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<ns0:Id>20250SB__128098AMD</ns0:Id>
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<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-20</ns0:ActionDate>
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<ns0:ActionText>AMENDED_SENATE</ns0:ActionText>
<ns0:ActionDate>2026-03-24</ns0:ActionDate>
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<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Senator Valladares</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Valladares</ns0:Name>
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<ns0:Title> An act to amend Section 1374.72 of the Health and Safety Code, and to amend Section 10144.5 of the Insurance Code, relating to health care.</ns0:Title>
<ns0:RelatingClause>health care</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Health care coverage for mental health and substance use disorders.</ns0:Subject>
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<html:p>Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of disability insurers by the Department of Insurance. Existing law requires a health care service plan contract or disability insurance policy issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions. Existing law requires a plan or insurer, if services for the medically necessary treatment of a mental health or substance use disorder are not available in network
within the geographic and timely access standards set by law or regulation, to arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. Existing law prohibits an enrollee or insured from paying an out-of-network provider more than the same cost sharing that the individual would pay for the same covered services received from an in-network provider.</html:p>
<html:p>This bill would require a health care service plan or disability insurer to reimburse a noncontracting individual health professional the greater of the average contracted rate or 125% of the amount Medicare reimburses for similar services, as specified, for out-of-network services that are provided as described above. The bill would prohibit an enrollee or insured from owing the health professional more than the in-network cost-sharing amount, and would
prohibit the health professional from billing or collecting an amount from the enrollee or insured that is more than that amount. The bill would require any communication from the health professional to an enrollee or insured, before the receipt of information about the amount the individual owes for services provided, to include a notice informing the individual that it is not a bill and not to pay until they are informed by their plan or insurer of any applicable cost sharing. The bill would require a plan or insurer to inform an enrollee or insured and the noncontracting individual health professional of the in-network cost-sharing amount owed by the individual at the time of payment by the plan or insurer to the health professional. Under the bill, the payments made by the plan or insurer and enrollee or insured pursuant to these provisions would constitute full payment. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated
local program.</html:p>
<html:p>The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.</html:p>
<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
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<ns0:Num>SECTION 1.</ns0:Num>
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Section 1374.72 of the
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is amended to read:
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<ns0:Num>1374.72.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
For purposes of this section, “mental health and substance use disorders” means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders or the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
For purposes of this section, “medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that
illness, injury, condition, or its symptoms, in a manner that is all of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
In accordance with the generally accepted standards of mental health and substance use disorder care.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Clinically appropriate in terms of type, frequency, extent, site, and duration.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
For purposes of this section, “health care provider” means any of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
A qualified autism service provider certified by a national entity as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
An associate professional clinical counselor
or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
A psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
A registered psychological associate, as described in Section 2913 of the Business and Professions Code.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
A psychology trainee or person
supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
For purposes of this section, “generally accepted standards of mental health and substance use disorder care” has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an
enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plan’s subsequent rescission, cancellation, or modification of the enrollee’s or subscriber’s contract, or the plan’s subsequent determination that it did not make an accurate determination of the enrollee’s or subscriber’s eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
The benefits that shall be covered
pursuant to this section shall include, but not be limited to, the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Basic health care services, as defined in subdivision (b) of Section 1345.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Prescription drugs, if the plan contract includes coverage for prescription drugs.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Maximum annual and
lifetime benefits, if not prohibited by applicable law.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Copayments and coinsurance.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Individual and family deductibles.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Out-of-pocket maximums.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
For the purposes of this subdivision, the following terms have the following meanings:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
“Arrange coverage to ensure the delivery of medically necessary out-of-network services” includes providing services to secure medically
necessary out-of-network options that are available to the enrollee within geographic and timely access standards.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
“Average contracted rate” means the average of the contracted commercial rate paid by the plan or delegated entity for the same or similar services in the geographic region.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the
maximum extent possible, meet those geographic and timely access standards.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
For services rendered pursuant to this subdivision, unless otherwise agreed to by the noncontracting individual health professional and the plan, the plan shall reimburse the greater of the average contracted rate or 125 percent of the amount
Medicare reimburses on a fee-for-service basis for the same or similar services in the general geographic region in which the services were rendered.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
An enrollee shall not owe the noncontracting individual health professional more than the in-network cost-sharing amount for services provided pursuant to this subdivision as determined by the plan.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
A noncontracting individual health professional shall not bill or collect an amount from the enrollee for services rendered pursuant to this subdivision that is more than the in-network cost-sharing amount as determined by the plan.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Any communication from the noncontracting individual health professional to the enrollee before the receipt of information
about the amount the enrollee owes for services provided as described in this subdivision shall include a notice in 12-point or larger bold type stating that the communication is not a bill and informing the enrollee that the enrollee shall not pay until they are informed by their plan of any applicable cost sharing.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
At the time of payment by the plan to the noncontracting individual health professional, the plan shall inform the enrollee and the noncontracting individual health professional of the in-network cost-sharing amount owed by the enrollee.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
A payment made by the health care service plan to the noncontracting health care professional pursuant to this section, in addition to the applicable cost sharing owed by the enrollee, shall constitute a payment in full
for services rendered.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
This section shall not apply to contracts entered into pursuant to 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, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A health care service plan shall provide
the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case
management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
This section shall not be construed to deny or restrict in any way the department’s authority to ensure plan compliance with this chapter.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those
services should be or could be covered by a public entitlement program.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.
</html:p>
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<ns0:Num>SEC. 2.</ns0:Num>
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Section 10144.5 of the
<ns0:DocName>Insurance Code</ns0:DocName>
is amended to read:
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<ns0:Num>10144.5.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
For purposes of this section, “mental health and substance use disorders” means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, or
that is listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders or the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
For purposes of this section, “medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating
an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
In accordance with the generally accepted standards of mental health and substance use disorder care.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Clinically appropriate in terms of type, frequency, extent, site, and duration.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
“Health care
provider” means any of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
A qualified autism service provider certified by a national entity as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
An
associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
A psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of Division 2 of the Business and Professions Code.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
For purposes of this section, “generally accepted standards of mental health and substance use disorder care” has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section
10144.52.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurer’s subsequent rescission, cancellation, or modification of the insured’s or policyholder’s contract, or the insurer’s subsequent determination that it did not make an accurate determination of the insured’s or policyholder’s eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Basic
health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Prescription drugs, if the policy includes coverage for prescription drugs.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:
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(1)
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Maximum and annual lifetime benefits, if not prohibited by applicable law.
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(2)
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Copayments and coinsurance.
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(3)
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Individual and family deductibles.
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(4)
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Out-of-pocket maximums.
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(d)
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(1)
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For the purposes of this subdivision, the following terms have the following meanings:
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(A)
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“Arrange coverage to ensure the delivery of medically necessary out-of-network services” includes providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access
standards.
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(B)
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“Average contracted rate” means the average of the contracted commercial rate paid by the plan or delegated entity for the same or similar services in the geographic region.
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(2)
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If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards.
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(3)
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For services rendered pursuant to this subdivision, unless otherwise agreed to by the noncontracting individual health professional and the insurer, the insurer shall reimburse the greater of the average contracted rate or 125 percent of the amount Medicare reimburses on a fee-for-service basis for the same or similar services in the general geographic region in which the services were rendered.
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(4)
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An insured shall not owe the noncontracting individual health professional more than the in-network cost-sharing amount for services provided pursuant to this subdivision as determined by the insurer.
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(5)
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A noncontracting individual health professional shall not bill or collect an amount from the insured for
services rendered pursuant to this subdivision that is more than the in-network cost-sharing amount as determined by the insurer.
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(6)
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Any communication from the noncontracting individual health professional to the insured before the receipt of information about the amount the insured owes for services provided as described in this subdivision shall include a notice in 12-point or larger bold type stating that the communication is not a bill and informing the insured that the insured shall not pay until they are informed by their insurer of any applicable cost sharing.
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(7)
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At the time of payment by the insurer to the noncontracting individual health professional, the insurer shall inform the insured and the noncontracting individual health professional of the in-network cost-sharing amount owed by the insured.
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(8)
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A payment made by the insurer to the noncontracting health care professional pursuant to this section, in addition to the applicable cost sharing owed by the insured, shall constitute a payment in full for services rendered.
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(e)
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This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.
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(f)
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(1)
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For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.
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(2)
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A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.
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(3)
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Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.
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(g)
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This section shall not be construed to deny or restrict in any way the department’s authority to ensure a disability insurer’s compliance with this code.
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(h)
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A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social
Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.
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(i)
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A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.
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(j)
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If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not
to exceed ten thousand dollars ($10,000) for each violation.
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<ns0:Num>SEC. 3.</ns0:Num>
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No reimbursement is required by this act pursuant to Section 6 of Article XIII
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B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII
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B of the California Constitution.
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