reglab/housing_qa huggingface dataset:
CA Health & Safety Code § 1374.28 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.5 - Health Care Service Plan Coverage Contract Changes|Section 1374.28.

1374.28.  In addition to any other penalty provided by law or the availability of any administrative procedure, if a health care service plan, after notice and hearing, is found to have violated this article, or regulations adopted pursuant to this article, or knowingly permits any person to do so, the director may suspend the authority of the plan to transact business.(Amended by Stats. 1999, Ch. 525, Sec. 114. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.29 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.5 - Health Care Service Plan Coverage Contract Changes|Section 1374.29.

1374.29.  The purpose of this article is to promote the public interest, to prevent unfair and unlawful health care business practices, and to promote adequate consumer and employer advance notice of changes in the cost of health coverage in order to allow for comparative shopping and to reduce the cost of health coverage.(Added by renumbering Section 1374.20 by Stats. 2002, Ch. 336, Sec. 3. Effective January 1, 2003.)
CA Health & Safety Code § 1374.31 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.55 - Appeals Seeking Independent Medical Reviews|Section 1374.31.

1374.31.  (a)  If there is an imminent and serious threat to the health of the enrollee, as specified in subdivision (c) of Section 1374.33, all necessary information and documents shall be delivered to an independent medical review organization within 24 hours of approval of the request for review. In reviewing a request for review, the department may waive the requirement that the enrollee follow the plan’s grievance process in extraordinary and compelling cases, where the director finds that the enrollee has acted reasonably. (b)  The department shall expeditiously review requests and immediately notify the enrollee in writing as to whether the request for an independent medical review has been approved, in whole or in part, and, if not approved, the reasons therefor. The plan shall promptly issue a notification to the enrollee, after submitting all of the required material to the independent medical review organization, that includes an annotated list of documents submitted and offer the enrollee the opportunity to request copies of those documents from the plan. The department shall promptly approve enrollee requests whenever the enrollee’s plan has agreed that the case is eligible for an independent medical review. The department shall not refer coverage decisions for independent review. To the extent an enrollee request for independent review is not approved by the department, the enrollee request shall be treated as an immediate request for the department to review the grievance pursuant to subdivision (b) of Section 1368. (c)  An independent medical review organization, specified in Section 1374.32, shall conduct the review in accordance with Section 1374.33 and any regulations or orders of the director adopted pursuant thereto. The organization’s review shall be limited to an examination of the medical necessity of the disputed health care services and shall not include any consideration of coverage decisions or other contractual issues. (Added by Stats. 1999, Ch. 533, Sec. 1. Effective January 1, 2000.)
CA Health & Safety Code § 1374.35 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.55 - Appeals Seeking Independent Medical Reviews|Section 1374.35.

1374.35.  (a)  After considering the results of a competitive bidding process and any other relevant information on program costs, the director shall establish a reasonable, per-case reimbursement schedule to pay the costs of independent medical review organization reviews, which may vary depending on the type of medical condition under review and on other relevant factors. (b)  The costs of the independent medical review system for enrollees shall be borne by health care service plans pursuant to an assessment fee system established by the director. In determining the amount to be assessed, the director shall consider all appropriations available for the support of this chapter, and existing fees paid to the department. The director may adjust fees upward or downward, on a schedule set by the department, to address shortages or overpayments, and to reflect utilization of the independent review process. (Added by Stats. 1999, Ch. 533, Sec. 1. Effective January 1, 2000.)
CA Health & Safety Code § 1374.36 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.55 - Appeals Seeking Independent Medical Reviews|Section 1374.36.

1374.36.  (a)  The director shall submit to the Legislature by March 1, 2002, a report on the initial implementation of this article. The report shall include a description of assessments imposed on plans to implement this article, increased staffing and other resources attributable to these new responsibilities, and any redirection of existing staff and resources to carry out these responsibilities. A single copy of the report shall be made available at no cost to members of the public upon request. The department may recover the cost of additional copies that are requested. (b)  This section shall become operative on January 1, 2001, and then only if Assembly Bill 55 of the 1999–2000 Regular Session is enacted. (Added by Stats. 1999, Ch. 542, Sec. 11. Effective January 1, 2000. Section operative January 1, 2001, by its own provisions.)
CA Health & Safety Code § 1374.60 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.60.

1374.60.  For purpose of this article, the following definitions shall apply:(a) A “point-of-service plan contract” means any plan contract offered by a health care service plan whereby the health care service plan assumes financial risk for both “in-network coverage or services” and “out-of-network coverage or services.”The term “point-of-service plan contract” shall not apply to a plan contract where the out-of-network coverage or service is underwritten by an insurance company admitted in this state or is provided by a self-insured employer and is offered in conjunction with in-network coverage or services provided pursuant to a health care service plan contract.(b) “Out-of-network coverage or services” means health care services received either from (1) providers who are not employed by, under contract with, or otherwise affiliated with the health care service plan, except for health care services received from these providers in an emergency or when referred or authorized by the plan under procedures specifically reviewed and approved by the director or (2) providers who are employed by, under contract with, or otherwise affiliated with a health care service plan in instances when the “in-network coverage or services” requirements for care set forth in the health care service plan’s approved evidence of coverage are not met.(c) “In-network coverage or services” means all of the following:(1) All the health care services provided or offered under the requirements of this chapter that are received from a provider employed by, under contract with, or otherwise affiliated with the health care service plan and in accordance with the procedures set forth in the plan’s approved evidence of coverage.(2) Health care services received from a provider not affiliated with the health care service plan when the plan arranges for the enrollee to receive services from that provider.(3) Out-of-area emergency care provided in accordance with the procedures set by the health care service plan to be followed in securing these services.(Amended by Stats. 1999, Ch. 525, Sec. 115. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.62 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.62.

1374.62.  A point-of-service plan contract, in which any risk for out-of-network coverage or services is transferred from a health care service plan through reinsurance, shall be subject to this article.(Added by Stats. 1993, Ch. 987, Sec. 3. Effective January 1, 1994.)
CA Health & Safety Code § 1374.65 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.65.

1374.65.  Point-of-service plan contracts shall:(a)  Provide incentives, including financial incentives, for enrollees to use in-network coverage or services. (b)  Only offer coverage or services obtained out-of-network if it also provides coverage or services on an in-network basis. (c)  Shall not consider the following to be out-of-network coverage or services: (1)  Health care services received from a provider not affiliated with the health care service plan when the plan arranges for the enrollee to receive services from that provider. (2)  Out-of-area emergency care provided in accordance with the procedures set by the health care service plan to be followed in securing these services. (Added by Stats. 1993, Ch. 987, Sec. 3. Effective January 1, 1994.)
CA Health & Safety Code § 1374.67 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.67.

1374.67.  A health care service plan offering a point-of-service plan contract is subject to the following limitations:(a) A health care service plan shall limit its offering of point-of-service plan contracts so that no more than 50 percent of the plan’s total premium revenue in any fiscal quarter is earned from point-of-service plan contracts.(b) A health care service plan offering a point-of-service plan contract shall not expend in any fiscal-year quarter more than 20 percent of its total health care expenditures for all its enrollees for out-of-network services for point-of-service enrollees.(c) If the amount specified in subdivision (a) or (b) is exceeded by 2 percent in any quarter, the health care service plan shall come into compliance with subdivisions (a) and (b) by the end of the next following quarter. If compliance with the amount specified in subdivisions (a) and (b) is not demonstrated in the health care service plan’s next quarterly report, the director may prohibit the health care service plan from offering a point-of-service plan contract to new groups, or may require the health care service plan to amend one or more of its point-of-service contracts at the time of renewal to delete some or all of the out-of-network coverage or services as may be necessary for the plan to demonstrate compliance to the director’s satisfaction.(d) The limitation imposed by this section shall not apply to a plan which in substantial part indemnified subscribers and enrollees pursuant to contracts issued under such plan’s former registration under the Knox-Mills Health Plan Act in 1975 and as of that date, and on September 1, 1993, was offering point-of-service plan contracts previously approved by the director.(Amended by Stats. 1999, Ch. 525, Sec. 118. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.68 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.68.

1374.68.  A health care service plan that offers a point-of-service plan contract shall do all of the following:(a) Deposit with the director or, at the discretion of the director, with any organization or trustee acceptable to the director through which a custodial or controlled account is maintained, cash, securities, or any combination of these, which is acceptable to the director, that at all times have a fair market value equal to the greater of either one of the following:(1) Two hundred thousand dollars ($200,000).(2) One hundred twenty percent of the plan’s current monthly claims payable plus incurred but not reported balance for coverage out-of-network coverage or services provided under point-of-service contracts.(b) Track out-of-network point-of-service utilization separately from in-network utilization.(c) Record point-of-service utilization in a manner that will permit utilization and cost reporting as the director may require.(d) Demonstrate to the satisfaction of the director that the health care service plan has the fiscal, administrative, and marketing capacity to control its point-of-service plan contract enrollment, utilization, and costs so as not to jeopardize the financial viability or organizational and administrative capacity of the health care service plan.(e) Maintain the deposit required under subdivision (a) in a manner agreed to by the director, subject to subdivision (a) of Section 1377 and any regulations adopted thereunder.(f) Any deposit made pursuant to this section shall be a credit against any deposit required by subdivision (a) of Section 1377.(Amended by Stats. 1999, Ch. 525, Sec. 119. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.69 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.69.

1374.69.  At least 20 business days prior to offering a point-of-service plan contract, a health care service plan shall file a notice of material modification in accordance with Section 1352. The notice of material modification shall include, but not be limited to, provisions specifying how the health care service plan shall accomplish all of the following:(a) Design the benefit levels and conditions of coverage for in-network coverage and services and out-of-network point-of-service utilization.(b) Provide or arrange for the provision of adequate systems to do all of the following:(1) Process and pay claims for all out-of-network coverage and services.(2) Generate accurate financial and utilization data and reports on a timely basis, so that it and any authorized regulatory agency can evaluate the health care service plan’s experience with point-of-service plan contracts and monitor compliance with point-of-service plan contract projections established by the health care service plan and regulatory requirements.(3) Track and monitor the quality of health care obtained out-of-network by plan enrollees to the extent reasonable and possible.(4) Respond promptly to enrollee grievances and complaints, written or oral, including those regarding services obtained out-of-network.(5) Meet the requirements for a point-of-service plan contract set forth in this section and any additional requirements that may be required by the director.(c) Comply initially and on an ongoing basis with the requirements of this article.(d) This section shall become operative July 1, 1995.(Amended by Stats. 1999, Ch. 525, Sec. 120. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.71 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.71.

1374.71.  No plan formerly registered under the Knox-Mills Health Plan Act (Article 2.5 (commencing with Section 12530) of Chapter 6 of Part 2 of Division 3 of Title 2 of the Government Code) in 1975 shall be required to file a notice of material modification under Section 1374.69 or 1374.70 for any point-of-service plan contract previously approved by the director under this chapter and offered by plan on or before September 1, 1993.(Amended by Stats. 1999, Ch. 525, Sec. 121. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1374.74 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.74.

1374.74.  (a) The department, in consultation with the Department of Insurance, shall convene an Autism Advisory Task Force by February 1, 2012, in collaboration with other agencies, departments, advocates, autism experts, health plan and health insurer representatives, and other entities and stakeholders that it deems appropriate. The Autism Advisory Task Force shall develop recommendations regarding behavioral health treatment that is medically necessary for the treatment of individuals with autism or pervasive developmental disorder. The Autism Advisory Task Force shall address all of the following:(1) Interventions that have been scientifically validated and have demonstrated clinical efficacy.(2) Interventions that have measurable treatment outcomes.(3) Patient selection, monitoring, and duration of therapy.(4) Qualifications, training, and supervision of providers.(5) Adequate networks of providers.(b) The Autism Advisory Task Force shall also develop recommendations regarding the education, training, and experience requirements that unlicensed individuals providing autism services shall meet in order to secure a license from the state.(c) The department shall submit a report of the Autism Advisory Task Force to the Governor, the President pro Tempore of the Senate, the Speaker of the Assembly, and the Senate and Assembly Committees on Health by December 31, 2012, on which date the task force shall cease to exist.(Amended by Stats. 2012, Ch. 162, Sec. 82. (SB 1171) Effective January 1, 2013.)
CA Health & Safety Code § 1374.76 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5.6 - Point-of-Service Health Care Service Plan Contracts|Section 1374.76.

1374.76.  (a) No later than January 1, 2015, a large group health care service plan contract shall provide all covered mental health and substance use disorder benefits in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343) and all rules, regulations, and guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).(b) No later than January 1, 2015, an individual or small group health care service plan contract shall provide all covered mental health and substance use disorder benefits in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), all rules, regulations, and guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26), and Section 1367.005.(c) Until January 1, 2016, the director may issue guidance to health care service plans regarding compliance with this section. This 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). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance under this subdivision.(Added by Stats. 2014, Ch. 31, Sec. 8. (SB 857) Effective June 20, 2014.)
CA Health & Safety Code § 1375.1 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 6 - Operation and Renewal Requirements and Procedures|Section 1375.1.

1375.1.  (a) Every plan shall have and shall demonstrate to the director that it has all of the following:(1) A fiscally sound operation and adequate provision against the risk of insolvency.(2) Assumed full financial risk on a prospective basis for the provision of covered health care services, except that a plan may obtain insurance or make other arrangements for the cost of providing to any subscriber or enrollee covered health care services, the aggregate value of which exceeds five thousand dollars ($5,000) in any year, for the cost of covered health care services provided to its members other than through the plan because medical necessity required their provision before they could be secured through the plan, and for not more than 90 percent of the amount by which its costs for any of its fiscal years exceed 115 percent of its income for that fiscal year.(3) A procedure for prompt payment or denial of provider and subscriber or enrollee claims, including those telehealth services, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, covered by the plan. Except as provided in Section 1371, a procedure meeting the requirements of Subchapter G of the regulations (29 C.F.R. Part 2560) under Public Law 93-406 (88 Stats. 829-1035, 29 U.S.C. Secs. 1001 et seq.) shall satisfy this requirement.(b) In determining whether the conditions of this section have been met, the director shall consider, but not be limited to, the following:(1) The financial soundness of the plan’s arrangements for health care services and the schedule of rates and charges used by the plan.(2) The adequacy of working capital.(3) Agreements with providers for the provision of health care services.(c) For the purposes of this section, “covered health care services” means health care services provided under all plan contracts.(Amended by Stats. 2012, Ch. 782, Sec. 7. (AB 1733) Effective January 1, 2013.)
CA Health & Safety Code § 1375.2 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 6 - Operation and Renewal Requirements and Procedures|Section 1375.2.

1375.2.  On and after October 1, 1977, every plan operating under a transitional license shall have a fiscally sound operation.(Added by Stats. 1977, Ch. 818.)