Cal. HSC § 1367.255 — California Code / Code hsc / Division 2 / Chapter 2.2 / Article 5 / Section 1367.255
Section 1367.255
Status: in_force

(a) (1) A health care service plan contract 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 and procedures. For a qualifying health plan for a health savings account, the carrier shall establish the plan’s cost sharing for vasectomy services and procedures at the minimum level necessary to preserve the enrollee’s ability to claim tax-exempt contributions and withdrawals from the enrollee’s health savings account under Internal Revenue Service laws, regulations, and guidance. Cost sharing shall not be imposed on a Medi-Cal beneficiary.

(2) A health care service plan shall not impose any restrictions or delays, including, but not limited to, prior authorization, on vasectomy services or procedures.

(3) Benefits for an enrollee under this section shall be the same for an enrollee’s covered spouse and covered nonspouse dependents.

(4) For purposes of this section, “health care service plan” includes Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to 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, to the extent that the benefits described in this subdivision are made the financial responsibility of the Medi-Cal managed care plan under its comprehensive risk contract with the State Department of Health Care Services. If some or all of the benefits described in this subdivision are not the financial responsibility of the Medi-Cal managed care plan, as determined by the State Department of Health Care Services, those benefits shall be available to Medi-Cal beneficiaries on a fee-for-service basis pursuant to subdivision (n) of Section 14132 of the Welfare and Institutions Code.

(5) Utilization controls applicable to services described in this section provided by a Medi-Cal managed care plan shall be subject to this section.

(b) Notwithstanding any other provision of this section, a religious employer may request a health care service plan contract without coverage for contraceptive methods that are contrary to the religious employer’s religious tenets. If so requested, a health care service plan contract 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) A health care service plan that contracts with a religious employer to provide a health care service plan 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 enrollee’s health care service plan.

(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 as described in Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended.

(c) This section shall not be construed to deny or restrict in any way the department’s authority to ensure plan compliance with this chapter when a plan provides coverage for contraceptive drugs, devices, and products.

(d) This section shall not be construed to require an individual or group health care service plan contract to cover experimental or investigational treatments.

(e) 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.