1373
. (a) (1) A plan contract may not provide an exception for
other coverage if the other coverage is entitlement to Medi-Cal
benefits under Chapter 7 (commencing with Section 14000) or Chapter 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code, or Medicaid benefits under Subchapter
19 (commencing with Section 1396) of Chapter 7 of Title 42 of the
United States Code.
(2) Each plan contract shall be interpreted not to provide an
exception for the Medi-Cal or Medicaid benefits.
(3) A plan contract shall not provide an exemption for enrollment
because of an applicant's entitlement to Medi-Cal benefits under
Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing
with Section 14200) of Part 3 of Division 9 of the Welfare and
Institutions Code, or Medicaid benefits under Subchapter 19
(commencing with Section 1396) of Chapter 7 of Title 42 of the United
States Code.
(4) A plan contract may not provide that the benefits payable
thereunder are subject to reduction if the individual insured has
entitlement to the Medi-Cal or Medicaid benefits.
(b) (1) A plan contract that provides coverage, whether by
specific benefit or by the effect of general wording, for
sterilization operations or procedures shall not impose any
disclaimer, restriction on, or limitation of, coverage relative to
the covered individual's reason for sterilization.
(2) As used in this section, "sterilization operations or
procedures" shall have the same meaning as that specified in Section
10120 of the Insurance Code.
(c) Every plan contract that provides coverage to the spouse or
dependents of the subscriber or spouse shall grant immediate accident
and sickness coverage, from and after the moment of birth, to each
newborn infant of any subscriber or spouse covered and to each minor
child placed for adoption from and after the date on which the
adoptive child's birth parent or other appropriate legal authority
signs a written document, including, but not limited to, a health
facility minor release report, a medical authorization form, or a
relinquishment form, granting the subscriber or spouse the right to
control health care for the adoptive child or, absent this written
document, on the date there exists evidence of the subscriber's or
spouse's right to control the health care of the child placed for
adoption. No plan may be entered into or amended if it contains any
disclaimer, waiver, or other limitation of coverage relative to the
coverage or insurability of newborn infants of, or children placed
for adoption with, a subscriber or spouse covered as required by this
subdivision.
(d) (1) Every plan contract that provides that coverage of a
dependent child of a subscriber shall terminate upon attainment of
the limiting age for dependent children specified in the plan, shall
also provide that attainment of the limiting age shall not operate to
terminate the coverage of the child while the child is and continues
to meet both of the following criteria:
(A) Incapable of self-sustaining employment by reason of a
physically or mentally disabling injury, illness, or condition.
(B) Chiefly dependent upon the subscriber for support and
maintenance.
(2) The plan shall notify the subscriber that the dependent child'
s coverage will terminate upon attainment of the limiting age unless
the subscriber submits proof of the criteria described in
subparagraphs (A) and (B) of paragraph (1) to the plan within 60 days
of the date of receipt of the notification. The plan shall send this
notification to the subscriber at least 90 days prior to the date
the child attains the limiting age. Upon receipt of a request by the
subscriber for continued coverage of the child and proof of the
criteria described in subparagraphs (A) and (B) of paragraph (1), the
plan shall determine whether the child meets that criteria before
the child attains the limiting age. If the plan fails to make the
determination by that date, it shall continue coverage of the child
pending its determination.
(3) The plan may subsequently request information about a
dependent child whose coverage is continued beyond the limiting age
under this subdivision but not more frequently than annually after
the two-year period following the child's attainment of the limiting
age.
(4) If the subscriber changes carriers to another plan or to a
health insurer, the new plan or insurer shall continue to provide
coverage for the dependent child. The new plan or insurer may request
information about the dependent child initially and not more
frequently than annually thereafter to determine if the child
continues to satisfy the criteria in subparagraphs (A) and (B) of
paragraph (1). The subscriber shall submit the information requested
by the new plan or insurer within 60 days of receiving the request.
(5) (A) Except as set forth in subparagraph (B), under no
circumstances shall the limiting age be less than 26 years of age
with respect to plan years beginning on or after September 23, 2010.
(B) For plan years beginning before January 1, 2014, a group
health care service plan contract that qualifies as a grandfathered
health plan under Section 1251 of the federal Patient Protection and
Affordable Care Act (Public Law 111-148) and that makes available
dependent coverage of children may exclude from coverage an adult
child who has not attained 26 years of age only if the adult child is
eligible to enroll in an eligible employer-sponsored health plan, as
defined in Section 5000A(f)(2) of the Internal Revenue Code, other
than a group health plan of a parent.
(C) (i) With respect to a child (I) whose coverage under a group
or individual plan contract ended, or who was denied or not eligible
for coverage under a group or individual plan contract, because under
the terms of the contract the availability of dependent coverage of
children ended before the attainment of 26 years of age, and (II) who
becomes eligible for that coverage by reason of the application of
this paragraph, the health care service plan shall give the child an
opportunity to enroll that shall continue for at least 30 days. This
opportunity and the notice described in clause (ii) shall be provided
not later than the first day of the first plan year beginning on or
after September 23, 2010, consistent with the federal Patient
Protection and Affordable Care Act (Public Law 111-148), as amended
by the federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any additional federal guidance or
regulations issued by the United States Secretary of Health and Human
Services.
(ii) The health care service plan shall provide written notice
stating that a dependent described in clause (i) who has not attained
26 years of age is eligible to enroll in the plan for coverage. This
notice may be provided to the dependent's parent on behalf of the
dependent. If the notice is included with other enrollment materials
for a group plan, the notice shall be prominent.
(iii) In the case of an individual who enrolls under this
subparagraph, coverage shall take effect no later than the first day
of the first plan year beginning on or after September 23, 2010.
(iv) A dependent enrolling in a group health plan for coverage
pursuant to this subparagraph shall be treated as a special enrollee
as provided under the rules of Section 146.117(d) of Title 45 of the
Code of Federal Regulations. The health care service plan shall offer
the recipient of the notice all of the benefit packages available to
similarly situated individuals who did not lose coverage by reason
of cessation of dependent status. Any difference in benefits or
cost-sharing requirements shall constitute a different benefit
package. A dependent enrolling in a group health plan for coverage
pursuant to this subparagraph shall not be required to pay more for
coverage than similarly situated individuals who did not lose
coverage by reason of cessation of dependent status.
(D) Nothing in this section shall require a health care service
plan to make coverage available for a child of a child receiving
dependent coverage. Nothing in this section shall be construed to
modify the definition of "dependent" as used in the Revenue and
Taxation Code with respect to the tax treatment of the cost of
coverage.
(e) A plan contract that provides coverage, whether by specific
benefit or by the effect of general wording, for both an employee and
one or more covered persons dependent upon the employee and provides
for an extension of the coverage for any period following a
termination of employment of the employee shall also provide that
this extension of coverage shall apply to dependents upon the same
terms and conditions precedent as applied to the covered employee,
for the same period of time, subject to payment of premiums, if any,
as required by the terms of the policy and subject to any applicable
collective bargaining agreement.
(f) A group contract shall not discriminate against handicapped
persons or against groups containing handicapped persons. Nothing in
this subdivision shall preclude reasonable provisions in a plan
contract against liability for services or reimbursement of the
handicap condition or conditions relating thereto, as may be allowed
by rules of the director.
(g) Every group contract shall set forth the terms and conditions
under which subscribers and enrollees may remain in the plan in the
event the group ceases to exist, the group contract is terminated, or
an individual subscriber leaves the group, or the enrollees'
eligibility status changes.
(h) (1) A health care service plan or specialized health care
service plan may provide for coverage of, or for payment for,
professional mental health services, or vision care services, or for
the exclusion of these services. If the terms and conditions include
coverage for services provided in a general acute care hospital or an
acute psychiatric hospital as defined in Section 1250 and do not
restrict or modify the choice of providers, the coverage shall extend
to care provided by a psychiatric health facility as defined in
Section 1250.2 operating pursuant to licensure by the State
Department of Health Care Services. A health care service plan that
offers outpatient mental health services but does not cover these
services in all of its group contracts shall communicate to
prospective group contractholders as to the availability of
outpatient coverage for the treatment of mental or nervous disorders.
(2) No plan shall prohibit the member from selecting any
psychologist who is licensed pursuant to the Psychology Licensing Law
(Chapter 6.6 (commencing with Section 2900) of Division 2 of the
Business and Professions Code), any optometrist who is the holder of
a certificate issued pursuant to Chapter 7 (commencing with Section
3000) of Division 2 of the Business and Professions Code or, upon
referral by a physician and surgeon licensed pursuant to the Medical
Practice Act (Chapter 5 (commencing with Section 2000) of Division 2
of the Business and Professions Code), (A) any marriage and family
therapist who is the holder of a license under Section 4980.50 of the
Business and Professions Code, (B) any licensed clinical social
worker who is the holder of a license under Section 4996 of the
Business and Professions Code, (C) any registered nurse licensed
pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of
the Business and Professions Code, who possesses a master's degree
in psychiatric-mental health nursing and is listed as a
psychiatric-mental health nurse by the Board of Registered Nursing,
(D) any advanced practice registered nurse certified as a clinical
nurse specialist pursuant to Article 9 (commencing with Section 2838)
of Chapter 6 of Division 2 of the Business and Professions Code who
participates in expert clinical practice in the specialty of
psychiatric-mental health nursing, to perform the particular services
covered under the terms of the plan, and the certificate holder is
expressly authorized by law to perform these services, or (E) any
professional clinical counselor who is the holder of a license under
Chapter 16 (commencing with Section 4999.10) of Division 2 of the
Business and Professions Code.
(3) Nothing in this section shall be construed to allow any
certificate holder or licensee enumerated in this section to perform
professional mental health services beyond his or her field or fields
of competence as established by his or her education, training, and
experience.
(4) For the purposes of this section:
(A) "Marriage and family therapist" means a licensed marriage and
family therapist who has received specific instruction in assessment,
diagnosis, prognosis, and counseling, and psychotherapeutic
treatment of premarital, marriage, family, and child relationship
dysfunctions, which is equivalent to the instruction required for
licensure on January 1, 1981.
(B) "Professional clinical counselor" means a licensed
professional clinical counselor who has received specific instruction
in assessment, diagnosis, prognosis, counseling, and
psychotherapeutic treatment of mental and emotional disorders, which
is equivalent to the instruction required for licensure on January 1,
2012.
(5) Nothing in this section shall be construed to allow a member
to select and obtain mental health or psychological or vision care
services from a certificate holder or licenseholder who is not
directly affiliated with or under contract to the health care service
plan or specialized health care service plan to which the member
belongs. All health care service plans and individual practice
associations that offer mental health benefits shall make reasonable
efforts to make available to their members the services of licensed
psychologists. However, a failure of a plan or association to comply
with the requirements of the preceding sentence shall not constitute
a misdemeanor.
(6) As used in this subdivision, "individual practice association"
means an entity as defined in subsection (5) of Section 1307 of the
federal Public Health Service Act (42 U.S.C. Sec. 300e-1(5)).
(7) Health care service plan coverage for professional mental
health services may include community residential treatment services
that are alternatives to inpatient care and that are directly
affiliated with the plan or to which enrollees are referred by
providers affiliated with the plan.
(i) If the plan utilizes arbitration to settle disputes, the plan
contracts shall set forth the type of disputes subject to
arbitration, the process to be utilized, and how it is to be
initiated.
(j) A plan contract that provides benefits that accrue after a
certain time of confinement in a health care facility shall specify
what constitutes a day of confinement or the number of consecutive
hours of confinement that are requisite to the commencement of
benefits.
(k) If a plan provides coverage for a dependent child who is over
26 years of age and enrolled as a full-time student at a secondary or
postsecondary educational institution, the following shall apply:
(1) Any break in the school calendar shall not disqualify the
dependent child from coverage.
(2) If the dependent child takes a medical leave of absence, and
the nature of the dependent child's injury, illness, or condition
would render the dependent child incapable of self-sustaining
employment, the provisions of subdivision (d) shall apply if the
dependent child is chiefly dependent on the subscriber for support
and maintenance.
(3) (A) If the dependent child takes a medical leave of absence
from school, but the nature of the dependent child's injury, illness,
or condition does not meet the requirements of paragraph (2), the
dependent child's coverage shall not terminate for a period not to
exceed 12 months or until the date on which the coverage is scheduled
to terminate pursuant to the terms and conditions of the plan,
whichever comes first. The period of coverage under this paragraph
shall commence on the first day of the medical leave of absence from
the school or on the date the physician and surgeon determines the
illness prevented the dependent child from attending school,
whichever comes first. Any break in the school calendar shall not
disqualify the dependent child from coverage under this paragraph.
(B) Documentation or certification of the medical necessity for a
leave of absence from school shall be submitted to the plan at least
30 days prior to the medical leave of absence from the school, if the
medical reason for the absence and the absence are foreseeable, or
30 days after the start date of the medical leave of absence from
school and shall be considered prima facie evidence of entitlement to
coverage under this paragraph.
(4) This subdivision shall not apply to a specialized health care
service plan or to a Medicare supplement plan.