Cal. INS § 10123.862 — California Code / Code ins / Division 2 / Part 2 / Chapter 1 / Article 1 / Section 10123.862
Section 10123.862
Status: in_force

(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.