§ 1367.251
548 words·~2 min read·
/ca/health-and-safety-code/1367-251A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(1)A health care service plan, except for a specialized health care service plan contract, that is issued, amended, renewed, or delivered on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on coverage for all abortion and abortion-related services, including preabortion and followup services.
(2)Except as otherwise authorized by this section, a health care service plan shall not impose any utilization management or utilization review, including prior authorization and annual or lifetime limits consistent with Sections 1367.001 and 1367.005, on the coverage for outpatient abortion services.
(3)Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code and their contracting providers, independent practice associations, preferred provider groups, and all delegated entities that provide physician services, utilization management, or utilization review shall be subject to this section.
(4)If a health care service plan delegates responsibilities under this section to a contracted entity, including a medical group or independent practice association, the delegated entity shall comply with this section.
(b)This section does not deny or restrict in any way the department's authority to ensure plan compliance with this chapter when a health care service plan provides coverage for abortion services.
(c)This section does not require an individual or group health care service plan contract to cover an experimental or investigational treatment.
(d)For purposes of this section, “abortion” means any medical treatment intended to induce the termination of a pregnancy except for the purpose of producing a live birth.
(e)For a health care service plan contract that is a high deductible health plan, as defined in Section 223(c)(2) of Title 26 of the United States Code, the cost-sharing limits in paragraph
(1)of subdivision
(a)shall apply once an enrollee’s deductible has been satisfied for the benefit year.
(1)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may interpret and implement this section, in consultation with the State Department of Health Care Services and the Department of Insurance, by means of plan letters or similar guidance without taking any further regulatory action. The department shall adopt regulations on or before January 1, 2026, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this section, consistent with any guidance issued by the department pursuant to paragraph (1), to the extent that guidance does not exceed Medi-Cal program coverage of abortion and abortion-related services, by means of plan letters, plan or provider bulletins, or similar guidance issued to Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, without taking any further regulatory action.