California Code of Regulations
Title 10 - Investment
Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California)
Article 3 - Benefits
Section 2699.6209 - Enrollee Share of Cost for Health Benefits
Universal Citation: 10 CA Code of Regs 2699.6209
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
Every participating carrier shall require copayments and deductibles for health benefits provided to enrollees subject to the following:
(a) For enrollees in health maintenance organizations, exclusive provider organizations, preferred provider organizations, health maintenance organizations with a point of service option, and exclusive provider organizations with a point of service option, the sum of the in-network copayments and deductibles shall not exceed $2,000 in a benefit year for an enrollee or $4,000 in a benefit year for an enrolled sole employee and enrolled dependents or for a guaranteed association member and enrolled dependents for covered benefits and services provided by a provider who contracts with the carrier to provide health care benefits and services. In any benefit year that an enrollee has paid the maximum copayments described in Section 2699.6209(b)(4)(B)(1)(a) or Section 2699.6209(b)(4)(D)(1)(a), the enrollee shall be deemed to have met the maximum in -network copayment requirement described in this section. For enrollees in indemnity plans the sum of all copayments and deductibles shall not exceed $2,000 in a benefit year for an enrollee or $4,000 in a benefit year for an enrolled sole employee and enrolled dependents or for a guaranteed association member and enrolled dependents for covered benefits and services.
(b) Participating carriers shall offer two options for enrollee share of cost: a standard option and a preferred option.
(1) In the
case of participating carriers which are health maintenance organizations or
exclusive provider organizations:
(A) A preferred
option shall consist of the following elements:
1.
A $5 copayment per visit for office or home visits, with the following exceptions:
a. treatment for infertility, including tests,
shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate
of payment, and
b. outpatient mental
health visits shall be subject to a $20 per visit copayment;
2. A $10 copayment per outpatient prescription for
up to a 31 day supply of a prescription drug. A $10 copayment shall apply to
additional supplies of the prescription in up to 31 day increments. However this
amount shall be $5 per prescription for up to a 31 day supply of a prescription drug
when a generic prescription drug is utilized or when a participating carrier has a
mandatory generic prescription drug substitution program which has been approved by
the program. A $5 copayment shall apply to additional supplies of such a
prescription in up to 31 day increments.
An exception to the above is that a $20 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $10 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.
3. A $50 copayment
whenever use of a hospital emergency room does not result in admission to a
hospital.
(B) A standard
option shall consist of the following elements:
1.
A $15 copayment per visit for office or home visits, with the following exceptions:
a. treatment for infertility, including tests,
shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate
of payment; and
b. visits for prenatal
care and pediatric visits up to the age of two (2) will be subject to a $5 copayment
per visit; and
c. outpatient mental
health visits shall be subject to a $20 per visit copayment;
2. A $15 copayment per outpatient prescription for
up to a 31 day supply of a prescription drug. A $15 copayment shall apply to
additional supplies of the prescription in up to 31 increments. However this amount
shall be $10 per prescription for up to a 31 day supply of a prescription drug when
a generic prescription drug is utilized or when a participating carrier has a
mandatory generic prescription drug substitution program which has been approved by
the program. A $10 copayment shall apply to additional supplies of such a
prescription in up to 31 day increments.
An exception to the above is that a $30 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $20 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.
3. A $100 copayment for
each hospital or skilled nursing facility admission; and
4. A $50 copayment whenever use of a hospital
emergency room does not result in admission to a
hospital.
(2) In the
case of participating carriers which are preferred provider organizations:
(A) A preferred option shall consist of the
following elements:
1. A copayment which shall be
20% of the contracted rate for covered benefits and services provided by a provider
who contracts with the preferred provider organization to provide health care
benefits and services other than outpatient prescription drugs, with the following
exceptions:
a. treatment for infertility
(including tests) provided by a provider who contracts with the preferred provider
organization to provide health care benefits and services shall be subject to a
copayment of 50% of the carrier's contracted rate of payment, and
b. outpatient mental health visits provided by a
provider who contracts with the preferred provider organization to provide health
care benefits and services shall be subject to a copayment of 50% of the carrier's
contracted rate of payment, and
c.
visits for prenatal care and pediatric visits up to the age of two for covered
benefits and services provided by a provider who contracts with the preferred
provider organization to provide health care benefits and services will not be
subject to a copayment.
2. A
copayment which shall be 40% of the scheduled rate of payment established by the
participating carrier for covered benefits and services provided by a provider who
does not contract with the preferred provider organization to provide health care
benefits and services, with the following exceptions:
a. treatment for infertility (including tests)
provided by a provider who does not contract with the preferred provider
organization to provide health care benefits and services shall be subject to a
copayment of 50% of the carrier's scheduled rate of payment.
b. outpatient mental health visits provided by a
provider who does not contract with the preferred provider organization to provide
health care benefits and services shall be subject to a copayment of 50% of the
carrier's scheduled rate of payment.
c.
the copayments described in 2., 2.a. and 2.b. above shall be limited to $5,000 in a
benefit year for an enrollee or $10,000 in a benefit year for an enrolled sole
employee and dependents or guaranteed association members and dependents.
d. enrollees are responsible for 100% of the
charges in excess of the carrier's scheduled rate of payment for health care
benefits and services provided by a provider who does not contract with the
preferred provider organization to provide health care benefits and services. These
amounts are not subject to the limitations in 2.c. on copayment
expenses.
3. A $50 copayment
whenever use of a hospital emergency room does not result in admission to a
hospital;
4. A copayment which shall be
30% of the contracted rate for prescription drugs provided by a provider who
contracts with the preferred provider organization to provide prescription drugs.
However this amount shall be 20% when a generic prescription drug is utilized or
when a participating carrier has a mandatory generic prescription drug substitution
program which has been approved by the program; and a copayment equivalent to that
for a 60 day supply of a prescription shall apply to a 90 day supply of the same
prescription drug. A participating carrier may limit availability of these 90 day
supply discounts to prescriptions obtained through a mail order prescription drug
program; and
5. A deductible which shall
be $250 per enrollee in a benefit year. The deductible may be reduced by an amount
equal to the amount an enrollee with qualifying prior coverage paid toward a
deductible under the qualifying prior coverage for services rendered within the 90
days immediately prior to the enrollee's effective date of enrollment in the
program. Such reduction may only be applied for the first full or partial benefit
year that the enrollee is enrolled in the program.
(B) A standard option shall consist of the
following elements:
1. A copayment which shall be
20% of the contracted rate for covered benefits and services provided by a provider
who contracts with the preferred provider organization to provide health care
benefits and services other than outpatient prescription drugs, with the following
exceptions:
a. treatment for infertility (including
tests) provided by a provider who contracts with the preferred provider organization
to provide health care benefits and services shall be subject to a copayment of 50%
of the carrier's contracted rate of payment, and
b. outpatient mental health visits provided by a
provider who contracts with the preferred provider organization to provide health
care benefits and services shall be subject to a copayment of 50% of the carrier's
contracted rate of payment, and
c.
visits for prenatal care and pediatric visits up to the age of two for covered
benefits and services provided by a provider who contracts with the preferred
provider organization to provide health care benefits and services shall not be
subject to a copayment.
2. A
copayment which shall be 40% of the scheduled rate of payment established by the
participating carrier for covered benefits and services provided by a provider who
does not contract with the preferred provider organization to provide health care
benefits and services, with the following exceptions:
a. treatment for infertility (including tests)
provided by a provider who does not contract with the preferred provider
organization to provide health care benefits and services shall be subject to a
copayment of 50% of the carrier's scheduled rate of payment, and
b. outpatient mental health visits provided by a
provider who does not contract with the preferred provider organization to provide
health care benefits and services shall be subject to a copayment of 50% of the
carrier's scheduled rate of payment, and
c. the copayments described in 2., 2.a. and 2.b.
above shall be limited to $5,000 in a benefit year for an enrollee or $10,000 in a
benefit year for an enrolled sole employee and dependents or guaranteed association
member and dependents, and
d. enrollees
are responsible for 100% of the charges in excess of the carrier's scheduled rate of
payment for health care benefits and services provided by a provider who does not
contract with the preferred provider organization to provide health care benefits
and services. These amounts are not subject to the limitations in 2.c. on copayment
expenses.
3. A $50 copayment
whenever use of a hospital emergency room does not result in admission to a
hospital;
4. A copayment which shall be
30% of the contracted rate for prescription drugs provided by a provider who
contracts with the preferred provider organization to provide prescription drugs.
However this amount shall be 20% when a generic prescription drug is utilized or
when a participating carrier has a mandatory generic prescription drug substitution
program which has been approved by the program; and a copayment equivalent to that
for a 60 day supply of a prescription shall apply to a 90 day supply of the same
prescription drug. A participating carrier may limit availability of these 90 day
supply discounts to prescriptions obtained through a mail order prescription drug
program; and
5. A deductible which shall
be $500 per enrollee in a benefit year. The deductible may be reduced by an amount
equal to the amount an enrollee with qualifying prior coverage paid toward a
deductible under the qualifying prior coverage for services rendered within the 90
days immediately prior to the enrollee's effective date of enrollment in the
program. Such reduction may only be applied for the first full or partial benefit
year that the enrollee is enrolled in the program.
(3) In the case of participating carriers which
offer indemnity plans:
(A) A preferred option
shall consist of the following elements:
1. A
copayment which shall be 20% of the scheduled rate of payment established by the
participating carrier for covered benefits and services, with the following
exceptions:
a. treatment for infertility
(including tests) shall be subject to a copayment of 50% of the carrier's scheduled
rate of payment.
b. outpatient mental
health visits shall be subject to a copayment of 50% of the carrier's scheduled rate
of payment.
c. enrollees are responsible
for 100% of the charges in excess of the carrier's scheduled rate of payment for
health care benefits and services. These amounts are not subject to the limitations
in Section 2699.6209(a) on
copayment expenses.
2. A $50
copayment whenever use of a hospital emergency room does not result in admission to
a hospital;
3. A copayment which shall
be 30% of the scheduled rate for prescription drugs. However this amount shall be
20% when a generic prescription drug is utilized; and a copayment equivalent to that
for a 60 day supply of a prescription shall apply to a 90 day supply of the same
prescription drug. A participating carrier may limit availability of these 90 day
supply discounts to prescriptions obtained through a mail order prescription drug
program; and
4. A deductible which shall
be $250 per enrollee in a benefit year. The deductible may be reduced by an amount
equal to the amount an enrollee with qualifying prior coverage paid toward a
deductible under the qualifying prior coverage for services rendered within the 90
days immediately prior to the enrollee's effective date of enrollment in the
program. Such reduction may only be applied for the first full or partial benefit
year that the enrollee is enrolled in the program.
(B) A standard option shall consist of the
following elements:
1. A copayment which shall be
20% of the scheduled rate of payment established by the participating carrier for
covered benefits and services, with the following exceptions:
a. treatment for infertility (including tests)
shall be subject to copayment of 50% of the carrier's scheduled rate of payment,
and
b. outpatient mental health visits
shall be subject to a copayment of 50% of the carrier's scheduled rate of payment,
and
c. enrollees are responsible for
100% of the charges in excess of the carrier's scheduled rate of payment for health
care benefits and services. These amounts are not subject to the limitations in
Section 2699.6209(a) on
copayment expenses.
2. A $50
copayment whenever use of a hospital emergency room does not result in admission to
a hospital;
3. A copayment which shall
be 30% of the scheduled rate for prescription drugs. However this amount shall be
20% when a generic prescription drug is utilized; and a copayment equivalent to that
for a 60 day supply of a prescription drug shall apply to a 90 day supply of the
same prescription drug. A participating carrier may limit availability of these 90
day supply discounts to prescriptions obtained through a mail order prescription
drug program; and
4. A deductible which
shall be $500 per enrollee in a benefit year. The deductible may be reduced by an
amount equal to the amount an enrollee with qualifying prior coverage paid toward a
deductible under the qualifying prior coverage for services rendered within the 90
days immediately prior to the enrollee's effective date of enrollment in the
program. Such reduction may only be applied for the first full or partial benefit
year that the enrollee is enrolled in the program.
(4) In the case of participating carriers which
are health maintenance organizations offering a point of service option or exclusive
provider organizations offering a point of service option:
(A) A preferred option shall consist of the
following elements:
1. When the enrollee receives
covered benefits and services in accordance with the health maintenance
organization's or exclusive provider organization's established procedures from
providers who contract with the health maintenance organization or exclusive
provider organization or when the enrollee, with health plan approval, receives
covered benefits and services from providers who do not contract with the health
maintenance organization or exclusive provider organization:
a. A $10 copayment per visit for office or home
visits, with the following exceptions:
i.
treatment for infertility, including tests, shall be subject to a copayment of 50%
of the carrier's contracted or scheduled rate of payment,
ii. visits for prenatal care and pediatric visits
up to the age of two (2) will be subject to a $5 copayment per visit; and
iii. outpatient mental health visits shall be
subject to a $20 per visit copayment;
b. A $15 copayment per outpatient prescription for
up to a 31 day supply of a prescription drug. A $15 copayment shall apply to
additional supplies of the prescription in up to 31 day increments. However, this
amount shall be $10 per prescription for up to 31 days of a prescription drug when a
generic prescription drug is utilized or when a participating carrier has a
mandatory generic prescription drug substitution program which has been approved by
the program. A $10 copayment shall apply to additional supplies of such a
prescription in up to 31 day increments.
An exception to the above is that a $30 copayment per prescription shall apply for a 90 day supply of a prescription drug. However, this amount shall be $20 per prescription for a 90 day supply of a generic prescription drug. A participating carrier may limit availability of these 90 day supply discounts to prescriptions obtained through a mail order prescription drug program.
c. A $100 copayment for
each hospital or skilled nursing facility admission; and
d. A $50 copayment whenever use of a hospital
emergency room does not result in admission to a hospital.
2. When the enrollee, without health plan
approval, receives covered benefits and services from providers who do not contract
with the health maintenance organization or exclusive provider organization or when
the enrollee receives covered benefits and services in violation of the health
plan's established procedures:
a. A copayment
which shall be 30% of the scheduled rate of payment established by the participating
carrier for covered benefits and services with the following exceptions:
i. the copayments described in 1. above shall be
limited to $5,000 in a benefit year for an enrollee or $10,000 in a benefit year for
an enrolled sole employee and dependents or guaranteed association members and
dependents.
ii. enrollees are
responsible for 100% of the charges in excess of the carrier's scheduled rate of
payment for health care benefits and services. These amounts are not subject to the
limitations in subsection "a" immediately above.
b. A $50 copayment whenever use of a hospital
emergency room does not result in admission to a hospital; and
c. A deductible which shall be $250 per enrollee
in a benefit year for an enrolled employee and the employee's enrolled dependents.
The deductible may be reduced by an amount equal to the amount an enrollee with
qualifying prior coverage paid toward a deductible under the qualifying prior
coverage for services rendered within the 90 days immediately prior to the
enrollee's effective date of enrollment in the program. Such reductions may only be
applied for the first full or partial benefit year that the enrollee is enrolled in
the program.
(B) A
standard option shall consist of the following elements:
1. When the enrollee receives covered benefits and
services in accordance with the health maintenance organization's or exclusive
provider organization's established procedures from providers who contract with the
health maintenance organization or exclusive provider organization or when the
enrollee, with health plan approval, receives covered benefits services from
providers who do not contract with the health maintenance organization or exclusive
provider organization:
a. A $10 copayment per
visit for office or home visits, with the following exceptions:
i. treatment for infertility, including tests,
shall be subject to a copayment of 50% of the carrier's contracted or scheduled rate
of payment;
ii. visits for prenatal care
and pediatric visits up to the age of two (2) will be subject to a $5 copayment per
visit; and
iii. outpatient mental health
visits shall be subject to a $20 per visit copayment.
b. A $15 copayment per outpatient prescription for
up to 31 days of a prescription drug. A $15 copayment shall apply to additional
supplies of the prescription in up to 31 day increments. However, this amount shall
be $10 per prescription for up to 31 days of a prescription drug when a generic
prescription drug is utilized or when a participating carrier has a mandatory
generic prescription drug substitution program which has been approved by the
program; and a $30 copayment per prescription shall apply for a 90 day supply of a
prescription drug. However, this amount shall be $20 per prescription for a 90 day
supply of a generic prescription drug. A participating carrier may limit
availability of these 90 day supply discounts to prescriptions obtained through a
mail order prescription drug program.
c.
A $100 copayment for each hospital or skilled nursing facility admission;
and
d. A $50 copayment whenever use of a
hospital emergency room does not result in admission to a
hospital.
2. When the
enrollee, without health plan approval, receives covered benefits and services from
providers who do not contract with the health maintenance organization or exclusive
provider organization or when the enrollee receives covered benefits and services in
violation of the health plan's established procedures:
a. A copayment which shall be 30% of the scheduled
rate of payment established by the participating carrier for covered benefits and
services with the following exceptions:
i. the
copayments described in 1. above shall be limited to $5,000 in a benefit year for an
enrollee or $10,000 in a benefit year for an enrolled sole employee and dependents
or guaranteed association members and dependents.
ii. enrollees are responsible for 100% of the
charges in excess of the carrier's scheduled rate of payment for health care
benefits and services. These amounts are not subject to the limitations in
subsection "a" immediately above.
b. A $50 copayment whenever use of a hospital
emergency room does not result in admission to a hospital; and
c. A deductible which shall be $500 per enrollee
in a benefit year for an enrolled employee and the employee's enrolled dependents.
The deductible may be reduced by an amount equal to the amount an enrollee with
qualifying prior coverage paid toward a deductible under the qualifying prior
coverage for services rendered within the 90 days immediately prior to the
enrollee's effective date of enrollment in the program. Such reductions may only be
applied for the first full or partial benefit year that the enrollee is enrolled in
the program.
1. Renumbering and
amendment of former section
2699.633 to section 2699.6209 filed
5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment filed
12-29-94 as an emergency; operative 12-29-94 (Register 94, No. 52). A Certificate of
Compliance must be transmitted to OAL 4-28-95 or emergency language will be repealed
by operation of law on the following day.
3. Certificate of Compliance as
to 12-29-94 order including amendment of subsections (b)(2)(A)2., (b)(2)(B)2.,
(b)(3)(A)1., and (b)(3)(B)1. transmitted to OAL 4-12-95 and filed 5-22-95 (Register
95, No. 21).
4. Amendment of section heading and section filed 5-2-96;
operative 6-1-96 (Register 96, No. 18).
5. Amendment filed 5-8-97;
operative 7-1-97 (Register 97, No. 19).
Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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