reglab/housing_qa huggingface dataset:
CA Health & Safety Code § 1367.18 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.18.

1367.18.  (a) Every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses on a group basis shall offer coverage for orthotic and prosthetic devices and services under the terms and conditions that may be agreed upon between the group subscriber and the plan. Every plan shall communicate the availability of that coverage to all group contractholders and to all prospective group contractholders with whom they are negotiating. Any 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. Any coverage for orthotic devices shall provide for coverage when 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. Every plan shall have the right to conduct a utilization review to determine medical necessity prior to 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 the basic health care services required to be provided under Section 1367. If the contract does not include any annual or lifetime benefit maximums applicable to basic health care services, the amount of the benefit for orthotic and prosthetic devices and services shall not be subject to an annual or lifetime maximum benefit level. Any 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 applied to the basic health care services required to be provided under Section 1367.(Amended by Stats. 2006, Ch. 756, Sec. 1. Effective January 1, 2007.)
CA Health & Safety Code § 1367.19 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.19.

1367.19.  On and after January 1, 1991, every health care service plan, except a specialized health care service plan, that covers hospital, medical, or surgical expenses on a group basis shall offer coverage as an option for special footwear needed by persons who suffer from foot disfigurement under such terms and conditions as may be agreed upon between the group contract holder and the plan.As used in this section, foot disfigurement shall include, but not be limited to, disfigurement from cerebral palsy, arthritis, polio, spinabifida, diabetes, and foot disfigurement caused by accident or developmental disability.(Added by Stats. 1990, Ch. 1680, Sec. 1.)
CA Health & Safety Code § 1367.20 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.20.

1367.20.  Every health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall provide to members of the public, upon request, a copy of the most current list of prescription drugs on the formulary of the plan by major therapeutic category, with an indication of whether any drugs on the list are preferred over other listed drugs. If the health care service plan maintains more than one formulary, the plan shall notify the requester that a choice of formulary lists is available.(Added by Stats. 1998, Ch. 69, Sec. 1. Effective January 1, 1999.)
CA Health & Safety Code § 1367.215 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.215.

1367.215.  (a)  Every health care service plan contract that covers prescription drug benefits shall provide coverage for appropriately prescribed pain management medications for terminally ill patients when medically necessary. The plan shall approve or deny the request by the provider for authorization of coverage for an enrollee who has been determined to be terminally ill in a timely fashion, appropriate for the nature of the enrollee’s condition, not to exceed 72 hours of the plan’s receipt of the information requested by the plan to make the decision. If the request is denied or if additional information is required, the plan shall contact the provider within one working day of the determination, with an explanation of the reason for the denial or the need for additional information. The requested treatment shall be deemed authorized as of the expiration of the applicable timeframe. The provider shall contact the plan within one business day of proceeding with the deemed authorized treatment, to do all of the following: (1)  Confirm that the timeframe has expired. (2)  Provide enrollee identification. (3)  Notify the plan of the provider or providers performing the treatment. (4)  Notify the plan of the facility or location where the treatment was rendered. (b)  This section does not apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the federal Food and Drug Administration. Coverage for different-use drugs is subject to Section 1367.21. (c)  Nothing in this section shall 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 prescription drugs. (Amended by Stats. 2002, Ch. 791, Sec. 2. Effective January 1, 2003.)
CA Health & Safety Code § 1367.22 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.22.

1367.22.  (a)  A health care service plan contract, issued, amended, or renewed on or after July 1, 1999, that covers prescription drug benefits shall not limit or exclude coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plan’s prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions as authorized by Section 4073 of the Business and Professions Code. For purposes of this section, a prescribing provider shall include a provider authorized to write a prescription, pursuant to subdivision (a) of Section 4059 of the Business and Professions Code, to treat a medical condition of an enrollee. (b)  This section does not apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the federal Food and Drug Administration. Coverage for different-use drugs is subject to Section 1367.21. (c)  This section shall not be construed to restrict or impair the application of any other provision of this chapter, including, but not limited to, Section 1367, which includes among its requirements that plans furnish services in a manner providing continuity of care and demonstrate that medical decisions are rendered by qualified medical providers unhindered by fiscal and administrative management. (d)  This section does not prohibit a health care service plan from charging a subscriber or enrollee a copayment or a deductible for prescription drug benefits or from setting forth, by contract, limitations on maximum coverage of prescription drug benefits, provided that the copayments, deductibles, or limitations are reported to, and held unobjectionable by, the director and set forth to the subscriber or enrollee pursuant to the disclosure provisions of Section 1363. (Amended by Stats. 2002, Ch. 760, Sec. 2. Effective January 1, 2003.)
CA Health & Safety Code § 1367.23 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.23.

1367.23.  (a)  On and after January 1, 1994, every group health care service plan contract, which is issued, amended, or renewed, shall include a provision requiring the health care service plan to notify the group contractholders in writing of the cancellation of the plan contract and shall include in their contract with group contractholders a provision requiring the group contractholder to mail promptly to each subscriber a legible, true copy of any notice of cancellation of the plan contract which may be received from the plan and to provide promptly to the plan proof of that mailing and the date thereof. (b)  The notice of cancellation from the group contractholder to the subscriber required by subdivision (a) shall include information regarding the conversion rights of persons covered under the plan contract upon termination of the plan contract. This information shall be in clear and easily understandable language. (Added by Stats. 1993, Ch. 1154, Sec. 1. Effective January 1, 1994.)
CA Health & Safety Code § 1367.243 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.243.

1367.243.  (a) (1) A health care service plan that reports rate information pursuant to Section 1385.03 or 1385.045 shall report the information described in paragraph (2) to the 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 care service plans.(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, 2019, 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 1385.045.(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. 1. (SB 17) Effective January 1, 2018.)
CA Health & Safety Code § 1367.244 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.244.

1367.244.  (a) A request for an exception to a health care service plan’s step therapy process for prescription drugs may be submitted in the same manner as a request for prior authorization for prescription drugs pursuant to Section 1367.241, and shall be treated in the same manner, and shall be responded to by the health care service plan in the same manner, as a request for prior authorization for prescription drugs.(b) The department and the Department of Insurance shall include a provision for step therapy exception requests in the uniform prior authorization form developed pursuant to subdivision (c) of Section 1367.241.(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 enrollee.(Amended by Stats. 2021, Ch. 742, Sec. 3. (AB 347) Effective January 1, 2022.)
CA Health & Safety Code § 1367.30 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.30.

1367.30.  Notwithstanding any other provision of law, every group health care service plan contract marketed, issued, or delivered to a resident of this state, regardless of the situs of the contract or the subscriber, shall be subject to Section 1374.58.(Added by Stats. 2011, Ch. 722, Sec. 1. (SB 757) Effective January 1, 2012.)
CA Health & Safety Code § 1367.31 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1367.31.

1367.31.  (a) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2017, shall be prohibited from requiring an enrollee to receive a referral prior to 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) For the purposes of this section, “reproductive and sexual health care services” do not include the services subject to a health care service plan’s referral procedures as required by subdivisions (a) and (b) of Section 1374.16.(3) This section applies whether or not the patient is a minor.(c) In implementing this section, a health care service plan may establish reasonable provisions governing utilization protocols for obtaining reproductive and sexual health care services, as provided for in subdivision (a), from health care providers participating in, or contracting with, the plan network, medical group, or independent practice association, provided that these provisions shall be consistent with the intent of this section and shall be those customarily applied to other health care providers, such as primary care physicians and surgeons, to whom the enrollee has direct access, and shall not be more restrictive for the provision of reproductive and sexual health care services. An enrollee shall not be required to obtain prior approval from another physician, another provider, or the health care service plan prior to obtaining direct access to reproductive and sexual health care services. A health care service plan may establish reasonable provisions governing communication with the enrollee’s primary care physician and surgeon regarding the enrollee’s condition, treatment, and any need for followup care.(d) This section shall not apply to a health care service plan contract that does not require enrollees to obtain a referral from their primary care physician prior to seeking covered health care services from a specialist.(e) A health care service plan shall not impose utilization protocols related to contraceptive drugs, supplies, and devices beyond the provisions outlined in Section 1367.25 of this code or Section 14132 of the Welfare and Institutions Code.(f) This section shall not apply to specialized health care service plan contracts or any health care service plan that is governed by Section 14131 of the Welfare and Institutions Code.(Added by Stats. 2016, Ch. 495, Sec. 3. (AB 1954) Effective January 1, 2017.)
CA Health & Safety Code § 1368.01 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.01.

1368.01.  (a)  The grievance system shall require the plan to resolve grievances within 30 days, except as provided in subdivision (c).(b)  The grievance system shall include a requirement for expedited plan review of grievances for cases involving an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function. When the plan has notice of a case requiring expedited review, the grievance system shall require the plan to immediately inform enrollees and subscribers in writing of their right to notify the department of the grievance. The grievance system shall also require the plan to provide enrollees, subscribers, and the department with a written statement on the disposition or pending status of the grievance no later than three days from receipt of the grievance, except as provided in subdivision (c). Paragraph (4) of subdivision (a) of Section 1368 shall not apply to grievances handled pursuant to this section.(c) A health care service plan contract in the individual, small group, or large group markets that provides coverage for outpatient prescription drugs shall comply with subdivision (c) of Section 156.122 of Title 45 of the Code of Federal Regulations. This subdivision shall not apply to Medi-Cal managed care health care service plan contracts or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.(Amended by Stats. 2015, Ch. 654, Sec. 4. (SB 282) Effective January 1, 2016.)
CA Health & Safety Code § 1368.02 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.02.

1368.02.  (a) The director shall establish and maintain a toll-free telephone number for the purpose of receiving complaints regarding health care service plans regulated by the director.(b) Every health care service plan shall publish the department’s toll-free telephone number, the department’s TDD line for the hearing and speech impaired, the plan’s telephone number, and the department’s internet website address, on every plan contract, on every evidence of coverage, on copies of plan grievance procedures, on plan complaint forms, and on all written notices to enrollees required under the grievance process of the plan, including any written communications to an enrollee that offer the enrollee the opportunity to participate in the grievance process of the plan and on all written responses to grievances. The department’s telephone number, the department’s TDD line, the plan’s telephone number, and the department’s internet website address shall be displayed by the plan in each of these documents in 12-point boldface type in the following regular type statement: “The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (insert health plan’s telephone number) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.” (Amended by Stats. 2019, Ch. 113, Sec. 3. (AB 1802) Effective January 1, 2020.)
CA Health & Safety Code § 1368.03 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.03.

1368.03.  (a) The department may require enrollees and subscribers to participate in a plan’s grievance process for up to 30 days before pursuing a grievance through the department or the independent medical review system. However, the department may not impose this waiting period for expedited review cases covered by subdivision (b) of Section 1368.01 or in any other case where the department determines that an earlier review is warranted.(b) Notwithstanding subdivision (a), the department may refer any grievance issue that does not pertain to compliance with this chapter to the State Department of Health Services, the California Department of Aging, the federal Health Care Financing Administration, or any other appropriate governmental entity for investigation and resolution.(c) This section shall become operative on January 1, 2001, and then only if Assembly Bill 55 of the 1999–2000 Regular Session is enacted.(Repealed (in Sec. 4) and added by Stats. 1999, Ch. 542, Sec. 5. Effective January 1, 2000. Section operative January 1, 2001, by its own provisions.)