reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.2 - Limits on Benefit Reductions in Group Disability Income Insurance Policies [Repealed] › Section 2232.45.1 - Authority and Purpose. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						790.10,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, (1989) 48 Cal.3d 805; and 20th
						Century Ins. Co. v. Garamendi (1994) 8 Cal.4th 216. Reference: Sections
						790.02 and
						790.03,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.2 - Limits on Benefit Reductions in Group Disability Income Insurance Policies [Repealed] › Section 2232.45.2 - Benefit Reductions Shall Not Be Based on Involuntary Retirement. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						790.10,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, (1989) 48 Cal.3d 805; and 20th
						Century Ins. Co. v. Garamendi (1994) 8 Cal.4th 216. Reference: Sections
						790.02 and
						790.03,
						Insurance Code; Kalvinskas v. California Institute of Technology (9th Cir.
						1996) 96 F.3d 1305; Gruenberg v. Aetna Insurance Company (1973) 9 Cal.3d 566;
						Smith v. Alum Rock Union Elementary School District (1992) 6 Cal. App.4th
						1651.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.2 - Limits on Benefit Reductions in Group Disability Income Insurance Policies [Repealed] › Section 2232.45.3 - Benefit Reductions Shall Not Be Based on Estimated Workers' Compensation Temporary Disability Benefits Not Actually Received by the Insured. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						790.10,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, (1989) 48 Cal.3d 805; and 20th
						Century Ins. Co. v. Garamendi (1994) 8 Cal.4th 216. Reference: Sections
						790.02 and
						790.03,
						Insurance Code; and Silberg v. Cal. Life Ins. Co. (1974) 11 Cal.3d
						452.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.2 - Limits on Benefit Reductions in Group Disability Income Insurance Policies [Repealed] › Section 2232.45.4 - Benefit Reductions Shall Not Be Based on Workers' Compensation Permanent Disability. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						790.10,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, (1989) 48 Cal.3d 805; and 20th
						Century Ins. Co. v. Garamendi (1994) 8 Cal.4th 216. Reference: Sections
						790.02 and
						790.03,
						Insurance Code; Erreca v. Western States Life Insurance Co.(1942) 19 Cal.2d
						388; Russell v. Bankers Life Co. (1975) 46 Cal. App.3d 405; and Canova v.
						N.L.R.B. (1983) 708 F.2d 1498.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.2 - Limits on Benefit Reductions in Group Disability Income Insurance Policies [Repealed] › Section 2232.45.5 - Benefit Reductions Based on Earnings Received for Work Performed While Disabled. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						790.10,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, (1989) 48 Cal.3d 805; and 20th
						Century Ins. Co. v. Garamendi (1994) 8 Cal.4th 216. Reference: Sections
						790.02 and
						790.03,
						Insurance Code; and Gruenberg v. Aetna Insurance Company (1973) 9 Cal.3d
						566.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.50 - Authority. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 Article 2.3 (Sections
					 2232.50 through
					 2232.60) filed 11-29-74;
					 designated effective January 1, 1975 (Register 74, No. 48).
2.
					 Repealer filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94
						and
						11515.5,
						Insurance Code. Reference: Sections
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.51 - Purpose. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.52 - Applicability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
These regulations do not require the use of overinsurance
					 provisions in group disability policies or group non-profit hospital service
					 plan contracts. If, however, such a policy or contract contains overinsurance
					 provisions, such provisions must be consistent with and no less favorable than
					 the Standard Group Coordination of Benefit Provisions and Instructions herein
					 established. To this end, overinsurance provisions, or provisions for the
					 reduction of benefits otherwise payable because of other insurance by whatever
					 name designated, which are less favorable than the Standard Coordination of
					 Benefit Provisions herein contained may not be used, except that plans of
					 coverage designated to be supplementary over the policyholder's underlying
					 basic plan of coverage may provide that its coverage shall be excess to that
					 specific policyholder's plan of basic coverage from whatever source provided.
					 (See Section
					 2232.35 of Article 2a
					 supra.)
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.53 - Standard Provisions for Coordination of Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every group disability policy which provides hospital,
					 medical and surgical benefits issued in this state may contain the following
					 standard provisions relating to Coordination of Benefits, as interpreted by the
					 special instructions hereinafter set forth.
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.54 - Benefits Subject to Coordination of Benefits Provision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
All of the benefits provided under this policy are subject
					 to this provision.
Instructions
When the policy or nonprofit hospital service contract
					 provides both integrated Major Medical Expense Benefits and the Basic Benefits,
					 but the coordination of benefit provision applies to all or some of the
					 benefits, use appropriate alternative wording such as illustrated below:
"Only the major medical expense benefits provided under
					 this policy are subject to this provision."
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2)
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.55 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Plan" means
				  any plan providing benefits or services for or by reason of medical or dental
				  care or treatment, which benefits or services are provided by:
(1) group, blanket or franchise insurance
				  coverage,
(2) service plan
				  contracts, group practice, individual practice and other prepayment
				  coverage,
(3) any coverage under
				  labor-management trusteed plans, union welfare plans, employer organization
				  plans, or employee benefit organization plans, and
(4) any coverage under governmental programs,
				  and any coverage required or provided by any statute.
The term "Plan" shall be construed separately with respect
					 to each policy, contract, or other arrangement for benefits or services and
					 separately with respect to that portion of any such policy, contract, or other
					 arrangement which reserves the right to take the benefits or services of other
					 Plans into consideration in determining its benefits and that portion which
					 does not.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.56 - Effect on Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  This provision shall apply in determining the benefits as to a person covered
				  under this Plan for any Claim Determination Period if, for the Allowable
				  Expenses incurred as to such person during such period, the sum of
(1) the benefits that would be payable under
				  this Plan in the absence of this provision, and
(2) the benefits that would be payable under
				  all other Plans in the absence therein of provisions of similar purpose to this
				  provision would exceed such Allowable Expenses.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.57 - Right to Receive and Release Necessary Information

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For the purpose of determining the applicability of and
					 implementing the terms of this provision of this Plan or any provision of
					 similar purpose of any other Plan, the insurer or service plan may, release to
					 or obtain from any other insurance company or other organization or person any
					 information, with respect to any person, which the insurer or service plan
					 deems to be necessary for such purposes. Any person claiming benefits under
					 this Plan shall furnish to the insurer or service plan such information as may
					 be necessary to implement this provision.
Instructions
Carriers are urged to use the following claims
					 administration procedures to expedite claim payments where COB is
					 involved:
(a) Each carrier should
				  establish a time limit after which full or partial payment should be made. When
				  payment of a claim is necessarily delayed for reasons other than the
				  application of a COB provision, investigation of other valid coverage should be
				  conducted concurrently so as to create no further delay in the ultimate payment
				  of benefits. Occasionally, this will necessitate a carrier making payment as
				  the primary carrier with a right of recovery in the event that subsequent
				  investigation proves that payment as a secondary carrier should have been
				  made.
(b) There should be continued
				  and improved education of claim personnel, stressing accurate and prompt
				  completion of the HIC Duplicate Coverage Inquiry (DUP-1) Form by the inquiring
				  carrier and the responding carrier. This education effort should also be
				  encouraged through local claim associations. Claim personnel should be
				  encouraged to make every effort to speed up exchange of COB
				  information.
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						791.06,
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.58 - Facility of Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Whenever payments which should have been made under this Plan in accordance
				  with this provision have been made under any other Plans, the insurer or
				  service plan shall have the right, exercisable alone and in its sole
				  discretion, to pay over to any organizations making such other payments any
				  amounts it shall determine to be warranted in order to satisfy the intent of
				  this provision, and amounts so paid shall be deemed to be benefits paid under
				  this Plan and, to the extent of such payments, the insurer or service plan
				  shall be fully discharged from liability under this plan.
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						10270-
						10298 and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.59 - Right of Recovery

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Whenever payments have been made by the insurer with
					 respect to Allowable Expenses in a total amount, at any time, in excess of the
					 maximum amount of payment necessary at that time to satisfy the intent of this
					 provision, the insurer or service plan shall have the right to recover such
					 payments, to the extent of such excess, from among one or more of the
					 following; as the insurer or service plan shall determine: any persons to or
					 for or with respect to whom such payments were made, any other insurers,
					 service plans or any other organizations.
1. Amendment
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
Note: Authority cited: Sections
						10270.94,
						10270.98,
						11515 and
						11515.5,
						Insurance Code. Reference: Sections
						10270.98
						and
						11515.5,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 2.3 - Forms of Standard Provisions for Coordination of Benefits › Section 2232.60 - Effective Date. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 1-8-86; effective thirtieth day thereafter (Register 86, No.
					 2).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 3 - Small Employer Health Insurance [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New article
				  3 (sections
				  2233-2233.99) filed 6-28-93;
				  operative 7-1-93 (Register 93, No. 27). This regulatory filing was deemed an
				  emergency by Insurance Code section
				  10704. A
				  Certificate of Compliance must be transmitted to OAL by 10-29-93 or emergency
				  language will be repealed by operation of law on the following day. For prior
				  history, see Register 77, No. 19.
2. Editorial correction amending
				  article heading (Register 93, No. 44).
3. New section refiled
				  10-28-93 as an emergency with amendments; operative 10-29-93 (Register 93, No.
				  44). This filing was deemed an emergency by Insurance Code section
				  10704. A
				  Certificate of Compliance must be transmitted to OAL by 2-28-94 or emergency
				  language will be repealed by operation of law on the following
				  day.
4. Expired by operation of Government Code section
				  11346.1(e)
				  (Register 94, No. 17).
5. New section filed as an emergency 4-28-94;
				  operative 5-1-94 (Register 94, No. 17). This filing was deemed an emergency by
				  Insurance Code section
				  10704. A
				  Certificate of Compliance must be transmitted to OAL by 8-29-94 or emergency
				  language will be repealed by operation of law on the following
				  day.
6. New section refiled 9-7-94 as an emergency; operative 9-6-94
				  (Register 94, No. 36). A Certificate of Compliance must be transmitted to OAL
				  by 1-4-95 or emergency language will be repealed by operation of law on the
				  following day.
7. Repealed by operation of Government Code section
				  11346.1(g)
				  (Register 95, No. 12).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236 - Forms to Which this Article is Applicable

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This Article comprises the Rules and Regulations of the
					 Insurance Commissioner relating to the substance, form and issuance of tuition
					 refund policies described in Section
					 10270.1 of
					 the Insurance Code and those blanket disability policies described in Section
					 10270.2 of
					 the Insurance Code except policies issued to pay benefits afforded by a
					 voluntary plan of employment compensation disability insurance pursuant to the
					 California Unemployment Insurance Code. The term "blanket disability policy" as
					 used herein, unless that context otherwise requires, refers to the policies to
					 which this Article applies, including tuition refunds policies described in
					 Section
					 10270.1 of
					 the Insurance Code. No blanket disability policy affected by this Article may
					 be delivered or issued for delivery in this State which does not, in substance
					 and in the method of its issuance, meet all of the applicable provisions and
					 requirements of Section
					 10270.1 of
					 the Insurance Code or Section
					 10270.2 of
					 the Insurance Code, as applicable, whether or not such form has heretofore been
					 authorized or approved by the Commissioner. The Commissioner shall not
					 hereafter approve any such policy unless it conforms with the rules set forth
					 in this Article, and no such form shall be issued hereafter except in
					 conformity with the rules set forth in the Article.
1. Repealer
					 of Article 4 (2236 and 2237) and new Article 4 (2236 through 2236.5) filed
					 4-4-56; effective thirtieth day thereafter (Register 56, No. 6).
2.
					 Repealer of Article 4 ( 2236 through 2236.5) and new Article 4 ( 2236 through
					 2236.7) filed 4-27-70; designated effective 7-1-70 (Register 70, No.
					 18).
Note: Authority cited for Article 4: Sections
						10270.1 and
						10270.2,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.1 - Certificates or Other Forms of Statements of Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No certificate or other form of statement of coverage need
					 be issued under a blanket disability policy, unless the policy itself provides
					 for the issuance of certificates or some other form of statement of coverage;
					 in which case, certificate forms or some other form of statement of coverage
					 adequately describing the coverage, the person covered, and the persons to whom
					 benefits are payable must be submitted for authorization, and upon
					 authorization must be issued in accordance with the policy provisions. Such
					 certificates or other statements of coverage are not required to be
					 individualized.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.2 - Addition of New Persons Eligible

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In the absence of a policy provision excluding coverage for
					 otherwise covered individuals who have not individually enrolled with the
					 policyholder and undertaken to pay all or a specified portion of the premium
					 applicable to such individual, a blanket disability policy (but not a tuition
					 refund policy) shall contain, in substance, a provision which provides that the
					 described insurance covers all persons who fall within the categories of
					 covered individuals defined in the policy, and that to the persons originally
					 insured by the policy shall be added automatically all such persons as they
					 come within the class of persons defined in the policy issued to the master
					 policyholder.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.4 - Insurance Code Sections Applicable

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Section
					 10191,
					 10270.3, subdivisions (a) and (d)
					 of Section
					 10270.6, subdivision (b) of
					 Section 10290, Section
					 10291, paragraph (1) of
					 subdivision (b) of Section
					 10291.5, subdivisions (a), (b),
					 (d), (e), (f), (g) and (h) of Section
					 10320, and Sections
					 10321,
					 10322,
					 10326,
					 10326.5,
					 10380,
					 10381, and
					 10382 of
					 the Insurance Code shall apply to blanket disability policies and reference in
					 such sections to the insured shall, in applying such sections to blanket
					 disability policies, be deemed to refer also to the individuals insured under
					 such policies.
1. Amendment
					 filed 5-6-77 as procedural and organizational; effective upon filing (Register
					 77, No. 19).
Note: Authority cited: Sections
						10270.1 and
						10270.2,
						Insurance Code. Reference: Sections
						10270.2 and
						10270.3,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.5 - "Employee" Includes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Whenever the word "employee" is used in Article 2a of
					 Subchapter 2 of Chapter 5 of Title 10, there may be substituted therefor the
					 word "camper," "participant," "member," "subscriber," "student," or "teacher,"
					 or any other word or words to properly describe or designate the individual or
					 individuals eligible for insurance under Sections
					 10270.1 and
					 10270.2 of
					 the Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.6 - "Employer" or "Policyholder" Includes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Whenever the word "employer" or the word "policyholder" is
					 used in Article 2a of Subchapter 2 of Chapter 5 of Title 10, it includes any
					 organization, entity or person to whom the policy may be issued under Sections
					 10270.1 or
					 10270.2 of
					 the Insurance Code. Whenever the word "employer" or the word "policyholder" is
					 used in any Uniform Provision in said Article 2a of Title 10, there may be
					 substituted therefor any word or words which properly describe or designate any
					 of the entities enumerated in subdivisions (a), (b), (c), (d), (e), or (f)
					 Section 10270.2.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4 - Blanket Disability and Tuition Refund Policies › Section 2236.7 - Use of Rider

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Changes in the forms of blanket disability policies
					 submitted to the Commissioner for approval which are necessary to bring them
					 into compliance with the rules and provisions hereby promulgated may be
					 effected by rider.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4.5 - Group Disability Income Policies Insuring Employees of California School Districts › Section 2237 - Preamble

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Certain group disability income policies providing
					 indemnity for loss-of-time to employees of California school districts contain
					 provisions permitting a reduction in benefit otherwise payable by an amount
					 equal to all or part of the benefits the insured employee receives or is
					 entitled to receive under any other policy of group income insurance. In some
					 cases, an employee of a school district is insured under two, or possibly more,
					 such group disability income policies, each or all of which contain a reduction
					 of benefits provision. Such a situation has caused delays in benefit payment
					 and could conceivably result in the school district employee receiving no
					 benefit payment. This action would constitute an unfair claim settlement
					 practice within the meaning of Insurance Code Section
					 790.03
					 (h).
1. New
					 Article 4.5 (Sections
					 2237-2237.4) filed 3-29-74 as an
					 emergency; effective upon filing (Register 74, No. 13).
2.
					 Certificate of Compliance filed 6-20-74 (Register 74, No.
					 25).
Note: Authority cited: Sections
						790.10 and
						10270.94,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4.5 - Group Disability Income Policies Insuring Employees of California School Districts › Section 2237.1 - Authority

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This regulation promulgated under the authority of
					 Insurance Code Sections
					 790.10 and
					 10270.94.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4.5 - Group Disability Income Policies Insuring Employees of California School Districts › Section 2237.2 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this regulation:
(a) "Group disability income policy" means a
				  group insurance policy providing indemnity for loss-of-time issued or issued
				  for delivery in this State pursuant to the provisions of Insurance Code Section
				  10270.5
				  under which eligibility for coverage is restricted substantially to employees
				  of California school districts, whether insured as members of an association or
				  as employees of a school district, and which contains a reduction of benefits
				  provision.
(b) "Reduction of
				  benefits provision" means a provision in a group disability income policy
				  permitting the insurer to reduce the disability income benefit payable
				  thereunder by an amount equal to all or part of the benefits the insured
				  receives or is entitled to receive under any other group disability income
				  policy.
(c) "Duplicating insurance"
				  means the coverage of the same California school district employee under two or
				  more group disability income policies.
(d) "Net benefit" means the amount of benefit
				  payable under a group disability income policy prior to the application of a
				  reduction of benefits provision, but after deducting all other items to be
				  subtracted to determine benefits as provided in the group disability income
				  policy (e.g., Social Security payments, workmen's compensation,
				  etc.).
(e) "Maximum net benefit"
				  means in the case of duplicating insurance the higher or highest net benefit
				  payable under any of the group disability income policies under which the
				  employee is entitled to receive benefits.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4.5 - Group Disability Income Policies Insuring Employees of California School Districts › Section 2237.3 - Standards for Reduction of Benefits Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The reduction in benefits provision in each group
					 disability income policy issued, issued for delivery or renewed in this State
					 after the effective date of this regulation shall provide in substance that in
					 the case of duplicating insurance the liability of the insurer under its group
					 disability income policy shall not be less than its pro rata share of the
					 maximum net benefit, which pro rata share shall be determined by dividing the
					 net benefit payable by the insurer under its group disability income policy by
					 the total of all net benefits under all group disability income policies under
					 which the insured is entitled to receive benefits and multiplying that result
					 by the maximum net benefit.
No reduction of benefits provision in a group disability
					 income policy not containing the standards described in this section or
					 standards not less favorable to the insured shall be approved by the
					 Commissioner. The reduction of benefits provision in each group disability
					 income policy heretofore issued in this State, which is renewed after the
					 effective date of this regulation, shall be amended to contain the standards
					 described in this section or standards not less favorable to the
					 insured.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 4.5 - Group Disability Income Policies Insuring Employees of California School Districts › Section 2237.4 - Exchange of Information

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Where a determination of the net benefit payable by another
					 insurer providing duplicating insurance is required by an insurer, at the
					 insurer's request, such other insurer shall furnish all necessary and pertinent
					 information concerning its net benefit sufficient to permit verification of
					 benefit determination by the insurer.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 5 - Facility of Payment Clauses [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer of
				  Article 5 (Section
				  2238) filed 5-6-77 as procedural
				  and organizational; effective upon filing (Register 77, No. 19). For prior
				  history, see Register 3 and Register 10, No. 5.
Note: Authority cited: Section
					 10369,
					 Insurance Code. Reference: Sections
					 10359-
					 10369,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 5.5 - Average Contracted Rate Methodology › Section 2238.10 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For purposes of
				  this article, the following definitions apply:
(1) "Average contracted rate" means the
				  average of the contracted commercial rates paid by a health insurer for the
				  same or similar health care services in the baseline year in the geographic
				  region in which the service was provided, for services most frequently subject
				  to Insurance Code section
				  10112.8.
				  This rate is then adjusted to the date the service was rendered by using the
				  inflation adjustment described in Insurance Code section
				  10112.82(a)(2)(B).
(2) "Baseline year" is calendar year
				  2015.
(3) "Bundled payments" means
				  a single payment for all services to treat a condition or provide a given
				  treatment. Bundled payments may also include facility fees and other
				  charges.
(4) "Geographic region"
				  for the calculation of the average contracted rate means:
(A) For individual and small group coverage:
				  the same geographic regions listed in Insurance Code section
				  10753.14(a)(2)(A);
				  and
(B) For large group coverage:
				  the same geographic region as the Medicare Physician Fee Schedule locality
				  structure pursuant to Section
				  1848 of the Social Security Act
				  (42 U.S.C. Section
				  1395w-4(e)(6)).
(5) "Modifiers" mean codes applied to the
				  service code that make the service description more specific and may adjust the
				  reimbursement rate or affect the processing or payment of the code
				  billed.
(6) "Same or similar
				  services" means a health care service billed under the same service code, or a
				  comparable code under a different procedural code system. The use of a
				  different service code as a proxy for the service code ordinarily applicable to
				  the actual service shall only be applied in a special or unique
				  circumstance.
(7) "Service code"
				  means the code that describes a service using the Current Procedural
				  Terminology (CPT) code or Healthcare Common Procedure Coding System
				  (HCPCS).
(8) "Service unit" means
				  the number of times the service described by a particular service code was
				  provided per claim for reimbursement.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 5.5 - Average Contracted Rate Methodology › Section 2238.11 - Methodology for Calculation of Average Contracted Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The reimbursement rate for services subject to Insurance
					 Code section
					 10112.8 is
					 the average contracted rate or 125 percent of the Medicare fee-for-service
					 rate, whichever is greater, unless otherwise agreed to by the noncontracting
					 individual health professional and the insurer or as determined through the
					 independent dispute resolution process pursuant to Insurance Code section
					 10112.81.
(a) The average contracted rate for services
				  most frequently subject to Section
				  10112.8, other than anesthesia
				  services, shall be calculated by dividing the total payment for a service code
				  by the total number of paid service units for that service code in each
				  geographic region across all commercial policies regulated by the Commissioner
				  during the baseline year, then adjusted to the date the service was rendered
				  using the inflation adjustment method described in Insurance Code section
				  10112.82(a)(2)(B).
(b) The average contracted rate for
				  anesthesia services most frequently subject to Section
				  10112.8 shall be calculated by
				  first determining the average anesthesia conversion factor. The average
				  anesthesia conversion factor shall be calculated by dividing the total payment
				  for anesthesia services by the sum of all base units, time units, and physical
				  status modifier units paid for those services, in each geographic region across
				  all commercial policies regulated by the Commissioner during the baseline year,
				  then adjusted to the date the service was rendered using the inflation
				  adjustment method described in Insurance Code section
				  10112.82(a)(2)(B).
				  This inflation-adjusted average anesthesia conversion factor shall then be
				  multiplied by the sum of the base unit, time unit, and physical status modifier
				  units of the patient to determine the reimbursement fate for the covered health
				  care service as of the date the service was rendered.
(1) The base units for an anesthesia service
				  code are the American Society of Anesthesiologists Relative Value Guide base
				  units for that service code.
(2)
				  The time unit is measured in 15 minute increments or a fraction
				  thereof.
(3) The physical status
				  modifier in a claim is a standard modifier describing the physical status of
				  the patient and is used to distinguish between various levels of complexity of
				  the anesthesia services provided, and is expressed as a unit with a value
				  between zero (0) and three (3).
(4)
				  The anesthesia conversion factor is expressed in dollars per unit and is a
				  contracted rate negotiated with the health insurer.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 5.5 - Average Contracted Rate Methodology › Section 2238.12 - Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For each
				  contracting health facility, health insurers shall annually provide to the
				  Department, with the network adequacy report submitted to the Department
				  pursuant to Section
				  2240.5 of Title 10 of the
				  California Code of Regulations, the following information:
(1) The following payment information for
				  each service subject to Insurance Code section
				  10112.8:
(A) Service code;
(B) Specialty, as applicable;
(C) Number of times payment was made for that
				  service code to non-contracting individual health professionals; and
(D) Number of times payment was made to a
				  contracting individual health professional for that service
				  code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 5.6 - Disclosure Forms in Health Insurance › Section 2239.10 - Summary of Dental Benefits and Coverage Disclosure Matrix

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Applicability: This Section shall apply
				  to insurers that issue, sell, renew, or offer a policy of health insurance as
				  defined in section
				  106 of the
				  Insurance Code that provides coverage for dental benefits in this
				  state.
(b) For purposes of this
				  Section only, the following definitions apply:
(1) "Group Policyholder" means a group,
				  association, or employer that contracts with an insurer to provide coverage for
				  dental benefits for members or employees.
(2) "Insurer" means an entity that provides
				  health insurance as defined in section
				  106 of the
				  Insurance Code, including its agents and representatives, and that issues,
				  sells, renews, or offers a policy that provides coverage for dental
				  benefits.
(3) "Policy year" means a
				  calendar year or other period of time during which a policy that provides
				  coverage for dental benefits is in effect, as designated in the contract
				  between the individual or group and the insurer.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 6 - Provider Network Access Standards for Health Insurance › Section 2240 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this Article:
(a) "Certificate" means an individual or
				  family certificate of coverage issued pursuant to an insurance
				  contract.
(b) "Covered person"
				  means either a primary covered person or a dependent covered person eligible to
				  receive health care services under the insurance contract providing network
				  provider services.
(c) "Dependent
				  covered person" means someone who is eligible for coverage under an insurance
				  contract through such person's relationship with or dependency upon a primary
				  covered person.
(d) "Emergency
				  health care services" means health care services rendered for any condition
				  manifesting itself by acute symptoms of sufficient severity (including severe
				  pain) such that the absence of immediate medical attention could reasonably be
				  expected to result in any of the following:
(1) Placing the patient's health in serious
				  jeopardy,
(2) Serious impairment to
				  bodily functions,
(3) Serious
				  dysfunction of any bodily organ or part,
(4) active labor. "Emergency health care
				  services" also includes services rendered for a psychiatric
				  emergency.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 6 - Provider Network Access Standards for Health Insurance › Section 2240.1 - Adequacy and Accessibility of Provider Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provisions of this article apply to
				  "health insurance" policies as defined by Insurance Code section
				  106(b).
				  The requirements of this article apply to all health care services covered by
				  the insurance policy. Notwithstanding the above, specialized health insurance
				  policies as defined in Insurance Code section
				  106(c),
				  other than specialized mental health insurance policies, are exempt from the
				  provisions of this article, except as specified below, in subdivisions (a)(1),
				  (a)(2), and (a)(3) of this Section
				  2240.1:
(1) Specialized health insurance policies
				  that provide coverage for dental care expenses only shall comply with the
				  following:
(A) Subdivisions (b)(7) and (e) of
				  Section 2240.1,
(B) Subdivisions (b)(1), (b)(3), (b)(4),
				  (b)(6), (b)(11), (b)(12), and (c)(1) of Section
				  2240.15,
(C) Section
				  2240.16, and
(D) Section
				  2240.3;
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 6 - Provider Network Access Standards for Health Insurance › Section 2240.15 - Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  For purposes of this section, the following definitions apply:
(1) "Appointment waiting time" means the time
				  from the initial request for health care services by a covered person or the
				  covered person's treating provider to the earliest date offered for the
				  appointment for services, inclusive of time for obtaining authorization from
				  the insurer or completing any other condition or requirement of the insurer or
				  its contracting providers.
(2)
				  "Preventive care" means health care provided for prevention and early detection
				  of disease, illness, injury or other health condition and, in the case of an
				  insurer includes but is not limited to all of the services required by
				  Insurance Code section
				  10112.2
				  (incorporating the requirements of
				  42 United States Code §
												300gg-13 (Public Health Service Act §
											2713), and 45 Code of Federal
				  Regulations §
											146.130) and subdivision
				  (a)(2)(A)(ii) of section
				  10112.27 of
				  the Insurance Code.
(3) "Provider
				  group" has the meaning set forth in subdivision (g)(3) of section
				  10133.56 of
				  the Insurance Code.
(4) "Triage" or
				  "screening" means the assessment of a covered person's health concerns and
				  symptoms via communication with a physician, registered nurse, or other
				  qualified health professional acting within the physician, registered nurse, or
				  other qualified health professional's scope of practice and who is trained to
				  screen or triage an insured who may need care, for the purpose of determining
				  the urgency of the covered person's need for care.
(5) "Triage or screening waiting time" means
				  the time waiting to speak by telephone with a physician, registered nurse, or
				  other qualified health professional acting within the physician, registered
				  nurse, or other qualified health professional's scope of practice and who is
				  trained to screen or triage an insured who may need care.
(6) "Urgent care" means health care for a
				  condition that requires prompt attention, consistent with subdivision (h)(2) of
				  section
				  10123.135
				  of the Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 6 - Provider Network Access Standards for Health Insurance › Section 2240.16 - Access Standards for Pediatric Vision and Oral Essential Health Benefits and Specialized Policies that Cover Dental Benefits Only

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Health
				  insurance policies covering the pediatric vision or oral essential health
				  benefit, as defined in subdivision (a)(4) and (a)(5), respectively, of
				  Insurance Code section
				  10112.27 (regardless of
				  whether such coverage is provided directly through the policy or through
				  subcontracting arrangements), specialized
				  health insurance policies that provide coverage for the pediatric oral
				  essential health benefit (as defined in subdivision (a)(5) of Insurance Code
				  section
				  10112.27),
				  and specialized health insurance policies that cover dental benefits only (as
				  defined in subdivision (c) of Insurance Code section
				  106) must
				  assure that there are adequate full-time equivalents of network providers
				  accepting new patients covered by the policy to accommodate anticipated
				  enrollment growth.
(b) In addition
				  to ensuring compliance with the clinical appropriateness standard set forth in
				  subdivision (b)(1) of Section
				  2240.15, each health insurance
				  policy covering the pediatric oral or vision essential health benefit,
				  specialized health insurance policies that provide coverage for the pediatric
				  oral essential health benefit (as defined in in subdivision (a)(5) of Insurance
				  Code section
				  10112.27),
				  and specialized health insurance policies that cover dental benefits only (as
				  defined in subdivision (c) of Insurance Code section
				  106) shall
				  ensure that contracted oral and vision provider networks have adequate capacity
				  and availability of licensed health care providers, including generalist and
				  specialist dentists, ophthalmologists, optometrists, and opticians -to offer
				  insureds appointments for covered oral and vision services in accordance with
				  the following requirements:
(1) Urgent
				  appointments shall be offered within 72 hours of the time of request for
				  appointment, when consistent with the covered person's individual needs and as
				  required by professionally recognized standards of practice;
(2) Non-urgent appointments shall be offered
				  within 36 business days of the request for appointment; and
(3) Preventive appointments shall be offered
				  within 40 business days of the request for appointment.