the insurer’s contracted network if unavailable within the network if medically necessary for the insured’s condition. Insured costs for medically necessary referrals to nonnetwork providers shall not exceed applicable in-network copayments, coinsurance, and deductibles. (8) An insurer shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone, as defined in subdivision (f). (A) An insurer shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the insured’s condition, and that the triage or screening waiting time does not exceed 30 minutes. (B) An insurer may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: insurer-operated telephone triage or screening services, telephone medical advice services pursuant to Section 10279, the insurer’s contracted primary care and mental health care or substance use disorder provider network, or other method that provides triage or screening services consistent with this section. (i) An insurer that arranges for the provision of telephone triage or screening services through contracted primary care and mental health care and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening insured telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine, an answering service, or office staff, that shall inform the caller of both of the following: (I) Regarding the length of wait for a return call from the provider. (II) How the caller may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or if needed, deliver urgent or emergency care. (ii) An insurer that arranges for the provision of triage or screening services through contracted primary care and mental health care and substance use disorder providers who are unable to meet the time-elapsed standards established in subparagraph (A) shall also provide or arrange for the provision of insurer-contracted or operated triage or screening services, which shall, at a minimum, be made available to insureds affected by that portion of the insurer’s network. (iii) An unlicensed staff person handling insured calls may ask questions on behalf of a licensed staff person to help ascertain the condition of an insured so that the insured may be referred to licensed staff. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions in an attempt to assess, evaluate, advise, or make a decision regarding the condition of an insured or determine when an insured needs to be seen by a licensed medical professional. (9) A health insurance policy providing coverage for the pediatric oral and vision essential health benefit, and a specialized health insurance policy that provides coverage for dental care expenses only, shall require that contracted providers employ an answering service or a telephone answering machine during nonbusiness hours, which provides instructions regarding how an insured may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or if needed, deliver urgent or emergency care. (10) An insurer shall ensure that, during normal business hours, the waiting time for an insured to speak by telephone with an insurer customer service representative knowledgeable and competent regarding the insured’s questions and concerns shall not exceed 10 minutes, or that the covered person will receive a scheduled call-back within 30 minutes. (c) Notwithstanding subdivision (b), a specialized health insurance policy, as defined in subdivision (c) of Section 106, other than a specialized mental health insurance policy, is exempt from this section, except as specified in this subdivision. A specialized health insurance policy that provides coverage for dental care expenses only shall comply with paragraphs (1), (3), (4), (6), (7), (9), and (10) of subdivision (b). (d) An insurer shall incorporate the standards set forth in the insurer’s quality assurance systems and processes, as set forth in subdivision (b), and the processes as set forth in Title 10 of the California Code of Regulations, including Sections 2240.1, 2240.15, and 2240.16. An insurer shall not prevent, discourage, or discipline a contracting provider or employee for informing an insured or policyholder about the timely access standards. (e) For purposes of this section: (1) “Appointment waiting time” means the time from the initial request for health care services by an insured or the insured’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the insurer or completing any other condition or requirement of the insurer or its contracting providers. (2) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or other health condition and includes, but is not limited to, all of the services required by all of the following laws: (A) Section 146.130 of Title 45 of the Code of Federal Regulations. (B) Section 10112.2 (incorporating the requirements of Section 2713 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-13)). (C) Clause (ii) of subparagraph (A) of paragraph (2) of subdivision (a) of Section 10112.27. (3) “Provider group” has the meaning set forth in subdivision (v) of Section 10133.15. (4) “Triage” or “screening” means the assessment of an insured’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an insured who may need care for the purpose of determining the urgency of the insured’s need for care. (5) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an insured who may need care. (6) “Urgent care” means health care for a condition which requires prompt attention, consistent with paragraph (2) of subdivision (h) of Section 10123.135. (f) (1) The department may issue guidance to insurers regarding annual timely access and network reporting methodologies. The development and adoption of these methodologies shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2025. (2) Notwithstanding paragraph (1), the department may take compliance or disciplinary action, including imposition of administrative penalties, on the basis of noncompliance with any of the provisions of this section, including, but not limited to, timeframes for appointments and followup appointments. (3) The department may review and adopt standards, in addition to those specified in this article, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. In so doing, the department shall consider the nature of physician practices, including individual and group practices, as well as the nature of the network. The department shall also consider various circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. If the department finds that insurers and health care providers have difficulty meeting these standards, the department may make recommendations to the Assembly Committee on Health and the Senate Committee on Health. The development and adoption of standards under this paragraph shall not be subject to the Administrative Procedure Act until December 31, 2028. The department shall consult with stakeholders in developing the standards and methodologies described in this section. (g) Nothing in this section shall be construed to prevent the department from developing additional standards to improve timely access to care and network adequacy. (Amended by Stats. 2022, Ch. 601, Sec. 3. (SB 225) Effective January 1, 2023.)
10133.55.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Certain group disability insurers must file continuity-of-care policies and give enrollees notice, review information, and limited continuation rights for treatment with noncontracting providers.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.55. (a) (1) Except as provided in paragraph (2), every disability insurer covering hospital, medical, and surgical expenses on a group basis that contracts with providers for alternative rates pursuant to Section 10133 and limits payments under those policies to services secured by insureds and subscribers from providers charging alternative rates pursuant to these contracts, shall file with the Department of Insurance, a written policy describing how the insurer shall facilitate the continuity of care for new insureds or enrollees receiving services during a current episode of care for an acute condition from a noncontracting provider. This written policy shall describe the process used to facilitate continuity of care, including the assumption of care by a contracting provider. (2) On or before July 1, 2002, every disability insurer covering hospital, medical, and surgical expenses on a group basis that contracts with providers for alternative rates pursuant to Section 10133 and limits payments under those policies to services secured by insureds and subscribers from providers charging alternative rates pursuant to these contracts, shall file with the department a written policy describing how the insurer shall facilitate the continuity of care for new enrollees who have been receiving services for an acute, serious, or chronic mental health condition from a nonparticipating mental health provider when the enrollee’s employer has changed policies. Every written policy shall allow the new enrollee a reasonable transition period to continue his or her course of treatment with the nonparticipating mental health provider prior to transferring to another participating provider and shall include the provision of mental health services on a timely, appropriate, and medically necessary basis from the nonparticipating provider. The policy may provide that the length of the transition period take into account the severity of the enrollee’s condition and the amount of time reasonably necessary to effect a safe transfer on a case-by-case basis. Nothing in this paragraph shall be construed to require the insurer to accept a nonparticipating mental health provider onto its panel for treatment of other enrollees. For purposes of the continuing treatment of the transferring enrollee, the insurer may require the nonparticipating mental health provider, as a condition of the right conferred under this section, to enter into the standard mental health provider contract. (b) Notice of the policy and information regarding how enrollees may request a review under the policy shall be provided to all new enrollees, except those enrollees who are not eligible as described in subdivision (e). A copy of the written policy shall be provided to eligible enrollees upon request. The written policy required to be filed under subdivision (a) shall describe how requests to continue services with an existing noncontracting provider are reviewed by the insurer. The policy shall ensure that reasonable consideration is given to the potential clinical effect that a change of provider would have on the insured’s or subscriber’s treatment for the acute condition. (c) An insurer may require any nonparticipating provider whose services are continued pursuant to the written policy to agree in writing to meet the same contractual terms and conditions that are imposed upon the insurer’s participating providers, including location within the service area, reimbursement methodologies, and rates of payment. If the insurer determines that a patient’s health care treatment should temporarily continue with the patient’s existing provider or nonparticipating mental health provider, the insurer shall not be liable for actions resulting solely from the negligence, malpractice, or other tortious or wrongful acts arising out of the provision of services by the existing provider or nonparticipating mental health provider. (d) Nothing in this section shall require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the policy contract. (e) The written policy shall not apply to any insured or subscriber who is offered an out-of-network option, or who had the option to continue with his or her previous health benefits carrier or provider and instead voluntarily chose to change. (f) This section shall not apply to insurer contracts that include out-of-network coverage under which the insured or subscriber is able to obtain services from the insured’s or subscriber’s existing provider or nonparticipating mental health provider. (g) (1) For purposes of this section, “provider” refers to a person who is described in subdivision (f) of Section 900 of the Business and Professions Code. (2) For purposes of this section, “nonparticipating mental health provider” refers to a psychiatrist, licensed psychologist, licensed marriage and family therapist, licensed clinical social worker, or licensed professional clinical counselor who is not part of the insurer’s contracted provider network. (h) This section shall only apply to a group disability insurance policy if it provides coverage for hospital, medical, or surgical benefits. (Amended by Stats. 2011, Ch. 381, Sec. 36. (SB 146) Effective January 1, 2012.)
10133.56.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A health insurer must help an insured finish covered treatment with a terminated or nonparticipating provider when the insured qualifies under this section’s conditions.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions: (A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition. (B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. (ii) Completion of covered services under clause (i) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured. (C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy. (ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individual’s treating health care provider, completion of covered services for the maternal mental health condition shall not exceed 12 months from the diagnosis or from the end of pregnancy, whichever occurs later. (D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured. (E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured. (F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date or within 180 days of the effective date of coverage for a newly covered insured. (2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the provider’s services beyond the contract termination date. (3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c). (b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i). (c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer. (d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met. (e) For the purposes of this section, the following terms have the following meanings: (1) “Provider” means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code. (2) “Provider group” includes a medical group, independent practice association, or any other similar organization. (3) “Nonparticipating provider” means a provider who is not contracted with the insured’s health insurer to provide services under the insured’s policy. A nonparticipating provider does not include a terminated provider. (4) “Terminated provider” means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurer’s contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group. (5) “Maternal mental health condition” means a mental health condition that can impact a woman during pregnancy, peri or postpartum, or that arises during pregnancy, in the peri or postpartum period, up to one year after delivery. (f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity. (g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract. (h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. This section does not preclude an insurer from providing continuity of care beyond the requirements of this section. (i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following: (A) The newly covered insured’s prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market. (B) At the time the insured’s coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a). (2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of their new coverage. (3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the provider’s services. (B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c). (C) A provider’s agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract. (Amended by Stats. 2019, Ch. 776, Sec. 2. (AB 577) Effective January 1, 2020.)
10133.6.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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This section states the Legislature’s intent to support efficient health care contracting and says it does not change existing antitrust law for certain exclusion agreements based on licensing or certification differences.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.6. It is the intent of the Legislature to ensure that the citizens of this state receive high-quality health care coverage in the most efficient and cost-effective manner possible. In furtherance of this intent, the Legislature finds and declares that it is in the public interest to promote various types of contracts between public or private payers of health care coverage, and institutional or professional providers of health care services. This intent has been demonstrated by the recent enactment of Chapters 328, 329, and 1594 of the Statutes of 1982 authorizing various types of contracts to be entered into between public or private payers of health care coverage, and institutional or professional providers of health care services. The Legislature further finds and declares that individual providers, whether institutional or professional and individual purchasers, have not proven to be efficient-sized bargaining units for these contracts, and that the formation of groups and combinations of institutional and professional providers and purchasing groups for the purpose of creating efficient-sized contracting units represents a meaningful addition to the health care marketplace. The Legislature further finds and declares that the public interest in ensuring that citizens of this state receive high-quality health care coverage in the most efficient and cost-effective manner possible is furthered by permitting negotiations for alternative rate contracts between purchasers and payers and both institutional and professional providers, or through a person or entity acting for, or on behalf of, a health insurer or an institutional or professional provider, pursuant to Sections 10133 and 11512. It is the intent of the Legislature, therefore, that the formation of groups and combinations of purchasers, payers, and institutional and professional providers of health care services for the purpose of creating efficient-sized contracting units be recognized as the creation of a new product within the health care marketplace, and be subject, therefore, only to those antitrust prohibitions applicable to the conduct of other presumptively legitimate enterprises. This section does not change existing antitrust law as it relates to any agreement or arrangement to exclude from any of the above-described groups or combinations, any person who is lawfully qualified to perform the services to be performed by the members of the group or combination, where the ground for the exclusion is failure to possess the same license or certification as is possessed by the members of the group or combination. (Added by Stats. 1985, Ch. 1592, Sec. 3.)
10133.64.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurer contracts may not block the insurer from sharing cost or quality information, and insurers must give providers or suppliers 30 days to review methodology and data before that information is shared.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.64. (a) A contract issued, amended, renewed, or delivered on or after January 1, 2015, by or on behalf of a health insurer and a provider or supplier shall not contain any provision that restricts the ability of the health insurer to furnish consumers or purchasers information concerning any of the following: (1) The cost range of a procedure or a full course of treatment, including, but not limited to, facility, professional, and diagnostic services, prescription drugs, durable medical equipment, and other items and services related to the treatment. (2) The quality of services performed by the provider or supplier. (b) Any contractual provision inconsistent with this section shall be void and unenforceable. (c) A health insurer shall provide the provider or supplier an advance opportunity of 30 days to review the methodology and data developed and compiled by the health insurer, and used pursuant to subdivision (a), before cost or quality information is provided to consumers or purchasers, including material revisions or additions of new information. At the time the health insurer provides a provider or supplier with the opportunity to review the methodology and data, it shall also notify the provider or supplier in writing of their opportunity to provide an Internet Web site link pursuant to subdivision (f). (d) If the information proposed to be furnished to policyholders and insureds on the quality of services performed by a provider or supplier is data that the insurer has developed and compiled, the insurer shall utilize appropriate risk adjustment factors to account for different characteristics of the population, such as case mix, severity of patient’s condition, comorbidities, outlier episodes, and other factors to account for differences in the use of health care resources among providers and suppliers. (e) Any Internet Web site owned or controlled by a health insurer, or operated by another person or entity under contract with or on behalf of a health insurer, that displays the information developed and compiled by the health insurer as referenced by this section shall prominently post the following statement: “Individual health care facilities or providers may disagree with the methodology used to define the cost ranges, the cost data, or quality measures. Many factors may influence cost or quality, including, but not limited to, the cost of uninsured and charity care, the type and severity of procedures, the case mix of a facility, special services such as trauma centers, burn units, medical and other educational programs, research, transplant services, technology, payer mix, and other factors affecting individual health care facilities and providers.” A health insurer and a provider or supplier shall not be precluded from mutually agreeing in writing to an alternative method of conveying this statement. (f) If a provider or supplier chooses to provide an Internet Web site link where a response to the health insurer’s posting may be found, it shall do so in a timely manner in order to satisfy the requirements of this section. If a provider or supplier chooses to provide a response, an insurer shall post, in an easily identified manner, a prominent link to the provider’s or supplier’s Internet Web site where a response to the health insurer’s posting may be found. A health insurer and a provider or supplier shall not be precluded from mutually agreeing in writing to an alternative method to convey a provider’s or supplier’s response. (g) For the purposes of this section, the following definitions shall apply: (1) “Consumers” means policyholders or insureds of the health insurer or beneficiaries of a self-funded health coverage arrangement administered by the health insurer or other persons entitled to access services through a network established by the health insurer. (2) “Provider” has the same meaning as that term is defined in Section 10117.52. (3) “Purchasers” means the sponsors of a self-funded health coverage arrangement administered by the health insurer. (4) “Supplier” has the same meaning as that term is defined in Section 10117.52. (Amended by Stats. 2014, Ch. 83, Sec. 2. (SB 1340) Effective January 1, 2015.)
10133.641.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurers may not use certain out-of-state judgments or lawful mifepristone/medication-abortion-related conduct as the sole basis to terminate, refuse to renew, penalize, or discriminate against a provider.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.641. (a) A contract between a health insurer and a provider of health care services shall not contain any term that would result in termination or nonrenewal of the contract or otherwise penalize the provider, based solely on either of the following: (1) A civil judgment issued in another state, a criminal conviction in another state, or another professional disciplinary action in another state, if the judgment, conviction, or professional disciplinary action is based solely on the application of another state’s law that interferes with a person’s right to receive care that would be lawful if provided in this state. (2) The manufacture, transport, distribution, delivery, receipt, acquisition, sale, possession, furnishment, dispensation, repackaging, or storage of brand name or generic mifepristone or any drug used for medication abortion that is lawful under the laws of the state. (b) A health insurer shall not discriminate, with respect to the provision of, or contracts for, professional services, against a licensed provider solely on the basis of either of the following: (1) A civil judgment issued in another state, a criminal conviction in another state, or another professional disciplinary action in another state if the judgment, conviction, or professional disciplinary action is based solely on the application of another state’s law that interferes with a person’s right to receive care that would be lawful if provided in this state. (2) The manufacture, transport, distribution, delivery, receipt, acquisition, sale, possession, furnishment, dispensation, repackaging, or storage of brand name or generic mifepristone or any drug used for medication abortion that is lawful under the laws of the state. (c) This section does not apply to a civil judgment, a criminal conviction, or a disciplinary action imposed in another state based upon conduct that would subject a provider to claim, charge, or action under the laws of this state. (d) The commissioner may enforce this section pursuant to Chapter 4.5 (commencing with Section 11400) or Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code. This subdivision does not impair or restrict the commissioner’s enforcement authority pursuant to another provision of this code or the Administrative Procedure Act. (Amended by Stats. 2025, Ch. 136, Sec. 20. (AB 260) Effective September 26, 2025.)
10133.65.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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Health insurer contracts with health care providers may not include certain terms, and some material changes require advance notice and a provider right to terminate.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.65. (a) This section shall be known and may be cited as the Health Care Providers’ Bill of Rights. (b) No contract issued, amended, or renewed on or after January 1, 2003, between a health insurer and a health care provider for the provision of covered benefits at alternative rates of payment to an insured shall contain any of the following terms: (1) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients’ access to, or continuity of, care. (2) A requirement to comply with quality improvement or utilization management programs or procedures of a health insurer, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the health insurer may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to subdivision (c). (3) A provision that waives or conflicts with any provision of the Insurance Code. (4) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information. (c) If a contract is with a health insurer that negotiates and arranges for alternative rates of payment with the provider to provide benefits to insureds, the contract may contain provisions permitting a material change to the contract by the health insurer if the health insurer provides at least 45 business days’ notice to the provider of the change, and the provider has the right to terminate the contract prior to implementation of the change. (d) With respect to a health insurance policy covering dental services or a specialized health insurance policy covering dental services, all of the following shall apply: (1) If a material change is made to the health insurer’s rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the insurer shall provide at least 45 business days’ written notice to the dentists contracting with the health insurer to provide services under the insurer’s individual or group health insurance policies, including specialized health insurance policies. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section. (2) For purposes of paragraph (1), a material change made to a health insurer’s rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the insurer adjudicates and pays claims for treatment that may cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the insurer that affect rates and fees paid to providers. (3) An insurer that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in subdivision (c) that have been made since the contract was issued or last renewed. (e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable. (f) The Department of Insurance shall annually compile all provider complaints that it receives under this section, and shall report to the Legislature and the Governor the number and nature of those complaints by March 15 of each calendar year. (g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between health insurers and health care providers. (h) For purposes of this section, the following definitions apply: (1) “Health care provider” means any professional person, medical group, independent practice association, organization, health facility, or other person or institution licensed or authorized by the state to deliver or furnish health care services. (2) “Health insurer” means any admitted insurer writing health insurance, as defined in Section 106, that enters into a contract with a provider to provide covered benefits at alternative rates of payment. (3) “Material” means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. (Amended by Stats. 2012, Ch. 447, Sec. 2. (AB 2252) Effective January 1, 2013.)
10133.66.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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A health insurer must follow specific claim-handling, reimbursement, acknowledgment, and disclosure rules.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.66. A health insurer shall comply with all the following: (a) Deadlines shall not be imposed for the receipt of a claim from a professional provider who submits a claim on behalf of an insured or pursuant to a professional provider’s contract with a health insurer that is less than 90 days for contracted providers and 180 days for noncontracted providers after the date of service, except as required by any state or federal law or regulation. If a health insurer is not the primary payor under coordination of benefits, the insurer shall not impose a deadline for submitting supplemental or coordination of benefits claims to any secondary payor that is less than 90 days from the date of payment or date of contest, denial, or notice from the primary payor. A health insurer that denies a claim because it was filed beyond the claim filing deadline shall, upon provider’s demonstration of good cause for the delay, accept and adjudicate the claim according to Section 10123.13 or 10123.147, whichever is applicable. This subdivision shall not alter or affect any rights providers may have under any applicable statute of limitations or antiforfeiture provisions available under the laws of the State of California. (b) Reimbursement requests for the overpayment of a claim shall not be made, including requests made pursuant to Section 10123.145, unless a written request for reimbursement is sent to the provider within 365 days of the date of payment on the overpaid claim. The written notice shall clearly identify the claim, the name of the patient, and the date of service, and shall include a clear explanation of the basis upon which it is believed the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim. The 365-day time limit shall not apply if the overpayment was caused in whole or in part by fraud or misrepresentation on the part of the provider. (c) The receipt of each claim shall be identified and acknowledged, whether or not complete, and the recorded date of receipt shall be disclosed in the same manner as the claim was submitted or provided through an electronic means, by telephone, Web site, or another mutually agreeable accessible method of notification, by which the provider may readily confirm the insurer’s receipt of the claim and the recorded date of receipt within 15 working days of the date of receipt of the claim by the office designated to receive the claim. If a claimant submits a claim to a health insurer using a claims clearinghouse, its identification and acknowledgment to the clearinghouse within the timeframes set forth above shall constitute compliance with this section. (d) Beginning July 1, 2006, prior to contracting, annually thereafter on or before the contract anniversary date, and in addition, upon the contracted provider’s written request, the health insurer shall disclose to contracting providers all of the following information in an electronic format: (1) The amount of payment for each service to be provided under the contract, including any fee schedules or other factors or units used in determining the fees for each service. To the extent that reimbursement is made pursuant to a specified fee schedule, the contract shall incorporate that fee schedule by reference, including the year of the schedule. For any proprietary fee schedule, the contract shall include sufficient detail that payment amounts related to that fee schedule can be accurately predicted. (2) The detailed payment policies and rules and nonstandard coding methodologies used to adjudicate claims, that shall, unless otherwise prohibited by state law do all of the following: (A) When available, be consistent with Current Procedural Terminology (CPT), and standards accepted by nationally recognized medical societies and organizations, federal regulatory bodies, and major credentialing organizations. (B) Clearly and accurately state what is covered by any global payment provisions for both professional and institutional services, any global payment provisions for all services necessary as part of a course of treatment in an institutional setting, and any other global arrangements such as per diem hospital payments. (C) At a minimum, clearly and accurately state the policies regarding all of the following: (i) Consolidation of multiple services or charges, and payment adjustments due to coding changes. (ii) Reimbursement for multiple procedures. (iii) Reimbursement for assistant surgeons. (iv) Reimbursement for the administration of immunizations and injectable medications. (v) Recognition of CPT modifiers. The information disclosures required by this section shall be in sufficient detail and in an understandable format that does not disclose proprietary trade secret information or violate copyright law or patented processes, so that a reasonable person with sufficient training, experience, and competence in claims processing can determine the payment to be made according to the terms of the contract. A health insurer may disclose the fee schedules mandated by this section through the use of a Web site so long as it provides written notice to the contracted provider at least 45 days prior to implementing a Web site transmission format or posting any changes to the information on the Web site. (Added by Stats. 2005, Ch. 441, Sec. 4. Effective January 1, 2006.)
10133.661.
## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. )
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The commissioner must provide complaint information, create a dedicated complaint web page, and respond to health insurance complaints within set deadlines.

## Insurance Code - INS ## DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.8] ( Division 2 enacted by Stats. 1935, Ch. 145. ) ## PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549] ( Part 2 enacted by Stats. 1935, Ch. 145. ) ## CHAPTER 1. The Contract [10110 - 10198.10] ( Chapter 1 enacted by Stats. 1935, Ch. 145. ) ## ARTICLE 2. Transfer [10129 - 10133.14] ( Article 2 enacted by Stats. 1935, Ch. 145. ) ## 10133.661. On or before July 1, 2006, the commissioner, pursuant to his or her authority under Section 12921.1, shall also complete all of the following duties: (a) Provide announcements that inform health insurance consumers and their health care providers of the department’s toll-free telephone number that is dedicated to the handling of complaints and of the availability of the Internet Web page established under this section, and the process to register a complaint with the department and to submit an inquiry to it. (b) Establish an Internet Web page located on the department’s public Internet Web site dedicated exclusively to processing complaints and inquiries relating to health insurance issues from insureds and their health care providers. The Web page shall provide insureds and their health care providers with information concerning filing a complaint and making an inquiry concerning a health insurer and, at a minimum, shall provide the following information: (1) The department’s toll-free telephone number. (2) A list of all health insurers licensed by the department. (3) Educational and informational guides for health insurance consumers and health care providers describing their rights under this code. The guides shall be easy to read and understand and shall be made available to the public, including access on the department’s Internet Web site. (4) A separate, standardized complaint form for health care providers to file a complaint. (c) An insured or health care provider may file a written complaint with the department with respect to the handling of a claim or other obligation under a health insurance policy by a health insurer or production agency, or with respect to the alleged misconduct by a health insurer or production agency. The commissioner shall notify the complainant of the receipt of the complaint within 10 business days of its receipt. The commissioner shall make a determination on the complaint within 60 calendar days of the date of its receipt, unless the commissioner, in his or her discretion, determines that additional time is reasonably necessary to fully and fairly evaluate the complaint. The commissioner shall notify the complainant of the final action taken on his or her complaint within 30 days of the final action. The notification shall include a summary explaining the commissioner’s reasons for the final action. (Added by renumbering Section 10133.66 (as added by Stats. 2005, Ch. 723) by Stats. 2006, Ch. 405, Sec. 9. Effective September 22, 2006. Operative January 1, 2007, by Sec. 14 of Ch. 405.)

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