Article 5 - STANDARDS

Section 1367 - Requirements for health care service plan and specialized health care service plan
Section 1367.001 - Prohibition on lifetime and annual limits on dollar amount of covered benefits for enrollees
Section 1367.002 - Minimum coverage; cost-sharing requirements
Section 1367.003 - Annual rebate
Section 1367.004 - Medical Loss Ratio report
Section 1367.005 - Coverage for essential health benefits
Section 1367.006 - Limit on annual out-of-pocket expenses for benefits
Section 1367.0061 - Deductibles and out-of-pocket expenses
Section 1367.0065 - [Repealed]
Section 1367.007 - Limitations on deductibles
Section 1367.008 - Nongrandfathered individual market; levels of coverage; actuarial value; catastrophic plan
Section 1367.0085 - Actuarial value for a nongrandfathered bronze level health plan
Section 1367.009 - Nongrandfathered small group market; levels of coverage; actuarial value; catastrophic plan
Section 1367.01 - Written policies and procedures for utilization review or management
Section 1367.010 - Discontinuance of large group contract providing a minimum value of less than 60 percent
Section 1367.012 - Renewal of certain small employer health care service plans
Section 1367.015 - Denial of authorization or claim reimbursement for mental health services
Section 1367.016 - [See Note] Acceptance of premium payments from third-party entities
Section 1367.02 - Filing of description of policies and procedures relating to economic profiling
Section 1367.03 - Standards for timeliness of access to needed health care services
Section 1367.031 - Information provided to enrollees
Section 1367.035 - Submission of data regarding network adequacy
Section 1367.04 - Regulations establishing standards and requirements to provide access to language assistance in obtaining health care services
Section 1367.041 - Non-English language marketing materials
Section 1367.042 - Notification to enrollees and general public
Section 1367.043 - Evidence-based cultural competency training required
Section 1367.045 - Provisions reserving discretionary authority
Section 1367.05 - Contract with dental college
Section 1367.06 - Coverage for management and treatment of pediatric asthma
Section 1367.07 - Report regarding internal policies and procedures related to cultural appropriateness
Section 1367.08 - Compensation disclosure
Section 1367.09 - Return to skilled nursing facility following discharge from acute care hospital
Section 1367.1 - Applicability to transitionally licensed plans
Section 1367.2 - Coverage for treatment of alcoholism
Section 1367.3 - Offer benefits for comprehensive preventive care of children
Section 1367.34 - Adverse childhood experiences screenings
Section 1367.34 - Health care plans to provide coverage for home test kits for sexually transmitted diseases (STD)
Section 1367.35 - Provision of benefits for comprehensive preventive care of children
Section 1367.36 - Financial risk for immunizations for children
Section 1367.4 - Coverage related to blindness or partial blindness
Section 1367.41 - Pharmacy and therapeutics committee
Section 1367.42 - Access to prescription drug benefits at in-network retail pharmacy
Section 1367.43 - Prorating cost for partial fill
Section 1367.45 - Coverage of vaccine for AIDS
Section 1367.46 - Coverage for HIV testing
Section 1367.47 - Maximum amount health care service plan may require enrollee to pay for prescription drugs
Section 1367.49 - Contractual provision restricting furnishing of information concerning cost range or quality of services prohibited
Section 1367.5 - Provision restricting compliance with Section 1262.5 prohibited
Section 1367.50 - Disclosure of claims data
Section 1367.51 - Coverage related to diabetes
Section 1367.54 - Coverage to participation in Expanded Alpha Fetoprotein program
Section 1367.6 - Coverage related to breast cancer
Section 1367.61 - Coverage for prosthetic devices to restore method of speaking for patient incident to laryngectomy
Section 1367.62 - Maternity coverage
Section 1367.625 - Development of maternal mental health program
Section 1367.626 - Maternal and infant health equity program; doula care; report
Section 1367.63 - Coverage for reconstructive surgery
Section 1367.635 - Coverage related to mastectomies and lymph node dissections
Section 1367.64 - Coverage related to prostrate cancer
Section 1367.65 - Coverage for mammography
Section 1367.656 - Coverage for certain orally administered anticancer medications
Section 1367.66 - Coverage for annual cervical cancer screening test
Section 1367.665 - Coverage for medically accepted cancer screening tests
Section 1367.667 - Coverage for medically necessary biomarker testing
Section 1367.668 - Colorectal cancer coverage
Section 1367.67 - Coverage related to osteoporosis
Section 1367.68 - Exclusion of coverage for surgical procedure for condition affecting jawbone
Section 1367.69 - Obstetrician-gynecologists as eligible primary care physicians
Section 1367.695 - Direct access to obstetrical and gynecological physician services
Section 1367.7 - Coverage for prenatal diagnosis of genetic disorders of fetus
Section 1367.71 - Coverage for general anesthesia and associated facility charges for dental procedures
Section 1367.8 - Refusal of coverage, limitation on coverage, or different charges because of physical or mental impairment
Section 1367.9 - Exclusion, reduction, or other limitations due to diethylstilbestrol prohibited
Section 1367.10 - Disclosures regarding choice of physician, hospital, or other health care providers, basic method of reimbursement, and financial bonuses or incentives
Section 1367.11 - [Repealed]
Section 1367.12 - No more than one form submitted per claim
Section 1367.15 - Block of business
Section 1367.18 - Coverage for orthotic and prosthetic devices
Section 1367.19 - Coverage as option for special footwear needed by persons who suffer from foot disfigurement
Section 1367.20 - Formulary lists
Section 1367.205 - Posting formularies on web site
Section 1367.206 - Step therapy
Section 1367.207 - Prescription drug coverage
Section 1367.21 - Limitation or exclusion of coverage for drug on basis that drug is prescribed for use different than approved use
Section 1367.215 - Coverage for pain management medications for terminally ill patients
Section 1367.22 - No limitation or exclusion of coverage for drug previously approved for coverage and prescribed by provider
Section 1367.23 - Notification of cancellation of plan contract
Section 1367.24 - Process to obtain authorization for medically necessary nonformulary prescription drug
Section 1367.241 - Acceptance of prior authorization form
Section 1367.243 - Reports to Department regarding drug cost information
Section 1367.244 - Request for exception to a step therapy process for prescription drugs
Section 1367.25 - Coverage for outpatient prescription drug benefits
Section 1367.251 - Deductible, coinsurance, copayment, or any other cost-sharing requirement on coverage for all abortion and abortion-related services prohibited
Section 1367.255 - Health care service plans after January 1, 2024; vasectomy services; religious employers and contraception coverage
Section 1367.26 - [Repealed]
Section 1367.27 - Provider directories
Section 1367.28 - Information identifying which of a plan's in-network providers offer and have provided gender-affirming services to be accessible
Section 1367.29 - Identification card
Section 1367.30 - Applicability of section 1374,58
Section 1367.31 - Requirement for referral to receive coverage or services for reproductive and sexual health care prohibited
Section 1367.32 - Information to be provided by health plan to employees of a religious employer that does not include coverage and benefits for both abortion and contraception
Section 1367.33 - Plans operated by institutions of higher learning to comply with the contraceptive coverage requirements
Section 1368 - Grievance system
Section 1368.01 - Expedites plan review of grievances
Section 1368.015 - Online grievance submission procedure
Section 1368.016 - Requirements related to coverage for professional mental health services
Section 1368.017 - [Effective 1/1/2025] Notice regarding benefits of behavioral health and wellness screening for children and adolescents
Section 1368.02 - Toll-free telephone number to receive complaints regarding health care service plans
Section 1368.03 - Waiting period
Section 1368.04 - Investigation; enforcement action; administrative penalties
Section 1368.05 - Transfer of consumer assistance duties
Section 1368.1 - Denial of coverage to enrollee with terminal illness
Section 1368.2 - Hospice care
Section 1368.5 - Payment or reimbursement of cost of service performed by pharmacist
Section 1368.6 - Pilot project to assess impact of health care service plan and pharmacy benefit manager prohibitions on the dispensing of prescription drugs by network retail pharmacies
Section 1368.7 - Enrollees displaced by state of emergency
Section 1369 - Procedures for subscribers and enrollees to participate in establishing public policy of plan
Section 1370 - Procedures for continuously reviewing quality of care, performance of medical personnel, utilization of services and facilities, and costs
Section 1370.1 - Subcommittees to participate in peer review activities
Section 1370.2 - Referral of contested claim to medical director
Section 1370.4 - External, independent review process for coverage decisions regarding experimental or investigational therapies
Section 1370.6 - Coverage of routine patient care costs related to clinical trial
Section 1371 - Reimbursement of claims within 30 or 45 working days
Section 1371.1 - Overpayment
Section 1371.2 - Request for reimbursement for overpayment or reduction of level of payment prohibited
Section 1371.22 - Lowest payment rate; cash payments by individual patients
Section 1371.25 - Liability
Section 1371.3 - Assignment of enrollee's or subscriber's right to reimbursement
Section 1371.30 - Establishment of independent dispute resolution process
Section 1371.31 - Reimbursement for services provided by noncontracting individual health professional
Section 1371.35 - Reimbursement within 30 or 45 working days; contest or denial of claim
Section 1371.36 - Denial of claim on basis that authorization not provided
Section 1371.37 - Engaging in unfair payment pattern prohibited
Section 1371.38 - Regulations requiring dispute resolution mechanism
Section 1371.39 - Report of unfair payment pattern or unfair billing pattern
Section 1371.4 - Access to obtain timely authorization for medically necessary care related to emergency services
Section 1371.5 - Prior authorization for ambulance as result of 911 request for service prohibited
Section 1371.55 - Covered services from noncontracting air ambulance provider; in-network cost-sharing amount
Section 1371.56 - In-networking cost sharing amount for ground ambulance services
Section 1371.8 - Rescission or modification of authorization of specific type of treatment by provider
Section 1371.9 - In-network-cost-sharing amount
Section 1372 - Offer of one or more plan contracts
Section 1373 - Exception for Medi-Cal or Medicaid benefits prohibited
Section 1373.1 - Conversion rights
Section 1373.2 - Conversion rights of covered dependent spouse
Section 1373.3 - Selection of primary care physician
Section 1373.4 - Restrictions related to maternity coverage
Section 1373.5 - Each spouse covered as employee
Section 1373.6 - Conversion contracts
Section 1373.62 - [Repealed]
Section 1373.620 - Notice for non-grandfathered health plans
Section 1373.621 - Offer to continue benefits following coverage under COBRA
Section 1373.622 - Continuing coverage after termination of pilot program
Section 1373.65 - Enrollee block transfer filing; written notice to enrollees
Section 1373.7 - Selection of psychologist
Section 1373.8 - Selection of clinical social worker psychiatric-mental health nurse advanced practice nurse marriage and family therapist or professional clinical counselor
Section 1373.9 - Consideration of proposals for affiliation by providers
Section 1373.10 - Coverage for expenses incurred as result of treatment by certain holders of certificates
Section 1373.11 - Consideration to affiliation with podiatrists
Section 1373.12 - Consideration to affiliation with chiropractors
Section 1373.13 - Dentists afforded equal professional status and privileges
Section 1373.14 - Prohibited exclusion from coverage offered for long-term care facility services or home-based care
Section 1373.18 - Calculation of amount of enrollee copayment
Section 1373.19 - Selection of single neutral arbitrator
Section 1373.20 - Requirements with respect to arbitration of disputes
Section 1373.21 - Written decision accompanying arbitration award
Section 1373.95 - Continuity of care policy
Section 1373.96 - Completion of covered services
Section 1374 - Coverage under conditions less favorable for employees than coverage provided for covered spouses prohibited
Section 1374.3 - Compliance with certain laws
Section 1374.1 - Dependent parent health care coverage
Section 1374.5 - Lifetime waiver of coverage unenforceable
Section 1374.51 - Restriction on determining eligibility for claim reimbursement of psychiatric inpatient admission
Section 1374.55 - Coverage for treatment of infertility
Section 1374.551 - Covered treatments that may cause Iatrogenic infertility
Section 1374.56 - Coverage for testing and treatment of PKU
Section 1374.57 - Exclusion of dependent child because child does not reside with employee or subscriber prohibited
Section 1374.58 - Coverage for registered domestic partner
Section 1374.7 - Restrictions related to genetic characteristics
Section 1374.75 - Victim of domestic violence
Section 1374.8 - Release of information to employer
Section 1374.9 - Violation related to release of information to employer; administrative penalties
Section 1374.10 - Benefits for home health care
Section 1374.11 - Denial of claim for sole reason that individual was confined in jail or was juvenile detained in facility prohibited
Section 1374.12 - Restriction on liability of plan because expenses incurred while member was in state hospital prohibited
Section 1374.13 - Payment for covered services provided through telehealth
Section 1374.14 - Coverage for telehealth services; inclusion in contracts
Section 1374.141 - Telehealth service through third-party telehealth provider
Section 1374.142 - Telehealth dental care; report; disclosure of impact of telehealth visits on benefits
Section 1374.15 - Disclosure of method and data used in calculating rates of payment
Section 1374.16 - Standing referral to specialist
Section 1374.17 - Denial of costs of transplantation services based on HIV infection prohibited
Section 1374.18 - Dental coverage disclosures
Section 1374.19 - Coordination of benefits policy for plan covering dental services
Section 1374.192 - Health care provider reimbursements
Section 1374.193 - Third party access to provider network contract or provider's dental services or contractual discounts
Section 1374.194 - Imposition of dental waiting period provision or preexisting condition provision prohibited
Section 1374.195 - Contract between plan and dentist to provide covered dental services; charges for dental services
Section 1374.196 - Health care service plans to maintain certain application programming interfaces (API)
Section 1374.197 - Health care coverage for mental health and substance use disorders; credentialing health care providers