Section 2594.2 - Mandatory Coverage and Standards(a) An individual or small group health insurance policy shall, at a minimum, provide coverage for essential health benefits, as defined in subdivision (a) of Insurance Code section 10112.27 and section 2594.3 of this article.(b) An individual or small group health insurance policy shall, at a minimum, provide coverage for essential health benefits that is substantially equal to the health benefits covered by the base-benchmark plan, the Medi-Cal Dental Program for pediatric oral care, and the Federal Employees Dental and Vision Insurance Program plan for pediatric vision care.(c) An individual or small group health insurance policy shall not impose treatment limitations on essential health benefits greater than the treatment limitations imposed by the base-benchmark plan, the Medi-Cal Dental Program for pediatric oral care, and the Federal Employees Dental and Vision Insurance Program plan for pediatric vision care. Treatment limitations in a health insurance policy subject to section 10112.27 of the Insurance Code shall comply with all other applicable laws and regulations, including, but not limited to, article 15.2 of this subchapter, commencing with section 2562.1.(d) An individual or small group health insurance policy shall not exclude an individual from coverage for essential health benefits except that an individual who does not satisfy the eligibility age for pediatric services may be excluded from the pediatric services category.(e) An individual or small group health insurance policy shall not substitute benefits within essential health benefit categories.(f) An individual or small group health insurance policy shall cover habilitative services and devices as follows: (1) All habilitative services and devices covered by the base-benchmark plan shall be covered.(2) Services and devices covered by the base-benchmark plan for the purpose of rehabilitation shall also be covered for the purpose of habilitation.(3) The same terms and conditions applied to coverage for rehabilitative services and devices shall be applied to coverage for habilitative services and devices.(4) Habilitative services and devices in addition to those covered by the base-benchmark plan shall be covered consistent with the definition in section 10112.27 of the Insurance Code.(5) Treatment limitations on habilitative and rehabilitative services and devices shall not be combined.(g) An individual or small group health insurance policy shall not include a benefit design, nor shall a health insurer implement a benefit design, that discriminates against an individual based on any of the following factors: (1) Age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions.(2) Race, color, religion, national origin, ancestry, sex, gender, gender identity, gender expression, sexual orientation, or genetic characteristics.Cal. Code Regs. Tit. 10, § 2594.2
1. New section filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013, No. 50). Pursuant to Insurance Code section 10112.27(o)(2) a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-9-2013 order, including repealer of subsection (b), subsection relettering and amendment of NOTE, transmitted to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 9).
4. Change without regulatory effect amending subsections (b) and (c), adopting subsection (f)(5) and amending NOTE filed 1-3-2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 1). Note: Authority cited: Sections 10112.27, 12921 and 12926, Insurance Code. Reference: Sections 10112.27, 10112.3, 10140, 10753.05 and 10965.5, Insurance Code.
1. New section filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013, No. 50). Pursuant to Insurance Code section 10112.27(o)(2) a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-9-2013 order, including repealer of subsection (b), subsection relettering and amendment of Note, transmitted to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to Government Code section 11343.4(b)(3)(Register 2014, No. 9).
4. Change without regulatory effect amending subsections (b) and (c), adopting subsection (f)(5) and amending Note filed 1-3-2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 1).