Workers’ compensation is a system of no-fault insurance that provides medical and monetary benefits to employees or their survivors for work-related injuries, diseases and deaths.
The California Workers’ Compensation Act (WCA) defines employer responsibilities under the state’s workers’ compensation program. The Division of Workers’ Compensation (DWC) of the California Department of Industrial Relations monitors and enforces employers’ compliance with these requirements throughout the state.
Almost all California employers must secure workers’ compensation coverage for their employees. The WCA defines an employee as any individual working for another individual or organization who is not an independent contractor. Employers are bound by WCA coverage requirements even if they only have one employee, regardless of whether the employee works full-time or part-time.
Coverage requirements also apply for temporary workers. Temporary employment agencies, employment referral services, labor contractors and any other similar entities hiring temporary workers are solely responsible for their employees’ coverage.
To meet coverage requirements, employers can either secure a workers’ compensation insurance policy from a private insurance company licensed to do business in California or apply for self-insurance certification with the Office of Self Insurance Plans (OSIP).
A self-insured employer uses its assets, rather than an insurance policy provided by an insurance carrier, to cover its obligations under the workers’ compensation program. Employers that wish to self-insure must obtain authorization from the OSIP. Whether the OSIP will grant this authorization depends on an employer’s financial strength, proposed benefit delivery system and loss prevention program. To qualify, an employer must:
- Have at least $5 million in shareholder equity;
- Have net profits of $500,000 or more for the five years immediately prior to the application;
- Make a deposit based on the employer’s expected future liabilities, with a minimum amount of $220,000;
- Hire a certified third-party administrator or ensure that internal staff becomes OSIP-certified to process and handle benefit claims; and
- Provide the following documents:
- Certified, independently-audited financial statements; and
- A proposed injury and illness prevention program that meets, at a minimum, Cal/OHSA safety and health regulations.
Self-insured employers are subject to audits by both the DWC and OSIP. These audits are used to verify that self-insured employers are making benefits payments promptly and properly.
Certain employers are not allowed to self-insure. These employers include:
- Professional employer organizations;
- Leasing employers;
- Temporary service employers;
- Any employer in the business of providing employees to other employers; and
- Employers that have allowed their coverage to lapse (unless they receive authorization from the DWC).
Multiple employers can create self-insurance groups by combining their assets to insure against their individual liabilities. Authorization for group self-insurance requires employer groups to show they have sufficient financial stability to meet all their obligations under the WCA. In addition, a group of employers seeking to self-insure must:
- Operate in the same industry;
- Make a deposit equal to 135 percent of its estimated future liabilities;
- Have sufficient funds to cover any losses and administrative expenses for at least eight of out of 10 years;
- Obtain excess insurance for claims over $500,000; and
- Report to each member of the group any possible conflict of interest between the group and any vendors.
Self-insurance Annual Renewal
Self-insured employers must submit annual reports to show their continued compliance with eligibility requirements. These reports are also used to assess the adequacy of each self-insurance deposit.
Employers that are required to deposit additional funds to their initial deposit must make their contributions within 60 days of filing their annual report or by May 1 of the year in question, whichever is comes first.
COVERAGE NOTICE REQUIREMENTS
Employers subject to the WCA must display a notice in a conspicuous place stating that they have workers’ compensation insurance coverage that complies with the WCA. Failing to display this notice constitutes a misdemeanor and may be considered evidence that the employer does not have insurance.
The coverage notice must be available in English and Spanish and must include specific information about the employee’s rights and obligations under the WCA. The DWC has issued a model poster that employers can use to fulfill these requirements.
An employer that fails to provide this notice must allow its employees to be treated by their physician of choice for any injuries that occur during the time the notice is not displayed.
In addition to the posting requirement, employers must provide the same information to new employees at the time of hiring (or by the end of their first pay period). New employees must also receive instructions on:
- How to obtain appropriate medical care for job-related injuries;
- The role and function of the primary treating physician; and
- How to obtain and submit the form the employee must use to notify the employer he or she wants to use a personal physician.
- If an employer is insured, the insurance carrier is responsible for providing the employer with copies of a notice that contains all the required information for new employees.
INJURY Reporting Requirements
Under the WCA, employers have reporting obligations any time an employee sustains a work-related condition that results in:
- Lost work time beyond the employee’s work shift at the time of injury; or
- Medical treatment beyond first aid.
For this purpose, “first aid” means any one-time treatment and any follow-up visit for observation of minor scratches, cuts, burns, splinters, or other minor industrial injuries that do not ordinarily require medical care. Treatment that meets this definition is still considered “first aid” even if it is provided by a medical professional.
Effective Jan. 1, 2017
, workers’ compensation insurance carriers are required to report all work-related injuries, including those that involve only first aid with no lost work time
, to the California Workers’ Compensation Insurance Rating Bureau
(WCIRB). The WCIRB uses this information to, among other things, help determine an employer’s premium rates for workers’ compensation insurance.
However, this change does not affect an employer’s injury-reporting obligations under the WCA. An employer may chose, but is still not required, to report injuries that do not result in lost work time or treatment beyond first aid.
When an employee incurs medical expenses for first aid, the billing medical provider has an obligation to report the treatment to both the DIR and the employer’s insurance carrier. The medical provider’s report (or an employer’s voluntary report of a first-aid-only injury for which no medical expenses are incurred) is what triggers an insurance carrier’s obligation to report the claim to the WCIRB under the new rule.
This reduces an insured employer’s incentive to pay medical bills for first-aid-only treatment out of pocket instead of allowing its workers’ compensation insurance carrier to cover the expenses, because these types of claims can now affect an employer’s premium rates regardless of how the first-aid treatment expenses are paid.Â Â
Within one working day after an employer receives notice or first obtains knowledge of an employee’s work-related injury that results in lost work time or medical treatment beyond first aid, the employer must:
- Provide the employee with Form DWC 1 (“Workers’ Compensation Claim Form & Notice of Potential Eligibility”);
- Ask the employee to complete the employee section of form DWC 1 and return it to the employer;
- Complete the employer section of the form; and
- Within one working day after receiving the form back from the employee, submit the fully completed form to its insurance carrier (or directly to the DIR, if the employer is self-insured) and provide a copy to the employee.
In addition, employers must fill out Form DLSR 5020 (“Employer’s Report of Occupational Injury or Illness”) and send it to their insurance carriers or claims administrators within five days after first receiving notice or obtaining knowledge of an injury.
In the event that an employee becomes the victim of a crime while on an employer’s premises, the employer must provide written notice to the employee, within one day of the crime, stating that he or she is eligible for benefits resulting from physical and psychiatric injuries.
Reporting for self-insured employers
When employers secure coverage with a policy from an insurance company, the insurance company will work with the employer on preparing, maintaining and submitting reports and records that the DWC requires to monitor compliance with California law.
An employer that decides to self-insure, however, must meet certain reporting obligations on its own. One of these obligations is to file an annual report as prescribed by the DWC. Annual reports must show:
- The amount of all compensation claims;
- The amount of benefits paid to date;
- An estimated amount of future liability on open claims under state and federal laws;
- The average number of employees and the total wages for each adjusting location;
- A list of all open indemnity claims; and
- The amount of security deposit made by the employer.
Please see the DWC website or contact Scurich Insurance for more information on workers’ compensation laws in California.
State health insurance mandates are laws regulating the terms of coverage for insured health plans. Mandates can affect various parts of health insurance plans as follows:
- Benefit mandates require health insurance plans to cover specific treatments, services or procedures. In some cases, however, benefit mandates require issuers to offer coverage for specific treatments, services or procedures to employers for purchase.
- Provider mandates require health insurance plans to pay for services provided by specific health care professionals. Often, provider mandates are in the form of nondiscrimination mandates that require coverage only if the health plan already reimburses services within the scope of the health care professional’s practice.
- Person mandates require health insurance plans to cover specific categories of people.
Additional mandates for health plans exist at the federal level. For instance, effective for plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) requires non-grandfathered plans in the small group and individual markets to provide coverage for items and services designated as “essential health benefits.” Health plan sponsors and issuers should work with their advisors to determine how to comply with applicable federal and state mandates.
California has a divided legal and regulatory system for health insurance plans. The Department of Managed Health Care (DMHC) regulates health care service plans, which include managed care plans such as health maintenance organizations (HMOs) and certain preferred provider organizations (PPOs). The California Department of Insurance (CDI) regulates health insurance policies.
This Employment Law Summary contains a chart outlining California’s benefit, provider and person mandates for insured group health plans. Please keep in mind that the following chart does not address federal benefit mandates, such as the ACA’s mandates.
Health insurance policies must offer coverage for expenses incurred as a result of treatment by acupuncturists. Mandate to offer coverage also applies to health care service plans, except health maintenance organizations (HMOs).
Health insurance policies and health care service plans must offer coverage for the treatment of alcoholism.
Asthma Management (Pediatric)
Health care service plans that cover outpatient prescription drugs must include coverage for the following when medically necessary for the management and treatment of pediatric asthma:
- Inhaler spacers;
- Nebulizers, including face masks and tubing; and
- Peak flow meters.
Education for pediatric asthma must be consistent with current professional medical practice. These pediatric asthma benefits must be provided under the same general terms and conditions, including copayments and deductibles, applicable to all other benefits provided by the plan.
Behavioral Health Treatment for Autism and Related Disorders (Effective July 1, 2012)
Health insurance policies and health care service plans must provide coverage for behavioral health treatment for pervasive developmental disorder or autism.
â€śBehavioral health treatmentâ€ť means professional services and treatment programs (including applied behavior analysis and evidence-based behavior intervention programs) that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:
- The treatment is prescribed by a licensed physician or is developed by a licensed psychologist;
- The treatment is provided under a treatment plan prescribed by a qualified autism service provider;
- The treatment is administered by a qualified autism service provider or by a qualified autism service professional or paraprofessional who is employed and supervised by the qualified autism service provider;
- The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated; and
- The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care or educational services and is not used to reimburse a parent for participating in the treatment program.
These benefits may be subject to case management, network providers, utilization review techniques, prior authorization, copayments or other cost sharing.
Insurers and plans subject to this mandate must maintain an adequate network that includes qualified autism service providers who supervise and employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment.
A â€śqualified autism service providerâ€ť means either of the following:
- A person, entity or group that is certified by a national entity (such as the Behavior Analyst Certification Board), that is accredited by the National Commission for Certifying Agencies, and that designs, supervises or provides treatment for pervasive developmental disorder or autism; or
- A person licensed as a physician, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist or audiologist who designs, supervises or provides treatment for pervasive developmental disorder or autism.
This mandate will expire on Jan. 1, 2017, unless a law is enacted before then to extend this mandate.
Blood Lead Levels Screening for Children
Health insurance policies and health care service plans must offer coverage for blood lead level screening for children.
Breast Cancer â€“ Screening, Diagnosis and Treatment
Health insurance policies and health care service plans must provide coverage for breast cancer screening, diagnosis and treatment. Breast cancer screening and diagnosis must be covered consistent with generally accepted medical practice and scientific evidence, upon the referral of the insuredâ€™s or enrolleeâ€™s physician.
Breast cancer treatment includes coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery must be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits.
Cancer Clinical Trials â€“ Routine Patient Care
Health insurance policies and health care service plans must provide coverage for all routine patient care costs for an insured or enrollee diagnosed with cancer and accepted into a phase I, phase II, phase III or phase IV clinical trial for cancer, if the treating physician recommends participation in the clinical trial after determining that participation in the clinical trial has a meaningful potential to benefit the insured or enrollee.
Copayments and deductibles must be consistent with those applied to the same services when they are not delivered in a clinical trial.
Cancer Screening Tests Health insurance policies and health service plans must provide coverage for all generally medically accepted cancer screening tests.
Cervical Cancer Screening
Health insurance policies and health care service plans that include coverage for treatment or surgery of cervical cancer must provide coverage for an annual cervical cancer screening test. This coverage includes the conventional Pap test, a human papillomavirus screening test that is approved by the federal Food and Drug Administration (FDA) and the option of any cervical cancer screening test approved by the federal FDA, upon the referral of the patient’s health care provider.
Health insurance policies and health care service plans that provide coverage for outpatient prescription drugs must include coverage for a variety of federal FDA-approved prescription contraceptive methods, under the same terms and conditions as applicable to all benefits. There is an exception for religious employers.
Health insurance policies and health care service plans must 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:
- Blood glucose monitors and blood glucose testing strips;
- Blood glucose monitors designed to assist the visually impaired;
- Insulin pumps and all related necessary supplies;
- Ketone urine testing strips;
- Lancets and lancet puncture devices;
- Pen delivery systems for the administration of insulin;
- Podiatric devices to prevent or treat diabetes-related complications;
- Insulin syringes; and
- Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin.
Health insurance policies and health care service plans that cover prescription benefits must include coverage for the following medically necessary prescription items:
- Prescriptive medications for the treatment of diabetes; and
The coinsurances and deductibles for these benefits cannot exceed those established for similar benefits under the policy.
Health insurance policies and health care service plans must provide coverage for diabetes outpatient self-management training, education and medical nutrition therapy necessary to enable an insured to properly use the diabetes equipment, supplies and medications. The coinsurances and deductibles may not exceed those established for physician office visits.
Health insurance issuers must also offer coverage for diabetic daycare self-management education programs (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).
Health insurance policies and health care service plans cannot contain any exclusion, reduction or other limitations, as to coverage, deductibles or coinsurance provisions applicable solely to conditions attributable to diethylstilbestrol or exposure to diethylstilbestrol.
Emergency Medical Transportation
Health insurance policies that provide coverage for emergency health care services must include coverage for ambulance services provided through the â€ś911â€ť emergency response system. A similar coverage mandate applies to health care service plans.
Foot Disfigurement â€“ Special Footwear
Health insurance policies and health care service plans must offer coverage for special footwear needed by persons who suffer from foot disfigurement (such as disfigurement from cerebral palsy, arthritis, polio, spina bifida and diabetes and foot disfigurement caused by accident or developmental disability).
General Anesthesia and Facility Charges for Dental Procedures
Health insurance policies and health care service plans must cover general anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center setting, when the clinical status or underlying medical condition of the patient requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital or surgery center setting. This coverage mandate applies to an insured or enrollee:
- Who is under seven years of age;
- Who is developmentally disabled, regardless of age; or
- Whose health is compromised and for whom general anesthesia is medically necessary, regardless of age.
HIV/AIDS, AIDS Vaccine
Health insurance policies and health care service plans must provide coverage for a vaccine for acquired immune deficiency syndrome (AIDS) that is approved for marketing by the federal FDA and is recommended by the United States Public Health Service.
HIV/AIDS, HIV Testing
Health insurance policies and health care service plans must provide coverage for human immunodeficiency virus (HIV) testing, regardless of whether the testing is related to a primary diagnosis.
HIV/AIDS, Transplantation Services
Health insurance policies and health care service plans cannot deny coverage that is otherwise available for the costs of solid organ or other tissue transplantation services because the insured or enrollee is HIV positive.
Home Health Care
Health insurance policies must offer benefits for home health care by a licensed home health agency. (In certain rural areas, the services of visiting nurses, if available, may be substituted for the services of a home health agency.)
Home health services consist of the following:
- Part-time or intermittent skilled nursing services provided by a registered nurse or licensed vocational nurse;
- Part-time or intermittent home health aide services that provide supportive services in the home under the supervision of a registered nurse or a physical, speech or occupational therapist;
- Physical, occupational or speech therapy; and
- Medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services, and laboratory services to the extent such charges or costs would have been covered under the policy if the insured person had remained in the hospital.
The number of covered home health visits cannot be less than 100 visits in any year for each person covered under the policy. Home health care benefits may be subject to an annual deductible of not more than $50 and coinsurance not less than 80 percent of the reasonable charges for the home health care services.
Health care service plans must include a provision for hospice care. In general, the hospice care benefits must be at least equivalent to the hospice care provided under Medicare.
Health insurance policies and health care service plans (except health maintenance organizations offering coverage to employers with less than 20 employees) must offer coverage for infertility treatment, except in vitro fertilization. Infertility treatments include procedures consistent with established medical practices in the treatment of infertility by licensed physicians, such as diagnosis, diagnostic tests, medication, surgery and gamete intrafallopian transfer. There is an exception for religious organizations.
Effective Jan. 1, 2014, coverage for the treatment of infertility must be offered and, if purchased, provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex or sexual orientation.
Intoxicants/Controlled Substances â€“ Exclusion Prohibited
Health insurance policies may not contain a general exclusion for when the insured is intoxicated or under the influence of any controlled substance.
Jawbone or Associated Bone Joints Health insurance policies must cover medically necessary surgical procedures for covered conditions that directly affect the upper or lower jawbone or associated bone joints. A similar coverage mandate applies to health service plans.
Health insurance policies must provide the following mammogram coverage (upon the referral of a nurse practitioner, certified nurse midwife, physician assistant or physician) for breast cancer screening or diagnostic purposes:
- A baseline mammogram for women ages 35 to 39;
- A mammogram for women ages 40 to 49 every two years or more frequently based on a physician’s recommendation; and
- A mammogram every year for women ages 50 and over.
A mammography coverage mandate also applies to health service plans.
Maternity Benefits Health insurance policies and health care service plans that provide maternity coverage cannot:
- Contain a copayment or deductible for inpatient hospital maternity services that exceeds the most common amount for other covered inpatient services; or
- Contain a copayment or deductible for ambulatory care maternity services that exceeds the most common amount for ambulatory care services provided for other covered medical conditions.
In addition, if a policy or plan has covered a person continuously from conception, it cannot contain any exclusion, reduction or other limitations as to coverage, deductibles or coinsurance provisions for involuntary complications of pregnancy, unless the provisions apply generally to all benefits paid under the policy or plan. Involuntary complications of pregnancy include: puerperal infection; eclampsia; cesarean section delivery; ectopic pregnancy; and toxemia.
See below for the maternity benefit mandate for health insurance policies that becomes effective on July 1, 2012.
Health insurance policies must provide coverage for maternity services for all insureds covered under the policy.
â€śMaternity servicesâ€ť include: prenatal care; ambulatory care maternity services; involuntary complications of pregnancy; neonatal care; and inpatient hospital maternity care, such as labor and delivery and postpartum care. Also, the covered maternity services must be consistent with the scope of benefits under the ACAâ€™s maternity benefit requirement.
Maternity Benefits â€“ Minimum Length of Stay
Health insurance policies and health care service plans that provide maternity coverage cannot restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section. However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if:
- The early discharge decision is made by the treating physician in consultation with the mother; and
- A post-discharge follow-up visit for the mother and newborn within 48 hours of discharge, when prescribed by the treating physician, is covered.
Maternity Benefits – Prenatal Diagnosis of Genetic Disorders Health insurance policies and health care service plans that provide maternity benefits must offer coverage for prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy.
Maternity Benefits – Prenatal Testing Program (Expanded Alpha Feto Protein Program)
Health insurance policies and health service plans that provide maternity benefits must cover participation in the Expanded Alpha Feto Protein (AFP) program, which is a statewide prenatal testing program administered by the California Department of Health Services.
Mastectomy and Lymph Node Dissection
Health insurance policies and health service plans that provide coverage for mastectomies and lymph node dissections must:
- Allow the length of hospital stay to be determined by the attending physician in consultation with the patient (post-surgery), consistent with sound clinical principles and processes;
- Cover prosthetic devices or reconstructive surgery, including devices or surgery to restore and achieve symmetry for the patient incident to the mastectomy; and
- Cover all complications from a mastectomy, including lymphedema.
Coverage for prosthetic devices and reconstructive surgery must be subject to the deductible and coinsurance conditions applicable to other benefits.
Mental and Nervous Disorders
Health insurance policies must offer coverage for mental or nervous disorders.
Mental Illness â€“ Severe Mental Illness and Serious Emotional Disturbances of Children
Health insurance policies and health care service plans must provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child under the same terms and conditions applied to other medical conditions. These benefits must include: outpatient services; inpatient hospital services; partial hospital services; and prescription drugs, if the policy or plan includes coverage for prescription drugs.
The maximum lifetime benefits, copayments, coinsurance and deductibles for these benefits must be applied equally to all benefits under the policy or plan.
â€śSevere mental illnessesâ€ť include: schizophrenia; schizoaffective disorder; bipolar disorder (manic-depressive illness); major depressive disorders; panic disorder; obsessive-compulsive disorder; pervasive developmental disorder or autism; anorexia nervosa; and bulimia nervosa.
The federal Mental Health Parity and Addiction Equity Act (MHPAEA) creates additional parity requirements for employers with more than 50 employees that offer mental health or substance use disorder benefits in their group health plans. Depending on a planâ€™s design, the MHPAEA may require stricter parity requirements than state law mandates. Also, beginning in 2014, the ACA requires non-grandfathered health plans in the individual and small group markets to cover mental health and substance use disorder services and comply with the federal parity law.
Orthotic and Prosthetic Devices and Services
Health insurance policies must offer coverage for orthotic and prosthetic devices and services, which must include original and replacement devices. The benefit amount cannot be less than the annual and lifetime benefit maximums applicable to all benefits in the policy. Any copayment, coinsurance, deductible and maximum out-of-pocket amount cannot be more than the most common amounts contained in the policy.
A similar mandate applies to health care service plans.
Health insurance policies and health care service plans must include coverage for services related to diagnosis, treatment and appropriate management of osteoporosis. The services may include all federal FDA-approved technologies, including bone mass measurement technologies as deemed medically appropriate.
Pain Management Medication for Terminally Ill Patients
Health care service plans that cover prescription drug benefits must provide coverage for appropriately prescribed pain management medications for terminally ill patients when medically necessary.
Health insurance policies and health care service plans must provide coverage for the testing and treatment of phenylketonuria (PKU). PKU coverage must include formulas and special food products that are part of a diet prescribed by a licensed physician, provided that the diet is deemed medically necessary to avert the development of serious physical or mental disabilities or to promote normal development or function as a consequence of PKU. Benefits are payable only to the extent that the cost of necessary formulas and special food products exceeds the cost of a normal diet.
Prescription Drugs â€“ Coverage for Drugs Approved Before July 1, 1999
Health care service plans that cover prescription drug benefits cannot limit or exclude coverage for a drug that was previously approved for coverage by the plan for an enrolleeâ€™s medical condition if the plan’s prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition.
Prescription Drugs â€“ Off-Label Use Health insurance policies and health care service plans that cover prescription drugs cannot limit or exclude coverage for the off-label use of a drug, provided the drug:
- Is approved by the FDA;
- Is prescribed for the treatment of a life-threatening condition or a chronic and seriously debilitating condition (provided the drug is medically necessary to treat that condition and the drug is on the insurer’s formulary, if any); and
- Has been recognized for treatment of that condition by the American Hospital Formulary Service’s Drug Information or certain medical compendia.
Preventive Care for Children – Age 16 and Younger Health insurance policies and health care service plans must provide benefits for the comprehensive preventive care of children 16 years of age or younger.
Covered benefits must include:
- Periodic health evaluations;
- Immunizations; and
- Laboratory services in connection with periodic health evaluations.
Preventive Care of Children – Age 17 or 18
Health insurance policies and health care service plans must offer benefits for the comprehensive preventive care of children 17 and 18 years of age. Benefits must be offered for the following:
- Periodic health evaluations;
- Immunizations; and
- Laboratory services in connection with periodic health evaluations.
Prostate Cancer â€“ Screening and Diagnosis
Health insurance plans and health care service plans must cover the screening and diagnosis of prostate cancer, including prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice.
Prosthetic Devices for Laryngectomy
Health insurance policies and health care service plans that cover the surgical procedure known as a laryngectomy (removal of the larynx for medically necessary reasons) must include coverage for prosthetic devices to restore a method of speaking.
Reconstructive Surgery (Including Cleft Palate)
Health insurance policies and health care service plans must cover reconstructive surgery. â€śReconstructive surgeryâ€ť means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It must be performed to either improve function or create a normal appearance, to the extent possible. This mandate does not cover cosmetic surgery.
This mandate also includes coverage for medically necessary dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures. â€śCleft palateâ€ť means a condition that may include cleft palate, cleft lip or other craniofacial anomalies associated with cleft palate.
This mandate does not require coverage for cosmetic surgery, which is surgery performed to alter or reshape normal structures of the body to improve the patientâ€™s appearance.
Sterilization Rationale Exclusion
Health insurance policies and health care service plans that cover all or part of the cost of a sterilization operation or procedure cannot include any exclusion, reduction or limitation on this benefit based upon the covered personâ€™s reason for requesting sterilization.
Health policy insurers must offer coverage for expenses incurred as a result of treatment by acupuncturists. Mandate to offer coverage also applies to health care service plans, except health maintenance organizations (HMOs). Acupuncturists are also subject to a nondiscrimination mandate, to the extent a policy or plan covers acupuncture.
A nondiscrimination mandate requires coverage if the health policy or plan reimburses services within the scope of the health care professionalâ€™s practice.
Advanced Practice Registered Nurse
Nondiscrimination mandate. To be covered under mandate, the nurse must be certified as a clinical nurse specialist and participate in expert clinical practice in the specialty of psychiatric-mental health nursing.
Autism Service Providers
For purposes of the behavioral health treatment mandate, a â€śqualified autism service providerâ€ť means either of the following:
- A person, entity or group that is certified by a national entity (such as the Behavior Analyst Certification Board), that is accredited by the National Commission for Certifying Agencies, and that designs, supervises or provides treatment for pervasive developmental disorder or autism; or
- A person licensed as a physician, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist who designs, supervises or provides treatment for pervasive developmental disorder or autism.
Clinical Social Worker
Marriage and Family Therapists
â€śMarriage and family therapistâ€ť 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.
Professional Clinical Counselor
A â€śprofessional clinical counselorâ€ť means a licensed professional clinical counselor who has received specific instruction in assessment, diagnosis, prognosis, counseling and psychotherapeutic treatment of mental and emotional disorders.
Registered Dispensing Optician
To be covered under mandate, a nurse must possess a master’s degree in psychiatric-mental health nursing and be listed as a psychiatric-mental health nurse by the Board of Registered Nursing.
Respiratory Care Practitioner
Therapists â€“ Occupational, Physical and Speech-Language
Continuation Coverage (Cal-COBRA)
Insurers that provide coverage under a group plan to a small employer (employers with fewer than 20 employees) must offer continuation coverage to a qualified beneficiary when a qualifying event occurs. The maximum coverage period is 36 months. The coverage must generally be provided under the same terms and conditions that apply to similarly situated individuals under the group plan.
A â€śqualified beneficiaryâ€ť means any individual who, on the day before the qualifying event, is covered under the group plan and has a qualifying event.
â€śQualifying eventâ€ť means any of the following events that, but for the election of continuation coverage, would result in a loss of coverage:
- The covered employeeâ€™s death;
- The covered employeeâ€™s termination of employment or reduction in hours (except for terminations due to gross misconduct);
- The covered employeeâ€™s divorce or legal separation from his or her spouse;
- A dependentâ€™s loss of dependent status; and
- With respect to a covered dependent only, the covered employee’s entitlement to benefits under Medicare.
In addition, an insurer must offer a coverage extension to an insured or enrollee who has exhausted his or her 18 months (or longer in special circumstances) of federal COBRA coverage. The extension may be for up to 36 months from the date the individualâ€™s continuation coverage began.
Dependent Child â€“ Limiting Age
For health insurance policies and health care service plans that provide dependent coverage, the limiting age for dependent children cannot be less than age 26.
However, for plan years beginning before Jan. 1, 2014, a health insurance policy or health care service plan with grandfathered status under the federal health care reform law may exclude from coverage an adult child who has not attained 26 years of age if the adult child is eligible to enroll in an eligible employer-sponsored health plan, other than a group health plan of a parent.
Dependent Child â€“ Not Residing with Employee
Health insurance policies and health care service plans cannot exclude a dependent child from eligibility or benefits solely because the dependent child does not reside with the employee.
Dependent Child â€“ Students
If a health insurance policy or health care service 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 conditions must apply to the coverage:
- Any break in the school calendar cannot disqualify the dependent child from coverage;
- If the dependent child takes a medical leave of absence and the child’s condition renders him or her incapable of self-sustaining employment, the childâ€™s coverage must continue if he or she is chiefly dependent on the policyholder or subscriber for support and maintenance;
- If the dependent child takes a medical leave of absence from school (but the dependent child’s condition does not fall under the paragraph above) the child’s coverage cannot terminate for a period of 12 months or until the date coverage is scheduled to terminate pursuant to the policyâ€™s or planâ€™s terms, whichever comes first.
If a plan or policy has a limiting age for dependent coverage, coverage must continue past the limiting age for a child who is (and continues to be) both incapable of self-sustaining employment by reason of an intellectual disability or physical handicap and chiefly dependent upon the insured for support and maintenance.
Domestic Partner Coverage
Health insurance policies and health care service plans must provide equal coverage to the registered domestic partner of an employee, insured, policyholder or subscriber to the same extent, and subject to the same terms and conditions, as provided to a spouse. In addition, policies and plans cannot discriminate in coverage between spouses or domestic partners of a different sex and spouses or domestic partners of the same sex.
Newborns and Adopted Minors
Health insurance policies and health care service plans that provide dependent coverage must provide coverage for newborn infants from and after the moment of birth and for any minor child placed for adoption from and after the moment the child is placed for adoption.
Persons with Dementia
Except for a preexisting condition, health insurance policies and health care service plans that provide coverage for long-term care facility services or home-based care cannot excluded covered persons from this coverage if they are diagnosed as having any significant destruction of brain tissue with resultant loss of brain function (such as Alzheimerâ€™s disease and other progressive, degenerative and dementing illnesses).
*While many of the mandates described in the above chart are applicable to managed care plans, such as health maintenance organizations (HMOs) and certain preferred provider organizations (PPOs), managed care plans may be subject to additional requirements under California statutes and regulations that are not specifically addressed in the above chart. In addition, the chart focuses on mandates applicable to health insurance plans sponsored by private employers, and does not address mandates specifically applicable to the health benefits provided by government employers.
California statutes: www.legislature.ca.gov Â
California Department of Insurance: www.insurance.ca.gov
California Department of Managed Care: www.dmhc.ca.gov Â