reglab/statecodes huggingface dataset:
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.34.

1367.34. (a) (1) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2022, 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 a clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2) A commercial health care plan is required to cover the services outlined in paragraph (1) when ordered for an enrollee by an in-network provider.
(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.
(c) This section shall not apply to health care service plans contracting with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. For those health care service plans, the Medi-Cal requirements contained in subdivision (af) of Section 14132 of the Welfare and Institutions Code shall apply.
(Added by Stats. 2021, Ch. 486, Sec. 3. (SB 306) Effective January 1, 2022. See same-numbered section added by Stats. 2021, Ch. 641.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.34.

1367.34. (a) A health care service plan contract 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 1367.002 and 1367.005, shall additionally include coverage for adverse childhood experiences screenings. This section does not prohibit a health care service plan 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 care service plans 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 care service plans. This section does not prohibit a health care service plan from exceeding the Medi-Cal program’s rules and regulations for trauma screening.
(Added by Stats. 2021, Ch. 641, Sec. 1. (SB 428) Effective January 1, 2022.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.35.

1367.35. (a) On and after January 1, 1993, every health care service plan that covers hospital, medical, or surgical expenses on a group basis shall provide benefits for the comprehensive preventive care of children 16 years of age or younger under terms and conditions agreed upon between the group subscriber and the plan. Every plan shall communicate the availability of these benefits to all group contractholders and to all prospective group contractholders with whom they are negotiating. This section shall apply to each plan that, by rule or order of the director, has been exempted from subdivision (i) of Section 1367, insofar as that section and the rules thereunder relate to the provision of the preventive health care services described in this section.
(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 Recommendations for Preventive Pediatric Health Care, as adopted by the American Academy of Pediatrics in September of 1987.
(B) The most current version of the Recommended Childhood Immunization Schedule/United States, jointly adopted by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians, unless the State Department of Health Services determines, within 45 days of the published date of the schedule, that the schedule is not consistent with the purposes of this section.
(2) Provide for all of the following:
(A) Periodic health evaluations.
(B) Immunizations.
(C) Laboratory services in connection with periodic health evaluations.
(Amended by Stats. 1999, Ch. 525, Sec. 97. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.36.

1367.36. (a)  A risk-based contract between a health care service plan and a physician or physician group that is issued, amended, delivered, or renewed in this state on or after January 1, 2001, shall not include a provision that requires a physician or a physician group to assume financial risk for the acquisition costs of required immunizations for children as a condition of accepting the risk-based contract. A physician or physician group shall not be required to assume financial risk for immunizations that are not part of the current contract.
(b)  Beginning January 1, 2001, with respect to immunizations for children that are not part of the current contract between a health care service plan and a physician or physician group, the health care service plan shall reimburse a physician or physician group at the lowest of the following, until the contract is renegotiated: (1) the physician’s actual acquisition cost, (2) the “average wholesale price” as published in the Drug Topics Red Book, or (3) the lowest acquisition cost through sources made available to the physician by the health care service plan. Reimbursements shall be made within 45 days of receipt by the plan of documents from the physician demonstrating that the immunizations were performed, consistent with Section 1371 or through an alternative funding mechanism mutually agreed to by the health care service plan and the physician or physician group. The alternative funding mechanism shall be based on reimbursements consistent with this subdivision.
(c)  Physicians and physician groups may assume financial risk for providing required immunizations, if the immunizations have experiential data that has been negotiated and agreed upon by the health care service plan and the physician risk-bearing organization. However, a health care service plan shall not require a physician risk-bearing organization to accept financial risk or impose additional risk on a physician risk-bearing organization in violation of subdivision (a).
(d)  A health care service plan shall not include the acquisition costs associated with required immunizations for children in the capitation rate of a physician who is individually capitated.
(Added by Stats. 2000, Ch. 845, Sec. 1. Effective January 1, 2001.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.4.

1367.4. No plan issuing, providing, or administering any contract of individual or group coverage providing medical, surgical, or dental expense benefits applied for and issued on or after January 1, 1986, shall refuse to cover, or refuse to continue to cover, or limit the amount, extent, or kind of coverage available to an individual, or charge a different rate for the same coverage solely because of blindness or partial blindness.
“Blindness or partial blindness” means central visual acuity of not more than 20/200 in the better eye, after correction, or visual acuity greater than 20/200 but with a limitation in the fields of vision so that the widest diameter of the visual field subtends an angle no greater than 20 degrees, certified by a licensed physician and surgeon who specializes in diseases of the eye or a licensed optometrist.
(Added by Stats. 1985, Ch. 971, Sec. 1.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.42.

1367.42. (a) For plan years commencing on or after January 1, 2017, a plan that provides essential health benefits shall allow an enrollee 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.
(b) A nongrandfathered individual or small group health plan contract may charge an enrollee a different cost sharing for obtaining a covered drug at a retail pharmacy, but all cost sharing shall count toward the plan’s annual limitation on cost sharing consistent with Section 1367.006.
(Added by Stats. 2015, Ch. 619, Sec. 4. (AB 339) Effective January 1, 2016.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.43.

1367.43. Commencing January 1, 2019, a health care service plan shall prorate an enrollee’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. 3. (AB 1048) Effective January 1, 2018.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.45.

1367.45. (a)  Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2002, that covers hospital, medical, or surgery expenses shall provide coverage for a vaccine for acquired immune deficiency syndrome (AIDS) that is approved for marketing by the federal Food and Drug Administration and that is recommended by the United States Public Health Service.
(b)  This section may not be construed to require a health care service plan to provide coverage for any clinical trials relating to an AIDS vaccine or for any AIDS vaccine that has been approved by the federal Food and Drug Administration in the form of an investigational new drug application.
(c)  A health care service plan that contracts directly with an individual provider or provider organization may not delegate the risk adjusted treatment cost of providing services under this section unless the requirements of Section 1375.5 are met.
(d)  Nothing in this section is to be construed in any manner to limit or impede a health care service plan’s power or responsibility to negotiate the most cost-effective price for vaccine purchases.
(e)  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. 5. Effective January 1, 2003.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.46.

1367.46. Every individual or group health care service plan contract that is issued, amended, or renewed on or after January 1, 2009, that covers hospital, medical, or surgery expenses shall provide coverage for human immunodeficiency virus (HIV) testing, regardless of whether the testing is related to a primary diagnosis.
(Added by Stats. 2008, Ch. 631, Sec. 1. Effective January 1, 2009.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.47.

1367.47. (a) The maximum amount a health care service plan may require an enrollee 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 care service plan shall not require a pharmacist or pharmacy to charge or collect from an enrollee 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 enrollee had purchased the prescription drug by paying the cost-sharing amount.
(Added by Stats. 2018, Ch. 770, Sec. 2. (AB 2863) Effective January 1, 2019.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.5.

1367.5. No health care service plan contract 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.
(Added by Stats. 2001, Ch. 691, Sec. 5. Effective January 1, 2002.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.50.

1367.50. (a) No contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health care service plan 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 an enrollee or subscriber of the health care service plan or beneficiaries of any self-funded health coverage arrangement administered by the health care service plan, 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. 2. (SB 1196) Effective January 1, 2013.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.54.

1367.54. (a) Every group health care service plan contract that provides maternity benefits, except for a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or after January 1, 1999, and every individual health care service plan contract of a type and form first offered for sale on or after January 1, 1999, that provides maternity benefits, except a specialized health care service plan contract, 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. Notwithstanding any other provision of law, a health care service plan that provides 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 by 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 and regulations adopted thereunder.
(Amended by Stats. 2015, Ch. 18, Sec. 7. (SB 75) Effective June 24, 2015.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.6.

1367.6. (a) Every health care service plan contract, except a specialized health care service plan contract, 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 health care service plan contract 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 health care service plan contract shall cover screening and diagnosis of breast cancer, consistent with generally accepted medical practice and scientific evidence, upon the referral of the enrollee’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 copayment, or deductible and coinsurance conditions, that are applicable 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.
(Amended by Stats. 2012, Ch. 449, Sec. 2. (SB 255) Effective January 1, 2013.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.61.

1367.61. Every health care service plan contract 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 all or part of the larynx for medically necessary reasons, as determined by a licensed physician and surgeon.
Any provision in any contract 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. 1. Effective January 1, 1993.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.625.

1367.625. (a) By July 1, 2023, a health care service plan shall develop a maternal mental health program designed to promote quality and cost-effective outcomes. 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 a maternal mental health program the health care service plan 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 enrollees about the program.
(b) For the purposes of this section, the following terms have the following meanings:
(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 enrollee’s health care service plan to provide services under the enrollee’s plan contract.
(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 shall not apply to specialized health care service plans, except specialized behavioral health-only plans offering professional mental health services.
(d) For purposes of this section, “health care service plan” shall include 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. The State Department of Health Care Services shall seek any federal approvals it deems necessary to implement this section. This section shall apply to Medi-Cal managed care plan contracts only to the extent that the State Department of Health Care Services obtains any necessary federal approvals, and federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.
(e) Notwithstanding subdivision (a), a Medi-Cal managed care plan shall continue to comply with any quality measures required or adopted by the State Department of Health Care Services. Quality measures included in a Medi-Cal managed care plan’s maternal mental health program shall not be inconsistent with quality measures required or adopted by the State Department of Health Care Services.
(Amended by Stats. 2022, Ch. 618, Sec. 2. (SB 1207) Effective January 1, 2023.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.626.

1367.626. (a) (1) On or before January 1, 2025, a health care service plan 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.
(2) (A) A Medi-Cal managed care plan shall be considered compliant with the requirements of this section by providing coverage of doula services so long as doula services are a Medi-Cal covered benefit.
(B) For the purpose of this section, “Medi-Cal managed care plan” has the same meaning as provided in subdivision (j) of Section 14184.101 of the Welfare and Institutions Code.
(b) The department, in consultation with the Department of Insurance, shall collect data and submit a report describing the doula coverage and programs established pursuant to subdivision (a) to the Legislature by January 1, 2027. The report may do both of the following:
(1) Include the department’s Healthcare Effectiveness Data and Information Set (HEDIS) measures or the Center for Data Insights and Innovation’s quality of care report card.
(2) Assess quality of care, increased access, ongoing barriers to access, and more.
(Added by Stats. 2023, Ch. 349, Sec. 2. (AB 904) Effective January 1, 2024.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.64.

1367.64. (a)  Every individual or group health care service plan contract, except for a specialized health care service plan contract, 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 establish a new mandated benefit or to prevent application of deductible or copayment provisions in a policy or plan, nor shall this section be construed to require that a policy or plan be extended to cover any other procedures under an individual or a group health care service plan contract. Nothing in this section shall be construed to authorize an enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the enrollee is referred to that provider by a participating physician or nurse practitioner providing care.
(Added by Stats. 1998, Ch. 839, Sec. 1. Effective January 1, 1999.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.65.

1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by 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 application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.
(Amended by Stats. 2013, Ch. 76, Sec. 108. (AB 383) Effective January 1, 2014.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.656.

1367.656. (a) Notwithstanding any other law, an individual or group health care service plan contract 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 enrollee 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 contract.
(2) For a health care service plan contract 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 enrollee’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 care service plan contract that covers only dental or vision benefits or any coverage under a health care service plan contract 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. 1. (SB 421) Effective January 1, 2024.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.66.

1367.66. (a) Every individual or group health care service plan contract, except for a specialized health care service plan, issued, amended, or renewed on or after January 1, 2002, shall provide coverage for an annual cervical cancer screening test upon the referral of the 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.
(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 establish a new mandated benefit or prevent application of deductible or copayment provisions in an existing plan contract. The Legislature intends in this section to provide that cervical cancer screening services are deemed to be covered if the plan contract includes coverage for cervical cancer treatment or surgery.
(b) A health care service plan contract, except for a specialized health care service plan, issued, amended, or renewed on or after January 1, 2024, shall provide coverage for the human papillomavirus vaccine for enrollees for whom the vaccine is approved by the FDA. A health care service plan contract shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided pursuant to this subdivision.
(Amended by Stats. 2023, Ch. 809, Sec. 3. (AB 659) Effective January 1, 2024.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.665.

1367.665. (a) A health care service plan contract, except for a specialized health care service plan contract, 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 terms and conditions that would otherwise apply.
(b) (1) A health care service plan contract, except for a specialized health care service plan contract, that is issued, amended, delivered, or renewed on or after July 1, 2022, shall not require prior authorization for either of the following:
(A) Biomarker testing for an enrollee with advanced or metastatic stage 3 or 4 cancer.
(B) Biomarker testing for cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer.
(2) This subdivision shall also apply to health care service plan contracts and Medi-Cal managed care plan contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
(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) Notwithstanding subdivision (b), this section does not prohibit a health care service plan from requiring prior authorization on biomarker testing that is not for an FDA-approved therapy for advanced or metastatic stage 3 or 4 cancer.
(e) This section does not limit, prohibit, or modify an enrollee’s rights to biomarker testing as part of an approved clinical trial under Section 1370.6.
(Amended by Stats. 2021, Ch. 605, Sec. 1. (SB 535) Effective January 1, 2022.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.668.

1367.668. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, or renewed on or after January 1, 2022, shall provide coverage without any 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 care service plan that has coverage for out-of-network benefits 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. 1. (AB 342) Effective January 1, 2022.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.67.

1367.67. Every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this 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.
(Added by Stats. 1993, Ch. 1208, Sec. 2. Effective January 1, 1994.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.68.

1367.68. (a)  Any provision in a health care service plan contract entered into, amended, or renewed in this state on or after July 1, 1995, that excludes coverage for any surgical procedure for any condition directly affecting the upper or lower jawbone, or associated bone joints, shall have no force or effect as to any enrollee if that provision results in any failure to provide medically-necessary basic health care services to the enrollee pursuant to the plan’s definition of medical necessity.
(b)  For purposes of this section, “plan contract” means every plan contract, except a specialized health care service plan contract, that covers hospital, medical, or surgical expenses.
(c)  Nothing in this section shall be construed to prohibit a plan from excluding coverage for dental services provided that any exclusion does not result in any failure to provide medically-necessary basic health care services.
(Added by Stats. 1994, Ch. 1282, Sec. 1. Effective January 1, 1995.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.69.

1367.69. (a)  On or after January 1, 1995, every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state, shall include obstetrician-gynecologists as eligible primary care physicians, provided they meet the plan’s 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.
(Added by Stats. 1994, Ch. 759, Sec. 2. Effective January 1, 1995.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.695.

1367.695. (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 health care service plan contract issued, amended, renewed, or delivered in this state, except a specialized health care service plan, shall allow an enrollee the option to seek obstetrical and gynecological physician services directly from a participating 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 health care service plan 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), participating in the plan network, medical group, or independent practice association, if those requirements are consistent with the intent of this section, are customarily applied to other physicians and surgeons, such as primary care physicians and surgeons, to whom the enrollee has direct access, and are no more restrictive for the provision of obstetrical and gynecological physician 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 obstetrical and gynecological physician services, but the plan may establish reasonable requirements for the participating obstetrician and gynecologist or family physician and surgeon, as provided for in subdivision (b), to communicate with the enrollee’s primary care physician and surgeon regarding the enrollee’s condition, treatment, and any need for followup care.
(d)  This section does not diminish the requirements of Section 1367.69.
(Amended by Stats. 2019, Ch. 632, Sec. 7. (AB 1622) Effective January 1, 2020.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.7.

1367.7. On and after January 1, 1980, every health care service plan contract that 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. Every health care service plan shall communicate the availability of such coverage to all group contract holders and to all groups with whom they are negotiating.
(Added by Stats. 1979, Ch. 629.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.71.

1367.71. (a)  Every health care service plan contract, other than a specialized health care service plan contract, 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 patient requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital or surgery center setting. The health care service plan 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 enrollees, and only if the enrollees meet the criteria in subdivision (a):
(1)  Enrollees who are under seven years of age.
(2)  Enrollees who are developmentally disabled, regardless of age.
(3)  Enrollees whose health is compromised and for whom general anesthesia is medically necessary, regardless of age.
(c)  Nothing in this section shall require the health care service plan to cover any charges for the dental procedure itself, including, but not limited to, 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 plan that apply generally to other benefits.
(d)  Nothing in this section shall be construed to allow a health care service plan to deny coverage for basic health care services, as defined in Section 1345.
(e)  A health care service plan may include coverage specified in subdivision (a) at any time prior to January 1, 2000.
(Added by Stats. 1998, Ch. 790, Sec. 1. Effective January 1, 1999.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.8.

1367.8. No plan issuing, providing, or administering any individual or group health care service plan entered into, amended, or issued on or after January 1, 1981, shall refuse to cover, or refuse to continue to cover, or limit the amount, extent or kind of coverage available to an individual, or charge a different rate for the same coverage solely because of a physical or mental impairment, except where the refusal, limitation or rate differential is based on sound actuarial principles applied to actual experience, or, if insufficient actual experience is available, then to sound underwriting practices.
This section shall not apply to a health maintenance organization qualified pursuant to Title XIII of the federal Public Health Service Act if such organization gives public notice 30 days in advance, in a newspaper of general circulation published in the area served by the health maintenance organization, of its open enrollment period required by such act.
(Added by Stats. 1980, Ch. 352.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.9.

1367.9. No health care service plan contract 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 or copayment provisions applicable solely to conditions attributable to diethylstilbestrol or exposure to diethylstilbestrol.
Any provision in any contract issued, amended, delivered, or renewed in this state on or after January 1, 1981, which is in conflict with this section shall be of no force or effect.
(Added by renumbering Section 1367.8 (as added by Stats. 1980, Ch. 776) by Stats. 1981, Ch. 714.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.10.

1367.10. (a) Every health care service plan shall include within its disclosure form and within its evidence of coverage a statement clearly describing how participation in the plan may affect the choice of physician, hospital, or other health care providers, the basic method of reimbursement, including the scope and general methods of payment made to its contracting providers of health care services, and whether financial bonuses or any other incentives are used. The disclosure form and evidence of coverage shall indicate that if an enrollee wishes to know more about these issues, the enrollee may request additional information from the health care service plan, the enrollee’s provider, or the provider’s medical group or independent practice association regarding the information required pursuant to subdivision (b).
(b) If a plan, medical group, independent practice association, or participating health care provider uses or receives financial bonuses or any other incentives, the plan, medical group, independent practice association, or health care provider shall provide a written summary to any person who requests it that includes all of the following:
(1) A general description of the bonus and any other incentive arrangements used in its compensation agreements. Nothing in this section shall be construed to require disclosure of trade secrets or commercial or financial information that is privileged or confidential, such as payment rates, as determined by the director, pursuant to state law.
(2) A description regarding whether, and in what manner, the bonuses and any other incentives are related to a provider’s use of referral services.
(c) The statements and written information provided pursuant to subdivisions (a) and (b) shall be communicated in clear and simple language that enables consumers to evaluate and compare health care service plans.
(d) The plan shall clearly inform prospective enrollees that participation in that plan will affect the person’s choice of provider by placing the following statement in a conspicuous place on all material required to be given to prospective 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 enrollees.
If the health care service plan provides a list of providers to patients or contracting providers, the plan shall include within the provider listing a notification that enrollees may contact the plan in order to obtain a list of the facilities with which the health care service plan is contracting for subacute care and/or transitional inpatient care.
(Amended by Stats. 1999, Ch. 525, Sec. 99. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.2 - Health Care Service Plans › ARTICLE 5 - Standards › Section 1367.12.

1367.12. No health care service plan that administers Medicare coverage and federal employee programs may require that more than one form be submitted per claim in order to receive payment or reimbursement under any or all of those policies or programs.
(Added by Stats. 1987, Ch. 1191, Sec. 1.)