Cal. Code Regs. tit. 10 § 2699.6209

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2699.6209 - Enrollee Share of Cost for Health Benefits

Every participating carrier shall require copayments and deductibles for health benefits provided to enrollees subject to the following:

(a) For enrollees in health maintenance organizations, exclusive provider organizations, preferred provider organizations, health maintenance organizations with a point of service option, and exclusive provider organizations with a point of service option, the sum of the in-network copayments and deductibles shall not exceed $2,000 in a benefit year for an enrollee or $4,000 in a benefit year for an enrolled sole employee and enrolled dependents or for a guaranteed association member and enrolled dependents for covered benefits and services provided by a provider who contracts with the carrier to provide health care benefits and services. In any benefit year that an enrollee has paid the maximum copayments described in Section 2699.6209(b)(4)(B)(1)(a) or Section 2699.6209(b)(4)(D)(1)(a), the enrollee shall be deemed to have met the maximum in -network copayment requirement described in this section. For enrollees in indemnity plans the sum of all copayments and deductibles shall not exceed $2,000 in a benefit year for an enrollee or $4,000 in a benefit year for an enrolled sole employee and enrolled dependents or for a guaranteed association member and enrolled dependents for covered benefits and services.

(b) Participating carriers shall offer two options for enrollee share of cost: a standard option and a preferred option.

(1) In the case of participating carriers which are health maintenance organizations or exclusive provider organizations:

(A) A preferred option shall consist of the following elements:

1. A $5 copayment per visit for office or home visits, with the following exceptions:

a. treatment for infertility, including tests, shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate of payment, and

b. outpatient mental health visits shall be subject to a $20 per visit copayment;

2. A $10 copayment per outpatient prescription for up to a 31 day supply of a prescription drug. A $10 copayment shall apply to additional supplies of the prescription in up to 31 day increments. However this amount shall be $5 per prescription for up to a 31 day supply of a prescription drug when a generic prescription drug is utilized or when a participating carrier has a mandatory generic prescription drug substitution program which has been approved by the program. A $5 copayment shall apply to additional supplies of such a prescription in up to 31 day increments.

An exception to the above is that a $20 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $10 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.

3. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital.

(B) A standard option shall consist of the following elements:

1. A $15 copayment per visit for office or home visits, with the following exceptions:

a. treatment for infertility, including tests, shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate of payment; and

b. visits for prenatal care and pediatric visits up to the age of two (2) will be subject to a $5 copayment per visit; and

c. outpatient mental health visits shall be subject to a $20 per visit copayment;

2. A $15 copayment per outpatient prescription for up to a 31 day supply of a prescription drug. A $15 copayment shall apply to additional supplies of the prescription in up to 31 increments. However this amount shall be $10 per prescription for up to a 31 day supply of a prescription drug when a generic prescription drug is utilized or when a participating carrier has a mandatory generic prescription drug substitution program which has been approved by the program. A $10 copayment shall apply to additional supplies of such a prescription in up to 31 day increments.

An exception to the above is that a $30 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $20 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.

3. A $100 copayment for each hospital or skilled nursing facility admission; and

4. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital.

(2) In the case of participating carriers which are preferred provider organizations:

(A) A preferred option shall consist of the following elements:

1. A copayment which shall be 20% of the contracted rate for covered benefits and services provided by a provider who contracts with the preferred provider organization to provide health care benefits and services other than outpatient prescription drugs, with the following exceptions:

a. treatment for infertility (including tests) provided by a provider who contracts with the preferred provider organization to provide health care benefits and services shall be subject to a copayment of 50% of the carrier's contracted rate of payment, and

b. outpatient mental health visits provided by a provider who contracts with the preferred provider organization to provide health care benefits and services shall be subject to a copayment of 50% of the carrier's contracted rate of payment, and

c. visits for prenatal care and pediatric visits up to the age of two for covered benefits and services provided by a provider who contracts with the preferred provider organization to provide health care benefits and services will not be subject to a copayment.

2. A copayment which shall be 40% of the scheduled rate of payment established by the participating carrier for covered benefits and services provided by a provider who does not contract with the preferred provider organization to provide health care benefits and services, with the following exceptions:

a. treatment for infertility (including tests) provided by a provider who does not contract with the preferred provider organization to provide health care benefits and services shall be subject to a copayment of 50% of the carrier's scheduled rate of payment.

b. outpatient mental health visits provided by a provider who does not contract with the preferred provider organization to provide health care benefits and services shall be subject to a copayment of 50% of the carrier's scheduled rate of payment.

c. the copayments described in 2., 2.a. and 2.b. above shall be limited to $5,000 in a benefit year for an enrollee or $10,000 in a benefit year for an enrolled sole employee and dependents or guaranteed association members and dependents.

d. enrollees are responsible for 100% of the charges in excess of the carrier's scheduled rate of payment for health care benefits and services provided by a provider who does not contract with the preferred provider organization to provide health care benefits and services. These amounts are not subject to the limitations in 2.c. on copayment expenses.

3. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital;

4. A copayment which shall be 30% of the contracted rate for prescription drugs provided by a provider who contracts with the preferred provider organization to provide prescription drugs. However this amount shall be 20% when a generic prescription drug is utilized or when a participating carrier has a mandatory generic prescription drug substitution program which has been approved by the program; and a copayment equivalent to that for a 60 day supply of a prescription shall apply to a 90 day supply of the same prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program; and

5. A deductible which shall be $250 per enrollee in a benefit year. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reduction may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

(B) A standard option shall consist of the following elements:

3. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital;

5. A deductible which shall be $500 per enrollee in a benefit year. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reduction may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

(3) In the case of participating carriers which offer indemnity plans:

(A) A preferred option shall consist of the following elements:

1. A copayment which shall be 20% of the scheduled rate of payment established by the participating carrier for covered benefits and services, with the following exceptions:

a. treatment for infertility (including tests) shall be subject to a copayment of 50% of the carrier's scheduled rate of payment.

b. outpatient mental health visits shall be subject to a copayment of 50% of the carrier's scheduled rate of payment.

c. enrollees are responsible for 100% of the charges in excess of the carrier's scheduled rate of payment for health care benefits and services. These amounts are not subject to the limitations in Section 2699.6209(a) on copayment expenses.

2. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital;

3. A copayment which shall be 30% of the scheduled rate for prescription drugs. However this amount shall be 20% when a generic prescription drug is utilized; and a copayment equivalent to that for a 60 day supply of a prescription shall apply to a 90 day supply of the same prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program; and

4. A deductible which shall be $250 per enrollee in a benefit year. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reduction may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

(B) A standard option shall consist of the following elements:

1. A copayment which shall be 20% of the scheduled rate of payment established by the participating carrier for covered benefits and services, with the following exceptions:

a. treatment for infertility (including tests) shall be subject to copayment of 50% of the carrier's scheduled rate of payment, and

b. outpatient mental health visits shall be subject to a copayment of 50% of the carrier's scheduled rate of payment, and

2. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital;

3. A copayment which shall be 30% of the scheduled rate for prescription drugs. However this amount shall be 20% when a generic prescription drug is utilized; and a copayment equivalent to that for a 60 day supply of a prescription drug shall apply to a 90 day supply of the same prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program; and

4. A deductible which shall be $500 per enrollee in a benefit year. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reduction may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

(4) In the case of participating carriers which are health maintenance organizations offering a point of service option or exclusive provider organizations offering a point of service option:

(A) A preferred option shall consist of the following elements:

1. When the enrollee receives covered benefits and services in accordance with the health maintenance organization's or exclusive provider organization's established procedures from providers who contract with the health maintenance organization or exclusive provider organization or when the enrollee, with health plan approval, receives covered benefits and services from providers who do not contract with the health maintenance organization or exclusive provider organization:

a. A $10 copayment per visit for office or home visits, with the following exceptions:

i. treatment for infertility, including tests, shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate of payment,

ii. visits for prenatal care and pediatric visits up to the age of two (2) will be subject to a $5 copayment per visit; and

iii. outpatient mental health visits shall be subject to a $20 per visit copayment;

b. A $15 copayment per outpatient prescription for up to a 31 day supply of a prescription drug. A $15 copayment shall apply to additional supplies of the prescription in up to 31 day increments. However, this amount shall be $10 per prescription for up to 31 days of a prescription drug when a generic prescription drug is utilized or when a participating carrier has a mandatory generic prescription drug substitution program which has been approved by the program. A $10 copayment shall apply to additional supplies of such a prescription in up to 31 day increments.

c. A $100 copayment for each hospital or skilled nursing facility admission; and

d. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital.

2. When the enrollee, without health plan approval, receives covered benefits and services from providers who do not contract with the health maintenance organization or exclusive provider organization or when the enrollee receives covered benefits and services in violation of the health plan's established procedures:

a. A copayment which shall be 30% of the scheduled rate of payment established by the participating carrier for covered benefits and services with the following exceptions:

i. the copayments described in 1. above shall be limited to $5,000 in a benefit year for an enrollee or $10,000 in a benefit year for an enrolled sole employee and dependents or guaranteed association members and dependents.

ii. enrollees are responsible for 100% of the charges in excess of the carrier's scheduled rate of payment for health care benefits and services. These amounts are not subject to the limitations in subsection "a" immediately above.

b. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital; and

c. A deductible which shall be $250 per enrollee in a benefit year for an enrolled employee and the employee's enrolled dependents. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reductions may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

(B) A standard option shall consist of the following elements:

1. When the enrollee receives covered benefits and services in accordance with the health maintenance organization's or exclusive provider organization's established procedures from providers who contract with the health maintenance organization or exclusive provider organization or when the enrollee, with health plan approval, receives covered benefits services from providers who do not contract with the health maintenance organization or exclusive provider organization:

a. A $10 copayment per visit for office or home visits, with the following exceptions:

i. treatment for infertility, including tests, shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate of payment;

ii. visits for prenatal care and pediatric visits up to the age of two (2) will be subject to a $5 copayment per visit; and

iii. outpatient mental health visits shall be subject to a $20 per visit copayment.

b. A $15 copayment per outpatient prescription for up to 31 days of a prescription drug. A $15 copayment shall apply to additional supplies of the prescription in up to 31 day increments. However, this amount shall be $10 per prescription for up to 31 days of a prescription drug when a generic prescription drug is utilized or when a participating carrier has a mandatory generic prescription drug substitution program which has been approved by the program; and a $30 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $20 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.

c. A $100 copayment for each hospital or skilled nursing facility admission; and

d. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital.

a. A copayment which shall be 30% of the scheduled rate of payment established by the participating carrier for covered benefits and services with the following exceptions:

b. A $50 copayment whenever use of a hospital emergency room does not result in admission to a hospital; and

c. A deductible which shall be $500 per enrollee in a benefit year for an enrolled employee and the employee's enrolled dependents. The deductible may be reduced by an amount equal to the amount an enrollee with qualifying prior coverage paid toward a deductible under the qualifying prior coverage for services rendered within the 90 days immediately prior to the enrollee's effective date of enrollment in the program. Such reductions may only be applied for the first full or partial benefit year that the enrollee is enrolled in the program.

Cal. Code Regs. Tit. 10, § 2699.6209

1. Renumbering and amendment of former section 2699.633 to section 2699.6209 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment filed 12-29-94 as an emergency; operative 12-29-94 (Register 94, No. 52). A Certificate of Compliance must be transmitted to OAL 4-28-95 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-29-94 order including amendment of subsections (b)(2)(A)2., (b)(2)(B)2., (b)(3)(A)1., and (b)(3)(B)1. transmitted to OAL 4-12-95 and filed 5-22-95 (Register 95, No. 21).
4. Amendment of section heading and section filed 5-2-96; operative 6-1-96 (Register 96, No. 18).
5. Amendment filed 5-8-97; operative 7-1-97 (Register 97, No. 19).

Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.