California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 6 - Provider Network Access Standards for Health Insurance
Section 2240.3 - Provisions of Policies and Certificates

Universal Citation: 10 CA Code of Regs 2240.3

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

Policies and certificates containing provisions covering network provider services shall contain the following:

(a) A description of the coverage provided by the contract for emergency health care services rendered to covered persons outside the service area.

(b) A description of the coverage, if any, provided by the contract for dependent covered persons who both live outside the service area and away from the principal residence of the primary covered person.

(c) A brief and prominent warning reflecting the limitations in the contract pertaining to network provider services. Such warning shall identify, by caption or number, the certificate provisions required by subdivisions (d), (e) and (f), below.

(1) Where the contract provides coverage outside the service area, the warning shall be in bold-face type or set off by other means from the surrounding text, and shall clearly specify the differences in coverage between network and non-network services in and out of the service area.

(2) Where the contract provides no coverage (except for emergency health care services) outside the service area, the warning shall include the warning required in (1) above, and shall additionally warn that no coverage is provided outside the service area, except for emergency health care services. The additional warning shall be in a point size at least twice that used in the body of the certificate (excluding captions).

(d) If applicable, a provision defining the service area wherein non-emergency coverage is restricted to services provided by network providers.

(e) A provision or attachment identifying all network providers or describing where a current directory of network providers can be found on the Internet.

(f) A prominent disclosure pursuant to Insurance Code Section 510 stating that covered persons who have complaints regarding their ability to access needed health care in a timely manner may complain to the insurer and to the California Department of Insurance. The disclosure shall include the address and the customer services telephone number of the insurer and the name address and toll free telephone number of the Consumer Services Division of the Department of Insurance.

(g) A prominent disclosure of the requirements of subdivision (e) of Section 2240.1.

(h) If applicable, a prominent disclosure stating that insureds must meet higher deductibles and higher out-of-pocket maximums for out-of-network provider services than for in-network provider services.

(i) If applicable, a prominent disclosure stating that the insured's financial obligation will vary depending on the tier in which a provider is classified.

1. Amendment of section and NOTE filed 1-8-2008; operative 2-7-2008 (Register 2008, No. 2).
2. Amendment of section heading, first paragraph and subsections (c), (d) and (f) and new subsections (g)-(i) filed 3-8-2016; operative 3-8-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 11).

Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 510, 10133 and 10133.5, Insurance Code.

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