SECTIONS 1367-1374.195 - California Statutes

HEALTH AND SAFETY CODE

SECTION 1367-1374.195

1367. A health care service plan and, if applicable, a specialized
health care service plan shall meet the following requirements:
(a) Facilities located in this state including, but not limited
to, clinics, hospitals, and skilled nursing facilities to be utilized
by the plan shall be licensed by the State Department of Health
Services, where licensure is required by law. Facilities not located
in this state shall conform to all licensing and other requirements
of the jurisdiction in which they are located.
(b) Personnel employed by or under contract to the plan shall be
licensed or certified by their respective board or agency, where
licensure or certification is required by law.
(c) Equipment required to be licensed or registered by law shall
be so licensed or registered, and the operating personnel for that
equipment shall be licensed or certified as required by law.
(d) The plan shall furnish services in a manner providing
continuity of care and ready referral of patients to other providers
at times as may be appropriate consistent with good professional
practice.
(e) (1) All services shall be readily available at reasonable
times to each enrollee consistent with good professional practice. To
the extent feasible, the plan shall make all services readily
accessible to all enrollees consistent with Section 1367.03.
(2) To the extent that telemedicine services are appropriately
provided through telemedicine, as defined in subdivision (a) of
Section 2290.5 of the Business and Professions Code, these services
shall be considered in determining compliance with Section 1300.67.2
of Title 28 of the California Code of Regulations.
(3) The plan shall make all services accessible and appropriate
consistent with Section 1367.04.
(f) The plan shall employ and utilize allied health manpower for
the furnishing of services to the extent permitted by law and
consistent with good medical practice.
(g) The plan shall have the organizational and administrative
capacity to provide services to subscribers and enrollees. The plan
shall be able to demonstrate to the department that medical decisions
are rendered by qualified medical providers, unhindered by fiscal
and administrative management.
(h) (1) Contracts with subscribers and enrollees, including group
contracts, and contracts with providers, and other persons furnishing
services, equipment, or facilities to or in connection with the
plan, shall be fair, reasonable, and consistent with the objectives
of this chapter. All contracts with providers shall contain
provisions requiring a fast, fair, and cost-effective dispute
resolution mechanism under which providers may submit disputes to the
plan, and requiring the plan to inform its providers upon
contracting with the plan, or upon change to these provisions, of the
procedures for processing and resolving disputes, including the
location and telephone number where information regarding disputes
may be submitted.
(2) A health care service plan shall ensure that a dispute
resolution mechanism is accessible to noncontracting providers for
the purpose of resolving billing and claims disputes.
(3) On and after January 1, 2002, a health care service plan shall
annually submit a report to the department regarding its dispute
resolution mechanism. The report shall include information on the
number of providers who utilized the dispute resolution mechanism and
a summary of the disposition of those disputes.
(i) A health care service plan contract shall provide to
subscribers and enrollees all of the basic health care services
included in subdivision (b) of Section 1345, except that the director
may, for good cause, by rule or order exempt a plan contract or any
class of plan contracts from that requirement. The director shall by
rule define the scope of each basic health care service that health
care service plans are required to provide as a minimum for licensure
under this chapter. Nothing in this chapter shall prohibit a health
care service plan from charging subscribers or enrollees a copayment
or a deductible for a basic health care service or from setting
forth, by contract, limitations on maximum coverage of basic health
care services, provided that the copayments, deductibles, or
limitations are reported to, and held unobjectionable by, the
director and set forth to the subscriber or enrollee pursuant to the
disclosure provisions of Section 1363.
(j) A health care service plan shall not require registration
under the Controlled Substances Act of 1970 (21 U.S.C. Sec. 801 et
seq.) as a condition for participation by an optometrist certified to
use therapeutic pharmaceutical agents pursuant to Section 3041.3 of
the Business and Professions Code.
Nothing in this section shall be construed to permit the director
to establish the rates charged subscribers and enrollees for
contractual health care services.
The director's enforcement of Article 3.1 (commencing with Section
1357) shall not be deemed to establish the rates charged subscribers
and enrollees for contractual health care services.
The obligation of the plan to comply with this section shall not
be waived when the plan delegates any services that it is required to
perform to its medical groups, independent practice associations, or
other contracting entities.

1367.002. To the extent required by federal law, a group or
individual health care service plan contract issued, amended,
renewed, or delivered on or after September 23, 2010, shall comply
with Section 2713 of the federal Public Health Service Act (42 U.S.C.
Sec. 300gg-13) and any rules or regulations issued under that
section.

1367.01. (a) A health care service plan and any entity with which
it contracts for services that include utilization review or
utilization management functions, that prospectively,
retrospectively, or concurrently reviews and approves, modifies,
delays, or denies, based in whole or in part on medical necessity,
requests by providers prior to, retrospectively, or concurrent with
the provision of health care services to enrollees, or that delegates
these functions to medical groups or independent practice
associations or to other contracting providers, shall comply with
this section.
(b) A health care service plan that is subject to this section
shall have written policies and procedures establishing the process
by which the plan prospectively, retrospectively, or concurrently
reviews and approves, modifies, delays, or denies, based in whole or
in part on medical necessity, requests by providers of health care
services for plan enrollees. These policies and procedures shall
ensure that decisions based on the medical necessity of proposed
health care services are consistent with criteria or guidelines that
are supported by clinical principles and processes. These criteria
and guidelines shall be developed pursuant to Section 1363.5. These
policies and procedures, and a description of the process by which
the plan reviews and approves, modifies, delays, or denies requests
by providers prior to, retrospectively, or concurrent with the
provision of health care services to enrollees, shall be filed with
the director for review and approval, and shall be disclosed by the
plan to providers and enrollees upon request, and by the plan to the
public upon request.
(c) A health care service plan subject to this section, except a
plan that meets the requirements of Section 1351.2, shall employ or
designate a medical director who holds an unrestricted license to
practice medicine in this state issued pursuant to Section 2050 of
the Business and Professions Code or pursuant to the Osteopathic Act,
or, if the plan is a specialized health care service plan, a
clinical director with California licensure in a clinical area
appropriate to the type of care provided by the specialized health
care service plan. The medical director or clinical director shall
ensure that the process by which the plan reviews and approves,
modifies, or denies, based in whole or in part on medical necessity,
requests by providers prior to, retrospectively, or concurrent with
the provision of health care services to enrollees, complies with the
requirements of this section.
(d) If health plan personnel, or individuals under contract to the
plan to review requests by providers, approve the provider's
request, pursuant to subdivision (b), the decision shall be
communicated to the provider pursuant to subdivision (h).
(e) No individual, other than a licensed physician or a licensed
health care professional who is competent to evaluate the specific
clinical issues involved in the health care services requested by the
provider, may deny or modify requests for authorization of health
care services for an enrollee for reasons of medical necessity. The
decision of the physician or other health care professional shall be
communicated to the provider and the enrollee pursuant to subdivision
(h).
(f) The criteria or guidelines used by the health care service
plan to determine whether to approve, modify, or deny requests by
providers prior to, retrospectively, or concurrent with, the
provision of health care services to enrollees shall be consistent
with clinical principles and processes. These criteria and guidelines
shall be developed pursuant to the requirements of Section 1363.5.
(g) If the health care service plan requests medical information
from providers in order to determine whether to approve, modify, or
deny requests for authorization, the plan shall request only the
information reasonably necessary to make the determination.
(h) In determining whether to approve, modify, or deny requests by
providers prior to, retrospectively, or concurrent with the
provision of health care services to enrollees, based in whole or in
part on medical necessity, a health care service plan subject to this
section shall meet the following requirements:
(1) Decisions to approve, modify, or deny, based on medical
necessity, requests by providers prior to, or concurrent with the
provision of health care services to enrollees that do not meet the
requirements for the time period for review required by paragraph
(2), shall be made in a timely fashion appropriate for the nature of
the enrollee's condition, not to exceed five business days from the
plan's receipt of the information reasonably necessary and requested
by the plan to make the determination. In cases where the review is
retrospective, the decision shall be communicated to the individual
who received services, or to the individual's designee, within 30
days of the receipt of information that is reasonably necessary to
make this determination, and shall be communicated to the provider in
a manner that is consistent with current law. For purposes of this
section, retrospective reviews shall be for care rendered on or after
January 1, 2000.
(2) When the enrollee's condition is such that the enrollee faces
an imminent and serious threat to his or her health, including, but
not limited to, the potential loss of life, limb, or other major
bodily function, or the normal timeframe for the decisionmaking
process, as described in paragraph (1), would be detrimental to the
enrollee's life or health or could jeopardize the enrollee's ability
to regain maximum function, decisions to approve, modify, or deny
requests by providers prior to, or concurrent with, the provision of
health care services to enrollees, shall be made in a timely fashion
appropriate for the nature of the enrollee's condition, not to exceed
72 hours or, if shorter, the period of time required under Section
2719 of the federal Public Health Service Act (42 U.S.C. Sec.
300gg-19) and any subsequent rules or regulations issued thereunder,
after the plan's receipt of the information reasonably necessary and
requested by the plan to make the determination. Nothing in this
section shall be construed to alter the requirements of subdivision
(b) of Section 1371.4. Notwithstanding Section 1371.4, the
requirements of this division shall be applicable to all health plans
and other entities conducting utilization review or utilization
management.
(3) Decisions to approve, modify, or deny requests by providers
for authorization prior to, or concurrent with, the provision of
health care services to enrollees shall be communicated to the
requesting provider within 24 hours of the decision. Except for
concurrent review decisions pertaining to care that is underway,
which shall be communicated to the enrollee's treating provider
within 24 hours, decisions resulting in denial, delay, or
modification of all or part of the requested health care service
shall be communicated to the enrollee in writing within two business
days of the decision. In the case of concurrent review, care shall
not be discontinued until the enrollee's treating provider has been
notified of the plan's decision and a care plan has been agreed upon
by the treating provider that is appropriate for the medical needs of
that patient.
(4) Communications regarding decisions to approve requests by
providers prior to, retrospectively, or concurrent with the provision
of health care services to enrollees shall specify the specific
health care service approved. Responses regarding decisions to deny,
delay, or modify health care services requested by providers prior
to, retrospectively, or concurrent with the provision of health care
services to enrollees shall be communicated to the enrollee in
writing, and to providers initially by telephone or facsimile, except
with regard to decisions rendered retrospectively, and then in
writing, and shall include a clear and concise explanation of the
reasons for the plan's decision, a description of the criteria or
guidelines used, and the clinical reasons for the decisions regarding
medical necessity. Any written communication to a physician or other
health care provider of a denial, delay, or modification of a
request shall include the name and telephone number of the health
care professional responsible for the denial, delay, or modification.
The telephone number provided shall be a direct number or an
extension, to allow the physician or health care provider easily to
contact the professional responsible for the denial, delay, or
modification. Responses shall also include information as to how the
enrollee may file a grievance with the plan pursuant to Section 1368,
and in the case of Medi-Cal enrollees, shall explain how to request
an administrative hearing and aid paid pending under Sections 51014.1
and 51014.2 of Title 22 of the California Code of Regulations.
(5) If the health care service plan cannot make a decision to
approve, modify, or deny the request for authorization within the
timeframes specified in paragraph (1) or (2) because the plan is not
in receipt of all of the information reasonably necessary and
requested, or because the plan requires consultation by an expert
reviewer, or because the plan has asked that an additional
examination or test be performed upon the enrollee, provided the
examination or test is reasonable and consistent with good medical
practice, the plan shall, immediately upon the expiration of the
timeframe specified in paragraph (1) or (2) or as soon as the plan
becomes aware that it will not meet the timeframe, whichever occurs
first, notify the provider and the enrollee, in writing, that the
plan cannot make a decision to approve, modify, or deny the request
for authorization within the required timeframe, and specify the
information requested but not received, or the expert reviewer to be
consulted, or the additional examinations or tests required. The plan
shall also notify the provider and enrollee of the anticipated date
on which a decision may be rendered. Upon receipt of all information
reasonably necessary and requested by the plan, the plan shall
approve, modify, or deny the request for authorization within the
timeframes specified in paragraph (1) or (2), whichever applies.
(6) If the director determines that a health care service plan has
failed to meet any of the timeframes in this section, or has failed
to meet any other requirement of this section, the director may
assess, by order, administrative penalties for each failure. A
proceeding for the issuance of an order assessing administrative
penalties shall be subject to appropriate notice to, and an
opportunity for a hearing with regard to, the person affected, in
accordance with subdivision (a) of Section 1397. The administrative
penalties shall not be deemed an exclusive remedy for the director.
These penalties shall be paid to the Managed Care Administrative
Fines and Penalties Fund and shall be used for the purposes specified
in Section 1341.45.
(i) A health care service plan subject to this section shall
maintain telephone access for providers to request authorization for
health care services.
(j) A health care service plan subject to this section that
reviews requests by providers prior to, retrospectively, or
concurrent with, the provision of health care services to enrollees
shall establish, as part of the quality assurance program required by
Section 1370, a process by which the plan's compliance with this
section is assessed and evaluated. The process shall include
provisions for evaluation of complaints, assessment of trends,
implementation of actions to correct identified problems, mechanisms
to communicate actions and results to the appropriate health plan
employees and contracting providers, and provisions for evaluation of
any corrective action plan and measurements of performance.
(k) The director shall review a health care service plan's
compliance with this section as part of its periodic onsite medical
survey of each plan undertaken pursuant to Section 1380, and shall
include a discussion of compliance with this section as part of its
report issued pursuant to that section.
(l) This section shall not apply to decisions made for the care or
treatment of the sick who depend upon prayer or spiritual means for
healing in the practice of religion as set forth in subdivision (a)
of Section 1270.
(m) Nothing in this section shall cause a health care service plan
to be defined as a health care provider for purposes of any
provision of law, including, but not limited to, Section 6146 of the
Business and Professions Code, Sections 3333.1 and 3333.2 of the
Civil Code, and Sections 340.5, 364, 425.13, 667.7, and 1295 of the
Code of Civil Procedure.

1367.015. In addition to complying with subdivision (h) of Section
1367.01, in determining whether to approve, modify, or deny requests
by providers prior to, retrospectively, or concurrent with the
provision of health care services to enrollees, based in whole or in
part on medical necessity, a health care service plan subject to
Section 1367.01 shall not base decisions to deny requests by
providers for authorization for mental health services or to deny
claim reimbursement for mental health services on either of the
following:
(a) Whether admission was voluntary or involuntary.
(b) The method of transportation to the health facility.

1367.02. (a) On or before July 1, 1999, for purposes of public
disclosure, every health care service plan shall file with the
department a description of any policies and procedures related to
economic profiling utilized by the plan and its medical groups and
individual practice associations. The filing shall describe how these
policies and procedures are used in utilization review, peer review,
incentive and penalty programs, and in provider retention and
termination decisions. The filing shall also indicate in what manner,
if any, the economic profiling system being used takes into
consideration risk adjustments that reflect case mix, type and
severity of patient illness, age of patients, and other enrollee
characteristics that may account for higher or lower than expected
costs or utilization of services. The filing shall also indicate how
the economic profiling activities avoid being in conflict with
subdivision (g) of Section 1367, which requires each plan to
demonstrate that medical decisions are rendered by qualified medical
providers, unhindered by fiscal and administrative management. Any
changes to the policies and procedures shall be filed with the
director pursuant to Section 1352. Nothing in this section shall be
construed to restrict or impair the department, in its discretion,
from utilizing the information filed pursuant to this section for
purposes of ensuring compliance with this chapter.
(b) The director shall make each plan's filing available to the
public upon request. The director shall not publicly disclose any
information submitted pursuant to this section that is determined by
the director to be confidential pursuant to state law.
(c) Each plan that uses economic profiling shall, upon request,
provide a copy of economic profiling information related to an
individual provider, contracting medical group, or individual
practice association to the profiled individual, group, or
association. In addition, each plan shall require as a condition of
contract that its medical groups and individual practice associations
that maintain economic profiles of individual providers shall, upon
request, provide a copy of individual economic profiling information
to the individual providers who are profiled. The economic profiling
information provided pursuant to this section shall be provided upon
request until 60 days after the date upon which the contract between
the plan and the individual provider, medical group, or individual
practice association terminates, or until 60 days after the date the
contract between the medical group or individual practice association
and the individual provider terminates, whichever is applicable.
(d) For the purposes of this article, "economic profiling" shall
mean any evaluation of a particular physician, provider, medical
group, or individual practice association based in whole or in part
on the economic costs or utilization of services associated with
medical care provided or authorized by the physician, provider,
medical group, or individual practice association.

1367.03. (a) Not later than January 1, 2004, the department shall
develop and adopt regulations to ensure that enrollees have access to
needed health care services in a timely manner. In developing these
regulations, the department shall develop indicators of timeliness of
access to care and, in so doing, shall consider the following as
indicators of timeliness of access to care:
(1) Waiting times for appointments with physicians, including
primary care and specialty physicians.
(2) Timeliness of care in an episode of illness, including the
timeliness of referrals and obtaining other services, if needed.
(3) Waiting time to speak to a physician, registered nurse, or
other qualified health professional acting within his or her scope of
practice who is trained to screen or triage an enrollee who may need
care.
(b) In developing these standards for timeliness of access, the
department shall consider the following:
(1) Clinical appropriateness.
(2) The nature of the specialty.
(3) The urgency of care.
(4) The requirements of other provisions of law, including Section
1367.01 governing utilization review, that may affect timeliness of
access.
(c) The department may adopt standards other than the time elapsed
between the time an enrollee seeks health care and obtains care. If
the department chooses a standard other than the time elapsed between
the time an enrollee first seeks health care and obtains it, the
department shall demonstrate why that standard is more appropriate.
In developing these standards, the department shall consider the
nature of the plan network.
(d) The department shall review and adopt standards, as needed,
concerning the availability of primary care physicians, specialty
physicians, hospital care, and other health care, so that consumers
have timely access to care. In so doing, the department shall
consider the nature of physician practices, including individual and
group practices as well as the nature of the plan network. The
department shall also consider various circumstances affecting the
delivery of care, including urgent care, care provided on the same
day, and requests for specific providers. If the department finds
that health care service plans and health care providers have
difficulty meeting these standards, the department may make
recommendations to the Assembly Committee on Health and the Senate
Committee on Insurance of the Legislature pursuant to subdivision
(i).
(e) In developing standards under subdivision (a), the department
shall consider requirements under federal law, requirements under
other state programs, standards adopted by other states, nationally
recognized accrediting organizations, and professional associations.
The department shall further consider the needs of rural areas,
specifically those in which health facilities are more than 30 miles
apart and any requirements imposed by the State Department of Health
Care Services on health care service plans that contract with the
State Department of Health Care Services to provide Medi-Cal managed
care.
(f) (1) Contracts between health care service plans and health
care providers shall assure compliance with the standards developed
under this section. These contracts shall require reporting by health
care providers to health care service plans and by health care
service plans to the department to ensure compliance with the
standards.
(2) Health care service plans shall report annually to the
department on compliance with the standards in a manner specified by
the department. The reported information shall allow consumers to
compare the performance of plans and their contracting providers in
complying with the standards, as well as changes in the compliance of
plans with these standards.
(g) (1) When evaluating compliance with the standards, the
department shall focus more upon patterns of noncompliance rather
than isolated episodes of noncompliance.
(2) The director may investigate and take enforcement action
against plans regarding noncompliance with the requirements of this
section. Where substantial harm to an enrollee has occurred as a
result of plan noncompliance, the director may, by order, assess
administrative penalties subject to appropriate notice of, and the
opportunity for, a hearing in accordance with Section 1397. The plan
may provide to the director, and the director may consider,
information regarding the plan's overall compliance with the
requirements of this section. The administrative penalties shall not
be deemed an exclusive remedy available to the director. These
penalties shall be paid to the Managed Care Administrative Fines and
Penalties Fund and shall be used for the purposes specified in
Section 1341.45. The director shall periodically evaluate grievances
to determine if any audit, investigative, or enforcement actions
should be undertaken by the department.
(3) The director may, after appropriate notice and opportunity for
hearing in accordance with Section 1397, by order, assess
administrative penalties if the director determines that a health
care service plan has knowingly committed, or has performed with a
frequency that indicates a general business practice, either of the
following:
(A) Repeated failure to act promptly and reasonably to assure
timely access to care consistent with this chapter.
(B) Repeated failure to act promptly and reasonably to require
contracting providers to assure timely access that the plan is
required to perform under this chapter and that have been delegated
by the plan to the contracting provider when the obligation of the
plan to the enrollee or subscriber is reasonably clear.
(C) The administrative penalties available to the director
pursuant to this section are not exclusive, and may be sought and
employed in any combination with civil, criminal, and other
administrative remedies deemed warranted by the director to enforce
this chapter.
(4) The administrative penalties shall be paid to the Managed Care
Administrative Fines and Penalties Fund and shall be used for the
purposes specified in Section 1341.45.
(h) The department shall work with the patient advocate to assure
that the quality of care report card incorporates information
provided pursuant to subdivision (f) regarding the degree to which
health care service plans and health care providers comply with the
requirements for timely access to care.
(i) The department shall report to the Assembly Committee on
Health and the Senate Committee on Insurance of the Legislature on
March 1, 2003, and on March 1, 2004, regarding the progress toward
the implementation of this section.
(j) Every three years, the department shall review information
regarding compliance with the standards developed under this section
and shall make recommendations for changes that further protect
enrollees.

1367.04. (a) Not later than January 1, 2006, the department shall
develop and adopt regulations establishing standards and requirements
to provide health care service plan enrollees with appropriate
access to language assistance in obtaining health care services.
(b) In developing the regulations, the department shall require
every health care service plan and specialized health care service
plan to assess the linguistic needs of the enrollee population,
excluding Medi-Cal enrollees, and to provide for translation and
interpretation for medical services, as indicated. A health care
service plan that participates in the Healthy Families Program may
assess the Healthy Families Program enrollee population separately
from the remainder of its enrollee population for purposes of
subparagraph (A) of paragraph (1). A health care service plan that
chooses to separate its Healthy Families Program enrollment from the
remainder of its enrollee population shall treat the Healthy Families
Program population separately for purposes of determining whether
subparagraph (A) of paragraph (1) is applicable, and shall also treat
the Healthy Families Program population separately for purposes of
applying the percentage and numerical thresholds in subparagraph (A)
of paragraph (1). The regulations shall include the following:
(1) Requirements for the translation of vital documents that
include the following:
(A) A requirement that all vital documents, as defined pursuant to
subparagraph (B), be translated into an indicated language, as
follows:
(i) A health care service plan with an enrollment of 1,000,000 or
more shall translate vital documents into the top two languages other
than English as determined by the needs assessment as required by
this subdivision and any additional languages when 0.75 percent or
15,000 of the enrollee population, whichever number is less,
excluding Medi-Cal enrollment and treating Healthy Families Program
enrollment separately indicates in the needs assessment as required
by this subdivision a preference for written materials in that
language.
(ii) A health care service plan with an enrollment of 300,000 or
more but less than 1,000,000 shall translate vital documents into the
top one language other than English as determined by the needs
assessment as required by this subdivision and any additional
languages when 1 percent or 6,000 of the enrollee population,
whichever number is less, excluding Medi-Cal enrollment and treating
Healthy Families Program enrollment separately indicates in the needs
assessment as required by this subdivision a preference for written
materials in that language.
(iii) A health care service plan with an enrollment of less than
300,000 shall translate vital documents into a language other than
English when 3,000 or more or 5 percent of the enrollee population,
whichever number is less, excluding Medi-Cal enrollment and treating
Healthy Families Program enrollment separately indicates in the needs
assessment as required by this subdivision a preference for written
materials in that language.
(B) Specification of vital documents produced by the plan that are
required to be translated. The specification of vital documents
shall not exceed that of the Department of Health and Human Services
(HHS) Office of Civil Rights (OCR) Policy Guidance (65 Federal
Register 52762 (August 30, 2000)), but shall include all of the
following:
(i) Applications.
(ii) Consent forms.
(iii) Letters containing important information regarding
eligibility and participation criteria.
(iv) Notices pertaining to the denial, reduction, modification, or
termination of services and benefits, and the right to file a
grievance or appeal.
(v) Notices advising limited-English-proficient persons of the
availability of free language assistance and other outreach materials
that are provided to enrollees.
(vi) Translated documents shall not include a health care service
plan's explanation of benefits or similar claim processing
information that is sent to enrollees, unless the document requires a
response by the enrollee.
(C) (i) For those documents described in subparagraph (B) that are
not standardized but contain enrollee specific information, health
care service plans shall not be required to translate the documents
into the threshold languages identified by the needs assessment as
required by this subdivision, but rather shall include with the
documents a written notice of the availability of interpretation
services in the threshold languages identified by the needs
assessment as required by this subdivision.
(ii) Upon request, the enrollee shall receive a written
translation of the documents described in clause (i). The health care
service plan shall have up to, but not to exceed, 21 days to comply
with the enrollee's request for a written translation. If an enrollee
requests a translated document, all timeframes and deadline
requirements related to the document that apply to the health care
service plan and enrollees under the provisions of this chapter and
under any regulations adopted pursuant to this chapter shall begin to
run upon the health care service plan's issuance of the translated
document.
(iii) For grievances that require expedited plan review and
response in accordance with subdivision (b) of Section 1368.01, the
health care service plan may satisfy this requirement by providing
notice of the availability and access to oral interpretation
services.
(D) A requirement that health care service plans advise
limited-English-proficient enrollees of the availability of
interpreter services.
(2) Standards to ensure the quality and accuracy of the written
translations and that a translated document meets the same standards
required for the English language version of the document. The
English language documents shall determine the rights and obligations
of the parties, and the translated documents shall be admissible in
evidence only if there is a dispute regarding a substantial
difference in the material terms and conditions of the English
language document and the translated document.
(3) Requirements for surveying the language preferences and needs
assessments of health care service plan enrollees within one year of
the effective date of the regulations that permit health care service
plans to utilize various survey methods, including, but not limited
to, the use of existing enrollment and renewal processes, subscriber
newsletters, or other mailings. Health care service plans shall
update the needs assessment, demographic profile, and language
translation requirements every three years.
(4) Requirements for individual enrollee access to interpretation
services.
(5) Standards to ensure the quality and timeliness of oral
interpretation services provided by health care service plans.
(c) In developing the regulations, standards, and requirements,
the department shall consider the following:
(1) Publications and standards issued by federal agencies, such as
the Culturally and Linguistically Appropriate Services (CLAS) in
Health Care issued by the United States Department of Health and
Human Services Office of Minority Health in December 2000, and the
Department of Health and Human Services (HHS) Office of Civil Rights
(OCR) Policy Guidance (65 Federal Register 52762 (August 30, 2000)).
(2) Other cultural and linguistic requirements under state
programs, such as Medi-Cal Managed Care Policy Letters, cultural and
linguistic requirements imposed by the State Department of Health
Services on health care service plans that contract to provide
Medi-Cal managed care services, and cultural and linguistic
requirements imposed by the Managed Risk Medical Insurance Board on
health care service plans that contract to provide services in the
Healthy Families Program.
(3) Standards adopted by other states pertaining to language
assistance requirements for health care service plans.
(4) Standards established by California or nationally recognized
accrediting, certifying, or licensing organizations and medical and
health care interpreter professional associations regarding
interpretation services.
(5) Publications, guidelines, reports, and recommendations issued
by state agencies or advisory committees, such as the report card to
the public on the comparative performance of plans and reports on
cultural and linguistic services issued by the Office of Patient
Advocate and the report to the Legislature from the Task Force on
Culturally and Linguistically Competent Physicians and Dentists
established by Section 852 of the Business and Professions Code.
(6) Examples of best practices relating to language assistance
services by health care providers and health care service plans,
including existing practices.
(7) Information gathered from complaints to the HMO Helpline and
consumer assistance centers regarding language assistance services.
(8) The cost of compliance and the availability of translation and
interpretation services and professionals.
(9) Flexibility to accommodate variations in plan networks and
method of service delivery. The department shall allow for health
care service plan flexibility in determining compliance with the
standards for oral and written interpretation services.
(d) The department shall work to ensure that the biennial reports
required by this section, and the data collected for those reports,
are consistent with reports required by government-sponsored programs
and do not require duplicative or conflicting data collection or
reporting.
(e) The department shall seek public input from a wide range of
interested parties through advisory bodies established by the
director.
(f) A contract between a health care service plan and a health
care provider shall require compliance with the standards developed
under this section. In furtherance of this section, the contract
shall require providers to cooperate with the plan by providing any
information necessary to assess compliance.
(g) The department shall report biennially to the Legislature and
advisory bodies established by the director regarding plan compliance
with the standards, including results of compliance audits made in
conjunction with other audits and reviews. The reported information
shall also be included in the publication required under subparagraph
(B) of paragraph (3) of subdivision (c) of Section 1368.02. The
department shall also utilize the reported information to make
recommendations for changes that further enhance standards pursuant
to this section. The department may also delay or otherwise phase-in
implementation of standards and requirements in recognition of costs
and availability of translation and interpretation services and
professionals.
(h) (1) Except for contracts with the State Department of Health
Services Medi-Cal program, the standards developed under this section
shall be considered the minimum required for compliance.
(2) The regulations shall provide that a health plan is in
compliance if the plan is required to meet the same or similar
standards by the Medi-Cal program, either by contract or state law,
if the standards provide as much access to cultural and linguistic
services as the standards established by this section for an equal or
higher number of enrollees and therefore meet or exceed the
standards of the regulations established pursuant to this section,
and the department determines that the health care service plan is in
compliance with the standards required by the Medi-Cal program. To
meet this requirement, the department shall not be required to
perform individual audits. The department shall, to the extent
feasible, rely on audits, reports, or other oversight and enforcement
methods used by the State Department of Health Services.
(3) The determination pursuant to paragraph (2) shall only apply
to the enrollees covered by the Medi-Cal program standards. A health
care service plan subject to paragraph (2) shall comply with the
standards established by this section with regard to enrollees not
covered by the Medi-Cal program.
(i) Nothing in this section shall prohibit a government purchaser
from including in their contracts additional translation or
interpretation requirements, to meet linguistic or cultural needs,
beyond those set forth pursuant to this section.

1367.05. (a) Nothing in this chapter shall prohibit a health care
service plan from entering into a contract with a dental college
approved by the Board of Dental Examiners of California under which
the dental college provides for or arranges for the provision of
dental care to enrollees of the plan through the practice of
dentistry by either of the following:
(1) Bona fide students of dentistry or dental hygiene operating
under subdivision (b) of Section 1626 of the Business and Professions
Code.
(2) Bona fide clinicians or instructors operating under
subdivision (c) of Section 1626 of the Business and Professions Code.
(b) A plan that contracts with a dental college for the delivery
of dental care pursuant to subdivision (a) shall disclose to
enrollees in the disclosure form and the evidence of coverage, or the
combined evidence of coverage and disclosure form, and, if the plan
provides a listing of providers to the enrollees, in the listing of
providers, that the dental care provided by the dental college will
be provided by students of dentistry or dental hygiene and clinicians
or instructors of the dental college.

1367.06. (a) A health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, delivered, or renewed on or after January 1, 2005, that
covers outpatient prescription drug benefits shall include coverage
for inhaler spacers when medically necessary for the management and
treatment of pediatric asthma.
(b) If a subscriber has coverage for outpatient prescription
drugs, a health care service plan contract, except a specialized
health care service plan contract, that is issued, amended,
delivered, or renewed on or after January 1, 2005, shall include
coverage for the following equipment and supplies when medically
necessary for the management and treatment of pediatric asthma:
(1) Nebulizers, including face masks and tubing.
(2) Peak flow meters.
(c) The quantity of the equipment and supplies required to be
covered pursuant to subdivisions (a) and (b) may be limited by the
health care service plan if the limitations do not inhibit
appropriate compliance with treatment as prescribed by the enrollee's
physician and surgeon. A health care service plan shall provide for
an expeditious process for approving additional or replacement
inhaler spacers, nebulizers, and peak flow meters when medically
necessary for an enrollee to maintain compliance with his or her
treatment regimen. The process required by Section 1367.24 may be
used to satisfy the requirements of this section for an inhaler
spacer.
(d) Education for pediatric asthma, including education to enable
an enrollee to properly use the device identified in subdivisions (a)
and (b), shall be consistent with current professional medical
practice.
(e) The coverage required by this section shall be provided under
the same general terms and conditions, including copayments and
deductibles, applicable to all other benefits provided by the plan.
(f) A health care service plan shall disclose the benefits under
this section in its evidence of coverage and disclosure forms.
(g) A health care service plan may not reduce or eliminate
coverage as a result of the requirements of this section.
(h) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter, if a plan provides coverage for prescription drugs.

1367.07. Within one year after a health care service plan's
assessment pursuant to subdivision (b) of Section 1367.04, the health
care service plan shall report to the department, in a format
specified by the department, regarding internal policies and
procedures related to cultural appropriateness in each of the
following contexts:
(a) Collection of data regarding the enrollee population pursuant
to the health care service plan's assessment conducted in accordance
with subdivision (b) of Section 1367.04.
(b) Education of health care service plan staff who have routine
contact with enrollees regarding the diverse needs of the enrollee
population.
(c) Recruitment and retention efforts that encourage workforce
diversity.
(d) Evaluation of the health care service plan's programs and
services with respect to the plan's enrollee population, using
processes such as an analysis of complaints and satisfaction survey
results.
(e) The periodic provision of information regarding the ethnic
diversity of the plan's enrollee population and any related
strategies to plan providers. Plans may use existing means of
communication.
(f) The periodic provision of educational information to plan
enrollees on the plan's services and programs. Plans may use existing
means of communication.

1367.08. A health care service plan shall annually disclose to the
governing board of a public agency that is the subscriber of a group
contract, the name and address of, and amount paid to, any agent,
broker, or individual to whom the plan paid fees or commissions
related to the public agency's group contract. As part of this
disclosure, the health care service plan shall include the name,
address, and amounts paid to the specific agents, brokers, or
individuals involved in transactions with the public agency. The
compensation disclosure required by this section is in addition to
any other compensation disclosure requirements that exist under law.

1367.09. (a) An enrollee with coverage for Medicare benefits who is
discharged from an acute care hospital shall be allowed to return to
a skilled nursing facility in which the enrollee resided prior to
hospitalization, or the skilled nursing unit of a continuing care
retirement community or multilevel facility in which the enrollee is
a resident for continuing treatment related to the acute care
hospital stay, if all of the following conditions are met:
(1) The enrollee is a resident of a continuing care retirement
community, as defined in paragraph (10) of subdivision (a) of Section
1771, or is a resident of a multilevel facility, as defined in
paragraph (9) of subdivision (d) of Section 15432 of the Government
Code, or has resided for at least 60 days in a skilled nursing
facility, as defined in Section 1250, that serves the needs of
special populations, including religious and cultural groups.
(2) The primary care physician, and the treating physician if
appropriate, in consultation with the patient, determines that the
medical care needs of the enrollee, including continuity of care, can
be met in the skilled nursing facility, or the skilled nursing unit
of the continuing care retirement community, or multilevel facility.
If a determination not to return the patient to the facility is made,
the physician shall document reasons in the patient's medical record
and share that written explanation with the patient.
(3) The skilled nursing facility, continuing care retirement
facility, or multilevel facility is within the service area and
agrees to abide by the plan's standards and terms and conditions
related to the following:
(A) Utilization review, quality assurance, peer review, and access
to health care services.
(B) Management and administrative procedures, including data and
financial reporting that may be required by the plan.
(C) Licensing and certification as required by Section 1367.
(D) Appropriate certification of the facility by the Health Care
Financing Administration or other federal and state agencies.
(4) (A) The skilled nursing facility, multilevel facility, or
continuing care retirement community agrees to accept reimbursement
from the health care service plan for covered services at either of
the following rates:
(i) The rate applicable to similar skilled nursing coverage for
facilities participating in the plan.
(ii) Upon mutual agreement, at a rate negotiated in good faith by
the health care service plan or designated agent on an individual,
per enrollee, contractual basis.
(B) Reimbursement shall not necessarily be based on actual costs
and may be comparable to similar skilled nursing facility
reimbursement methods available for other plan contracted facilities
available to the individual member.
(b) The health care service plan, or designated agent, shall be
required to reimburse the skilled nursing facility, continuing care
retirement facility, or multilevel facility at the rate agreed to in
paragraph (4) of subdivision (a).
(c) No skilled nursing facility, multilevel facility, or
continuing care retirement community shall collect, or attempt to
collect, or maintain any action of law, against a subscriber or
enrollee to collect reimbursement owed by the health care service
plan for health care services provided pursuant to this section, or
for any amount in excess of the payment amount that the facility has
agreed to accept in its agreement with the health care service plan.
(d) Reimbursement by the health care service plan or designated
agent shall be for those services included in the Medicare risk
contract between the health care service plan and enrollee.
(e) Nothing in this section requires a skilled nursing facility,
continuing care retirement facility, or multilevel facility to accept
as a skilled nursing unit patient anyone other than a resident of
the facility.
(f) This section shall apply to a health care service plan
contract that is issued, amended, or renewed on or after January 1,
1999.

1367.1. Subdivision (i) of Section 1367 shall apply to
transitionally licensed plans only insofar as it relates to contracts
entered into, amended, delivered, or renewed in this state on or
after October 1, 1977.

1367.2. (a) On and after January 1, 1990, every health care service
plan that covers hospital, medical, or surgical expenses on a group
basis shall offer coverage for the treatment of alcoholism under such
terms and conditions as may be agreed upon between the group
subscriber and the health care service plan. Every plan shall
communicate the availability of such coverage to all group
subscribers and to all prospective group subscribers with whom they
are negotiating.
(b) If the group subscriber or policyholder agrees to such
coverage or to coverage for treatment of chemical dependency, or
nicotine use, the treatment may take place in facilities licensed to
provide alcoholism or chemical dependency services under Chapter 2
(commencing with Section 1250) of Division 2.

1367.3. (a) On and after January 1, 1993, every health care service
plan that covers hospital, medical, or surgical expenses on a group
basis shall offer benefits for the comprehensive preventive care of
children. This section shall apply to children 17 and 18 years of
age, except as provided in paragraph (4) of subdivision (b). Every
plan shall communicate the availability of these benefits to all
group contractholders and to all prospective group contractholders
with whom they are negotiating. This section shall apply to a plan
which, by rule or order of the director, has been exempted from
subdivision (i) of Section 1367, insofar as that section and the
rules thereunder relate to the provision of the preventive health
care services described herein.
(b) For purposes of this section, benefits for the comprehensive
preventive care of children shall comply with both of the following:
(1) Be consistent with both of the following:
(A) The Recommendations for Preventive Pediatric Health Care, as
adopted by the American Academy of Pediatrics in September of 1987.
(B) The most current version of the Recommended Childhood
Immunization Schedule/United States, jointly adopted by the American
Academy of Pediatrics, the Advisory Committee on Immunization
Practices, and the American Academy of Family Physicians, unless the
State Department of Health Services determines, within 45 days of the
published date of the schedule, that the schedule is not consistent
with the purposes of this section.
(2) Provide for the following:
(A) Periodic health evaluations.
(B) Immunizations.
(C) Laboratory services in connection with periodic health
evaluations.
(D) For health care service plan contracts within the scope of
this section that are issued, amended, or renewed on and after
January 1, 1993, screening for blood lead levels in children at risk
for lead poisoning, as determined by a physician and surgeon
affiliated with the plan, when the screening is prescribed by a
physician and surgeon affiliated with the plan. This subparagraph
shall be applicable to all children and shall not be limited to
children 17 and 18 years of age.

1367.35. (a) On and after January 1, 1993, every health care
service plan that covers hospital, medical, or surgical expenses on a
group basis shall provide benefits for the comprehensive preventive
care of children 16 years of age or younger under terms and
conditions agreed upon between the group subscriber and the plan.
Every plan shall communicate the availability of these benefits to
all group contractholders and to all prospective group
contractholders with whom they are negotiating. This section shall
apply to each plan that, by rule or order of the director, has been
exempted from subdivision (i) of Section 1367, insofar as that
section and the rules thereunder relate to the provision of the
preventive health care services described in this section.
(b) For purposes of this section, benefits for the comprehensive
preventive care of children shall comply with both of the following:
(1) Be consistent with both of the following:
(A) The Recommendations for Preventive Pediatric Health Care, as
adopted by the American Academy of Pediatrics in September of 1987.
(B) The most current version of the Recommended Childhood
Immunization Schedule/United States, jointly adopted by the American
Academy of Pediatrics, the Advisory Committee on Immunization
Practices, and the American Academy of Family Physicians, unless the
State Department of Health Services determines, within 45 days of the
published date of the schedule, that the schedule is not consistent
with the purposes of this section.
(2) Provide for all of the following:
(A) Periodic health evaluations.
(B) Immunizations.
(C) Laboratory services in connection with periodic health
evaluations.

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

1367.4. No plan issuing, providing, or administering any contract
of individual or group coverage providing medical, surgical, or
dental expense benefits applied for and issued on or after January 1,
1986, shall refuse to cover, or refuse to continue to cover, or
limit the amount, extent, or kind of coverage available to an
individual, or charge a different rate for the same coverage solely
because of blindness or partial blindness.
"Blindness or partial blindness" means central visual acuity of
not more than 20/200 in the better eye, after correction, or visual
acuity greater than 20/200 but with a limitation in the fields of
vision so that the widest diameter of the visual field subtends an
angle no greater than 20 degrees, certified by a licensed physician
and surgeon who specializes in diseases of the eye or a licensed
optometrist.

1367.45. (a) Every individual or group health care service plan
contract that is issued, amended, or renewed on or after January 1,
2002, that covers hospital, medical, or surgery expenses shall
provide coverage for a vaccine for acquired immune deficiency
syndrome (AIDS) that is approved for marketing by the federal Food
and Drug Administration and that is recommended by the United States
Public Health Service.
(b) This section may not be construed to require a health care
service plan to provide coverage for any clinical trials relating to
an AIDS vaccine or for any AIDS vaccine that has been approved by the
federal Food and Drug Administration in the form of an
investigational new drug application.
(c) A health care service plan that contracts directly with an
individual provider or provider organization may not delegate the
risk adjusted treatment cost of providing services under this section
unless the requirements of Section 1375.5 are met.
(d) Nothing in this section is to be construed in any manner to
limit or impede a health care service plan's power or responsibility
to negotiate the most cost-effective price for vaccine purchases.
(e) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for prescription drugs.

1367.46. Every individual or group health care service plan
contract that is issued, amended, or renewed on or after January 1,
2009, that covers hospital, medical, or surgery expenses shall
provide coverage for human immunodeficiency virus (HIV) testing,
regardless of whether the testing is related to a primary diagnosis.

1367.5. No health care service plan contract that is issued,
amended, renewed, or delivered on and after January 1, 2002, shall
contain a provision that prohibits or restricts any health facilities'
compliance with the requirements of Section 1262.5.

1367.51. (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, delivered, or renewed on or after January 1, 2000, and that
covers hospital, medical, or surgical expenses shall include coverage
for the following equipment and supplies for the management and
treatment of insulin-using diabetes, non-insulin-using diabetes, and
gestational diabetes as medically necessary, even if the items are
available without a prescription:
(1) Blood glucose monitors and blood glucose testing strips.
(2) Blood glucose monitors designed to assist the visually
impaired.
(3) Insulin pumps and all related necessary supplies.
(4) Ketone urine testing strips.
(5) Lancets and lancet puncture devices.
(6) Pen delivery systems for the administration of insulin.
(7) Podiatric devices to prevent or treat diabetes-related
complications.
(8) Insulin syringes.
(9) Visual aids, excluding eyewear, to assist the visually
impaired with proper dosing of insulin.
(b) Every health care service plan contract, except a specialized
health care service plan contract, that is issued, amended,
delivered, or renewed on or after January 1, 2000, that covers
prescription benefits shall include coverage for the following
prescription items if the items are determined to be medically
necessary:
(1) Insulin.
(2) Prescriptive medications for the treatment of diabetes.
(3) Glucagon.
(c) The copayments and deductibles for the benefits specified in
subdivisions (a) and (b) shall not exceed those established for
similar benefits within the given plan.
(d) Every plan shall provide coverage for diabetes outpatient
self-management training, education, and medical nutrition therapy
necessary to enable an enrollee to properly use the equipment,
supplies, and medications set forth in subdivisions (a) and (b), and
additional diabetes outpatient self-management training, education,
and medical nutrition therapy upon the direction or prescription of
those services by the enrollee's participating physician. If a plan
delegates outpatient self-management training to contracting
providers, the plan shall require contracting providers to ensure
that diabetes outpatient self-management training, education, and
medical nutrition therapy are provided by appropriately licensed or
registered health care professionals.
(e) The diabetes outpatient self-management training, education,
and medical nutrition therapy services identified in subdivision (d)
shall be provided by appropriately licensed or registered health care
professionals as prescribed by a participating health care
professional legally authorized to prescribe the service. These
benefits shall include, but not be limited to, instruction that will
enable diabetic patients and their families to gain an understanding
of the diabetic disease process, and the daily management of diabetic
therapy, in order to thereby avoid frequent hospitalizations and
complications.
(f) The copayments for the benefits specified in subdivision (d)
shall not exceed those established for physician office visits by the
plan.
(g) Every health care service plan governed by this section shall
disclose the benefits covered pursuant to this section in the plan's
evidence of coverage and disclosure forms.
(h) A health care service plan may not reduce or eliminate
coverage as a result of the requirements of this section.
(i) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for prescription drugs.

1367.54. Every group health care service plan contract that
provides maternity benefits, except for a specialized health care
service plan contract, that is issued, amended, renewed, or delivered
on or after January 1, 1999, and every individual health care
service plan contract of a type and form first offered for sale on or
after January 1, 1999, that provides maternity benefits, except a
specialized health care service plan contract, shall provide coverage
for participation in the Expanded Alpha Feto Protein (AFP) program,
whi