State Codes and Statutes

Statutes > California > Hsc > 1359-1366.4

HEALTH AND SAFETY CODE
SECTION 1359-1366.4



1359.  (a) The director may require that solicitors and solicitor
firms, and principal persons engaged in the supervision of
solicitation for plans of solicitor firms, meet such reasonable and
appropriate standards with respect to training, experience, and other
qualifications as the director finds necessary and appropriate in
the public interest or for the protection of subscribers, enrollees,
and plans. For such purposes, the director may do the following:
   (1) Appropriately classify such persons and individuals.
   (2) Specify that all or any portion of such standards shall be
applicable to any such class.
   (3) Require individuals in any such class to pass examinations
prescribed in accordance with such rules.
   (b) The director may prescribe by rule reasonable fees and charges
to defray the costs of carrying out this section, including, but not
limited to, fees for any examination administered by the director or
under his or her direction.



1360.  (a) No plan, solicitor, solicitor firm, or representative
shall use or permit the use of any advertising or solicitation which
is untrue or misleading, or any form of evidence of coverage which is
deceptive. For purposes of this article:
   (1) A written or printed statement or item of information shall be
deemed untrue if it does not conform to fact in any respect which
is, or may be significant to an enrollee or subscriber, or potential
enrollee or subscriber in a plan.
   (2) A written or printed statement or item of information shall be
deemed misleading whether or not it may be literally true, if, in
the total context in which the statement is made or such item of
information is communicated, such statement or item of information
may be understood by a person not possessing special knowledge
regarding health care coverage, as indicating any benefit or
advantage, or the absence of any exclusion, limitation, or
disadvantage of possible significance to an enrollee, or potential
enrollee or subscriber, in a plan, and such is not the case.
   (3) An evidence of coverage shall be deemed to be deceptive if the
evidence of coverage taken as a whole and with consideration given
to typography and format, as well as language, shall be such as to
cause a reasonable person, not possessing special knowledge of plans,
and evidence of coverage therefor to expect benefits, service
charges, or other advantages which the evidence of coverage does not
provide or which the plan issuing such coverage or evidence of
coverage does not regularly make available to enrollees or
subscribers covered under such evidence of coverage.
   (b) No plan, or solicitor, or representative shall use or permit
the use of any verbal statement which is untrue, misleading, or
deceptive or make any representations about coverage offered by the
plan or its cost that does not conform to fact. All verbal statements
are to be held to the same standards as those for printed matter
provided in subdivision (a).



1360.1.  It is unlawful for any person, including a plan, subject to
this chapter to represent or imply in any manner that the person or
plan has been sponsored, recommended, or approved, or that the person'
s or plan's abilities or qualifications have in any respect been
passed upon, by the director. Nothing in this section prohibits a
statement (other than in a paid advertisement) that a person or plan
holds a license under this chapter, if such statement is true and if
the effect of such licensing is not misrepresented.



1361.  (a) Except as provided in subdivision (b), no plan shall
publish or distribute, or allow to be published or distributed on its
behalf, any advertisement not subject to Section 1352.1 unless (1) a
true copy thereof has first been filed with the director, at least
30 days prior to any such use, or any shorter period as the director
by rule or order may allow, and (2) the director by notice has not
found the advertisement, wholly or in part, to be untrue, misleading,
deceptive, or otherwise not in compliance with this chapter or the
rules thereunder, and specified the deficiencies, within the 30 days
or any shorter time as the director by rule or order may allow.
   (b) Except as provided in subdivision (c), a licensed plan which
has been continuously licensed under this chapter for the preceding
18 months may publish or distribute or allow to be published or
distributed on its behalf an advertisement not subject to Section
1352.1 without having filed the same for the director's prior
approval, if the plan and the material comply with each of the
following conditions:
   (1) The advertisement or a material provision thereof has not been
previously disapproved by the director by written notice to the plan
and the plan reasonably believes that the advertisement does not
violate any requirement of this chapter or the rules thereunder.
   (2) The plan files a true copy of each new or materially revised
advertisement, used by it or by any person acting on behalf of the
plan, with the director not later than 10 business days after
publication or distribution of the advertisement or within such
additional period as the director may allow by rule or order.
   (c) If the director finds that any advertisement of a plan has
materially failed to comply with this chapter or the rules
thereunder, the director may, by order, require the plan to publish
in the same or similar medium, an approved correction or retraction
of any untrue, misleading, or deceptive statement contained in the
advertising, and may prohibit the plan from publishing or
distributing, or allowing to be published or distributed on its
behalf the advertisement or any new materially revised advertisement
without first having filed a copy thereof with the director, 30 days
prior to the publication or distribution thereof, or any shorter
period specified in the order. An order issued under this subdivision
shall be effective for 12 months from its issuance, and may be
renewed by order if the advertisements submitted under this
subdivision indicate difficulties of voluntary compliance with the
applicable provisions of this chapter and the rules thereunder.
   (d) A licensed plan or other person regulated under this chapter
may, within 30 days after receipt of any notice or order under this
section, file a written request for a hearing with the director.
   (e) The director by rule or order may classify plans and
advertisements and exempt certain classes, wholly or in part, either
unconditionally or upon specified terms and conditions or for
specified periods, from the application of subdivisions (a) and (b).



1361.1.  (a) It is an unfair business practice for a solicitor,
solicitor firm, or representative of a health care service plan to
sell, solicit, or negotiate the purchase of health care coverage
products by any of the following methods:
   (1) The use of a marketing technique known as cold lead
advertising when marketing a Medicare product. As used in this
section, "cold lead advertising" means making use directly or
indirectly of a method of marketing that fails to disclose in a
conspicuous manner that a purpose of the marketing is health care
service plan sales solicitation and that contact will be made by a
solicitor, solicitor firm, or representative of a health care service
plan.
   (2) The use of an appointment that was made to discuss a
particular Medicare product or to solicit the sale of a particular
Medicare product in order to solicit the sale of another Medicare
product or other health care coverage products, unless the consumer
specifically agrees in advance of the appointment to discuss that
other Medicare product or other types of health care coverage
products during the same appointment.
   (b) As used in this section, "Medicare product" includes Medicare
Parts A, B, C, and D, and Medicare supplement plans.



1362.  As used in Sections 1363 and 1364:
   (a) "Benefits and coverage" means the health care services
available under a plan contract.
   (b) "Exception" means any provision in a plan contract whereby
coverage for a specified hazard or condition is entirely eliminated.
   (c) "Reduction" means any provision in a plan contract which
reduces the amount of a plan benefit to some amount or period less
than would be otherwise payable for medically authorized expenses or
services had such a reduction not been used.
   (d) "Limitation" means any provision other than an exception or a
reduction which restricts coverage under the plan.
   (e) "Presenting for examination or sale" means either (1)
publication and dissemination of any brochure, mailer, advertisement,
or form which constitutes a presentation of the provisions of the
plan and which provides a plan enrollment or application form, or (2)
consultations or discussions between prospective plan members or
their contract agents and solicitors or representatives of a plan,
when such consultations or discussions include presentation of
formal, organized information about the plan which is intended to
influence or inform the prospective member or contract holder, such
as brochures, summaries, charts, slides, or other modes of
information.
   (f) "Disclosure form" means the disclosure form, material, or
information required pursuant to Section 1363.
   (g) For the purposes of Sections 1363 and 1364, where the
definition of the term "hospital" in the plan contract omits care in
any "health facility" defined pursuant to subdivision (a) or (b) of
Section 1250 of this code, the omitted coverage shall constitute a
limitation; and where the definition of the term "nursing home" in
the plan omits care in any "health facility" defined pursuant to
subdivision (c) or (d) of Section 1250 of this code, the omitted
coverage shall constitute a limitation.


1363.  (a) The director shall require the use by each plan of
disclosure forms or materials containing information regarding the
benefits, services, and terms of the plan contract as the director
may require, so as to afford the public, subscribers, and enrollees
with a full and fair disclosure of the provisions of the plan in
readily understood language and in a clearly organized manner. The
director may require that the materials be presented in a reasonably
uniform manner so as to facilitate comparisons between plan contracts
of the same or other types of plans. Nothing contained in this
chapter shall preclude the director from permitting the disclosure
form to be included with the evidence of coverage or plan contract.
   The disclosure form shall provide for at least the following
information, in concise and specific terms, relative to the plan,
together with additional information as may be required by the
director, in connection with the plan or plan contract:
   (1) The principal benefits and coverage of the plan, including
coverage for acute care and subacute care.
   (2) The exceptions, reductions, and limitations that apply to the
plan.
   (3) The full premium cost of the plan.
   (4) Any copayment, coinsurance, or deductible requirements that
may be incurred by the member or the member's family in obtaining
coverage under the plan.
   (5) The terms under which the plan may be renewed by the plan
member, including any reservation by the plan of any right to change
premiums.
   (6) A statement that the disclosure form is a summary only, and
that the plan contract itself should be consulted to determine
governing contractual provisions. The first page of the disclosure
form shall contain a notice that conforms with all of the following
conditions:
   (A) (i) States that the evidence of coverage discloses the terms
and conditions of coverage.
   (ii) States, with respect to individual plan contracts, small
group plan contracts, and any other group plan contracts for which
health care services are not negotiated, that the applicant has a
right to view the evidence of coverage prior to enrollment, and, if
the evidence of coverage is not combined with the disclosure form,
the notice shall specify where the evidence of coverage can be
obtained prior to enrollment.
   (B) Includes a statement that the disclosure and the evidence of
coverage should be read completely and carefully and that individuals
with special health care needs should read carefully those sections
that apply to them.
   (C) Includes the plan's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the plan or a statement where the telephone number or
numbers are located in the disclosure form.
   (D) For individual contracts, and small group plan contracts as
defined in Article 3.1 (commencing with Section 1357), the disclosure
form shall state where the health plan benefits and coverage matrix
is located.
   (E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
   (7) A statement as to when benefits shall cease in the event of
nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon an enrollee who is hospitalized or undergoing
treatment for an ongoing condition.
   (8) To the extent that the plan permits a free choice of provider
to its subscribers and enrollees, the statement shall disclose the
nature and extent of choice permitted and the financial liability
that is, or may be, incurred by the subscriber, enrollee, or a third
party by reason of the exercise of that choice.
   (9) A summary of the provisions required by subdivision (g) of
Section 1373, if applicable.
   (10) If the plan utilizes arbitration to settle disputes, a
statement of that fact.
   (11) A summary of, and a notice of the availability of, the
process the plan uses to authorize, modify, or deny health care
services under the benefits provided by the plan, pursuant to
Sections 1363.5 and 1367.01.
   (12) A description of any limitations on the patient's choice of
primary care physician, specialty care physician, or nonphysician
health care practitioner, based on service area and limitations on
the patient's choice of acute care hospital care, subacute or
transitional inpatient care, or skilled nursing facility.
   (13) General authorization requirements for referral by a primary
care physician to a specialty care physician or a nonphysician health
care practitioner.
   (14) Conditions and procedures for disenrollment.
   (15) A description as to how an enrollee may request continuity of
care as required by Section 1373.96 and request a second opinion
pursuant to Section 1383.15.
   (16) Information concerning the right of an enrollee to request an
independent review in accordance with Article 5.55 (commencing with
Section 1374.30).
   (17) A notice as required by Section 1364.5.
   (b) (1) As of July 1, 1999, the director shall require each plan
offering a contract to an individual or small group to provide with
the disclosure form for individual and small group plan contracts a
uniform health plan benefits and coverage matrix containing the plan'
s major provisions in order to facilitate comparisons between plan
contracts. The uniform matrix shall include the following category
descriptions together with the corresponding copayments and
limitations in the following sequence:
   (A) Deductibles.
   (B) Lifetime maximums.
   (C) Professional services.
   (D) Outpatient services.
   (E) Hospitalization services.
   (F) Emergency health coverage.
   (G) Ambulance services.
   (H) Prescription drug coverage.
   (I) Durable medical equipment.
   (J) Mental health services.
   (K) Chemical dependency services.
   (L) Home health services.
   (M) Other.
   (2) The following statement shall be placed at the top of the
matrix in all capital letters in at least 10-point boldface type:

   THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN
CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE
BENEFITS AND LIMITATIONS.

   (c) Nothing in this section shall prevent a plan from using
appropriate footnotes or disclaimers to reasonably and fairly
describe coverage arrangements in order to clarify any part of the
matrix that may be unclear.
   (d) All plans, solicitors, and representatives of a plan shall,
when presenting any plan contract for examination or sale to an
individual prospective plan member, provide the individual with a
properly completed disclosure form, as prescribed by the director
pursuant to this section for each plan so examined or sold.
   (e) In the case of group contracts, the completed disclosure form
and evidence of coverage shall be presented to the contractholder
upon delivery of the completed health care service plan agreement.
   (f) Group contractholders shall disseminate copies of the
completed disclosure form to all persons eligible to be a subscriber
under the group contract at the time those persons are offered the
plan. If the individual group members are offered a choice of plans,
separate disclosure forms shall be supplied for each plan available.
Each group contractholder shall also disseminate or cause to be
disseminated copies of the evidence of coverage to all applicants,
upon request, prior to enrollment and to all subscribers enrolled
under the group contract.
   (g) In the case of conflicts between the group contract and the
evidence of coverage, the provisions of the evidence of coverage
shall be binding upon the plan notwithstanding any provisions in the
group contract that may be less favorable to subscribers or
enrollees.
   (h) In addition to the other disclosures required by this section,
every health care service plan and any agent or employee of the plan
shall, when presenting a plan for examination or sale to any
individual purchaser or the representative of a group consisting of
25 or fewer individuals, disclose in writing the ratio of premium
costs to health services paid for plan contracts with individuals and
with groups of the same or similar size for the plan's preceding
fiscal year. A plan may report that information by geographic area,
provided the plan identifies the geographic area and reports
information applicable to that geographic area.
   (i) Subdivision (b) shall not apply to any coverage provided by a
plan for the Medi-Cal program or the Medicare program pursuant to
Title XVIII and Title XIX of the Social Security Act.



1363.01.  (a) Every plan that covers prescription drug benefits
shall provide notice in the evidence of coverage and disclosure form
to enrollees regarding whether the plan uses a formulary. The notice
shall be in language that is easily understood and in a format that
is easy to understand. The notice shall include an explanation of
what a formulary is, how the plan determines which prescription drugs
are included or excluded, and how often the plan reviews the
contents of the formulary.
   (b) Every plan that covers prescription drug benefits shall
provide to members of the public, upon request, information regarding
whether a specific drug or drugs are on the plan's formulary. Notice
of the opportunity to secure this information from the plan,
including the plan's telephone number for making a request of this
nature, shall be included in the evidence of coverage and disclosure
form to enrollees.
   (c) Every plan shall notify enrollees, and members of the public
who request formulary information, that the presence of a drug on the
plan's formulary does not guarantee that an enrollee will be
prescribed that drug by his or her prescribing provider for a
particular medical condition.
   (d) This section shall become operative July 1, 1999.



1363.02.  (a) The Legislature finds and declares that the right of
every patient to receive basic information necessary to give full and
informed consent is a fundamental tenet of good public health policy
and has long been the established law of this state. Some hospitals
and other providers do not provide a full range of reproductive
health services and may prohibit or otherwise not provide
sterilization, infertility treatments, abortion, or contraceptive
services, including emergency contraception. It is the intent of the
Legislature that every patient be given full and complete information
about the health care services available to allow patients to make
well informed health care decisions.
   (b) On or before July 1, 2001, a health care service plan that
covers hospital, medical, and surgical benefits shall do both of the
following:
   (1) Include the following statement, in at least 12-point boldface
type, at the beginning of each provider directory:

   "Some hospitals and other providers do not provide one or more of
the following services that may be covered under your plan contract
and that you or your family member might need: family planning;
contraceptive services, including emergency contraception;
sterilization, including tubal ligation at the time of labor and
delivery; infertility treatments; or abortion. You should obtain more
information before you enroll. Call your prospective doctor, medical
group, independent practice association, or clinic, or call the
health plan at (insert the health plan's membership services number
or other appropriate number that individuals can call for assistance)
to ensure that you can obtain the health care services that you
need."

   (2) Place the statement described in paragraph (1) in a prominent
location on any provider directory posted on the health plan's
website, if any, and include this statement in a conspicuous place in
the plan's evidence of coverage and disclosure forms.
   (c) A health care service plan shall not be required to provide
the statement described in paragraph (1) of subdivision (b) in a
service area in which none of the hospitals, health facilities,
clinics, medical groups, or independent practice associations with
which it contracts limit or restrict any of the reproductive services
described in the statement.
   (d) This section shall not apply to specialized health care
service plans or Medicare supplement plans.



1363.03.  (a) Every health care service plan that covers
prescription drug benefits and that issues a card to enrollees for
claims processing purposes shall issue to each of its enrollees a
uniform card containing uniform prescription drug information. The
uniform prescription drug information card shall, at a minimum,
include the following information:
   (1) The name or logo of the benefit administrator or health care
service plan issuing the card, which shall be displayed on the front
side of the card.
   (2) The enrollee's identification number, or the subscriber's
identification number when the enrollee is a dependent who accesses
services using the subscriber's identification number, which shall be
displayed on the front side of the card.
   (3) A telephone number that pharmacy providers may call for
assistance.
   (4) Information required by the benefit administrator or health
care service plan that is necessary to commence processing the
pharmacy claim, except as provided for in paragraph (5).
   (5) A health care service plan shall not be required to print any
of the following information on a member card:
   (A) Any number that is the same for all of its members, provided
that the health care service plan provides this number to the
pharmacy on an annual basis.
   (B) Any information that may result in fraudulent use of the card.
   (C) Any information that is otherwise prohibited from being
included on the card.
   (b) Beginning July 1, 2002, the new uniform prescription drug
information card required by subdivision (a) shall be issued by a
health care service plan to an enrollee upon enrollment or upon any
change in the enrollee's coverage that impacts the data content or
format of the card.
   (c) Nothing in this section requires a health care service plan to
issue a separate card for prescription drug coverage if the plan
issues a card for health care coverage in general and the card is
able to accommodate the information required by subdivision (a).
   (d) This bill shall not apply to a nonprofit health care service
plan with at least 3.5 million enrollees that owns or operates its
own pharmacies and that provides health care services to enrollees in
a specific geographic area through a mutually exclusive contract
with a single medical group.
   (e) "Card" as used in this section includes other technology that
performs substantially the same function as a card.
   (f) For purposes of this section, if a health care service plan
delegates responsibility for issuing the uniform prescription drug
information card to a contractor or agent, then the contract between
the health care service plan and its contractor or agent shall
require compliance with this section.



1363.05.  (a) For every plan contract that provides or supplements
Medicare benefits, a plan shall include within its disclosure form
the following statement in at least 12-point type:

   "For additional information concerning covered benefits, contact
the Health Insurance Counseling and Advocacy Program (HICAP) or your
agent. HICAP provides health insurance counseling for California
senior citizens. Call the HICAP toll-free telephone number,
1-800-434-0222, for a referral to your local HICAP office. HICAP is a
service provided free of charge by the State of California."

   (b) For every plan contract that provides or supplements Medicare
benefits, a plan shall modify its disclosure forms to comply with
subdivision (a) no later than January 1, 1998.
   (c) Every health care service plan that provides or supplements
Medicare benefits shall notify those current enrollees who enrolled
prior to the modification of disclosure forms to include the
disclosure statement required by subdivision (a) of the availability
of the HICAP program. That notification shall include the same
language as is required by subdivision (a). That notification may be
by free standing document and shall be made no later than January 1,
1998.



1363.06.  (a) The Department of Managed Health Care and the
Department of Insurance shall compile information as required by this
section and Section 10127.14 of the Insurance Code into two
comparative benefit matrices. The first matrix shall compare benefit
packages offered pursuant to Section 1373.62 and Section 10127.15 of
the Insurance Code. The second matrix shall compare benefit packages
offered pursuant to Sections 1366.35, 1373.6, and 1399.804 and
Sections 10785, 10901.2, and 12682.1 of the Insurance Code.
   (b) The comparative benefit matrix shall include:
   (1) Benefit information submitted by health care service plans
pursuant to subdivision (d) and by health insurers pursuant to
Section 10127.14 of the Insurance Code.
   (2) The following statements in at least 12-point type at the top
of the matrix:
   (A) "This benefit summary is intended to help you compare coverage
and benefits and is a summary only. For a more detailed description
of coverage, benefits, and limitations, please contact the health
care service plan or health insurer."
   (B) "The comparative benefit summary is updated annually, or more
often if necessary to be accurate."
   (C) "The most current version of this comparative benefit summary
is available on (address of the plan's or insurer's site)."
   This subparagraph applies only to those plans or insurers that
maintain an Internet Web site.
   (3) The telephone number or numbers that may be used by an
applicant to contact either the department or the Department of
Insurance, as appropriate, for further assistance.
   (c) The Department of Managed Health Care and the Department of
Insurance shall jointly prepare two standardized templates for use by
health care service plans and health insurers in submitting the
information required pursuant to subdivision (d) and subdivision (d)
of Section 10127.14 of the Insurance Code. The templates shall be
exempt from the provisions of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
   (d) Health care service plans, except specialized health care
service plans, shall submit the following to the department by
January 31, 2003, and annually thereafter:
   (1) A summary explanation of the following for each product
described in subdivision (a).
   (A) Eligibility requirements.
   (B) The full premium cost of each benefit package in the service
area in which the individual and eligible dependents work or reside.
   (C) When and under what circumstances benefits cease.
   (D) The terms under which coverage may be renewed.
   (E) Other coverage that may be available if benefits under the
described benefit package cease.
   (F) The circumstances under which choice in the selection of
physicians and providers is permitted.
   (G) Lifetime and annual maximums.
   (H) Deductibles.
   (2) A summary explanation of coverage for the following, together
with the corresponding copayments and limitations, for each product
described in subdivision (a):
   (A) Professional services.
   (B) Outpatient services.
   (C) Hospitalization services.
   (D) Emergency health coverage.
   (E) Ambulance services.
   (F) Prescription drug coverage.
   (G) Durable medical equipment.
   (H) Mental health services.
   (I) Residential treatment.
   (J) Chemical dependency services.
   (K) Home health services.
   (L) Custodial care and skilled nursing facilities.
   (3) The telephone number or numbers that may be used by an
applicant to access a health care service plan customer service
representative and to request additional information about the plan
contract.
   (4) Any other information specified by the department in the
template.
   (e) Each health care service plan shall provide the department
with updates to the information required by subdivision (d) at least
annually, or more often if necessary to maintain the accuracy of the
information.
   (f) The department and the Department of Insurance shall make the
comparative benefit matrices available on their respective Internet
Web sites and to the health care service plans and health insurers
for dissemination as required by Section 1373.6 and Section 12682.1
of the Insurance Code, after confirming the accuracy of the
description of the matrices with the health care service plans and
health insurers.
   (g) As used in this section and Section 1363.07, "benefit matrix"
shall have the same meaning as benefit summary.



1363.07.  (a) Each health care service plan shall send copies of the
comparative benefit matrix prepared pursuant to Section 1363.06 on
an annual basis, or more frequently as the matrix is updated by the
department and the Department of Insurance, to solicitors and
solicitor firms and employers with whom the plan contracts.
   (b) Each health care service plan shall require its
representatives and solicitors and soliciting firms with which it
contracts, to provide a copy of the comparative benefit matrix to
individuals when presenting any benefit package for examination or
sale.
   (c) Each health care service plan that maintains an Internet Web
site shall make a downloadable copy of the comparative benefit matrix
described in Section 1363.06 available through a link on its site to
the Internet Web sites of the department and the Department of
Insurance.


1363.1.  Any health care service plan that includes terms that
require binding arbitration to settle disputes and that restrict, or
provide for a waiver of, the right to a jury trial shall include, in
clear and understandable language, a disclosure that meets all of the
following conditions:
   (a) The disclosure shall clearly state whether the plan uses
binding arbitration to settle disputes, including specifically
whether the plan uses binding arbitration to settle claims of medical
malpractice.
   (b) The disclosure shall appear as a separate article in the
agreement issued to the employer group or individual subscriber and
shall be prominently displayed on the enrollment form signed by each
subscriber or enrollee.
   (c) The disclosure shall clearly state whether the subscriber or
enrollee is waiving his or her right to a jury trial for medical
malpractice, other disputes relating to the delivery of service under
the plan, or both, and shall be substantially expressed in the
wording provided in subdivision (a) of Section 1295 of the Code of
Civil Procedure.
   (d) In any contract or enrollment agreement for a health care
service plan, the disclosure required by this section shall be
displayed immediately before the signature line provided for the
representative of the group contracting with a health care service
plan and immediately before the signature line provided for the
individual enrolling in the health care service plan.



1363.2.  On or before July 1, 1999, the disclosure form required
pursuant to Section 1363 shall also contain a statement that
enrollees are encouraged to use appropriately the "911" emergency
response system, in areas where the system is established and
operating, when they have an emergency medical condition that
requires an emergency response.



1363.5.  (a) A plan shall disclose or provide for the disclosure to
the director and to network providers the process the plan, its
contracting provider groups, or any entity with which the plan
contracts for services that include utilization review or utilization
management functions, uses to authorize, modify, or deny health care
services under the benefits provided by the plan, including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. A plan shall also disclose those
processes to enrollees or persons designated by an enrollee, or to
any other person or organization, upon request. The disclosure to the
director shall include the policies, procedures, and the description
of the process that are filed with the director pursuant to
subdivision (b) of Section 1367.01.
   (b) The criteria or guidelines used by plans, or any entities with
which plans contract for services that include utilization review or
utilization management functions, to determine whether to authorize,
modify, or deny health care services shall:
   (1) Be developed with involvement from actively practicing health
care providers.
   (2) Be consistent with sound clinical principles and processes.
   (3) Be evaluated, and updated if necessary, at least annually.
   (4) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the enrollee in that specified case.
   (5) Be available to the public upon request. A plan shall only be
required to disclose the criteria or guidelines for the specific
procedures or conditions requested. A plan may charge reasonable fees
to cover administrative expenses related to disclosing criteria or
guidelines pursuant to this paragraph, limited to copying and postage
costs. The plan may also make the criteria or guidelines available
through electronic communication means.
   (c) The disclosure required by paragraph (5) of subdivision (b)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this plan to authorize, modify, or
deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the
benefits covered under your contract."



1364.  Where the director finds it necessary in the interest of full
and fair disclosure, all advertising and other consumer information
disseminated by a plan for the purpose of influencing persons to
become members of a plan shall contain such supplemental disclosure
information as the director may require.



1364.1.  Within 30 days of receiving the notice required by Section
1255.1, a health care service plan shall notify, or provide for the
notification of, enrollees who have selected a medical group or
independent practice association that uses a hospital that the
hospital will reduce or eliminate its emergency services. The plan
may require that its contracting medical groups and independent
practice associations that use the hospital provide this notice. The
notice shall include a list of alternate hospitals that may be used
by enrollees for emergency services.



1364.5.  (a) On or before July 1, 2001, every health care service
plan shall file with the director a copy of their policies and
procedures to protect the security of patient medical information to
ensure compliance with the Confidentiality of Information Act (Part
2.6 (commencing with Section 56) of Division 1 of the Civil Code).
Any amendment to the policies and procedures shall be filed in
accordance with Section 1352.
   (b) On and after July 1, 2001, every health care service plan
shall, upon request, provide to enrollees and subscribers a written
statement that describes how the contracting organization or health
care service plan maintains the confidentiality of medical
information obtained by and in the possession of the contracting
organization or the health care service plan.
   (c) The statement required by subdivision (b) shall be in at least
12-point type and meet the following requirements:
   (1) The statement shall describe how the contracting organization
or health care service plan protects the confidentiality of medical
information pursuant to this article and inform patients or enrollees
and subscribers that any disclosure of medical information beyond
the provisions of the law is prohibited.
   (2) The statement shall describe the types of medical information
that may be collected and the type of sources that may be used to
collect the information, the purposes for which the contracting
organization or plan will obtain medical information from other
health care providers.
   (3) The statement shall describe the circumstances under which
medical information may be disclosed without prior authorization,
pursuant to Section 56.10 of the Civil Code.
   (4) The statement shall describe how patients or enrollees and
subscribers may obtain access to medical information created by and
in the possession of the contracting organization or health care
service plan, including copies of medical information.
   (d) On and after July 1, 2001, every health care service plan
shall include in its evidence of coverage or disclosure form the
following notice, in 12-point type:

   A STATEMENT DESCRIBING (NAME OR PLAN OR "OUR") POLICIES AND
PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS
AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.



1365.  (a) An enrollment or a subscription shall not be canceled or
not renewed except for the following reasons:
   (1) (A) For nonpayment of the required premiums by the individual,
employer, or contractholder if the individual, employer, or
contractholder has been duly notified and billed for the charge and
at least a 30-day grace period has elapsed since the date of
notification or, if longer, the period of time required for notice
and any other requirements pursuant to Section 2703, 2712, or 2742 of
the federal Public Health Service Act (42 U.S.C. Secs. 300gg-2,
300gg-12, and 300gg-42) and any subsequent rules or regulations has
elapsed.
   (B) Pursuant to subparagraph (A), a health care service plan shall
continue to provide coverage as required by the individual's,
employer's, or contractholder's health care service plan contract
during the period described in subparagraph (A).
   (2) The plan demonstrates fraud or an intentional
misrepresentation of material fact under the terms of the health care
service plan contract by the individual contractholder or employer.
   (3) In the case of an individual health care service plan
contract, the individual subscriber no longer resides, lives, or
works in the plan's service area, but only if the coverage is
terminated uniformly without regard to any health status-related
factor of covered individuals.
   (4) In the case of a group health care service plan contract,
violation of a material contract provision relating to employer
contribution or group participation rates by the, contractholder, or
employer.
   (5) If the plan ceases to provide or arrange for the provision of
health benefit for new health care service plan contracts in the
individual or group market, or all markets, in this state, provided,
however, that the following conditions are satisfied:
   (A) Notice of the decision to cease new or existing health benefit
plans in the state is provided to the director and to the individual
or group contractholder or employer, and the enrollees covered under
those contracts, at least 180 days prior to discontinuation of those
contracts.
   (B) Health benefit plans shall not be canceled for 180 days after
the date of the notice required under subparagraph (A) and for that
business of a plan that remains in force, any plan that ceases to
offer for sale new health benefit plans shall continue to be governed
by this section with respect to business conducted under this
section.
   (C) Except as authorized under subdivision (b) of Section 1357.09
and Section 1357.10, a plan that ceases to write new health benefit
plans in the individual or group market, or all markets, in this
state shall be prohibited from offering for sale health benefit plans
in that market or markets in this state for a period of five years
from the date of the discontinuation of the last coverage not so
renewed.
   (6) If the plan withdraws a health benefit plan from the market,
provided that all of the following conditions are satisfied:
   (A) The plan notifies all affected subscribers, contractholders,
employers, and enrollees and the director at least 90 days prior to
the discontinuation of the plan.
   (B) The plan makes available to the individual or group
contractholder or employer all health benefit plans that it makes
available to new individual or group business, respectively.
   (C) In exercising the option to discontinue a health benefit plan
under this paragraph and in offering the option of coverage under
subparagraph (B), the plan acts uniformly without regard to the
claims experience of the individual or contractholder or employer, or
any health-status related factor relating to enrollees or potential
enrollees.
   (D) For small employer health care service plan contracts offered
under Article 3.1 (commencing with Section 1357), the premium for the
new plan contract complies with the renewal increase requirements
set forth in Section 1357.12. This subparagraph shall not apply after
December 31, 2013.
   (7) In the case of a group health benefit plan, if an individual
or employer ceases to be a member of a guaranteed association, as
defined in subdivision (n) of Section 1357, but only if that coverage
is terminated under this paragraph uniformly without regard to any
health status-related factor relating to any enrollee.
   (b) (1) An enrollee or subscriber who alleges that an enrollment
or subscription has been or will be improperly canceled, rescinded,
or not renewed may request a review by the director pursuant to
Section 1368.
   (2) If the director determines that a proper complaint exists, the
director shall notify the plan and the enrollee or subscriber who
requested the review.
   (3) If, after review, the director determines that the
cancellation, rescission, or failure to renew is contrary to existing
law, the director shall order the plan to reinstate the enrollee or
subscriber. Within 15 days after receipt of that order, the health
care service plan shall request a hearing or reinstate the enrollee
or subscriber.
   (4) If an enrollee or subscriber requests a review of the health
care service plan's determination to cancel or rescind or failure to
renew the enrollee's or subscriber's health care service plan
contract pursuant to this section, the health care service plan shall
continue to provide coverage to the enrollee or subscriber under the
terms of the contract until a final determination of the enrollee's
or subscriber's request for review has been made by the director.
This paragraph shall not apply if the health care service plan
cancels or does not renew the enrollee's or subscriber's health care
service plan contract for nonpayment of premiums pursuant to
paragraph (1) of subdivision (a).
   (5) A reinstatement pursuant to this subdivision shall be
retroactive to the time of cancellation, rescission, or failure to
renew and the plan shall be liable for the expenses incurred by the
subscriber or enrollee for covered health care services from the date
of cancellation, rescission, or nonrenewal to and including the date
of reinstatement. The health care service plan shall reimburse the
enrollee or subscriber for any expenses incurred pursuant to this
paragraph within 30 days of receipt of the completed claim.
   (c) This section shall not abrogate any preexisting contracts
entered into prior to the effective date of this chapter between a
subscriber or enrollee and a health care service plan or a
specialized health care service plan including, but not limited to,
the financial liability of the plan, except that each plan shall, if
directed to do so by the director, exercise its authority, if any,
under those preexisting contracts to conform them to the provisions
of existing law.
   (d) As used in this section, "health benefit plan" means any
individual or group insurance policy or health care service plan
contract that provides medical, hospital, and surgical benefits. The
term does not include accident only, credit, or disability income
coverage, coverage of Medicare services pursuant to contracts with
the United States government, Medicare supplement insurance,
long-term care insurance, dental or vision coverage, coverage issued
as a supplement to liability insurance, insurance arising out of
workers' compensation law or similar law, automobile medical payment
insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
   (e) On or before July 1, 2011, the director may issue guidance to
health care service plans regarding compliance with this section and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code). Any guidance issued
pursuant to this subdivision shall only be effective through December
31, 2013, or until the director adopts and effects regulations
pursuant to the Administrative Procedure Act, whichever occurs first.




1365.5.  (a) No health care service plan or specialized health care
service plan shall refuse to enter into any contract or shall cancel
or decline to renew or reinstate any contract because of the race,
color, national origin, ancestry, religion, sex, marital status,
sexual orientation, or age of any contracting party, prospective
contracting party, or person reasonably expected to benefit from that
contract as a subscriber, enrollee, member, or otherwise.
   (b) The terms of any contract shall not be modified, and the
benefits or coverage of any contract shall not be subject to any
limitations, exceptions, exclusions, reductions, copayments,
coinsurance, deductibles, reservations, or premium, price, or charge
differentials, or other modifications because of the race, color,
national origin, ancestry, religion, sex, marital status, sexual
orientation, or age of any contracting party, potential contracting
party, or person reasonably expected to benefit from that contract as
a subscriber, enrollee, member, or otherwise; except that premium,
price, or charge differentials because of the age of any individual
when based on objective, valid, and up-to-date statistical and
actuarial data are not prohibited.
   (c) It shall be deemed a violation of subdivision (a) for any
health care service plan to utilize marital status, living
arrangements, occupation, sex, beneficiary designation, ZIP Codes or
other territorial classification, or any combination thereof for the
purpose of establishing sexual orientation. Nothing in this section
shall be construed to alter in any manner the existing law
prohibiting health care service plans from conducting tests for the
presence of human immunodeficiency virus or evidence thereof.
   (d) This section shall not be construed to limit the authority of
the director to adopt or enforce regulations prohibiting
discrimination because of sex, marital status, or sexual orientation.
   (e) "Sex" as used in this section shall have the same meaning as
"gender," as defined in Section 422.56 of the Penal Code.
   (f) The changes made to this section by the act adding this
subdivision shall only apply to contracts issued, amended, or renewed
on or after January 1, 2011.


1366.  (a) No plan may use in its name, any of the words "insurance,"
"casualty," "surety," "mutual," or any other words descriptive of
the insurance, casualty, or surety business or use any name similar
to the name or description of any insurance or surety corporation
doing business in this state unless such plan controls or is
controlled by an entity licensed as an insurer pursuant to the
provisions of the Insurance Code and the plan employs a name related
to that of such controlled or controlling entity.
   (b) Section 2415 of the Business and Professions Code, pertaining
to fictitious names, shall not apply to plans, except specialized
health care service plans.
   (c) No plan or solicitor firm may adopt a name style that is
deceptive, or one that could cause the public to believe the plan is
affiliated with, or recommended by any governmental or private entity
unless such affiliation or endorsement exists.



1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families program.
   (c) (1) At least 30 days before a health care service plan files
for modification of its license with the department in order to
withdraw from a county with a population of 500,000 or less, or a
portion of that county, the health care service plan shall hold a
public meeting in the county or portion of the county from which it
intends to withdraw, and shall do all of the following:
   (A) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers, advocates, public officials, and other interested parties.
   (B) Provide notice announcing the public meeting at least 30 days
prior to the public meeting in a newspaper of general circulation
within the affected county or portion of the affected county.
   (C) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (D) Send a summary of the comments received at the public meeting
to the department.
   (E) Send a summary of the comments received at the public meeting
to the Centers for Medicare and Medicaid Services if the modification
would affect Medicare beneficiaries.
   (F) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under subparagraphs (A) and (B).
   (2) A representative of the department shall attend the public
meeting.


1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families Program.
   (4) The federal Medicare program.
   (c) At least 30 days before a health care service plan files a
notice of material modification of its license with the department to
withdraw from a county with a population of 500,000 or less, the
health care service plan shall hold a public meeting in the county
from which it is intending to withdraw, and shall do all of the
following:
   (1) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers with which it contracts, the members of the board of
supervisors of the affected county, the members of the city councils
of cities in the affected county, and members of the Legislature who
represent the affected county.
   (2) Provide notice announcing the public meeting at least 15 days
prior to the public meeting in a newspaper of general circulation
within the affected county.
   (3) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (4) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under paragraphs (1) and (2).
   (d) The department may require a health care service plan that has
filed to withdraw from a portion of a county with a population of
less than 500,000, to hold a hearing for affected enrollees.
   (e) A representative of the department shall attend the public
meeting described in this section.


1366.2.  (a) A full health care service plan shall make available to
a group subscriber, upon request, the termination date of all major
health care provider contracts that are for services in the
geographic area for which the group subscriber has secured coverage
and that include a specified termination date.
   (b) For purposes of this section, the following terms have the
following meanings:
   (1) "Enrollee" means a person who is enrolled in a health care
service plan and who is a recipient of services from the plan.
   (2) "Full health care service plan" means a plan that meets the
definition set forth in subdivision (f) of Section 1345, and that has
a total enrolled membership exceeding 499,999 enrollees.
   (3) "Hospital" means a general acute care hospital.
   (4) "Major health care provider contract" means a contract between
a full service plan and provider group or hospital covering more
than 25,000 of that plan's enrollees. "Major health care provider
contract" does not mean a provider contract between a specialized
health care service plan and a provider group or hospital.
   (5) "Provider group" means a medical group, independent practice
association, or other similar group of providers with a total
enrolled membership exceeding 99,999 enrollees.




1366.3.  (a) On and after January 1, 2005, a health care service
plan issuing individual plan contracts that ceases to offer
individual coverage in this state shall offer coverage to the
subscribers who had been covered by those contracts at the time of
withdrawal under the same terms and conditions as provided in
paragraph (3) of subdivision (a), paragraphs (2) to (4), inclusive,
of subdivision (b), subdivisions (c) to (e), inclusive, and
subdivision (h) of Section 1373.6.
   (b) A health care service plan that ceases to offer individual
coverage in a service area shall offer the coverage required by
subdivision (a) to subscribers who had been covered by those
contracts at the time of withdrawal, if the plan continues to offer
group coverage in that service area. This subdivision shall not apply
to coverage provided pursuant to a preferred provider organization.
   (c) The department may adopt regulations to implement this
section.
   (d) This section shall not apply when a plan participating in
Medi-Cal, Healthy Families, Access for Infants and Mothers, or any
other contract between the plan and a government entity no longer
contracts with the government entity to provide health coverage in
the state, or a specified area of the state, nor shall this section
apply when a plan ceases entirely to market, offer, and issue any and
all forms of coverage in any part of this state after the effective
date of this section.



1366.4.  (a) A medical group, physician, or independent practice
association that contracts with a health care service plan may enter
into contracts with licensed nonphysician providers to provide
services, as defined in Section 1300.67(a)(1) of Title 28 of the
California Code of Regulations, to plan enrollees covered by the
contract between the plan and the group, physician, or association.
   (b) The licensed nonphysician provider described in subdivision
(a) that contracts with a medical group, physician, or independent
practice association may directly bill, if direct billing is
otherwise permitted by law, a health care service plan for covered
services pursuant to a contract with the health care service plan
that specifies direct billing. Direct billing pursuant to this
subdivision is permitted only to the extent that the same services
are not billed for by the medical group, physician, or independent
practice association.
   (c) A health care service plan may require the nonphysician
provider to complete an appropriate credentialing process.
   (d) Every health care service plan may either list licensed
nonphysician providers that contract with medical groups, physicians,
and independent practice associations pursuant to subdivision (b) in
any listing or directory of plan health care providers that is
provided to enrollees or to the public, or may include a notification
in the plan's evidence of coverage or provider list that the health
care service plan has contracts with nonphysician providers, pursuant
to subdivision (b), and may list the types of contracted
nonphysician providers. The notification may inform an enrollee that
he or she may obtain a list of the nonphysician providers by
contacting his or her primary or specialist medical group. The
listing may indicate whether licensed nonphysician providers may be
accessed directly by enrollees.
   (e) Nothing in this section shall be construed to authorize, or
otherwise require the director to approve, a risk-sharing arrangement
between a plan and a provider.

State Codes and Statutes

Statutes > California > Hsc > 1359-1366.4

HEALTH AND SAFETY CODE
SECTION 1359-1366.4



1359.  (a) The director may require that solicitors and solicitor
firms, and principal persons engaged in the supervision of
solicitation for plans of solicitor firms, meet such reasonable and
appropriate standards with respect to training, experience, and other
qualifications as the director finds necessary and appropriate in
the public interest or for the protection of subscribers, enrollees,
and plans. For such purposes, the director may do the following:
   (1) Appropriately classify such persons and individuals.
   (2) Specify that all or any portion of such standards shall be
applicable to any such class.
   (3) Require individuals in any such class to pass examinations
prescribed in accordance with such rules.
   (b) The director may prescribe by rule reasonable fees and charges
to defray the costs of carrying out this section, including, but not
limited to, fees for any examination administered by the director or
under his or her direction.



1360.  (a) No plan, solicitor, solicitor firm, or representative
shall use or permit the use of any advertising or solicitation which
is untrue or misleading, or any form of evidence of coverage which is
deceptive. For purposes of this article:
   (1) A written or printed statement or item of information shall be
deemed untrue if it does not conform to fact in any respect which
is, or may be significant to an enrollee or subscriber, or potential
enrollee or subscriber in a plan.
   (2) A written or printed statement or item of information shall be
deemed misleading whether or not it may be literally true, if, in
the total context in which the statement is made or such item of
information is communicated, such statement or item of information
may be understood by a person not possessing special knowledge
regarding health care coverage, as indicating any benefit or
advantage, or the absence of any exclusion, limitation, or
disadvantage of possible significance to an enrollee, or potential
enrollee or subscriber, in a plan, and such is not the case.
   (3) An evidence of coverage shall be deemed to be deceptive if the
evidence of coverage taken as a whole and with consideration given
to typography and format, as well as language, shall be such as to
cause a reasonable person, not possessing special knowledge of plans,
and evidence of coverage therefor to expect benefits, service
charges, or other advantages which the evidence of coverage does not
provide or which the plan issuing such coverage or evidence of
coverage does not regularly make available to enrollees or
subscribers covered under such evidence of coverage.
   (b) No plan, or solicitor, or representative shall use or permit
the use of any verbal statement which is untrue, misleading, or
deceptive or make any representations about coverage offered by the
plan or its cost that does not conform to fact. All verbal statements
are to be held to the same standards as those for printed matter
provided in subdivision (a).



1360.1.  It is unlawful for any person, including a plan, subject to
this chapter to represent or imply in any manner that the person or
plan has been sponsored, recommended, or approved, or that the person'
s or plan's abilities or qualifications have in any respect been
passed upon, by the director. Nothing in this section prohibits a
statement (other than in a paid advertisement) that a person or plan
holds a license under this chapter, if such statement is true and if
the effect of such licensing is not misrepresented.



1361.  (a) Except as provided in subdivision (b), no plan shall
publish or distribute, or allow to be published or distributed on its
behalf, any advertisement not subject to Section 1352.1 unless (1) a
true copy thereof has first been filed with the director, at least
30 days prior to any such use, or any shorter period as the director
by rule or order may allow, and (2) the director by notice has not
found the advertisement, wholly or in part, to be untrue, misleading,
deceptive, or otherwise not in compliance with this chapter or the
rules thereunder, and specified the deficiencies, within the 30 days
or any shorter time as the director by rule or order may allow.
   (b) Except as provided in subdivision (c), a licensed plan which
has been continuously licensed under this chapter for the preceding
18 months may publish or distribute or allow to be published or
distributed on its behalf an advertisement not subject to Section
1352.1 without having filed the same for the director's prior
approval, if the plan and the material comply with each of the
following conditions:
   (1) The advertisement or a material provision thereof has not been
previously disapproved by the director by written notice to the plan
and the plan reasonably believes that the advertisement does not
violate any requirement of this chapter or the rules thereunder.
   (2) The plan files a true copy of each new or materially revised
advertisement, used by it or by any person acting on behalf of the
plan, with the director not later than 10 business days after
publication or distribution of the advertisement or within such
additional period as the director may allow by rule or order.
   (c) If the director finds that any advertisement of a plan has
materially failed to comply with this chapter or the rules
thereunder, the director may, by order, require the plan to publish
in the same or similar medium, an approved correction or retraction
of any untrue, misleading, or deceptive statement contained in the
advertising, and may prohibit the plan from publishing or
distributing, or allowing to be published or distributed on its
behalf the advertisement or any new materially revised advertisement
without first having filed a copy thereof with the director, 30 days
prior to the publication or distribution thereof, or any shorter
period specified in the order. An order issued under this subdivision
shall be effective for 12 months from its issuance, and may be
renewed by order if the advertisements submitted under this
subdivision indicate difficulties of voluntary compliance with the
applicable provisions of this chapter and the rules thereunder.
   (d) A licensed plan or other person regulated under this chapter
may, within 30 days after receipt of any notice or order under this
section, file a written request for a hearing with the director.
   (e) The director by rule or order may classify plans and
advertisements and exempt certain classes, wholly or in part, either
unconditionally or upon specified terms and conditions or for
specified periods, from the application of subdivisions (a) and (b).



1361.1.  (a) It is an unfair business practice for a solicitor,
solicitor firm, or representative of a health care service plan to
sell, solicit, or negotiate the purchase of health care coverage
products by any of the following methods:
   (1) The use of a marketing technique known as cold lead
advertising when marketing a Medicare product. As used in this
section, "cold lead advertising" means making use directly or
indirectly of a method of marketing that fails to disclose in a
conspicuous manner that a purpose of the marketing is health care
service plan sales solicitation and that contact will be made by a
solicitor, solicitor firm, or representative of a health care service
plan.
   (2) The use of an appointment that was made to discuss a
particular Medicare product or to solicit the sale of a particular
Medicare product in order to solicit the sale of another Medicare
product or other health care coverage products, unless the consumer
specifically agrees in advance of the appointment to discuss that
other Medicare product or other types of health care coverage
products during the same appointment.
   (b) As used in this section, "Medicare product" includes Medicare
Parts A, B, C, and D, and Medicare supplement plans.



1362.  As used in Sections 1363 and 1364:
   (a) "Benefits and coverage" means the health care services
available under a plan contract.
   (b) "Exception" means any provision in a plan contract whereby
coverage for a specified hazard or condition is entirely eliminated.
   (c) "Reduction" means any provision in a plan contract which
reduces the amount of a plan benefit to some amount or period less
than would be otherwise payable for medically authorized expenses or
services had such a reduction not been used.
   (d) "Limitation" means any provision other than an exception or a
reduction which restricts coverage under the plan.
   (e) "Presenting for examination or sale" means either (1)
publication and dissemination of any brochure, mailer, advertisement,
or form which constitutes a presentation of the provisions of the
plan and which provides a plan enrollment or application form, or (2)
consultations or discussions between prospective plan members or
their contract agents and solicitors or representatives of a plan,
when such consultations or discussions include presentation of
formal, organized information about the plan which is intended to
influence or inform the prospective member or contract holder, such
as brochures, summaries, charts, slides, or other modes of
information.
   (f) "Disclosure form" means the disclosure form, material, or
information required pursuant to Section 1363.
   (g) For the purposes of Sections 1363 and 1364, where the
definition of the term "hospital" in the plan contract omits care in
any "health facility" defined pursuant to subdivision (a) or (b) of
Section 1250 of this code, the omitted coverage shall constitute a
limitation; and where the definition of the term "nursing home" in
the plan omits care in any "health facility" defined pursuant to
subdivision (c) or (d) of Section 1250 of this code, the omitted
coverage shall constitute a limitation.


1363.  (a) The director shall require the use by each plan of
disclosure forms or materials containing information regarding the
benefits, services, and terms of the plan contract as the director
may require, so as to afford the public, subscribers, and enrollees
with a full and fair disclosure of the provisions of the plan in
readily understood language and in a clearly organized manner. The
director may require that the materials be presented in a reasonably
uniform manner so as to facilitate comparisons between plan contracts
of the same or other types of plans. Nothing contained in this
chapter shall preclude the director from permitting the disclosure
form to be included with the evidence of coverage or plan contract.
   The disclosure form shall provide for at least the following
information, in concise and specific terms, relative to the plan,
together with additional information as may be required by the
director, in connection with the plan or plan contract:
   (1) The principal benefits and coverage of the plan, including
coverage for acute care and subacute care.
   (2) The exceptions, reductions, and limitations that apply to the
plan.
   (3) The full premium cost of the plan.
   (4) Any copayment, coinsurance, or deductible requirements that
may be incurred by the member or the member's family in obtaining
coverage under the plan.
   (5) The terms under which the plan may be renewed by the plan
member, including any reservation by the plan of any right to change
premiums.
   (6) A statement that the disclosure form is a summary only, and
that the plan contract itself should be consulted to determine
governing contractual provisions. The first page of the disclosure
form shall contain a notice that conforms with all of the following
conditions:
   (A) (i) States that the evidence of coverage discloses the terms
and conditions of coverage.
   (ii) States, with respect to individual plan contracts, small
group plan contracts, and any other group plan contracts for which
health care services are not negotiated, that the applicant has a
right to view the evidence of coverage prior to enrollment, and, if
the evidence of coverage is not combined with the disclosure form,
the notice shall specify where the evidence of coverage can be
obtained prior to enrollment.
   (B) Includes a statement that the disclosure and the evidence of
coverage should be read completely and carefully and that individuals
with special health care needs should read carefully those sections
that apply to them.
   (C) Includes the plan's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the plan or a statement where the telephone number or
numbers are located in the disclosure form.
   (D) For individual contracts, and small group plan contracts as
defined in Article 3.1 (commencing with Section 1357), the disclosure
form shall state where the health plan benefits and coverage matrix
is located.
   (E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
   (7) A statement as to when benefits shall cease in the event of
nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon an enrollee who is hospitalized or undergoing
treatment for an ongoing condition.
   (8) To the extent that the plan permits a free choice of provider
to its subscribers and enrollees, the statement shall disclose the
nature and extent of choice permitted and the financial liability
that is, or may be, incurred by the subscriber, enrollee, or a third
party by reason of the exercise of that choice.
   (9) A summary of the provisions required by subdivision (g) of
Section 1373, if applicable.
   (10) If the plan utilizes arbitration to settle disputes, a
statement of that fact.
   (11) A summary of, and a notice of the availability of, the
process the plan uses to authorize, modify, or deny health care
services under the benefits provided by the plan, pursuant to
Sections 1363.5 and 1367.01.
   (12) A description of any limitations on the patient's choice of
primary care physician, specialty care physician, or nonphysician
health care practitioner, based on service area and limitations on
the patient's choice of acute care hospital care, subacute or
transitional inpatient care, or skilled nursing facility.
   (13) General authorization requirements for referral by a primary
care physician to a specialty care physician or a nonphysician health
care practitioner.
   (14) Conditions and procedures for disenrollment.
   (15) A description as to how an enrollee may request continuity of
care as required by Section 1373.96 and request a second opinion
pursuant to Section 1383.15.
   (16) Information concerning the right of an enrollee to request an
independent review in accordance with Article 5.55 (commencing with
Section 1374.30).
   (17) A notice as required by Section 1364.5.
   (b) (1) As of July 1, 1999, the director shall require each plan
offering a contract to an individual or small group to provide with
the disclosure form for individual and small group plan contracts a
uniform health plan benefits and coverage matrix containing the plan'
s major provisions in order to facilitate comparisons between plan
contracts. The uniform matrix shall include the following category
descriptions together with the corresponding copayments and
limitations in the following sequence:
   (A) Deductibles.
   (B) Lifetime maximums.
   (C) Professional services.
   (D) Outpatient services.
   (E) Hospitalization services.
   (F) Emergency health coverage.
   (G) Ambulance services.
   (H) Prescription drug coverage.
   (I) Durable medical equipment.
   (J) Mental health services.
   (K) Chemical dependency services.
   (L) Home health services.
   (M) Other.
   (2) The following statement shall be placed at the top of the
matrix in all capital letters in at least 10-point boldface type:

   THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN
CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE
BENEFITS AND LIMITATIONS.

   (c) Nothing in this section shall prevent a plan from using
appropriate footnotes or disclaimers to reasonably and fairly
describe coverage arrangements in order to clarify any part of the
matrix that may be unclear.
   (d) All plans, solicitors, and representatives of a plan shall,
when presenting any plan contract for examination or sale to an
individual prospective plan member, provide the individual with a
properly completed disclosure form, as prescribed by the director
pursuant to this section for each plan so examined or sold.
   (e) In the case of group contracts, the completed disclosure form
and evidence of coverage shall be presented to the contractholder
upon delivery of the completed health care service plan agreement.
   (f) Group contractholders shall disseminate copies of the
completed disclosure form to all persons eligible to be a subscriber
under the group contract at the time those persons are offered the
plan. If the individual group members are offered a choice of plans,
separate disclosure forms shall be supplied for each plan available.
Each group contractholder shall also disseminate or cause to be
disseminated copies of the evidence of coverage to all applicants,
upon request, prior to enrollment and to all subscribers enrolled
under the group contract.
   (g) In the case of conflicts between the group contract and the
evidence of coverage, the provisions of the evidence of coverage
shall be binding upon the plan notwithstanding any provisions in the
group contract that may be less favorable to subscribers or
enrollees.
   (h) In addition to the other disclosures required by this section,
every health care service plan and any agent or employee of the plan
shall, when presenting a plan for examination or sale to any
individual purchaser or the representative of a group consisting of
25 or fewer individuals, disclose in writing the ratio of premium
costs to health services paid for plan contracts with individuals and
with groups of the same or similar size for the plan's preceding
fiscal year. A plan may report that information by geographic area,
provided the plan identifies the geographic area and reports
information applicable to that geographic area.
   (i) Subdivision (b) shall not apply to any coverage provided by a
plan for the Medi-Cal program or the Medicare program pursuant to
Title XVIII and Title XIX of the Social Security Act.



1363.01.  (a) Every plan that covers prescription drug benefits
shall provide notice in the evidence of coverage and disclosure form
to enrollees regarding whether the plan uses a formulary. The notice
shall be in language that is easily understood and in a format that
is easy to understand. The notice shall include an explanation of
what a formulary is, how the plan determines which prescription drugs
are included or excluded, and how often the plan reviews the
contents of the formulary.
   (b) Every plan that covers prescription drug benefits shall
provide to members of the public, upon request, information regarding
whether a specific drug or drugs are on the plan's formulary. Notice
of the opportunity to secure this information from the plan,
including the plan's telephone number for making a request of this
nature, shall be included in the evidence of coverage and disclosure
form to enrollees.
   (c) Every plan shall notify enrollees, and members of the public
who request formulary information, that the presence of a drug on the
plan's formulary does not guarantee that an enrollee will be
prescribed that drug by his or her prescribing provider for a
particular medical condition.
   (d) This section shall become operative July 1, 1999.



1363.02.  (a) The Legislature finds and declares that the right of
every patient to receive basic information necessary to give full and
informed consent is a fundamental tenet of good public health policy
and has long been the established law of this state. Some hospitals
and other providers do not provide a full range of reproductive
health services and may prohibit or otherwise not provide
sterilization, infertility treatments, abortion, or contraceptive
services, including emergency contraception. It is the intent of the
Legislature that every patient be given full and complete information
about the health care services available to allow patients to make
well informed health care decisions.
   (b) On or before July 1, 2001, a health care service plan that
covers hospital, medical, and surgical benefits shall do both of the
following:
   (1) Include the following statement, in at least 12-point boldface
type, at the beginning of each provider directory:

   "Some hospitals and other providers do not provide one or more of
the following services that may be covered under your plan contract
and that you or your family member might need: family planning;
contraceptive services, including emergency contraception;
sterilization, including tubal ligation at the time of labor and
delivery; infertility treatments; or abortion. You should obtain more
information before you enroll. Call your prospective doctor, medical
group, independent practice association, or clinic, or call the
health plan at (insert the health plan's membership services number
or other appropriate number that individuals can call for assistance)
to ensure that you can obtain the health care services that you
need."

   (2) Place the statement described in paragraph (1) in a prominent
location on any provider directory posted on the health plan's
website, if any, and include this statement in a conspicuous place in
the plan's evidence of coverage and disclosure forms.
   (c) A health care service plan shall not be required to provide
the statement described in paragraph (1) of subdivision (b) in a
service area in which none of the hospitals, health facilities,
clinics, medical groups, or independent practice associations with
which it contracts limit or restrict any of the reproductive services
described in the statement.
   (d) This section shall not apply to specialized health care
service plans or Medicare supplement plans.



1363.03.  (a) Every health care service plan that covers
prescription drug benefits and that issues a card to enrollees for
claims processing purposes shall issue to each of its enrollees a
uniform card containing uniform prescription drug information. The
uniform prescription drug information card shall, at a minimum,
include the following information:
   (1) The name or logo of the benefit administrator or health care
service plan issuing the card, which shall be displayed on the front
side of the card.
   (2) The enrollee's identification number, or the subscriber's
identification number when the enrollee is a dependent who accesses
services using the subscriber's identification number, which shall be
displayed on the front side of the card.
   (3) A telephone number that pharmacy providers may call for
assistance.
   (4) Information required by the benefit administrator or health
care service plan that is necessary to commence processing the
pharmacy claim, except as provided for in paragraph (5).
   (5) A health care service plan shall not be required to print any
of the following information on a member card:
   (A) Any number that is the same for all of its members, provided
that the health care service plan provides this number to the
pharmacy on an annual basis.
   (B) Any information that may result in fraudulent use of the card.
   (C) Any information that is otherwise prohibited from being
included on the card.
   (b) Beginning July 1, 2002, the new uniform prescription drug
information card required by subdivision (a) shall be issued by a
health care service plan to an enrollee upon enrollment or upon any
change in the enrollee's coverage that impacts the data content or
format of the card.
   (c) Nothing in this section requires a health care service plan to
issue a separate card for prescription drug coverage if the plan
issues a card for health care coverage in general and the card is
able to accommodate the information required by subdivision (a).
   (d) This bill shall not apply to a nonprofit health care service
plan with at least 3.5 million enrollees that owns or operates its
own pharmacies and that provides health care services to enrollees in
a specific geographic area through a mutually exclusive contract
with a single medical group.
   (e) "Card" as used in this section includes other technology that
performs substantially the same function as a card.
   (f) For purposes of this section, if a health care service plan
delegates responsibility for issuing the uniform prescription drug
information card to a contractor or agent, then the contract between
the health care service plan and its contractor or agent shall
require compliance with this section.



1363.05.  (a) For every plan contract that provides or supplements
Medicare benefits, a plan shall include within its disclosure form
the following statement in at least 12-point type:

   "For additional information concerning covered benefits, contact
the Health Insurance Counseling and Advocacy Program (HICAP) or your
agent. HICAP provides health insurance counseling for California
senior citizens. Call the HICAP toll-free telephone number,
1-800-434-0222, for a referral to your local HICAP office. HICAP is a
service provided free of charge by the State of California."

   (b) For every plan contract that provides or supplements Medicare
benefits, a plan shall modify its disclosure forms to comply with
subdivision (a) no later than January 1, 1998.
   (c) Every health care service plan that provides or supplements
Medicare benefits shall notify those current enrollees who enrolled
prior to the modification of disclosure forms to include the
disclosure statement required by subdivision (a) of the availability
of the HICAP program. That notification shall include the same
language as is required by subdivision (a). That notification may be
by free standing document and shall be made no later than January 1,
1998.



1363.06.  (a) The Department of Managed Health Care and the
Department of Insurance shall compile information as required by this
section and Section 10127.14 of the Insurance Code into two
comparative benefit matrices. The first matrix shall compare benefit
packages offered pursuant to Section 1373.62 and Section 10127.15 of
the Insurance Code. The second matrix shall compare benefit packages
offered pursuant to Sections 1366.35, 1373.6, and 1399.804 and
Sections 10785, 10901.2, and 12682.1 of the Insurance Code.
   (b) The comparative benefit matrix shall include:
   (1) Benefit information submitted by health care service plans
pursuant to subdivision (d) and by health insurers pursuant to
Section 10127.14 of the Insurance Code.
   (2) The following statements in at least 12-point type at the top
of the matrix:
   (A) "This benefit summary is intended to help you compare coverage
and benefits and is a summary only. For a more detailed description
of coverage, benefits, and limitations, please contact the health
care service plan or health insurer."
   (B) "The comparative benefit summary is updated annually, or more
often if necessary to be accurate."
   (C) "The most current version of this comparative benefit summary
is available on (address of the plan's or insurer's site)."
   This subparagraph applies only to those plans or insurers that
maintain an Internet Web site.
   (3) The telephone number or numbers that may be used by an
applicant to contact either the department or the Department of
Insurance, as appropriate, for further assistance.
   (c) The Department of Managed Health Care and the Department of
Insurance shall jointly prepare two standardized templates for use by
health care service plans and health insurers in submitting the
information required pursuant to subdivision (d) and subdivision (d)
of Section 10127.14 of the Insurance Code. The templates shall be
exempt from the provisions of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
   (d) Health care service plans, except specialized health care
service plans, shall submit the following to the department by
January 31, 2003, and annually thereafter:
   (1) A summary explanation of the following for each product
described in subdivision (a).
   (A) Eligibility requirements.
   (B) The full premium cost of each benefit package in the service
area in which the individual and eligible dependents work or reside.
   (C) When and under what circumstances benefits cease.
   (D) The terms under which coverage may be renewed.
   (E) Other coverage that may be available if benefits under the
described benefit package cease.
   (F) The circumstances under which choice in the selection of
physicians and providers is permitted.
   (G) Lifetime and annual maximums.
   (H) Deductibles.
   (2) A summary explanation of coverage for the following, together
with the corresponding copayments and limitations, for each product
described in subdivision (a):
   (A) Professional services.
   (B) Outpatient services.
   (C) Hospitalization services.
   (D) Emergency health coverage.
   (E) Ambulance services.
   (F) Prescription drug coverage.
   (G) Durable medical equipment.
   (H) Mental health services.
   (I) Residential treatment.
   (J) Chemical dependency services.
   (K) Home health services.
   (L) Custodial care and skilled nursing facilities.
   (3) The telephone number or numbers that may be used by an
applicant to access a health care service plan customer service
representative and to request additional information about the plan
contract.
   (4) Any other information specified by the department in the
template.
   (e) Each health care service plan shall provide the department
with updates to the information required by subdivision (d) at least
annually, or more often if necessary to maintain the accuracy of the
information.
   (f) The department and the Department of Insurance shall make the
comparative benefit matrices available on their respective Internet
Web sites and to the health care service plans and health insurers
for dissemination as required by Section 1373.6 and Section 12682.1
of the Insurance Code, after confirming the accuracy of the
description of the matrices with the health care service plans and
health insurers.
   (g) As used in this section and Section 1363.07, "benefit matrix"
shall have the same meaning as benefit summary.



1363.07.  (a) Each health care service plan shall send copies of the
comparative benefit matrix prepared pursuant to Section 1363.06 on
an annual basis, or more frequently as the matrix is updated by the
department and the Department of Insurance, to solicitors and
solicitor firms and employers with whom the plan contracts.
   (b) Each health care service plan shall require its
representatives and solicitors and soliciting firms with which it
contracts, to provide a copy of the comparative benefit matrix to
individuals when presenting any benefit package for examination or
sale.
   (c) Each health care service plan that maintains an Internet Web
site shall make a downloadable copy of the comparative benefit matrix
described in Section 1363.06 available through a link on its site to
the Internet Web sites of the department and the Department of
Insurance.


1363.1.  Any health care service plan that includes terms that
require binding arbitration to settle disputes and that restrict, or
provide for a waiver of, the right to a jury trial shall include, in
clear and understandable language, a disclosure that meets all of the
following conditions:
   (a) The disclosure shall clearly state whether the plan uses
binding arbitration to settle disputes, including specifically
whether the plan uses binding arbitration to settle claims of medical
malpractice.
   (b) The disclosure shall appear as a separate article in the
agreement issued to the employer group or individual subscriber and
shall be prominently displayed on the enrollment form signed by each
subscriber or enrollee.
   (c) The disclosure shall clearly state whether the subscriber or
enrollee is waiving his or her right to a jury trial for medical
malpractice, other disputes relating to the delivery of service under
the plan, or both, and shall be substantially expressed in the
wording provided in subdivision (a) of Section 1295 of the Code of
Civil Procedure.
   (d) In any contract or enrollment agreement for a health care
service plan, the disclosure required by this section shall be
displayed immediately before the signature line provided for the
representative of the group contracting with a health care service
plan and immediately before the signature line provided for the
individual enrolling in the health care service plan.



1363.2.  On or before July 1, 1999, the disclosure form required
pursuant to Section 1363 shall also contain a statement that
enrollees are encouraged to use appropriately the "911" emergency
response system, in areas where the system is established and
operating, when they have an emergency medical condition that
requires an emergency response.



1363.5.  (a) A plan shall disclose or provide for the disclosure to
the director and to network providers the process the plan, its
contracting provider groups, or any entity with which the plan
contracts for services that include utilization review or utilization
management functions, uses to authorize, modify, or deny health care
services under the benefits provided by the plan, including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. A plan shall also disclose those
processes to enrollees or persons designated by an enrollee, or to
any other person or organization, upon request. The disclosure to the
director shall include the policies, procedures, and the description
of the process that are filed with the director pursuant to
subdivision (b) of Section 1367.01.
   (b) The criteria or guidelines used by plans, or any entities with
which plans contract for services that include utilization review or
utilization management functions, to determine whether to authorize,
modify, or deny health care services shall:
   (1) Be developed with involvement from actively practicing health
care providers.
   (2) Be consistent with sound clinical principles and processes.
   (3) Be evaluated, and updated if necessary, at least annually.
   (4) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the enrollee in that specified case.
   (5) Be available to the public upon request. A plan shall only be
required to disclose the criteria or guidelines for the specific
procedures or conditions requested. A plan may charge reasonable fees
to cover administrative expenses related to disclosing criteria or
guidelines pursuant to this paragraph, limited to copying and postage
costs. The plan may also make the criteria or guidelines available
through electronic communication means.
   (c) The disclosure required by paragraph (5) of subdivision (b)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this plan to authorize, modify, or
deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the
benefits covered under your contract."



1364.  Where the director finds it necessary in the interest of full
and fair disclosure, all advertising and other consumer information
disseminated by a plan for the purpose of influencing persons to
become members of a plan shall contain such supplemental disclosure
information as the director may require.



1364.1.  Within 30 days of receiving the notice required by Section
1255.1, a health care service plan shall notify, or provide for the
notification of, enrollees who have selected a medical group or
independent practice association that uses a hospital that the
hospital will reduce or eliminate its emergency services. The plan
may require that its contracting medical groups and independent
practice associations that use the hospital provide this notice. The
notice shall include a list of alternate hospitals that may be used
by enrollees for emergency services.



1364.5.  (a) On or before July 1, 2001, every health care service
plan shall file with the director a copy of their policies and
procedures to protect the security of patient medical information to
ensure compliance with the Confidentiality of Information Act (Part
2.6 (commencing with Section 56) of Division 1 of the Civil Code).
Any amendment to the policies and procedures shall be filed in
accordance with Section 1352.
   (b) On and after July 1, 2001, every health care service plan
shall, upon request, provide to enrollees and subscribers a written
statement that describes how the contracting organization or health
care service plan maintains the confidentiality of medical
information obtained by and in the possession of the contracting
organization or the health care service plan.
   (c) The statement required by subdivision (b) shall be in at least
12-point type and meet the following requirements:
   (1) The statement shall describe how the contracting organization
or health care service plan protects the confidentiality of medical
information pursuant to this article and inform patients or enrollees
and subscribers that any disclosure of medical information beyond
the provisions of the law is prohibited.
   (2) The statement shall describe the types of medical information
that may be collected and the type of sources that may be used to
collect the information, the purposes for which the contracting
organization or plan will obtain medical information from other
health care providers.
   (3) The statement shall describe the circumstances under which
medical information may be disclosed without prior authorization,
pursuant to Section 56.10 of the Civil Code.
   (4) The statement shall describe how patients or enrollees and
subscribers may obtain access to medical information created by and
in the possession of the contracting organization or health care
service plan, including copies of medical information.
   (d) On and after July 1, 2001, every health care service plan
shall include in its evidence of coverage or disclosure form the
following notice, in 12-point type:

   A STATEMENT DESCRIBING (NAME OR PLAN OR "OUR") POLICIES AND
PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS
AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.



1365.  (a) An enrollment or a subscription shall not be canceled or
not renewed except for the following reasons:
   (1) (A) For nonpayment of the required premiums by the individual,
employer, or contractholder if the individual, employer, or
contractholder has been duly notified and billed for the charge and
at least a 30-day grace period has elapsed since the date of
notification or, if longer, the period of time required for notice
and any other requirements pursuant to Section 2703, 2712, or 2742 of
the federal Public Health Service Act (42 U.S.C. Secs. 300gg-2,
300gg-12, and 300gg-42) and any subsequent rules or regulations has
elapsed.
   (B) Pursuant to subparagraph (A), a health care service plan shall
continue to provide coverage as required by the individual's,
employer's, or contractholder's health care service plan contract
during the period described in subparagraph (A).
   (2) The plan demonstrates fraud or an intentional
misrepresentation of material fact under the terms of the health care
service plan contract by the individual contractholder or employer.
   (3) In the case of an individual health care service plan
contract, the individual subscriber no longer resides, lives, or
works in the plan's service area, but only if the coverage is
terminated uniformly without regard to any health status-related
factor of covered individuals.
   (4) In the case of a group health care service plan contract,
violation of a material contract provision relating to employer
contribution or group participation rates by the, contractholder, or
employer.
   (5) If the plan ceases to provide or arrange for the provision of
health benefit for new health care service plan contracts in the
individual or group market, or all markets, in this state, provided,
however, that the following conditions are satisfied:
   (A) Notice of the decision to cease new or existing health benefit
plans in the state is provided to the director and to the individual
or group contractholder or employer, and the enrollees covered under
those contracts, at least 180 days prior to discontinuation of those
contracts.
   (B) Health benefit plans shall not be canceled for 180 days after
the date of the notice required under subparagraph (A) and for that
business of a plan that remains in force, any plan that ceases to
offer for sale new health benefit plans shall continue to be governed
by this section with respect to business conducted under this
section.
   (C) Except as authorized under subdivision (b) of Section 1357.09
and Section 1357.10, a plan that ceases to write new health benefit
plans in the individual or group market, or all markets, in this
state shall be prohibited from offering for sale health benefit plans
in that market or markets in this state for a period of five years
from the date of the discontinuation of the last coverage not so
renewed.
   (6) If the plan withdraws a health benefit plan from the market,
provided that all of the following conditions are satisfied:
   (A) The plan notifies all affected subscribers, contractholders,
employers, and enrollees and the director at least 90 days prior to
the discontinuation of the plan.
   (B) The plan makes available to the individual or group
contractholder or employer all health benefit plans that it makes
available to new individual or group business, respectively.
   (C) In exercising the option to discontinue a health benefit plan
under this paragraph and in offering the option of coverage under
subparagraph (B), the plan acts uniformly without regard to the
claims experience of the individual or contractholder or employer, or
any health-status related factor relating to enrollees or potential
enrollees.
   (D) For small employer health care service plan contracts offered
under Article 3.1 (commencing with Section 1357), the premium for the
new plan contract complies with the renewal increase requirements
set forth in Section 1357.12. This subparagraph shall not apply after
December 31, 2013.
   (7) In the case of a group health benefit plan, if an individual
or employer ceases to be a member of a guaranteed association, as
defined in subdivision (n) of Section 1357, but only if that coverage
is terminated under this paragraph uniformly without regard to any
health status-related factor relating to any enrollee.
   (b) (1) An enrollee or subscriber who alleges that an enrollment
or subscription has been or will be improperly canceled, rescinded,
or not renewed may request a review by the director pursuant to
Section 1368.
   (2) If the director determines that a proper complaint exists, the
director shall notify the plan and the enrollee or subscriber who
requested the review.
   (3) If, after review, the director determines that the
cancellation, rescission, or failure to renew is contrary to existing
law, the director shall order the plan to reinstate the enrollee or
subscriber. Within 15 days after receipt of that order, the health
care service plan shall request a hearing or reinstate the enrollee
or subscriber.
   (4) If an enrollee or subscriber requests a review of the health
care service plan's determination to cancel or rescind or failure to
renew the enrollee's or subscriber's health care service plan
contract pursuant to this section, the health care service plan shall
continue to provide coverage to the enrollee or subscriber under the
terms of the contract until a final determination of the enrollee's
or subscriber's request for review has been made by the director.
This paragraph shall not apply if the health care service plan
cancels or does not renew the enrollee's or subscriber's health care
service plan contract for nonpayment of premiums pursuant to
paragraph (1) of subdivision (a).
   (5) A reinstatement pursuant to this subdivision shall be
retroactive to the time of cancellation, rescission, or failure to
renew and the plan shall be liable for the expenses incurred by the
subscriber or enrollee for covered health care services from the date
of cancellation, rescission, or nonrenewal to and including the date
of reinstatement. The health care service plan shall reimburse the
enrollee or subscriber for any expenses incurred pursuant to this
paragraph within 30 days of receipt of the completed claim.
   (c) This section shall not abrogate any preexisting contracts
entered into prior to the effective date of this chapter between a
subscriber or enrollee and a health care service plan or a
specialized health care service plan including, but not limited to,
the financial liability of the plan, except that each plan shall, if
directed to do so by the director, exercise its authority, if any,
under those preexisting contracts to conform them to the provisions
of existing law.
   (d) As used in this section, "health benefit plan" means any
individual or group insurance policy or health care service plan
contract that provides medical, hospital, and surgical benefits. The
term does not include accident only, credit, or disability income
coverage, coverage of Medicare services pursuant to contracts with
the United States government, Medicare supplement insurance,
long-term care insurance, dental or vision coverage, coverage issued
as a supplement to liability insurance, insurance arising out of
workers' compensation law or similar law, automobile medical payment
insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
   (e) On or before July 1, 2011, the director may issue guidance to
health care service plans regarding compliance with this section and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code). Any guidance issued
pursuant to this subdivision shall only be effective through December
31, 2013, or until the director adopts and effects regulations
pursuant to the Administrative Procedure Act, whichever occurs first.




1365.5.  (a) No health care service plan or specialized health care
service plan shall refuse to enter into any contract or shall cancel
or decline to renew or reinstate any contract because of the race,
color, national origin, ancestry, religion, sex, marital status,
sexual orientation, or age of any contracting party, prospective
contracting party, or person reasonably expected to benefit from that
contract as a subscriber, enrollee, member, or otherwise.
   (b) The terms of any contract shall not be modified, and the
benefits or coverage of any contract shall not be subject to any
limitations, exceptions, exclusions, reductions, copayments,
coinsurance, deductibles, reservations, or premium, price, or charge
differentials, or other modifications because of the race, color,
national origin, ancestry, religion, sex, marital status, sexual
orientation, or age of any contracting party, potential contracting
party, or person reasonably expected to benefit from that contract as
a subscriber, enrollee, member, or otherwise; except that premium,
price, or charge differentials because of the age of any individual
when based on objective, valid, and up-to-date statistical and
actuarial data are not prohibited.
   (c) It shall be deemed a violation of subdivision (a) for any
health care service plan to utilize marital status, living
arrangements, occupation, sex, beneficiary designation, ZIP Codes or
other territorial classification, or any combination thereof for the
purpose of establishing sexual orientation. Nothing in this section
shall be construed to alter in any manner the existing law
prohibiting health care service plans from conducting tests for the
presence of human immunodeficiency virus or evidence thereof.
   (d) This section shall not be construed to limit the authority of
the director to adopt or enforce regulations prohibiting
discrimination because of sex, marital status, or sexual orientation.
   (e) "Sex" as used in this section shall have the same meaning as
"gender," as defined in Section 422.56 of the Penal Code.
   (f) The changes made to this section by the act adding this
subdivision shall only apply to contracts issued, amended, or renewed
on or after January 1, 2011.


1366.  (a) No plan may use in its name, any of the words "insurance,"
"casualty," "surety," "mutual," or any other words descriptive of
the insurance, casualty, or surety business or use any name similar
to the name or description of any insurance or surety corporation
doing business in this state unless such plan controls or is
controlled by an entity licensed as an insurer pursuant to the
provisions of the Insurance Code and the plan employs a name related
to that of such controlled or controlling entity.
   (b) Section 2415 of the Business and Professions Code, pertaining
to fictitious names, shall not apply to plans, except specialized
health care service plans.
   (c) No plan or solicitor firm may adopt a name style that is
deceptive, or one that could cause the public to believe the plan is
affiliated with, or recommended by any governmental or private entity
unless such affiliation or endorsement exists.



1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families program.
   (c) (1) At least 30 days before a health care service plan files
for modification of its license with the department in order to
withdraw from a county with a population of 500,000 or less, or a
portion of that county, the health care service plan shall hold a
public meeting in the county or portion of the county from which it
intends to withdraw, and shall do all of the following:
   (A) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers, advocates, public officials, and other interested parties.
   (B) Provide notice announcing the public meeting at least 30 days
prior to the public meeting in a newspaper of general circulation
within the affected county or portion of the affected county.
   (C) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (D) Send a summary of the comments received at the public meeting
to the department.
   (E) Send a summary of the comments received at the public meeting
to the Centers for Medicare and Medicaid Services if the modification
would affect Medicare beneficiaries.
   (F) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under subparagraphs (A) and (B).
   (2) A representative of the department shall attend the public
meeting.


1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families Program.
   (4) The federal Medicare program.
   (c) At least 30 days before a health care service plan files a
notice of material modification of its license with the department to
withdraw from a county with a population of 500,000 or less, the
health care service plan shall hold a public meeting in the county
from which it is intending to withdraw, and shall do all of the
following:
   (1) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers with which it contracts, the members of the board of
supervisors of the affected county, the members of the city councils
of cities in the affected county, and members of the Legislature who
represent the affected county.
   (2) Provide notice announcing the public meeting at least 15 days
prior to the public meeting in a newspaper of general circulation
within the affected county.
   (3) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (4) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under paragraphs (1) and (2).
   (d) The department may require a health care service plan that has
filed to withdraw from a portion of a county with a population of
less than 500,000, to hold a hearing for affected enrollees.
   (e) A representative of the department shall attend the public
meeting described in this section.


1366.2.  (a) A full health care service plan shall make available to
a group subscriber, upon request, the termination date of all major
health care provider contracts that are for services in the
geographic area for which the group subscriber has secured coverage
and that include a specified termination date.
   (b) For purposes of this section, the following terms have the
following meanings:
   (1) "Enrollee" means a person who is enrolled in a health care
service plan and who is a recipient of services from the plan.
   (2) "Full health care service plan" means a plan that meets the
definition set forth in subdivision (f) of Section 1345, and that has
a total enrolled membership exceeding 499,999 enrollees.
   (3) "Hospital" means a general acute care hospital.
   (4) "Major health care provider contract" means a contract between
a full service plan and provider group or hospital covering more
than 25,000 of that plan's enrollees. "Major health care provider
contract" does not mean a provider contract between a specialized
health care service plan and a provider group or hospital.
   (5) "Provider group" means a medical group, independent practice
association, or other similar group of providers with a total
enrolled membership exceeding 99,999 enrollees.




1366.3.  (a) On and after January 1, 2005, a health care service
plan issuing individual plan contracts that ceases to offer
individual coverage in this state shall offer coverage to the
subscribers who had been covered by those contracts at the time of
withdrawal under the same terms and conditions as provided in
paragraph (3) of subdivision (a), paragraphs (2) to (4), inclusive,
of subdivision (b), subdivisions (c) to (e), inclusive, and
subdivision (h) of Section 1373.6.
   (b) A health care service plan that ceases to offer individual
coverage in a service area shall offer the coverage required by
subdivision (a) to subscribers who had been covered by those
contracts at the time of withdrawal, if the plan continues to offer
group coverage in that service area. This subdivision shall not apply
to coverage provided pursuant to a preferred provider organization.
   (c) The department may adopt regulations to implement this
section.
   (d) This section shall not apply when a plan participating in
Medi-Cal, Healthy Families, Access for Infants and Mothers, or any
other contract between the plan and a government entity no longer
contracts with the government entity to provide health coverage in
the state, or a specified area of the state, nor shall this section
apply when a plan ceases entirely to market, offer, and issue any and
all forms of coverage in any part of this state after the effective
date of this section.



1366.4.  (a) A medical group, physician, or independent practice
association that contracts with a health care service plan may enter
into contracts with licensed nonphysician providers to provide
services, as defined in Section 1300.67(a)(1) of Title 28 of the
California Code of Regulations, to plan enrollees covered by the
contract between the plan and the group, physician, or association.
   (b) The licensed nonphysician provider described in subdivision
(a) that contracts with a medical group, physician, or independent
practice association may directly bill, if direct billing is
otherwise permitted by law, a health care service plan for covered
services pursuant to a contract with the health care service plan
that specifies direct billing. Direct billing pursuant to this
subdivision is permitted only to the extent that the same services
are not billed for by the medical group, physician, or independent
practice association.
   (c) A health care service plan may require the nonphysician
provider to complete an appropriate credentialing process.
   (d) Every health care service plan may either list licensed
nonphysician providers that contract with medical groups, physicians,
and independent practice associations pursuant to subdivision (b) in
any listing or directory of plan health care providers that is
provided to enrollees or to the public, or may include a notification
in the plan's evidence of coverage or provider list that the health
care service plan has contracts with nonphysician providers, pursuant
to subdivision (b), and may list the types of contracted
nonphysician providers. The notification may inform an enrollee that
he or she may obtain a list of the nonphysician providers by
contacting his or her primary or specialist medical group. The
listing may indicate whether licensed nonphysician providers may be
accessed directly by enrollees.
   (e) Nothing in this section shall be construed to authorize, or
otherwise require the director to approve, a risk-sharing arrangement
between a plan and a provider.


State Codes and Statutes

State Codes and Statutes

Statutes > California > Hsc > 1359-1366.4

HEALTH AND SAFETY CODE
SECTION 1359-1366.4



1359.  (a) The director may require that solicitors and solicitor
firms, and principal persons engaged in the supervision of
solicitation for plans of solicitor firms, meet such reasonable and
appropriate standards with respect to training, experience, and other
qualifications as the director finds necessary and appropriate in
the public interest or for the protection of subscribers, enrollees,
and plans. For such purposes, the director may do the following:
   (1) Appropriately classify such persons and individuals.
   (2) Specify that all or any portion of such standards shall be
applicable to any such class.
   (3) Require individuals in any such class to pass examinations
prescribed in accordance with such rules.
   (b) The director may prescribe by rule reasonable fees and charges
to defray the costs of carrying out this section, including, but not
limited to, fees for any examination administered by the director or
under his or her direction.



1360.  (a) No plan, solicitor, solicitor firm, or representative
shall use or permit the use of any advertising or solicitation which
is untrue or misleading, or any form of evidence of coverage which is
deceptive. For purposes of this article:
   (1) A written or printed statement or item of information shall be
deemed untrue if it does not conform to fact in any respect which
is, or may be significant to an enrollee or subscriber, or potential
enrollee or subscriber in a plan.
   (2) A written or printed statement or item of information shall be
deemed misleading whether or not it may be literally true, if, in
the total context in which the statement is made or such item of
information is communicated, such statement or item of information
may be understood by a person not possessing special knowledge
regarding health care coverage, as indicating any benefit or
advantage, or the absence of any exclusion, limitation, or
disadvantage of possible significance to an enrollee, or potential
enrollee or subscriber, in a plan, and such is not the case.
   (3) An evidence of coverage shall be deemed to be deceptive if the
evidence of coverage taken as a whole and with consideration given
to typography and format, as well as language, shall be such as to
cause a reasonable person, not possessing special knowledge of plans,
and evidence of coverage therefor to expect benefits, service
charges, or other advantages which the evidence of coverage does not
provide or which the plan issuing such coverage or evidence of
coverage does not regularly make available to enrollees or
subscribers covered under such evidence of coverage.
   (b) No plan, or solicitor, or representative shall use or permit
the use of any verbal statement which is untrue, misleading, or
deceptive or make any representations about coverage offered by the
plan or its cost that does not conform to fact. All verbal statements
are to be held to the same standards as those for printed matter
provided in subdivision (a).



1360.1.  It is unlawful for any person, including a plan, subject to
this chapter to represent or imply in any manner that the person or
plan has been sponsored, recommended, or approved, or that the person'
s or plan's abilities or qualifications have in any respect been
passed upon, by the director. Nothing in this section prohibits a
statement (other than in a paid advertisement) that a person or plan
holds a license under this chapter, if such statement is true and if
the effect of such licensing is not misrepresented.



1361.  (a) Except as provided in subdivision (b), no plan shall
publish or distribute, or allow to be published or distributed on its
behalf, any advertisement not subject to Section 1352.1 unless (1) a
true copy thereof has first been filed with the director, at least
30 days prior to any such use, or any shorter period as the director
by rule or order may allow, and (2) the director by notice has not
found the advertisement, wholly or in part, to be untrue, misleading,
deceptive, or otherwise not in compliance with this chapter or the
rules thereunder, and specified the deficiencies, within the 30 days
or any shorter time as the director by rule or order may allow.
   (b) Except as provided in subdivision (c), a licensed plan which
has been continuously licensed under this chapter for the preceding
18 months may publish or distribute or allow to be published or
distributed on its behalf an advertisement not subject to Section
1352.1 without having filed the same for the director's prior
approval, if the plan and the material comply with each of the
following conditions:
   (1) The advertisement or a material provision thereof has not been
previously disapproved by the director by written notice to the plan
and the plan reasonably believes that the advertisement does not
violate any requirement of this chapter or the rules thereunder.
   (2) The plan files a true copy of each new or materially revised
advertisement, used by it or by any person acting on behalf of the
plan, with the director not later than 10 business days after
publication or distribution of the advertisement or within such
additional period as the director may allow by rule or order.
   (c) If the director finds that any advertisement of a plan has
materially failed to comply with this chapter or the rules
thereunder, the director may, by order, require the plan to publish
in the same or similar medium, an approved correction or retraction
of any untrue, misleading, or deceptive statement contained in the
advertising, and may prohibit the plan from publishing or
distributing, or allowing to be published or distributed on its
behalf the advertisement or any new materially revised advertisement
without first having filed a copy thereof with the director, 30 days
prior to the publication or distribution thereof, or any shorter
period specified in the order. An order issued under this subdivision
shall be effective for 12 months from its issuance, and may be
renewed by order if the advertisements submitted under this
subdivision indicate difficulties of voluntary compliance with the
applicable provisions of this chapter and the rules thereunder.
   (d) A licensed plan or other person regulated under this chapter
may, within 30 days after receipt of any notice or order under this
section, file a written request for a hearing with the director.
   (e) The director by rule or order may classify plans and
advertisements and exempt certain classes, wholly or in part, either
unconditionally or upon specified terms and conditions or for
specified periods, from the application of subdivisions (a) and (b).



1361.1.  (a) It is an unfair business practice for a solicitor,
solicitor firm, or representative of a health care service plan to
sell, solicit, or negotiate the purchase of health care coverage
products by any of the following methods:
   (1) The use of a marketing technique known as cold lead
advertising when marketing a Medicare product. As used in this
section, "cold lead advertising" means making use directly or
indirectly of a method of marketing that fails to disclose in a
conspicuous manner that a purpose of the marketing is health care
service plan sales solicitation and that contact will be made by a
solicitor, solicitor firm, or representative of a health care service
plan.
   (2) The use of an appointment that was made to discuss a
particular Medicare product or to solicit the sale of a particular
Medicare product in order to solicit the sale of another Medicare
product or other health care coverage products, unless the consumer
specifically agrees in advance of the appointment to discuss that
other Medicare product or other types of health care coverage
products during the same appointment.
   (b) As used in this section, "Medicare product" includes Medicare
Parts A, B, C, and D, and Medicare supplement plans.



1362.  As used in Sections 1363 and 1364:
   (a) "Benefits and coverage" means the health care services
available under a plan contract.
   (b) "Exception" means any provision in a plan contract whereby
coverage for a specified hazard or condition is entirely eliminated.
   (c) "Reduction" means any provision in a plan contract which
reduces the amount of a plan benefit to some amount or period less
than would be otherwise payable for medically authorized expenses or
services had such a reduction not been used.
   (d) "Limitation" means any provision other than an exception or a
reduction which restricts coverage under the plan.
   (e) "Presenting for examination or sale" means either (1)
publication and dissemination of any brochure, mailer, advertisement,
or form which constitutes a presentation of the provisions of the
plan and which provides a plan enrollment or application form, or (2)
consultations or discussions between prospective plan members or
their contract agents and solicitors or representatives of a plan,
when such consultations or discussions include presentation of
formal, organized information about the plan which is intended to
influence or inform the prospective member or contract holder, such
as brochures, summaries, charts, slides, or other modes of
information.
   (f) "Disclosure form" means the disclosure form, material, or
information required pursuant to Section 1363.
   (g) For the purposes of Sections 1363 and 1364, where the
definition of the term "hospital" in the plan contract omits care in
any "health facility" defined pursuant to subdivision (a) or (b) of
Section 1250 of this code, the omitted coverage shall constitute a
limitation; and where the definition of the term "nursing home" in
the plan omits care in any "health facility" defined pursuant to
subdivision (c) or (d) of Section 1250 of this code, the omitted
coverage shall constitute a limitation.


1363.  (a) The director shall require the use by each plan of
disclosure forms or materials containing information regarding the
benefits, services, and terms of the plan contract as the director
may require, so as to afford the public, subscribers, and enrollees
with a full and fair disclosure of the provisions of the plan in
readily understood language and in a clearly organized manner. The
director may require that the materials be presented in a reasonably
uniform manner so as to facilitate comparisons between plan contracts
of the same or other types of plans. Nothing contained in this
chapter shall preclude the director from permitting the disclosure
form to be included with the evidence of coverage or plan contract.
   The disclosure form shall provide for at least the following
information, in concise and specific terms, relative to the plan,
together with additional information as may be required by the
director, in connection with the plan or plan contract:
   (1) The principal benefits and coverage of the plan, including
coverage for acute care and subacute care.
   (2) The exceptions, reductions, and limitations that apply to the
plan.
   (3) The full premium cost of the plan.
   (4) Any copayment, coinsurance, or deductible requirements that
may be incurred by the member or the member's family in obtaining
coverage under the plan.
   (5) The terms under which the plan may be renewed by the plan
member, including any reservation by the plan of any right to change
premiums.
   (6) A statement that the disclosure form is a summary only, and
that the plan contract itself should be consulted to determine
governing contractual provisions. The first page of the disclosure
form shall contain a notice that conforms with all of the following
conditions:
   (A) (i) States that the evidence of coverage discloses the terms
and conditions of coverage.
   (ii) States, with respect to individual plan contracts, small
group plan contracts, and any other group plan contracts for which
health care services are not negotiated, that the applicant has a
right to view the evidence of coverage prior to enrollment, and, if
the evidence of coverage is not combined with the disclosure form,
the notice shall specify where the evidence of coverage can be
obtained prior to enrollment.
   (B) Includes a statement that the disclosure and the evidence of
coverage should be read completely and carefully and that individuals
with special health care needs should read carefully those sections
that apply to them.
   (C) Includes the plan's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the plan or a statement where the telephone number or
numbers are located in the disclosure form.
   (D) For individual contracts, and small group plan contracts as
defined in Article 3.1 (commencing with Section 1357), the disclosure
form shall state where the health plan benefits and coverage matrix
is located.
   (E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
   (7) A statement as to when benefits shall cease in the event of
nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon an enrollee who is hospitalized or undergoing
treatment for an ongoing condition.
   (8) To the extent that the plan permits a free choice of provider
to its subscribers and enrollees, the statement shall disclose the
nature and extent of choice permitted and the financial liability
that is, or may be, incurred by the subscriber, enrollee, or a third
party by reason of the exercise of that choice.
   (9) A summary of the provisions required by subdivision (g) of
Section 1373, if applicable.
   (10) If the plan utilizes arbitration to settle disputes, a
statement of that fact.
   (11) A summary of, and a notice of the availability of, the
process the plan uses to authorize, modify, or deny health care
services under the benefits provided by the plan, pursuant to
Sections 1363.5 and 1367.01.
   (12) A description of any limitations on the patient's choice of
primary care physician, specialty care physician, or nonphysician
health care practitioner, based on service area and limitations on
the patient's choice of acute care hospital care, subacute or
transitional inpatient care, or skilled nursing facility.
   (13) General authorization requirements for referral by a primary
care physician to a specialty care physician or a nonphysician health
care practitioner.
   (14) Conditions and procedures for disenrollment.
   (15) A description as to how an enrollee may request continuity of
care as required by Section 1373.96 and request a second opinion
pursuant to Section 1383.15.
   (16) Information concerning the right of an enrollee to request an
independent review in accordance with Article 5.55 (commencing with
Section 1374.30).
   (17) A notice as required by Section 1364.5.
   (b) (1) As of July 1, 1999, the director shall require each plan
offering a contract to an individual or small group to provide with
the disclosure form for individual and small group plan contracts a
uniform health plan benefits and coverage matrix containing the plan'
s major provisions in order to facilitate comparisons between plan
contracts. The uniform matrix shall include the following category
descriptions together with the corresponding copayments and
limitations in the following sequence:
   (A) Deductibles.
   (B) Lifetime maximums.
   (C) Professional services.
   (D) Outpatient services.
   (E) Hospitalization services.
   (F) Emergency health coverage.
   (G) Ambulance services.
   (H) Prescription drug coverage.
   (I) Durable medical equipment.
   (J) Mental health services.
   (K) Chemical dependency services.
   (L) Home health services.
   (M) Other.
   (2) The following statement shall be placed at the top of the
matrix in all capital letters in at least 10-point boldface type:

   THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN
CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE
BENEFITS AND LIMITATIONS.

   (c) Nothing in this section shall prevent a plan from using
appropriate footnotes or disclaimers to reasonably and fairly
describe coverage arrangements in order to clarify any part of the
matrix that may be unclear.
   (d) All plans, solicitors, and representatives of a plan shall,
when presenting any plan contract for examination or sale to an
individual prospective plan member, provide the individual with a
properly completed disclosure form, as prescribed by the director
pursuant to this section for each plan so examined or sold.
   (e) In the case of group contracts, the completed disclosure form
and evidence of coverage shall be presented to the contractholder
upon delivery of the completed health care service plan agreement.
   (f) Group contractholders shall disseminate copies of the
completed disclosure form to all persons eligible to be a subscriber
under the group contract at the time those persons are offered the
plan. If the individual group members are offered a choice of plans,
separate disclosure forms shall be supplied for each plan available.
Each group contractholder shall also disseminate or cause to be
disseminated copies of the evidence of coverage to all applicants,
upon request, prior to enrollment and to all subscribers enrolled
under the group contract.
   (g) In the case of conflicts between the group contract and the
evidence of coverage, the provisions of the evidence of coverage
shall be binding upon the plan notwithstanding any provisions in the
group contract that may be less favorable to subscribers or
enrollees.
   (h) In addition to the other disclosures required by this section,
every health care service plan and any agent or employee of the plan
shall, when presenting a plan for examination or sale to any
individual purchaser or the representative of a group consisting of
25 or fewer individuals, disclose in writing the ratio of premium
costs to health services paid for plan contracts with individuals and
with groups of the same or similar size for the plan's preceding
fiscal year. A plan may report that information by geographic area,
provided the plan identifies the geographic area and reports
information applicable to that geographic area.
   (i) Subdivision (b) shall not apply to any coverage provided by a
plan for the Medi-Cal program or the Medicare program pursuant to
Title XVIII and Title XIX of the Social Security Act.



1363.01.  (a) Every plan that covers prescription drug benefits
shall provide notice in the evidence of coverage and disclosure form
to enrollees regarding whether the plan uses a formulary. The notice
shall be in language that is easily understood and in a format that
is easy to understand. The notice shall include an explanation of
what a formulary is, how the plan determines which prescription drugs
are included or excluded, and how often the plan reviews the
contents of the formulary.
   (b) Every plan that covers prescription drug benefits shall
provide to members of the public, upon request, information regarding
whether a specific drug or drugs are on the plan's formulary. Notice
of the opportunity to secure this information from the plan,
including the plan's telephone number for making a request of this
nature, shall be included in the evidence of coverage and disclosure
form to enrollees.
   (c) Every plan shall notify enrollees, and members of the public
who request formulary information, that the presence of a drug on the
plan's formulary does not guarantee that an enrollee will be
prescribed that drug by his or her prescribing provider for a
particular medical condition.
   (d) This section shall become operative July 1, 1999.



1363.02.  (a) The Legislature finds and declares that the right of
every patient to receive basic information necessary to give full and
informed consent is a fundamental tenet of good public health policy
and has long been the established law of this state. Some hospitals
and other providers do not provide a full range of reproductive
health services and may prohibit or otherwise not provide
sterilization, infertility treatments, abortion, or contraceptive
services, including emergency contraception. It is the intent of the
Legislature that every patient be given full and complete information
about the health care services available to allow patients to make
well informed health care decisions.
   (b) On or before July 1, 2001, a health care service plan that
covers hospital, medical, and surgical benefits shall do both of the
following:
   (1) Include the following statement, in at least 12-point boldface
type, at the beginning of each provider directory:

   "Some hospitals and other providers do not provide one or more of
the following services that may be covered under your plan contract
and that you or your family member might need: family planning;
contraceptive services, including emergency contraception;
sterilization, including tubal ligation at the time of labor and
delivery; infertility treatments; or abortion. You should obtain more
information before you enroll. Call your prospective doctor, medical
group, independent practice association, or clinic, or call the
health plan at (insert the health plan's membership services number
or other appropriate number that individuals can call for assistance)
to ensure that you can obtain the health care services that you
need."

   (2) Place the statement described in paragraph (1) in a prominent
location on any provider directory posted on the health plan's
website, if any, and include this statement in a conspicuous place in
the plan's evidence of coverage and disclosure forms.
   (c) A health care service plan shall not be required to provide
the statement described in paragraph (1) of subdivision (b) in a
service area in which none of the hospitals, health facilities,
clinics, medical groups, or independent practice associations with
which it contracts limit or restrict any of the reproductive services
described in the statement.
   (d) This section shall not apply to specialized health care
service plans or Medicare supplement plans.



1363.03.  (a) Every health care service plan that covers
prescription drug benefits and that issues a card to enrollees for
claims processing purposes shall issue to each of its enrollees a
uniform card containing uniform prescription drug information. The
uniform prescription drug information card shall, at a minimum,
include the following information:
   (1) The name or logo of the benefit administrator or health care
service plan issuing the card, which shall be displayed on the front
side of the card.
   (2) The enrollee's identification number, or the subscriber's
identification number when the enrollee is a dependent who accesses
services using the subscriber's identification number, which shall be
displayed on the front side of the card.
   (3) A telephone number that pharmacy providers may call for
assistance.
   (4) Information required by the benefit administrator or health
care service plan that is necessary to commence processing the
pharmacy claim, except as provided for in paragraph (5).
   (5) A health care service plan shall not be required to print any
of the following information on a member card:
   (A) Any number that is the same for all of its members, provided
that the health care service plan provides this number to the
pharmacy on an annual basis.
   (B) Any information that may result in fraudulent use of the card.
   (C) Any information that is otherwise prohibited from being
included on the card.
   (b) Beginning July 1, 2002, the new uniform prescription drug
information card required by subdivision (a) shall be issued by a
health care service plan to an enrollee upon enrollment or upon any
change in the enrollee's coverage that impacts the data content or
format of the card.
   (c) Nothing in this section requires a health care service plan to
issue a separate card for prescription drug coverage if the plan
issues a card for health care coverage in general and the card is
able to accommodate the information required by subdivision (a).
   (d) This bill shall not apply to a nonprofit health care service
plan with at least 3.5 million enrollees that owns or operates its
own pharmacies and that provides health care services to enrollees in
a specific geographic area through a mutually exclusive contract
with a single medical group.
   (e) "Card" as used in this section includes other technology that
performs substantially the same function as a card.
   (f) For purposes of this section, if a health care service plan
delegates responsibility for issuing the uniform prescription drug
information card to a contractor or agent, then the contract between
the health care service plan and its contractor or agent shall
require compliance with this section.



1363.05.  (a) For every plan contract that provides or supplements
Medicare benefits, a plan shall include within its disclosure form
the following statement in at least 12-point type:

   "For additional information concerning covered benefits, contact
the Health Insurance Counseling and Advocacy Program (HICAP) or your
agent. HICAP provides health insurance counseling for California
senior citizens. Call the HICAP toll-free telephone number,
1-800-434-0222, for a referral to your local HICAP office. HICAP is a
service provided free of charge by the State of California."

   (b) For every plan contract that provides or supplements Medicare
benefits, a plan shall modify its disclosure forms to comply with
subdivision (a) no later than January 1, 1998.
   (c) Every health care service plan that provides or supplements
Medicare benefits shall notify those current enrollees who enrolled
prior to the modification of disclosure forms to include the
disclosure statement required by subdivision (a) of the availability
of the HICAP program. That notification shall include the same
language as is required by subdivision (a). That notification may be
by free standing document and shall be made no later than January 1,
1998.



1363.06.  (a) The Department of Managed Health Care and the
Department of Insurance shall compile information as required by this
section and Section 10127.14 of the Insurance Code into two
comparative benefit matrices. The first matrix shall compare benefit
packages offered pursuant to Section 1373.62 and Section 10127.15 of
the Insurance Code. The second matrix shall compare benefit packages
offered pursuant to Sections 1366.35, 1373.6, and 1399.804 and
Sections 10785, 10901.2, and 12682.1 of the Insurance Code.
   (b) The comparative benefit matrix shall include:
   (1) Benefit information submitted by health care service plans
pursuant to subdivision (d) and by health insurers pursuant to
Section 10127.14 of the Insurance Code.
   (2) The following statements in at least 12-point type at the top
of the matrix:
   (A) "This benefit summary is intended to help you compare coverage
and benefits and is a summary only. For a more detailed description
of coverage, benefits, and limitations, please contact the health
care service plan or health insurer."
   (B) "The comparative benefit summary is updated annually, or more
often if necessary to be accurate."
   (C) "The most current version of this comparative benefit summary
is available on (address of the plan's or insurer's site)."
   This subparagraph applies only to those plans or insurers that
maintain an Internet Web site.
   (3) The telephone number or numbers that may be used by an
applicant to contact either the department or the Department of
Insurance, as appropriate, for further assistance.
   (c) The Department of Managed Health Care and the Department of
Insurance shall jointly prepare two standardized templates for use by
health care service plans and health insurers in submitting the
information required pursuant to subdivision (d) and subdivision (d)
of Section 10127.14 of the Insurance Code. The templates shall be
exempt from the provisions of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
   (d) Health care service plans, except specialized health care
service plans, shall submit the following to the department by
January 31, 2003, and annually thereafter:
   (1) A summary explanation of the following for each product
described in subdivision (a).
   (A) Eligibility requirements.
   (B) The full premium cost of each benefit package in the service
area in which the individual and eligible dependents work or reside.
   (C) When and under what circumstances benefits cease.
   (D) The terms under which coverage may be renewed.
   (E) Other coverage that may be available if benefits under the
described benefit package cease.
   (F) The circumstances under which choice in the selection of
physicians and providers is permitted.
   (G) Lifetime and annual maximums.
   (H) Deductibles.
   (2) A summary explanation of coverage for the following, together
with the corresponding copayments and limitations, for each product
described in subdivision (a):
   (A) Professional services.
   (B) Outpatient services.
   (C) Hospitalization services.
   (D) Emergency health coverage.
   (E) Ambulance services.
   (F) Prescription drug coverage.
   (G) Durable medical equipment.
   (H) Mental health services.
   (I) Residential treatment.
   (J) Chemical dependency services.
   (K) Home health services.
   (L) Custodial care and skilled nursing facilities.
   (3) The telephone number or numbers that may be used by an
applicant to access a health care service plan customer service
representative and to request additional information about the plan
contract.
   (4) Any other information specified by the department in the
template.
   (e) Each health care service plan shall provide the department
with updates to the information required by subdivision (d) at least
annually, or more often if necessary to maintain the accuracy of the
information.
   (f) The department and the Department of Insurance shall make the
comparative benefit matrices available on their respective Internet
Web sites and to the health care service plans and health insurers
for dissemination as required by Section 1373.6 and Section 12682.1
of the Insurance Code, after confirming the accuracy of the
description of the matrices with the health care service plans and
health insurers.
   (g) As used in this section and Section 1363.07, "benefit matrix"
shall have the same meaning as benefit summary.



1363.07.  (a) Each health care service plan shall send copies of the
comparative benefit matrix prepared pursuant to Section 1363.06 on
an annual basis, or more frequently as the matrix is updated by the
department and the Department of Insurance, to solicitors and
solicitor firms and employers with whom the plan contracts.
   (b) Each health care service plan shall require its
representatives and solicitors and soliciting firms with which it
contracts, to provide a copy of the comparative benefit matrix to
individuals when presenting any benefit package for examination or
sale.
   (c) Each health care service plan that maintains an Internet Web
site shall make a downloadable copy of the comparative benefit matrix
described in Section 1363.06 available through a link on its site to
the Internet Web sites of the department and the Department of
Insurance.


1363.1.  Any health care service plan that includes terms that
require binding arbitration to settle disputes and that restrict, or
provide for a waiver of, the right to a jury trial shall include, in
clear and understandable language, a disclosure that meets all of the
following conditions:
   (a) The disclosure shall clearly state whether the plan uses
binding arbitration to settle disputes, including specifically
whether the plan uses binding arbitration to settle claims of medical
malpractice.
   (b) The disclosure shall appear as a separate article in the
agreement issued to the employer group or individual subscriber and
shall be prominently displayed on the enrollment form signed by each
subscriber or enrollee.
   (c) The disclosure shall clearly state whether the subscriber or
enrollee is waiving his or her right to a jury trial for medical
malpractice, other disputes relating to the delivery of service under
the plan, or both, and shall be substantially expressed in the
wording provided in subdivision (a) of Section 1295 of the Code of
Civil Procedure.
   (d) In any contract or enrollment agreement for a health care
service plan, the disclosure required by this section shall be
displayed immediately before the signature line provided for the
representative of the group contracting with a health care service
plan and immediately before the signature line provided for the
individual enrolling in the health care service plan.



1363.2.  On or before July 1, 1999, the disclosure form required
pursuant to Section 1363 shall also contain a statement that
enrollees are encouraged to use appropriately the "911" emergency
response system, in areas where the system is established and
operating, when they have an emergency medical condition that
requires an emergency response.



1363.5.  (a) A plan shall disclose or provide for the disclosure to
the director and to network providers the process the plan, its
contracting provider groups, or any entity with which the plan
contracts for services that include utilization review or utilization
management functions, uses to authorize, modify, or deny health care
services under the benefits provided by the plan, including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. A plan shall also disclose those
processes to enrollees or persons designated by an enrollee, or to
any other person or organization, upon request. The disclosure to the
director shall include the policies, procedures, and the description
of the process that are filed with the director pursuant to
subdivision (b) of Section 1367.01.
   (b) The criteria or guidelines used by plans, or any entities with
which plans contract for services that include utilization review or
utilization management functions, to determine whether to authorize,
modify, or deny health care services shall:
   (1) Be developed with involvement from actively practicing health
care providers.
   (2) Be consistent with sound clinical principles and processes.
   (3) Be evaluated, and updated if necessary, at least annually.
   (4) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the enrollee in that specified case.
   (5) Be available to the public upon request. A plan shall only be
required to disclose the criteria or guidelines for the specific
procedures or conditions requested. A plan may charge reasonable fees
to cover administrative expenses related to disclosing criteria or
guidelines pursuant to this paragraph, limited to copying and postage
costs. The plan may also make the criteria or guidelines available
through electronic communication means.
   (c) The disclosure required by paragraph (5) of subdivision (b)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this plan to authorize, modify, or
deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the
benefits covered under your contract."



1364.  Where the director finds it necessary in the interest of full
and fair disclosure, all advertising and other consumer information
disseminated by a plan for the purpose of influencing persons to
become members of a plan shall contain such supplemental disclosure
information as the director may require.



1364.1.  Within 30 days of receiving the notice required by Section
1255.1, a health care service plan shall notify, or provide for the
notification of, enrollees who have selected a medical group or
independent practice association that uses a hospital that the
hospital will reduce or eliminate its emergency services. The plan
may require that its contracting medical groups and independent
practice associations that use the hospital provide this notice. The
notice shall include a list of alternate hospitals that may be used
by enrollees for emergency services.



1364.5.  (a) On or before July 1, 2001, every health care service
plan shall file with the director a copy of their policies and
procedures to protect the security of patient medical information to
ensure compliance with the Confidentiality of Information Act (Part
2.6 (commencing with Section 56) of Division 1 of the Civil Code).
Any amendment to the policies and procedures shall be filed in
accordance with Section 1352.
   (b) On and after July 1, 2001, every health care service plan
shall, upon request, provide to enrollees and subscribers a written
statement that describes how the contracting organization or health
care service plan maintains the confidentiality of medical
information obtained by and in the possession of the contracting
organization or the health care service plan.
   (c) The statement required by subdivision (b) shall be in at least
12-point type and meet the following requirements:
   (1) The statement shall describe how the contracting organization
or health care service plan protects the confidentiality of medical
information pursuant to this article and inform patients or enrollees
and subscribers that any disclosure of medical information beyond
the provisions of the law is prohibited.
   (2) The statement shall describe the types of medical information
that may be collected and the type of sources that may be used to
collect the information, the purposes for which the contracting
organization or plan will obtain medical information from other
health care providers.
   (3) The statement shall describe the circumstances under which
medical information may be disclosed without prior authorization,
pursuant to Section 56.10 of the Civil Code.
   (4) The statement shall describe how patients or enrollees and
subscribers may obtain access to medical information created by and
in the possession of the contracting organization or health care
service plan, including copies of medical information.
   (d) On and after July 1, 2001, every health care service plan
shall include in its evidence of coverage or disclosure form the
following notice, in 12-point type:

   A STATEMENT DESCRIBING (NAME OR PLAN OR "OUR") POLICIES AND
PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS
AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.



1365.  (a) An enrollment or a subscription shall not be canceled or
not renewed except for the following reasons:
   (1) (A) For nonpayment of the required premiums by the individual,
employer, or contractholder if the individual, employer, or
contractholder has been duly notified and billed for the charge and
at least a 30-day grace period has elapsed since the date of
notification or, if longer, the period of time required for notice
and any other requirements pursuant to Section 2703, 2712, or 2742 of
the federal Public Health Service Act (42 U.S.C. Secs. 300gg-2,
300gg-12, and 300gg-42) and any subsequent rules or regulations has
elapsed.
   (B) Pursuant to subparagraph (A), a health care service plan shall
continue to provide coverage as required by the individual's,
employer's, or contractholder's health care service plan contract
during the period described in subparagraph (A).
   (2) The plan demonstrates fraud or an intentional
misrepresentation of material fact under the terms of the health care
service plan contract by the individual contractholder or employer.
   (3) In the case of an individual health care service plan
contract, the individual subscriber no longer resides, lives, or
works in the plan's service area, but only if the coverage is
terminated uniformly without regard to any health status-related
factor of covered individuals.
   (4) In the case of a group health care service plan contract,
violation of a material contract provision relating to employer
contribution or group participation rates by the, contractholder, or
employer.
   (5) If the plan ceases to provide or arrange for the provision of
health benefit for new health care service plan contracts in the
individual or group market, or all markets, in this state, provided,
however, that the following conditions are satisfied:
   (A) Notice of the decision to cease new or existing health benefit
plans in the state is provided to the director and to the individual
or group contractholder or employer, and the enrollees covered under
those contracts, at least 180 days prior to discontinuation of those
contracts.
   (B) Health benefit plans shall not be canceled for 180 days after
the date of the notice required under subparagraph (A) and for that
business of a plan that remains in force, any plan that ceases to
offer for sale new health benefit plans shall continue to be governed
by this section with respect to business conducted under this
section.
   (C) Except as authorized under subdivision (b) of Section 1357.09
and Section 1357.10, a plan that ceases to write new health benefit
plans in the individual or group market, or all markets, in this
state shall be prohibited from offering for sale health benefit plans
in that market or markets in this state for a period of five years
from the date of the discontinuation of the last coverage not so
renewed.
   (6) If the plan withdraws a health benefit plan from the market,
provided that all of the following conditions are satisfied:
   (A) The plan notifies all affected subscribers, contractholders,
employers, and enrollees and the director at least 90 days prior to
the discontinuation of the plan.
   (B) The plan makes available to the individual or group
contractholder or employer all health benefit plans that it makes
available to new individual or group business, respectively.
   (C) In exercising the option to discontinue a health benefit plan
under this paragraph and in offering the option of coverage under
subparagraph (B), the plan acts uniformly without regard to the
claims experience of the individual or contractholder or employer, or
any health-status related factor relating to enrollees or potential
enrollees.
   (D) For small employer health care service plan contracts offered
under Article 3.1 (commencing with Section 1357), the premium for the
new plan contract complies with the renewal increase requirements
set forth in Section 1357.12. This subparagraph shall not apply after
December 31, 2013.
   (7) In the case of a group health benefit plan, if an individual
or employer ceases to be a member of a guaranteed association, as
defined in subdivision (n) of Section 1357, but only if that coverage
is terminated under this paragraph uniformly without regard to any
health status-related factor relating to any enrollee.
   (b) (1) An enrollee or subscriber who alleges that an enrollment
or subscription has been or will be improperly canceled, rescinded,
or not renewed may request a review by the director pursuant to
Section 1368.
   (2) If the director determines that a proper complaint exists, the
director shall notify the plan and the enrollee or subscriber who
requested the review.
   (3) If, after review, the director determines that the
cancellation, rescission, or failure to renew is contrary to existing
law, the director shall order the plan to reinstate the enrollee or
subscriber. Within 15 days after receipt of that order, the health
care service plan shall request a hearing or reinstate the enrollee
or subscriber.
   (4) If an enrollee or subscriber requests a review of the health
care service plan's determination to cancel or rescind or failure to
renew the enrollee's or subscriber's health care service plan
contract pursuant to this section, the health care service plan shall
continue to provide coverage to the enrollee or subscriber under the
terms of the contract until a final determination of the enrollee's
or subscriber's request for review has been made by the director.
This paragraph shall not apply if the health care service plan
cancels or does not renew the enrollee's or subscriber's health care
service plan contract for nonpayment of premiums pursuant to
paragraph (1) of subdivision (a).
   (5) A reinstatement pursuant to this subdivision shall be
retroactive to the time of cancellation, rescission, or failure to
renew and the plan shall be liable for the expenses incurred by the
subscriber or enrollee for covered health care services from the date
of cancellation, rescission, or nonrenewal to and including the date
of reinstatement. The health care service plan shall reimburse the
enrollee or subscriber for any expenses incurred pursuant to this
paragraph within 30 days of receipt of the completed claim.
   (c) This section shall not abrogate any preexisting contracts
entered into prior to the effective date of this chapter between a
subscriber or enrollee and a health care service plan or a
specialized health care service plan including, but not limited to,
the financial liability of the plan, except that each plan shall, if
directed to do so by the director, exercise its authority, if any,
under those preexisting contracts to conform them to the provisions
of existing law.
   (d) As used in this section, "health benefit plan" means any
individual or group insurance policy or health care service plan
contract that provides medical, hospital, and surgical benefits. The
term does not include accident only, credit, or disability income
coverage, coverage of Medicare services pursuant to contracts with
the United States government, Medicare supplement insurance,
long-term care insurance, dental or vision coverage, coverage issued
as a supplement to liability insurance, insurance arising out of
workers' compensation law or similar law, automobile medical payment
insurance, or insurance under which benefits are payable with or
without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
   (e) On or before July 1, 2011, the director may issue guidance to
health care service plans regarding compliance with this section and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code). Any guidance issued
pursuant to this subdivision shall only be effective through December
31, 2013, or until the director adopts and effects regulations
pursuant to the Administrative Procedure Act, whichever occurs first.




1365.5.  (a) No health care service plan or specialized health care
service plan shall refuse to enter into any contract or shall cancel
or decline to renew or reinstate any contract because of the race,
color, national origin, ancestry, religion, sex, marital status,
sexual orientation, or age of any contracting party, prospective
contracting party, or person reasonably expected to benefit from that
contract as a subscriber, enrollee, member, or otherwise.
   (b) The terms of any contract shall not be modified, and the
benefits or coverage of any contract shall not be subject to any
limitations, exceptions, exclusions, reductions, copayments,
coinsurance, deductibles, reservations, or premium, price, or charge
differentials, or other modifications because of the race, color,
national origin, ancestry, religion, sex, marital status, sexual
orientation, or age of any contracting party, potential contracting
party, or person reasonably expected to benefit from that contract as
a subscriber, enrollee, member, or otherwise; except that premium,
price, or charge differentials because of the age of any individual
when based on objective, valid, and up-to-date statistical and
actuarial data are not prohibited.
   (c) It shall be deemed a violation of subdivision (a) for any
health care service plan to utilize marital status, living
arrangements, occupation, sex, beneficiary designation, ZIP Codes or
other territorial classification, or any combination thereof for the
purpose of establishing sexual orientation. Nothing in this section
shall be construed to alter in any manner the existing law
prohibiting health care service plans from conducting tests for the
presence of human immunodeficiency virus or evidence thereof.
   (d) This section shall not be construed to limit the authority of
the director to adopt or enforce regulations prohibiting
discrimination because of sex, marital status, or sexual orientation.
   (e) "Sex" as used in this section shall have the same meaning as
"gender," as defined in Section 422.56 of the Penal Code.
   (f) The changes made to this section by the act adding this
subdivision shall only apply to contracts issued, amended, or renewed
on or after January 1, 2011.


1366.  (a) No plan may use in its name, any of the words "insurance,"
"casualty," "surety," "mutual," or any other words descriptive of
the insurance, casualty, or surety business or use any name similar
to the name or description of any insurance or surety corporation
doing business in this state unless such plan controls or is
controlled by an entity licensed as an insurer pursuant to the
provisions of the Insurance Code and the plan employs a name related
to that of such controlled or controlling entity.
   (b) Section 2415 of the Business and Professions Code, pertaining
to fictitious names, shall not apply to plans, except specialized
health care service plans.
   (c) No plan or solicitor firm may adopt a name style that is
deceptive, or one that could cause the public to believe the plan is
affiliated with, or recommended by any governmental or private entity
unless such affiliation or endorsement exists.



1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families program.
   (c) (1) At least 30 days before a health care service plan files
for modification of its license with the department in order to
withdraw from a county with a population of 500,000 or less, or a
portion of that county, the health care service plan shall hold a
public meeting in the county or portion of the county from which it
intends to withdraw, and shall do all of the following:
   (A) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers, advocates, public officials, and other interested parties.
   (B) Provide notice announcing the public meeting at least 30 days
prior to the public meeting in a newspaper of general circulation
within the affected county or portion of the affected county.
   (C) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (D) Send a summary of the comments received at the public meeting
to the department.
   (E) Send a summary of the comments received at the public meeting
to the Centers for Medicare and Medicaid Services if the modification
would affect Medicare beneficiaries.
   (F) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under subparagraphs (A) and (B).
   (2) A representative of the department shall attend the public
meeting.


1366.1.  (a) The department shall adopt regulations on or before
July 1, 2003, that establish an extended geographic accessibility
standard for access to health care providers served by a health care
service plan in counties with a population of 500,000 or less, and
that, as of January 1, 2002, have two or fewer health care service
plans providing coverage to the entire county in the commercial
market.
   (b) This section shall not apply to specialized health care
service plans or health care service plan contracts that provide
benefits to enrollees through any of the following:
   (1) Preferred provider contracting arrangements.
   (2) The Medi-Cal program.
   (3) The Healthy Families Program.
   (4) The federal Medicare program.
   (c) At least 30 days before a health care service plan files a
notice of material modification of its license with the department to
withdraw from a county with a population of 500,000 or less, the
health care service plan shall hold a public meeting in the county
from which it is intending to withdraw, and shall do all of the
following:
   (1) Provide notice announcing the public meeting at least 30 days
prior to the public meeting to all affected enrollees, health care
providers with which it contracts, the members of the board of
supervisors of the affected county, the members of the city councils
of cities in the affected county, and members of the Legislature who
represent the affected county.
   (2) Provide notice announcing the public meeting at least 15 days
prior to the public meeting in a newspaper of general circulation
within the affected county.
   (3) At the public meeting, allow testimony, which may be limited
to a certain length of time by the health care service plan, of all
interested parties.
   (4) File with the department for review, no less than 30 days
prior to the date of mailing or publication, the notices required
under paragraphs (1) and (2).
   (d) The department may require a health care service plan that has
filed to withdraw from a portion of a county with a population of
less than 500,000, to hold a hearing for affected enrollees.
   (e) A representative of the department shall attend the public
meeting described in this section.


1366.2.  (a) A full health care service plan shall make available to
a group subscriber, upon request, the termination date of all major
health care provider contracts that are for services in the
geographic area for which the group subscriber has secured coverage
and that include a specified termination date.
   (b) For purposes of this section, the following terms have the
following meanings:
   (1) "Enrollee" means a person who is enrolled in a health care
service plan and who is a recipient of services from the plan.
   (2) "Full health care service plan" means a plan that meets the
definition set forth in subdivision (f) of Section 1345, and that has
a total enrolled membership exceeding 499,999 enrollees.
   (3) "Hospital" means a general acute care hospital.
   (4) "Major health care provider contract" means a contract between
a full service plan and provider group or hospital covering more
than 25,000 of that plan's enrollees. "Major health care provider
contract" does not mean a provider contract between a specialized
health care service plan and a provider group or hospital.
   (5) "Provider group" means a medical group, independent practice
association, or other similar group of providers with a total
enrolled membership exceeding 99,999 enrollees.




1366.3.  (a) On and after January 1, 2005, a health care service
plan issuing individual plan contracts that ceases to offer
individual coverage in this state shall offer coverage to the
subscribers who had been covered by those contracts at the time of
withdrawal under the same terms and conditions as provided in
paragraph (3) of subdivision (a), paragraphs (2) to (4), inclusive,
of subdivision (b), subdivisions (c) to (e), inclusive, and
subdivision (h) of Section 1373.6.
   (b) A health care service plan that ceases to offer individual
coverage in a service area shall offer the coverage required by
subdivision (a) to subscribers who had been covered by those
contracts at the time of withdrawal, if the plan continues to offer
group coverage in that service area. This subdivision shall not apply
to coverage provided pursuant to a preferred provider organization.
   (c) The department may adopt regulations to implement this
section.
   (d) This section shall not apply when a plan participating in
Medi-Cal, Healthy Families, Access for Infants and Mothers, or any
other contract between the plan and a government entity no longer
contracts with the government entity to provide health coverage in
the state, or a specified area of the state, nor shall this section
apply when a plan ceases entirely to market, offer, and issue any and
all forms of coverage in any part of this state after the effective
date of this section.



1366.4.  (a) A medical group, physician, or independent practice
association that contracts with a health care service plan may enter
into contracts with licensed nonphysician providers to provide
services, as defined in Section 1300.67(a)(1) of Title 28 of the
California Code of Regulations, to plan enrollees covered by the
contract between the plan and the group, physician, or association.
   (b) The licensed nonphysician provider described in subdivision
(a) that contracts with a medical group, physician, or independent
practice association may directly bill, if direct billing is
otherwise permitted by law, a health care service plan for covered
services pursuant to a contract with the health care service plan
that specifies direct billing. Direct billing pursuant to this
subdivision is permitted only to the extent that the same services
are not billed for by the medical group, physician, or independent
practice association.
   (c) A health care service plan may require the nonphysician
provider to complete an appropriate credentialing process.
   (d) Every health care service plan may either list licensed
nonphysician providers that contract with medical groups, physicians,
and independent practice associations pursuant to subdivision (b) in
any listing or directory of plan health care providers that is
provided to enrollees or to the public, or may include a notification
in the plan's evidence of coverage or provider list that the health
care service plan has contracts with nonphysician providers, pursuant
to subdivision (b), and may list the types of contracted
nonphysician providers. The notification may inform an enrollee that
he or she may obtain a list of the nonphysician providers by
contacting his or her primary or specialist medical group. The
listing may indicate whether licensed nonphysician providers may be
accessed directly by enrollees.
   (e) Nothing in this section shall be construed to authorize, or
otherwise require the director to approve, a risk-sharing arrangement
between a plan and a provider.