text:
(a) A policy of health insurance that covers outpatient prescription drugs shall cover medically necessary drugs. The policy may provide for step therapy and prior authorization consistent with Section 1342.7 of the Health and Safety Code and any regulations adopted pursuant to that section.

(b) (1) Commencing January 1, 2017, an insurer shall maintain a pharmacy and therapeutics committee that shall be responsible for developing, maintaining, and overseeing any drug formulary list. If the insurer delegates responsibility for the formulary to any entity, the obligation of the insurer to comply with this part shall not be waived.

(2) The pharmacy and therapeutics committee board membership shall conform with both of the following:

(A) Represent a sufficient number of clinical specialties to adequately meet the needs of insureds.

(B) Consist of a majority of individuals who are practicing physicians, practicing pharmacists, and other practicing health professionals who are licensed to prescribe drugs.

(3) Members of the board shall abstain from voting on any issue in which the member has a conflict of interest with respect to the issuer or a pharmaceutical manufacturer.

(4) At least 20 percent of the board membership shall not have a conflict of interest with respect to the issuer or any pharmaceutical manufacturer.

(5) The pharmacy and therapeutics committee shall meet at least quarterly and shall maintain written documentation of the rationale for its decisions regarding the development of, or revisions to, the formulary drug list.

(6) The pharmacy and therapeutics committee shall do all of the following:

(A) Develop and document procedures to ensure appropriate drug review and inclusion.

(B) Base clinical decisions on the strength of the scientific evidence and standards of practice, including assessing peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other related information.

(C) Consider the therapeutic advantages of drugs in terms of safety and efficacy when selecting formulary drugs.

(D) Review policies that guide exceptions and other utilization management processes, including drug utilization review, quantity limits, and therapeutic interchange.

(E) Evaluate and analyze treatment protocols and procedures related to the insurer’s formulary at least annually.

(F) Review and approve all clinical prior authorization criteria, step therapy protocols, and quantity limit restrictions applied to each covered drug.

(G) Review new United States Food and Drug Administration-approved drugs and new uses for existing drugs.

(H) Ensure the insurer’s formulary drug list or lists cover a range of drugs across a broad distribution of therapeutic categories and classes and recommended drug treatment regimens that treat all disease states and does not discourage enrollment by any group of insureds.

(I) Ensure the insurer’s formulary drug list or lists provide appropriate access to drugs that are included in broadly accepted treatment guidelines and that are indicative of general best practices at the time.

(7) This subdivision shall be interpreted consistent with federal guidance issued under paragraph (3) of subdivision (a) of Section 156.122 of Title 45 of the Code of Federal Regulations. This subdivision shall apply to the individual, small group, and large group markets.

(c) (1) A health insurer may impose prior authorization requirements on prescription drug benefits, consistent with the requirements of this part.

(2) (A) If there is more than one drug that is clinically appropriate for the treatment of a medical condition, a health insurer may require step therapy.

(B) A health insurer shall expeditiously grant a request for a step therapy exception within the applicable time limit required by Section 10123.191 if a prescribing provider submits necessary justification and supporting clinical documentation supporting the provider’s determination that the required prescription drug is inconsistent with good professional practice for provision of medically necessary covered services to the insured, taking into consideration the insured’s needs and medical history, along with the professional judgment of the insured’s provider. The basis of the provider’s determination may include, but is not limited to, any of the following criteria:

(i) The required prescription drug is contraindicated or is likely, or expected, to cause an adverse reaction or physical or mental harm to the insured in comparison to the requested prescription drug, based on the known clinical characteristics of the insured and the known characteristics and history of the insured’s prescription drug regimen.

(ii) The required prescription drug is expected to be ineffective based on the known clinical characteristics of the insured and the known characteristics and history of the insured’s prescription drug regimen.

(iii) The insured has tried the required prescription drug while covered by their current or previous health coverage or Medicaid, and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse reaction. The health insurer may require the submission of documentation demonstrating that the insured tried the required prescription drug before it was discontinued.

(iv) The required prescription drug is not clinically appropriate for the insured because the required drug is expected to do any of the following, as determined by the insured’s prescribing provider:

(I) Worsen a comorbid condition.

(II) Decrease the capacity to maintain a reasonable functional ability in performing daily activities.

(III) Pose a significant barrier to adherence to, or compliance with, the insured’s drug regimen or plan of care.

(v) The insured is stable on a prescription drug selected by the insured’s prescribing provider for the medical condition under consideration while covered by their current or previous health coverage or Medicaid.

(C) (i) This section does not prohibit a health care provider from prescribing a prescription drug that is clinically appropriate.

(ii) This section does not prohibit an insurer or utilization review organization from requiring an insured to try an AB-rated generic equivalent, biosimilar, as defined in Section 262(i)(2) of Title 42 of the United States Code, or interchangeable biological product, as defined in Section 262(i)(3) of Title 42 of the United States Code, before providing coverage for the equivalent branded prescription drug.

(iii) Clause (ii) does not prohibit or supersede a step therapy exception request as described in subparagraph (B) of paragraph (2) of subdivision (c).

(3) An insurer shall provide coverage for the medically necessary dosage and quantity of the drug prescribed for the treatment of a medical condition consistent with professionally recognized standards of practice.

(4) For plan years commencing on or after January 1, 2017, an insurer that provides essential health benefits shall allow an insured 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. A nongrandfathered individual or small group health insurer may charge an insured a different cost sharing for obtaining a covered drug at a retail pharmacy, but all cost sharing shall count toward the policy’s annual limitation on cost sharing consistent with Section 10112.28.

(d) A health care provider or prescribing provider may file an internal appeal of a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request consistent with the health insurer’s current utilization management processes.

(e) An insured or the insured’s designee or guardian may appeal a denial of an exception request for coverage of a nonformulary drug, prior authorization request, or step therapy exception request by filing an internal appeal with the health insurer pursuant to Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any subsequent rules or regulations issued thereunder.

(f) Every health insurer that provides prescription drug benefits shall maintain all of the following information, which shall be made available to the commissioner upon request:

(1) The complete drug formulary or formularies of the insurer, if the insurer maintains a formulary, including a list of the prescription drugs on the formulary of the insurer by major therapeutic category with an indication of whether any drugs are preferred over other drugs.

(2) Records developed by the pharmacy and therapeutics committee of the insurer, or by others responsible for developing, modifying, and overseeing formularies, including medical groups, individual practice associations, and contracting pharmaceutical benefit management companies, used to guide the drugs prescribed for the insureds of the insurer, that fully describe the reasoning behind formulary decisions.

(3) Any insurer arrangements with prescribing providers, medical groups, individual practice associations, pharmacists, contracting pharmaceutical benefit management companies, or other entities that are associated with activities of the insurer to encourage formulary compliance or otherwise manage prescription drug benefits.

(g) If an insurer provides prescription drug benefits, the commissioner shall, as part of its market conduct examination, review the performance of the insurer in providing those benefits, including, but not limited to, a review of the procedures and information maintained pursuant to this section, and describe the performance of the insurer as part of its report issued as part of its market conduct examination.

(h) The commissioner shall not publicly disclose any information reviewed pursuant to this section that is determined by the commissioner to be confidential pursuant to state law.

(i) For purposes of this section, the following definitions shall apply:

(1) “Authorization” means approval by the health insurer to provide payment for the prescription drug.

(2) “Step therapy” means a type of protocol that specifies the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are to be prescribed.

(3) “Step therapy exception” means a decision to override a generally applicable step therapy protocol in favor of coverage of the prescription drug prescribed by a health care provider for an individual insured.

(4) “Utilization review organization” means an entity that conducts utilization review, other than a health insurer performing its own utilization review.

(j) Nonformulary prescription drugs shall include any drug for which an insured’s copayment or out-of-pocket costs are different than the copayment for a formulary prescription drug, except as otherwise provided by law or regulation.

(k) This section does not affect an insured’s or policyholder’s eligibility to submit a complaint to the department for review or to apply to the department for an independent medical review under Article 3.5 (commencing with Section 10169).

(l) This section does not restrict or impair the application of any other provision of this part.

(m) This section and Section 10123.191 apply to both the health insurer and a utilization review organization that performs utilization review or utilization management functions on the insurer’s behalf. Commencing January 1, 2022, a contract between a health insurer and a utilization review organization that performs utilization review or utilization management functions on the insurer’s behalf shall include terms that require the utilization review organization to comply with this section and Section 10123.191.

history: (History: Amended by Stats. 2023, Ch. 495, Sec. 2. (SB 621) Effective January 1, 2024.)

article: 1. General Provisions


kind: section

code: INS

text:
(a) A health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, excluding specialized health insurance policies, shall be prohibited from requiring an insured to receive a referral before receiving coverage or services for reproductive and sexual health care.

(b) (1) For the purposes of this section, “reproductive and sexual health care services” are all reproductive and sexual health services described in Sections 6925, 6926, 6927, and 6928 of the Family Code, or Section 121020 of the Health and Safety Code, obtained by a patient.

(2) This section applies whether or not the patient is a minor.

(c) In implementing this section, a health insurer may establish reasonable provisions governing utilization protocols for obtaining reproductive and sexual health care services, as provided for in subdivision (a), if these provisions are consistent with the intent of this section and are those customarily applied to other health care providers, such as primary care physicians and surgeons, to whom the insured has direct access, and are not more restrictive for reproductive and sexual health care services. An insured shall not be required to obtain prior approval from another physician, another provider, or the insurer before obtaining direct access to reproductive and sexual health care services. An insurer may establish reasonable provisions governing communication with the insured’s primary care physician and surgeon regarding the insured’s condition, treatment, and a need for followup care.

(d) This section shall not apply to a health insurance policy that does not require insureds to obtain a referral from their primary care physician before seeking covered health care services from a specialist.

(e) A health insurer shall not impose utilization protocols related to contraceptive drugs, supplies, and devices beyond those in Section 10123.196.

(f) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRICARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.

history: (History: Amended by Stats. 2018, Ch. 687, Sec. 11. (SB 910) Effective January 1, 2019.)

division: 2. CLASSES OF INSURANCE

part: 2. LIFE AND DISABILITY INSURANCE

chapter: 1. The Contract

article: 1. General Provisions

path: 2. CLASSES OF INSURANCE > 2. LIFE AND DISABILITY INSURANCE > 1. The Contract > 1. General Provisions


text: Commencing January 1, 2019, an insurer shall prorate an insured’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.

history: (History: Added by Stats. 2017, Ch. 615, Sec. 6. (AB 1048) Effective January 1, 2018.)

article: 1. General Provisions


text:
(a) A health insurance policy issued, amended, delivered, or renewed on or after July 1, 2023, that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:

(1) Upon request of an insured or an insured’s prescribing provider, furnish all of the following information regarding a prescription drug to the insured or the insured’s prescribing health care provider:

(A) The insured’s eligibility for the prescription drug.

(B) The most current formulary or formularies.

(C) Cost-sharing information for the prescription drug and other formulary alternatives, consistent with cost-sharing requirements as set forth in the policy and accurate at the time it is provided, including any variance in cost sharing based on the patient’s preferred dispensing pharmacy, whether retail or mail order, or the health care provider.

(D) Applicable utilization management requirements for the prescription drug and other formulary alternatives.

(2) Respond in real time to a request made pursuant to paragraph (1) through a standard API.

(3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1).

(4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time.

(5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code.

(b) A health insurer shall not do any of the following:

(1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a).

(2) Restrict, prohibit, or otherwise hinder a prescribing provider from communicating or sharing to an insured any of the following:

(A) The information provided pursuant to subdivision (a).

(B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the insured’s health insurance policy.

(C) Information about the cash price of the drug.

(3) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a). “Interfere with, prevent, or materially discourage access, exchange, or use of the information” includes charging fees for access to the information, not responding to a request at the time made consistent with this section, or instituting insured consent requirements.

(4) Penalize a prescribing provider for disclosing the information provided pursuant to subdivision (a). For purposes of this paragraph, “penalize” includes an action intended to punish a provider for disclosing the information set forth in subdivision (a) or intended to discourage a provider from disclosing this information in the future.

(5) Penalize a prescribing provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug. For purposes of this paragraph, “penalize” includes an action intended to punish a provider who has prescribed, administered, or ordered a lower cost or clinically appropriate alternative drug, or intended to discourage a provider from prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug in the future.

(c) For purposes of this section:

(1) “Cost sharing” includes applicable copayments, coinsurances, or deductibles.

(2) “Cost-sharing information” means the actual out-of-pocket amount an insured would be required to pay a dispensing pharmacy or prescribing provider for a prescription drug under the terms of the insured’s health insurance policy.

(3) “Formulary” has the same meaning as in Section 10123.192.

(4) “Interoperability element” means integrated technologies or services necessary to provide a response to an insured or an insured’s prescribing provider.

(5) “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition, including prescriptions to treat mental health and substance use disorders, for an insured.

(6) “Standard API” means an application interface that is standardized for vendors to conform to in order to access the information pursuant to Section 170.215 of Title 45 of the Code of Federal Regulations.

(d) (1) This section does not authorize further disclosure inconsistent with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code).

(2) This section does not alter or interfere with requirements that a health insurer cover prescription drugs consistent with this chapter and regulations promulgated thereunder.

(3) This section does not alter or interfere with a health insurer’s other obligations under this article, including requirements to disclose or explain its prescription drug benefit.

history: (History: Added by Stats. 2022, Ch. 590, Sec. 2. (AB 2352) Effective January 1, 2023.)

article: 1. General Provisions


text:
(a) (1) A health insurer that reports rate information pursuant to Section 10181.3 or 10181.45 shall report the information described in paragraph (2) to the department no later than October 1 of each year, beginning October 1, 2018.

(2) For all covered prescription drugs, including generic drugs, brand name drugs, and specialty drugs dispensed at a plan pharmacy, network pharmacy, or mail order pharmacy for outpatient use, all of the following shall be reported:

(A) The 25 most frequently prescribed drugs.

(B) The 25 most costly drugs by total annual plan spending.

(C) The 25 drugs with the highest year-over-year increase in total annual plan spending.

(b) The department shall compile the information reported pursuant to subdivision (a) into a report for the public and legislators that demonstrates the overall impact of drug costs on health care premiums. The data in the report shall be aggregated and shall not reveal information specific to individual health insurers.

(c) For the purposes of this section, a “specialty drug” is one that exceeds the threshold for a specialty drug under the Medicare Part D program (Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173)).

(d) By January 1 of each year, beginning January 1, 2018, the department shall publish on its Internet Web site the report required pursuant to subdivision (b).

(e) After the report required in subdivision (b) is released, the department shall include the report as part of the public meeting required pursuant to subdivision (b) of Section 10181.45.

(f) Except for the report required pursuant to subdivision (b), the department shall keep confidential all of the information provided to the department pursuant to this section, and the information shall be protected from public disclosure.

history: (History: Added by Stats. 2017, Ch. 603, Sec. 5. (SB 17) Effective January 1, 2018.)

article: 1. General Provisions


text:
(a) Notwithstanding any other law, an individual or group health insurance policy 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 insured 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 policy.

(2) For a health insurance policy 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 insured’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 insurance policy that covers only dental or vision benefits or any coverage under a health insurance policy for the Medicare Program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).

history: (History: Amended by Stats. 2023, Ch. 607, Sec. 2. (SB 421) Effective January 1, 2024.)

article: 1. General Provisions


text:
(a) Every health insurance policy, except a specialized health insurance policy, that is issued, amended, or renewed on or after January 1, 2022, shall provide coverage without 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 insurer that has a network of providers from imposing cost-sharing requirements for the items or services described in this section that are delivered by an out-of-network provider.

history: (History: Added by Stats. 2021, Ch. 436, Sec. 2. (AB 342) Effective January 1, 2022.)

article: 1. General Provisions


text:
(a) A health insurance policy issued, amended, renewed, or delivered on or after January 1, 2022, excluding specialized health insurance policies, 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 an in-network clinician, or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.

(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.

history: (History: Added by Stats. 2021, Ch. 486, Sec. 7. (SB 306) Effective January 1, 2022.)

article: 1. General Provisions


text:
(a) A health insurance policy that is issued, amended, delivered, or renewed on or after July 1, 2024, shall include coverage for medically necessary biomarker testing, subject to utilization review management, pursuant to this section. Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an insured’s disease or condition to guide treatment decisions. Coverage shall include biomarker tests that meet any of the following:

(1) A labeled indication for a test that has been approved or cleared by the United States Food and Drug Administration (FDA) or is an indicated test for an FDA-approved drug.

(2) A national coverage determination made by the federal Centers for Medicare and Medicaid Services.

(3) A local coverage determination made by a Medicare Administrative Contractor for California.

(4) Evidence-based clinical practice guidelines, supported by peer-reviewed literature and peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.

(5) Standards set by the National Academy of Medicine.

(b) A health insurer shall use the process described in subdivision (f) of Section 10123.135 to determine whether biomarker testing is medically necessary for purposes of this section.

(c) A health insurance policy that is subject to this section shall ensure that biomarker testing is provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples. This section shall not be construed to require coverage of biomarker testing for screening purposes unless otherwise required by this part.

(d) Restricted or denied use of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is subject to grievance and appeal processes under state and federal law, including Section 2719 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-19) and any regulations subsequently adopted thereunder, and the Independent Medical Review System under Article 3.5 (commencing with Section 10169).

(e) For purposes of this section, the following definitions apply:

(1) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a specific therapeutic intervention. A biomarker includes, but is not limited to, gene mutations or protein expression.

(2) “Biomarker testing” means the analysis of an individual’s tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker testing includes, but is not limited to, single-analyte tests, multiplex panel tests, and whole genome sequencing.

(f) This section is subject to the provisions of Section 10123.20 as amended by Chapter 605 of the Statutes of 2021 for an insured with advanced or metastatic stage III or IV cancer.

history: (History: Added by Stats. 2023, Ch. 401, Sec. 2. (SB 496) Effective January 1, 2024.)

article: 1. General Provisions


text:
(a) A health insurer that provides health coverage to the employees of a religious employer that does not include coverage and benefits for both abortion and contraception shall provide, in writing upon initial enrollment and annually thereafter upon renewal, each insured with information regarding both of the following:

(1) Abortion and contraception benefits or services that are not included in the insured’s health insurance policy.

(2) Abortion and contraception benefits or services that may be available at no cost through the California Reproductive Health Equity Program.

(b) For purposes of this section:

(1) “Abortion” has the same meaning as defined in Section 123464 of the Health and Safety Code.

(2) “California Reproductive Health Equity Program” means the program established pursuant to Section 127632 of the Health and Safety Code.

(3) “Contraception” means the services and contraceptive methods described in paragraph (1) of subdivision (b) of Section 10123.196.

(4) “Religious employer” has the same meaning as described in Section 10123.196.

(c) This section does not alter the applicability of any other requirement of this chapter.

history: (History: Added by Stats. 2022, Ch. 562, Sec. 3. (AB 2134) Effective January 1, 2023.)

article: 1. General Provisions


text:
(a) (1) A health insurance policy that is issued, amended, or renewed on or after July 1, 2025, excluding a specialized health insurance policy, shall provide coverage for emergency room medical care and followup health care treatment for an insured who is treated following a rape or sexual assault, as defined in Sections 261, 261.6, 263, 263.1, 286, 287, and 288.7 of the Penal Code, without imposing cost sharing, including copayments, coinsurance, or deductibles, for the first nine months after the enrollee initiates treatment.

(2) For the purposes of this section, “followup health care treatment” includes medical or surgical services for the diagnosis, prevention, or treatment of medical conditions arising from an instance of rape or sexual assault.

(3) The waiver of the imposition of cost sharing pursuant to paragraph (1) shall only apply if the enrollee’s treating provider submits all requests for claims payments using accurate diagnosis codes specific to rape or sexual assault.

(b) A health insurer shall not require any of the following to provide coverage under this section:

(1) An insured to file a police report on the rape or sexual assault.

(2) Charges to be brought against an assailant.

(3) An assailant to be convicted of an offense listed in subdivision (a).

(c) (1) This section does not authorize an insured to receive followup health care treatment required to be covered by this section if treatment is furnished by a nonparticipating provider, except as specified in paragraphs (2) and (3).

(2) A health insurer shall arrange for the provision of followup health care treatment required by this section from providers outside the insurer’s network if those services are unavailable within the network to ensure timely access to covered health care services consistent with Section 10133.54.

(3) A health insurer shall cover followup health care treatment if those services are for emergency services and care as defined in Section 1317.1 of the Health and Safety Code.

(d) For a health insurance policy 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, this section shall only apply once an enrollee’s deductible has been satisfied for the year.

(e) “Cost sharing” includes any copayment, coinsurance, or deductible, or any other form of cost sharing paid by the insured other than premium or share of premium.

(f) This section does not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.

(g) Coverage provided under this section is coverage of sensitive services provided to a protected individual as those terms are defined in Section 791.02 and pursuant to Section 791.29.

history: (History: Added by Stats. 2024, Ch. 971, Sec. 3. (AB 2843) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) Every individual or group policy of disability insurance that covers hospital, medical, or surgical benefits 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 require an individual or group policy to cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, and combined hormonal therapy, or to prevent application of deductible or copayment provisions contained in the policy, nor shall this section be construed to require that coverage under an individual or group policy be extended to any other procedures.

(c) This section shall not apply to specified accident, specified disease, hospital indemnity, Medicare supplement, or long-term care health insurance policies.

history: (History: Added by renumbering Section 10123.83 (as added by Stats. 1998, Ch. 839) by Stats. 2009, Ch. 234, Sec. 11. (AB 299) Effective January 1, 2010.)

article: 1. General Provisions


text:
(a) (1) A contract between a health insurer and a health care provider for an alternative rate of payment pursuant to Section 10133 shall specify that the health insurer shall reimburse the treating or consulting health care provider for the diagnosis, consultation, or treatment of an insured or policyholder appropriately delivered through telehealth services on the same basis and to the same extent that the health insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment.

(2) This section does not limit the ability of a health insurer and a health care provider to negotiate the rate of reimbursement for a health care service provided pursuant to a contract subject to this section. Services that are the same, as determined by the provider’s description of the service on the claim, shall be reimbursed at the same rate whether provided in person or through telehealth. When negotiating a rate of reimbursement for telehealth services for which no in-person equivalent exists, a health insurer and the provider shall ensure the rate is consistent with subdivision (a) of Section 10123.137.

(b) (1) A policy of health insurance that provides benefits through contracts with providers at alternative rates of payment shall specify that the health insurer shall provide coverage for health care services appropriately delivered through telehealth services on the same basis and to the same extent that the health insurer is responsible for coverage for the same service through in-person diagnosis, consultation, or treatment. Coverage shall not be limited only to services delivered by select third-party corporate telehealth providers.

(2) This section does not alter the existing statutory or regulatory obligations of a health insurer to ensure that insureds have access to all covered services through an adequate network of contracted providers, as required by Sections 10133 and 10133.5 and the regulations promulgated thereunder.

(3) This section does not require a health insurer to deliver health care services through telehealth services.

(4) This section does not require a health insurer to cover telehealth services provided by an out-of-network provider, unless coverage is required under other provisions of law.

(c) A health insurer may offer a policy containing a copayment or coinsurance requirement for a health care service delivered through telehealth services, provided that the copayment or coinsurance does not exceed the copayment or coinsurance applicable if the same services were delivered through in-person diagnosis, consultation, or treatment. This subdivision does not require cost sharing for services provided through telehealth.

(d) Services provided through telehealth and covered pursuant to this chapter shall be subject to the same deductible and annual or lifetime dollar maximum as equivalent services that are not provided through telehealth.

(e) The definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code apply to this section.

(f) The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

history: (History: Amended by Stats. 2021, Ch. 439, Sec. 6. (AB 457) Effective January 1, 2022.)

article: 1. General Provisions


text:
(a) If a health insurer offers a service via telehealth to an insured through a third-party corporate telehealth provider, all of the following conditions shall be met:

(1) The health insurer shall disclose to the insured in any promotion or coordination of the service both of the following:

(A) The availability of receiving the service on an in-person basis or via telehealth, if available, from the insured’s primary care provider, treating specialist, or from another contracting individual health professional, a contracting clinic, or a contracting health facility consistent with the service and existing timeliness and geographic access standards in Section 10133.5 and regulations promulgated thereunder.

(B) If the insured has coverage for out-of-network benefits, a reminder of the availability of receiving the service either via telehealth or on an in-person basis using the insured’s out-of-network benefits, and the cost sharing obligation for out-of-network benefits compared to in-network benefits and balance billing protections for services received from contracted providers.

(2) After being notified pursuant to paragraph (1), the insured chooses to receive the service via telehealth through a third-party corporate telehealth provider.

(3) The insured consents to the service consistent with Section 2290.5 of the Business and Professions Code.

(4) If the insured is currently receiving specialty telehealth services for a mental or behavioral health condition, the insured is given the option of continuing to receive that service with the contracting individual health professional, a contracting clinic, or a contracting health facility.

(b) For purposes of this section, the following definitions shall apply:

(1) “Contracting individual health professional” means a physician and surgeon or other professional who is licensed by the state to deliver or furnish health care services, including mental or behavioral health services, and who is contracted with the insured’s health insurer. A “contracting individual health professional” shall not include a dentist licensed pursuant to the Dental Practice Act (Chapter 4 (commencing with Section 1600) of Division 2 of the Business and Professions Code). Application of this definition is not precluded by a contracting individual health professional’s affiliation with a group.

(2) “Contracting clinic” means a clinic, as defined in Section 1200 of the Health and Safety Code, that is contracted with the insured’s health insurer.

(3) “Contracting health facility” mean a health facility, as defined in Section 1250 of the Health and Safety Code, that is contracted with the insured’s health insurer.

(4) “Third-party corporate telehealth provider” means a corporation directly contracted with a health insurer that provides health care services exclusively through a telehealth technology platform and has no physical location at which a patient can receive services.

(c) If services are provided to an insured through a third-party corporate telehealth provider, a health insurer shall comply with all of the following:

(1) Notify the insured of the insured’s right to access the insured’s medical records pursuant to, and consistent with, Chapter 1 (commencing with Section 123100) of Part 1 of Division 106 of the Health and Safety Code.

(2) Notify the insured that the record of any services provided to the insured through a third-party corporate telehealth provider shall be shared with the insured’s primary care provider, unless the insured objects.

(3) Ensure that the records are entered into a patient record system shared with the insured’s primary care provider or are otherwise provided to the insured’s primary care provider, unless the insured objects, in a manner consistent with state and federal law.

(4) Notify the insured that all services received through the third-party corporate telehealth provider are considered to be in network available at in-network cost-sharing and out-of-pocket costs shall accrue to any applicable deductible or out-of-pocket maximum.

(d) A health insurer shall include in its reports submitted to the department pursuant to Section 10133.5 and regulations adopted pursuant to that section, in a manner specified by the commissioner, all of the following for each product type:

(1) By specialty, the total number of services delivered via telehealth provided by third-party corporate telehealth providers.

(2) The names of each third-party corporate telehealth provider contracted with the insurer and, for each, the number of services provided by specialty.

(3) For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party corporate telehealth provider’s contracted providers available to the insurer’s insured that are also contracting individual health professionals.

(4) For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by insureds, including frequency of use, gender, age, and any other information as determined by the department.

(5) For each enrollee that has accessed services for a third-party corporate telehealth provider, enrollee demographic data, including gender and age, and any other information as determined by the department.

(e) The commissioner shall investigate and take enforcement action, as appropriate, against a health insurer that fails to comply with these requirements and shall periodically evaluate contracts between health insurers and third-party corporate telehealth providers to determine if any audit, evaluation, or enforcement actions should be undertaken by the commissioner.

(f) This section shall not apply when an insured seeks services directly from a third-party corporate telehealth provider.

history: (History: Added by Stats. 2021, Ch. 439, Sec. 7. (AB 457) Effective January 1, 2022.)

article: 1. General Provisions


text:
(a) A health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized health insurance policy covering dental services that offers a service via telehealth to an insured through a third-party corporate telehealth provider shall report to the department, in a manner specified by the department, all of the following for each product type:

(1) The total number of services delivered via telehealth by a third-party corporate telehealth provider.

(2) For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party telehealth provider’s contracted providers available to the insurer’s insured that are also network providers.

(3) For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by insureds, including information on the gender and age of the insured, and any other information as determined by the department.

(b) A health insurer that issues, sells, renews, or offers a policy covering dental services, including a specialized health care policy covering dental services that offers a service via telehealth to an insured through a third-party corporate telehealth provider, shall disclose to the insured the impact of third-party telehealth visits on the insured’s benefit limitations, including frequency limitations and the insured’s annual maximum.

(c) Section 10123.856 shall not apply to specialized health insurance policies covering dental services.

(d) For the purposes of this section, “third-party corporate telehealth provider” means a corporation that provides dental services exclusively through a telehealth technology platform and has no physical location at which a patient can receive services, and is directly contracted with a health insurer that issues, sells, renews, or offers a policy, including a specialized health insurance policy, that covers dental services.

history: (History: Amended by Stats. 2024, Ch. 444, Sec. 5. (SB 577) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) A health insurance policy that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date of this section shall include coverage for United States Food and Drug Administration-approved treatments used to treat menopausal symptoms, as medically necessary, including, but not limited to, all of the following:

(1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss.

(2) Low-dose antidepressants.

(3) Anticonvulsants.

(4) Medications to prevent or treat osteoporosis.

(5) Nonhormonal medications for vasomotor-related symptoms.

(b) A health insurance policy that is issued, amended, or renewed on or after January 1, 2027, shall include a program to ensure insured individuals have access to current menopause information and covered items and services.

(c) For the program to satisfy subdivision (b), the insurer shall do all of the following:

(1) Provide, no later than July 1, 2027, and biannually thereafter, all contracted providers delivering primary care with information about current clinical care recommendations for menopause care, including hormone therapy, from the Menopause Society or other nationally recognized professional association. The insurer shall encourage providers delivering primary care to review the information.

(2) Establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall identify the Current Procedural Terminology (CPT) codes for services commonly used to evaluate, diagnose, and treat symptoms resulting from menopause.

(3) Establish and maintain a policy to provide insured individuals who may experience menopause and who are 40 years of age and older with an annual menopause assessment during primary care and obstetrician-gynecologist appointments. Insured individuals may opt out of receiving the assessments. The policy shall include a copy of the assessment tool and information on how it was developed or chosen.

(4) Provide insured individuals who may experience menopause and who are 40 years of age and older with a notice that includes a definition of menopause and that lists the covered items and services used to evaluate and treat symptoms resulting from menopause. The first notice shall be sent within 60 days of the insured individual’s 40th birthday and shall be sent biannually thereafter. Insured individuals may opt out of receiving the notices. The notice shall include a description of at least all of the following types of federal Food and Drug Administration-approved items and services:

(A) Hormone therapy in the full range of formulations and methods of administration.

(B) Low-dose antidepressants.

(C) Anticonvulsants.

(D) Medications to prevent or treat osteoporosis.

(E) Nonhormonal medications for vasomotor-related symptoms.

(5) Establish and maintain a policy to contract with providers delivering primary care, including advanced practice providers such as licensed nurse practitioners and certified nurse-midwives, who hold a certification or credential in menopause care from a nationally recognized organization, such as the Menopause Society or other similar organization. The policy shall state what steps the insurer will take to incentivize providers to receive and maintain the certification or credential.

(d) The health insurer shall file with the commissioner within six months of the operative date of this statute the policies and notices specified in subdivision (c). The insurer shall also disclose the policies to network providers, provider groups, and delegated entities that may be impacted by the policies and notices and shall attest to that disclosure to the commissioner.

(e) Coverage for the treatment options pursuant to this section shall be provided without discrimination on the basis of gender expression or identity.

(f) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause.

(g) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause.

history: (History: Added by Stats. 2026, Ch. 27, Sec. 56. (SB 164) Effective June 29, 2026.)

article: 1. General Provisions


text:
(a) A health insurer shall base a medical necessity determination or the utilization review criteria that the insurer, and an entity acting on the insurer’s behalf, applies to determine the medical necessity of health care services and benefits for the treatment of symptoms resulting from menopause on current generally accepted standards of menopause care.

(b) Beginning January 1, 2027, when conducting utilization review of all covered health care services and benefits for the treatment of symptoms resulting from menopause, a health insurer shall apply criteria and guidelines developed by the Menopause Society or another nationally recognized professional association, as specified by the commissioner.

(c) In conducting utilization review involving patient care decisions that are within the scope of the sources specified in subdivision (b), a health insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in those sources. This subdivision does not prohibit an insurer from applying utilization review criteria to health care services and benefits for menopause care that meet either of the following criteria:

(1) Are outside the scope of the criteria and guidelines set forth in the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).

(2) Relate to advancements in technology or types of care that are not covered in the most recent versions of the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).

(d) If a health insurer purchases or licenses utilization review criteria pursuant to paragraph (1) or (2) of subdivision (c), the insurer shall verify and document before use that the criteria were developed in accordance with subdivision (a).

(e) A health insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with this section.

(f) For purposes of this section, the following definitions apply:

(1) “Generally accepted standards of menopause care” means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties, including gynecology, endocrinology, and family practice. Valid, evidence-based sources establishing generally accepted standards of menopause care include peer reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit health care provider professional associations, specialty societies, and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.

(2) “Menopause” includes perimenopause, menopause, and postmenopause.

(3) “Utilization review” means either of the following:

(A) Prospectively, retrospectively, or concurrently reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests by health care providers, insured individuals, or their authorized representatives for coverage of health care services prior to, retrospectively, or concurrent with the provision of health care services to insured individuals.

(B) Evaluating the medical necessity, appropriateness, or efficacy of health care services, benefits, or procedures, under any circumstances, to determine if a health care service or benefit subject to a medical necessity coverage requirement in a health insurance policy is covered as medically necessary for an insured individual.

(4) “Utilization review criteria” means criteria, standards, protocols, or guidelines used by a health insurer to conduct utilization review.

(g) (1) This section applies to all health care services and benefits for the treatment of symptoms resulting from menopause covered by a health insurance policy, including prescription drugs.

(2) This section applies to a health insurer that conducts utilization review and an entity or contracting provider that performs utilization review or utilization management functions on an insurer’s behalf.

(3) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause.

(h) If the commissioner determines that a health insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation.

(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and Section 10123.861 through guidance or similar instructions, without taking regulatory action, until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care and interested stakeholders in developing guidance.

history: (History: Added by Stats. 2026, Ch. 27, Sec. 57. (SB 164) Effective June 29, 2026.)

article: 1. General Provisions


text: The provision of medically necessary pasteurized donor human milk obtained from a tissue bank licensed pursuant to Chapter 4.1 (commencing with Section 1635) of Division 2 of the Health and Safety Code is a basic health care service, as described in Sections 10112.27 and 10112.281 and any regulations adopted thereunder.

history: (History: Added by Stats. 2024, Ch. 975, Sec. 4. (AB 3059) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) Commencing no later than July 1, 2012, an individual health insurance policy shall provide coverage for maternity services for all insureds covered under the policy.

(b) For purposes of this section, “maternity services” include prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and postpartum care. This definition of “maternity services” shall remain in effect until the time as federal regulations and guidance issued pursuant to the federal Patient Protection and Affordable Care Act (Public Law 111-148) define the scope of benefits to be provided under the maternity benefit requirement of that act, after which time the definition of that term under the federal act and associated regulations and guidance shall apply for purposes of this section.

(c) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.

history: (History: Amended by Stats. 2018, Ch. 687, Sec. 7. (SB 910) Effective January 1, 2019.)

article: 1. General Provisions


text:
(a) Commencing no later than July 1, 2012, a group health insurance policy shall provide coverage for maternity services for all insureds covered under the policy.

(b) For purposes of this section, “maternity services” include prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and postpartum care. This definition of “maternity services” shall remain in effect until the time as federal regulations and guidance issued pursuant to the federal Patient Protection and Affordable Care Act (Public Law 111-148) define the scope of benefits to be provided under the maternity benefit requirement of that act, after which time the definition of that term under the federal act and associated regulations and guidance shall apply for purposes of this section.

(c) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.

history: (History: Amended by Stats. 2018, Ch. 687, Sec. 8. (SB 910) Effective January 1, 2019.)

article: 1. General Provisions


text:
(a) A health insurer shall develop a maternal mental health program designed to promote quality and cost-effective outcomes. The program shall consist of at least one maternal mental health screening to be conducted during pregnancy, at least one additional screening to be conducted during the first six weeks of the postpartum period, and additional postpartum screenings, if determined to be medically necessary and clinically appropriate in the judgment of the treating provider. 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 the maternal mental health program, a health insurer 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 insureds about the program.

(b) For the purposes of this section:

(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 insured’s health insurer to provide services under the insured’s health insurance policy.

(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 does not apply to specialized health insurers, except behavioral health-only insurers that provide coverage for professional mental health services.

history: (History: Amended by Stats. 2024, Ch. 815, Sec. 2. (AB 1936) Effective January 1, 2025.)

article: 1. General Provisions


text: On or before January 1, 2025, a health insurer 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.

history: (History: Added by Stats. 2023, Ch. 349, Sec. 3. (AB 904) Effective January 1, 2024.)

article: 1. General Provisions


text:
(a) A contract between a health insurer and a health care provider issued, amended, or renewed on or after January 1, 2025, shall authorize a provider to separately bill for devices, implants, or professional services, or a combination thereof, associated with immediate postpartum contraception if the birth takes place in a general acute care hospital or licensed birth center. The provider contract shall not consider those devices, implants, or services to be part of a payment for a general obstetric procedure.

(b) For purposes of this section, “immediate postpartum contraception” means the postpartum insertion of intrauterine devices or contraceptive implants performed before the insured is discharged from the general acute care hospital or licensed birth center and includes the devices or implants themselves.

(c) This section does not affect an insured’s right to directly access women’s health care services, including contraceptive services, and informed consent.

history: (History: Added by Stats. 2024, Ch. 950, Sec. 2. (AB 2129) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) (1) With respect to an individual or group policy of health insurance subject to Section 10112.28, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed two hundred fifty dollars ($250), except as provided in paragraphs (2) and (3).

(2) With respect to products with actuarial value at or equivalent to the bronze level, cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed five hundred dollars ($500), except as provided in paragraph (3).

(3) For a policy of health insurance that is a “high deductible health plan” under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code, paragraphs (1) and (2) of this subdivision shall apply only once an insured’s deductible has been satisfied for the year.

(4) For a nongrandfathered individual or small group policy of health insurance, the annual deductible for outpatient drugs, if any, shall not exceed twice the amount specified in paragraph (1) or (2), respectively.

(5) For purposes of paragraphs (1) and (2), “any other form of cost sharing” shall not include a deductible.

(6) A copayment or percentage coinsurance shall not exceed 50 percent of the cost to the insurer, as described in Section 1300.67.24 of Title 28 of the California Code of Regulations.

(7) If there is a generic equivalent to a brand name drug, an insurer shall ensure that the insured is subject to the lowest cost sharing that would be applied, whether or not both the generic equivalent and the brand name drug are on the formulary. This paragraph shall not be construed to require both the generic equivalent and the brand name drug to be on the formulary.

(b) (1) If a policy of health insurance offered, sold, or renewed in the nongrandfathered individual or small group market maintains a drug formulary grouped into tiers that includes a fourth tier, a policy of health insurance shall use the following definitions for each tier of the drug formulary:

(A) Tier one shall consist of most generic drugs and low-cost preferred brand name drugs.

(B) Tier two shall consist of nonpreferred generic drugs, preferred brand name drugs, and any other drugs recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost.

(C) Tier three shall consist of nonpreferred brand name drugs or drugs that are recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost, or that generally have a preferred and often less costly therapeutic alternative at a lower tier.

(D) Tier four shall consist of drugs that the Food and Drug Administration of the United States Department of Health and Human Services or the manufacturer requires to be distributed through a specialty pharmacy, drugs that require the insured to have special training or clinical monitoring for self-administration, or drugs that cost the health insurer more than six hundred dollars ($600) net of rebates for a one-month supply.

(2) In placing specific drugs on specific tiers, or choosing to place a drug on the formulary, the insurer shall comply with the other provisions of this section and this part.

(3) A policy of health insurance may maintain a drug formulary with fewer than four tiers. A policy of health insurance shall not maintain a drug formulary with more than four tiers.

(4) This section shall not be construed to limit a health insurer from placing any drug in a lower tier.

history: (History: Amended by Stats. 2023, Ch. 820, Sec. 2. (AB 948) Effective January 1, 2024.)

article: 1. General Provisions


text:
(a) (1) Notwithstanding Section 10123.201, a health insurer shall not subject antiretroviral drugs that are medically necessary for the prevention of AIDS/HIV, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy, except as provided in paragraph (2).

(2) If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a drug, device, or product for the prevention of AIDS/HIV, this section does not require a health insurer to cover all of the therapeutically equivalent versions without prior authorization or step therapy, if at least one therapeutically equivalent version is covered without prior authorization or step therapy.

(b) Notwithstanding any other law, a health insurer shall not prohibit, or permit a contracted pharmacy benefit manager to prohibit, a pharmacist from dispensing preexposure prophylaxis or postexposure prophylaxis.

(c) A health insurer shall cover preexposure prophylaxis and postexposure prophylaxis that has been furnished by a pharmacist, as authorized in Sections 4052.02 and 4052.03 of the Business and Professions Code, including the pharmacist’s services and related testing ordered by the pharmacist. A health insurer shall pay or reimburse, consistent with the requirements of this chapter, for the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the health insurer has an out-of-network pharmacy benefit.

history: (History: Amended by Stats. 2024, Ch. 1, Sec. 3. (SB 339) Effective February 6, 2024.)

article: 1. General Provisions


text:
(a) Notwithstanding any other law, a group or individual health insurer offering an outpatient prescription drug benefit shall provide coverage for at least one medication approved by the United States Food and Drug Administration in each of the following categories without prior authorization, step therapy, or utilization review:

(1) Medication for the reversal of opioid overdose, including a naloxone product or another opioid antagonist.

(2) Medication for the detoxification or maintenance treatment of a substance use disorder, including a daily oral buprenorphine product.

(3) A long-acting buprenorphine product.

(4) A long-acting injectable naltrexone product.

(b) This section does not prohibit a health insurer from selecting an AB-rated generic equivalent, biosimilar, as defined in Section 262(i)(2) of Title 42 of the United States Code, or interchangeable biological product, as defined in Section 262(i)(3) of Title 42 of the United States Code, to meet the requirements of subdivision (a).

history: (History: Added by Stats. 2024, Ch. 633, Sec. 2. (AB 1842) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) (1) A disability insurance policy issued, amended, renewed, or delivered on or after January 1, 2024, except for a grandfathered health plan or a qualifying health plan for a health savings account, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on vasectomy services or procedures. For a qualifying health plan for a health savings account, an insurer shall establish the plan’s cost sharing for vasectomy services and procedures at the minimum level necessary to preserve the insured’s ability to claim tax-exempt contributions and withdrawals from the insured’s health savings account under Internal Revenue Service laws, regulations, and guidance.

(2) An insurer shall not impose any restrictions or delays, including, but not limited to, prior authorization, on vasectomy services and procedures.

(3) Coverage with respect to an insured under this section shall be identical for an insured’s covered spouse and covered nonspouse dependents.

(b) This section shall not be construed to deny or restrict in any way an existing right or benefit provided under law or by contract.

(c) This section shall not be construed to require an individual or group disability insurance policy to cover experimental or investigational treatments.

(d) Notwithstanding any other provision of this section, a religious employer may request a disability insurance policy without coverage for contraceptive methods that are contrary to the religious employer’s religious tenets. If so requested, a disability insurance policy shall be provided without coverage for vasectomy services and procedures. The exclusion from coverage under this provision shall not apply to vasectomy services or procedures for purposes other than contraception.

(1) An insurer that contracts with a religious employer to provide a disability insurance policy that does not include coverage and benefits for vasectomy services and procedures shall notify, in writing, upon initial enrollment and annually thereafter upon renewal, each enrollee that vasectomy services and procedures are not included in the insured’s disability insurance policy.

(2) For purposes of this section, a “religious employer” is an entity for which each of the following is true:

(A) The inculcation of religious values is the purpose of the entity.

(B) The entity primarily employs persons who share the religious tenets of the entity.

(C) The entity serves primarily persons who share the religious tenets of the entity.

(D) The entity is a nonprofit organization pursuant to Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended.

(e) This section only applies to disability insurance policies or contracts that are defined as health benefit plans pursuant to subdivision (a) of Section 10198.6, except that for accident only, specified disease, or hospital indemnity coverage, coverage for benefits under this section applies to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy or contract. This section shall not be construed as imposing a new benefit mandate on accident only, specified disease, or hospital indemnity insurance.

(f) For purposes of this section, the following definitions apply:

(1) “Grandfathered health plan” has the meaning set forth in Section 1251 of PPACA.

(2) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued thereunder.

history: (History: Added by Stats. 2022, Ch. 630, Sec. 16. (SB 523) Effective January 1, 2023.)

article: 1. General Provisions


text:
(a) (1) The requirements of this section shall apply to a group or individual policy or certificate of health insurance or student blanket disability insurance that provides coverage for hospital, medical, or surgical expenses that is issued, amended, renewed, or delivered on or after January 1, 2023. This section does not apply to a specialized health insurance policy. A policy or certificate subject to the requirements of this section shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement on coverage for all abortion and abortion-related services, including preabortion and followup services.

(2) Except as otherwise authorized by this section, an insurer shall not impose any utilization management or utilization review, including prior authorization and annual or lifetime limits consistent with Sections 10112.1 and 10112.27, on the coverage for outpatient abortion services.

(b) This section does not deny or restrict in any way the department's authority to ensure an insurer’s compliance with this chapter when the insurer provides coverage for abortion services.

(c) This section does not require an individual or group disability insurance policy to cover an experimental or investigational treatment.

(d) For purposes of this section, “abortion” means any medical treatment intended to induce the termination of a pregnancy except for the purpose of producing a live birth.

(e) For a group or individual policy or certificate of health insurance or student blanket disability insurance that is a high deductible health plan, as defined in Section 223(c)(2) of Title 26 of the United States Code, the cost-sharing limits in paragraph (1) of subdivision (a) shall apply once an insured’s deductible has been satisfied for the benefit year.

(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the commissioner may interpret and implement this section by issuing guidance without taking any further regulatory action. The commissioner shall consult with the Department of Managed Health Care in issuing guidance under this section. The department shall adopt regulations on or before January 1, 2026, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.

history: (History: Added by Stats. 2022, Ch. 11, Sec. 2. (SB 245) Effective January 1, 2023.)

article: 1. General Provisions


text:
(a) (1) A health insurer shall provide to insureds a written or electronic notice regarding the benefits of a behavioral health and wellness screening for children and adolescents 8 to 18 years of age.

(2) “Behavioral health and wellness screening” means a screening, test, or assessment to identify indicators or symptoms of behavioral health issues in an individual, including, but not limited to, depression or anxiety.

(b) The notice shall provide information regarding the benefits of behavioral health and wellness screenings for both depression and anxiety.

(c) A health insurer shall provide notice pursuant to this section annually.

(d) This section does not apply to Medi-Cal managed care that contracts with the State Department of Health Care Services entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code.

history: (History: Amended by Stats. 2025, Ch. 243, Sec. 10. (SB 862) Effective January 1, 2026.)

article: 1. General Provisions


text:
(a) A health insurance policy issued, amended, or renewed on or after January 1, 2026, that provides prescription drug coverage shall not calculate an insured’s cost sharing at an amount that exceeds the actual rate paid by the insurer for the prescription drug. Cost sharing shall include deductibles and coinsurance.

(b) To the extent that a health insurance policy with a pharmacy benefit manager issued, amended, or renewed on or after January 1, 2026, includes disclosure of the net price paid by the pharmacy benefit manager or group purchasing organization, then an insured’s cost sharing shall not be calculated at an amount that exceeds that net price paid.

(c) (1) Commencing January 1, 2026, if a preexisting contract between a pharmacy benefit manager licensed pursuant to Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code and a health insurer authorizes spread pricing, as that term is defined by Section 1385.001 of the Health and Safety Code, any subsequent amendment or renewal of that contract shall not authorize spread pricing.

(2) A contract that is executed on or after January 1, 2026, between a pharmacy benefit manager licensed pursuant to Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code and a health insurer shall not authorize spread pricing, as that term is defined by Section 1385.001 of the Health and Safety Code.

history: (History: Added by Stats. 2025, Ch. 605, Sec. 16. (SB 41) Effective January 1, 2026.)

article: 1. General Provisions


text:
(a) A self-insured employee welfare benefit plan delivered or issued for delivery in this state more than 120 days after the effective date of this section, which provides that coverage of a dependent child of an employee shall terminate upon attainment of the limiting age for dependent children specified in the policy or contract, shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to be both (1) incapable of self-sustaining employment by reason of an intellectual disability or physical handicap and (2) chiefly dependent upon the employee for support and maintenance, provided proof of the incapacity and dependency is furnished to the employer or employee organization providing the plan or program of benefits by the employee within 31 days of the child’s attainment of the limiting age and subsequently as may be required by the employer or employee organization, but not more frequently than annually after the two-year period following the child’s attainment of the limiting age.

(b) As used in this section, “self-insured employee welfare benefit plan” means a plan or program of benefits provided by an employer or an employee organization, or both, for the purpose of providing hospital, medical, surgical, nursing, or dental services, or indemnification for the costs incurred for these services, to the employer’s employees or their dependents.

history: (History: Amended by Stats. 2013, Ch. 76, Sec. 138. (AB 383) Effective January 1, 2014.)

article: 1. General Provisions


text:
Each self-insured employee benefit plan issued or renewed on or after the effective date of this section shall provide, where feasible, that benefits for confinement in an extended care facility, as defined in subsection (j) of Section 1395x of Title 42 of the United States Code, may be provided under such terms and conditions as may be agreed upon between the employer and the employee or employee organization.

Nothing in this section shall preclude a self-insured employee benefit plan from providing benefits for confinement in institutions other than extended care facilities as defined in this section.

history: (History: Added by renumbering Section 10124 (as added by Stats. 1972, Ch. 522) by Stats. 1977, Ch. 579.)

article: 1. General Provisions


text:
(a) On and after January 1, 1974, every insurer issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer coverage for expenses incurred as a result of mental or nervous disorders, under the terms and conditions which may be agreed upon between the group policyholder and the insurer. If the terms and conditions include coverage for inpatient care for nervous or mental disorders, the coverage shall extend to treatment provided at all of the following facilities:

(1) A general acute care hospital as defined in subdivision (a) of Section 1250 of the Health and Safety Code.

(2) An acute psychiatric hospital as defined in subdivision (b) of Section 1250 of the Health and Safety Code.

(3) A psychiatric health facility as defined by Section 1250.2 of the Health and Safety Code operating pursuant to licensure by the State Department of Health Care Services.

Nothing in this subdivision prohibits an insurer that negotiates and enters into a contract with a professional or institutional provider for alternative rates of payment pursuant to Section 10133 from restricting or modifying the choice of providers.

(b) Every insurer shall communicate to prospective group policyholders as to the availability of outpatient coverage for the treatment of mental or nervous disorders. Every insurer shall communicate the availability of that coverage to all group policyholders and to all prospective group policyholders with whom they are negotiating. This coverage may include community residential treatment services, as described in former Section 5458 of the Welfare and Institutions Code, that are alternatives to institutional care.

history: (History: Amended by Stats. 2013, Ch. 23, Sec. 21. (AB 82) Effective June 27, 2013.)

article: 1. General Provisions


text:
(a) Every insurer issuing disability insurance that covers hospital, medical, or surgical expenses that offers coverage for a service that is within the scope of practice of a duly licensed pharmacist shall pay or reimburse the cost of the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the insurer has an out-of-network pharmacy benefit.

(b) Payment or reimbursement may be made pursuant to this section for a service performed by a duly licensed pharmacist only when all of the following conditions are met:

(1) The service performed is within the lawful scope of practice of the pharmacist.

(2) The coverage otherwise provides reimbursement for identical services performed by other licensed health care providers.

(c) Nothing in this section shall require the insurer to pay a claim to more than one provider for duplicate service or be interpreted to limit physician reimbursement.

history: (History: Amended by Stats. 2023, Ch. 322, Sec. 2. (AB 317) Effective January 1, 2024.)

article: 1. General Provisions


text:
(a) A pharmacy benefit manager that contracts with a health insurer shall comply with Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code, including Sections 1385.004 and 1385.006 of the Health and Safety Code.

(b) A complaint made by an insured that includes potential violations by a pharmacy benefit manager of the terms of Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code may be considered by the department to be a complaint against the health insurer.

(c) If a health insurer delegates functions to a pharmacy benefit manager, the pharmacy benefits manager shall comply with this code, as applicable. A health insurer shall specify by contract the pharmacy benefits manager’s responsibilities and shall monitor the pharmacy benefit manager to ensure compliance with this code. Notwithstanding delegation pursuant to this subdivision, the health insurer shall remain responsible for compliance with this code.

(d) A contract between a health insurer and a pharmacy benefit manager issued, amended, or renewed on or after January 1, 2027, or the date on which the Department of Managed Health Care has established the pharmacy benefit manager licensure process, whichever is later, shall require the pharmacy benefit manager to be licensed and in good standing with the Department of Managed Health Care. A contract term that violates Article 6.1 (commencing with Section 1385.001) of Chapter 2.2 of Division 2 of the Health and Safety Code shall be void on and after January 1, 2029.

(e) The department may issue guidance regarding implementation of, and compliance with, this section and Sections 10125.2, 10123.2045, and 10123.205. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 1340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2030. The department shall consult with stakeholders in developing guidance pursuant to this subdivision.

history: (History: Amended by Stats. 2025, Ch. 605, Sec. 17. (SB 41) Effective January 1, 2026.)

article: 1. General Provisions


text: Every policy of group disability insurance issued, amended, or renewed on or after January 1, 1977, which provides hospital, medical, or surgical expense benefits for employees or members and their dependents and which contains provisions granting the employee or member the right to convert the insurance coverage in the event of termination of employment or membership, shall include in such conversion provisions the same conversion rights and conditions to a covered dependent spouse of the employee or member in the event the covered dependent spouse ceases to be a qualified family member by reason of termination of marriage or death of the employee or member. Such conversion rights shall not require a physical examination or a statement of health.

history: (History: Amended by Stats. 1976, Ch. 1173.)

article: 1. General Provisions


text: If a disability insurance policy between an insurer that covers hospital, medical, or surgical expenses and a provider requires that the provider accept, as payment from the insurer, the lowest payment rate charged by the provider to any patient or third party, this policy provision shall not be deemed to apply to, or take into consideration, any cash payments made to the provider by individual patients who do not have any private or public form of health care coverage for the service rendered by the provider, as described in subdivision (c) of Section 657 of the Business and Professions Code. This section shall apply to a provider contract that is issued, amended, or renewed on or after the effective date of this section.

history: (History: Added by Stats. 1998, Ch. 20, Sec. 3. Effective April 14, 1998.)

article: 1. General Provisions


text:
(a) Every policy of disability insurance that provides hospital, medical, or surgical coverage under a health benefit plan, defined in subdivision (a) of Section 10198.6, that provides coverage for emergency health care services, that is issued, amended, delivered, or renewed in this state on or after January 1, 1999, shall include coverage for emergency medical transportation services, as defined in subdivision (b). This coverage shall be provided without regard to whether the emergency provider has a contractual arrangement with the insurer or whether there was prior authorization, subject to the terms and conditions of the policy.

(b) For purposes of this section, “emergency medical transportation services” means ambulance services provided through the “911” emergency response system.

history: (History: Added by Stats. 1998, Ch. 979, Sec. 5. Effective January 1, 1999.)

article: 1. General Provisions


text:
(a) A health insurance policy issued, amended, or renewed on or after July 1, 2025, shall establish a process to reimburse for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program.

(b) (1) A health insurance policy issued, amended, or renewed on or after July 1, 2025, shall require an insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternate destination program, or mobile integrated health program.

(2) Notwithstanding any other law, reimbursement rates adopted pursuant to this subdivision shall not exceed the health insurer’s usual and customary charges for services rendered.

(c) For purposes of this section, the following definitions apply:

(1) “Community paramedicine program” means a program defined in Section 1815 of the Health and Safety Code.

(2) “Mobile integrated health program” means a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the emergency medical services system.

(3) “Triage to alternate destination program” means a program defined in Section 1819 of the Health and Safety Code.

history: (History: Added by Stats. 2024, Ch. 884, Sec. 2. (SB 1180) Effective January 1, 2025.)

article: 1. General Provisions


text:
(a) (1) Notwithstanding Section 10352, a health insurance policy issued, amended, or renewed on or after January 1, 2020, shall provide that if an insured or subscriber receives covered services from a noncontracting air ambulance provider, the insured or subscriber shall pay no more than the same cost sharing that the insured or subscriber would pay for the same covered services received from a contracting air ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.”

(2) A subscriber or insured shall not owe the noncontracting provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured or subscriber and the noncontracting provider of the in-network cost-sharing amount owed by the insured or subscriber.

(b) The following shall apply for purposes of this section:

(1) Any cost sharing paid by the insured or subscriber for the services subject to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.

(2) Cost sharing arising from services subject to this section shall be counted toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.

(3) The cost sharing paid by the insured or subscriber pursuant to this section shall satisfy the insured’s or subscriber’s obligation to pay cost sharing for the health service.

(c) A noncontracting provider may advance to collections only the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured or subscriber failed to pay.

(d) A health insurer or a provider may seek relief in any court for the purpose of resolving a payment dispute. A provider is not prohibited from using a health insurer’s existing dispute resolution processes.

history: (History: Added by Stats. 2019, Ch. 537, Sec. 3. (AB 651) Effective January 1, 2020.)

article: 1. General Provisions


text:
(a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.”

(2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insured’s coverage is regulated by the department or if the coverage is not state-regulated.

(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.

(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.

(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insured’s obligation to pay cost sharing for the health service.

(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.

(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not do either of the following:

(A) Report adverse information to a consumer credit reporting agency.

(B) Commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).

(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.

(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:

(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.

(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:

(i) The ambulance provider’s training, qualifications, and length of time in practice.

(ii) The nature of the services provided.

(iii) The fees usually charged by the ambulance provider.

(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.

(v) Other aspects of the economics of the ambulance provider’s practice that are relevant.

(vi) Any unusual circumstances in the case.

(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:

(A) The ground ambulance transport is initiated within the boundaries of the local government’s regulatory jurisdiction.

(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.

(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.

(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.

(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurer’s existing dispute resolution process under Section 10123.137.

(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.

history: (History: Amended by Stats. 2024, Ch. 520, Sec. 13. (SB 1061) Effective January 1, 2025.)

article: 1. General Provisions


text: On and after January 1, 1974, every self-insured employee welfare benefit plan that provides coverage for hospital, medical, or surgical expenses shall offer coverage for expenses incurred as a result of mental or nervous disorders, under the terms and conditions which may be agreed upon between the self-insured welfare benefit plan and the member. If the terms and conditions include coverage for services provided in a general acute care hospital, or an acute psychiatric hospital as defined in Section 1250 of the Health and Safety Code, and do not restrict or modify the choice of providers, the coverage shall extend to care provided by a psychiatric health facility, as defined by Section 1250.2 of the Health and Safety Code, operating pursuant to licensure by the State Department of Health Care Services. Every plan shall communicate to prospective members as to the availability of outpatient coverage for the treatment of mental or nervous disorders. Every self-insured welfare benefit plan shall communicate the availability of this coverage to all members and prospective members. This coverage may include community residential treatment services, as described in former Section 5458 of the Welfare and Institutions Code, that are alternatives to institutional care.

history: (History: Amended by Stats. 2013, Ch. 23, Sec. 22. (AB 82) Effective June 27, 2013.)

article: 1. General Provisions