California Insurance Code

§ 10133.54

INS § 10133.54 Effective Jan 1, 2023Div. 2 · Part 2 · Ch. 1 · Art. 2

Statute text

(a)This section applies to policies of health insurance, as defined by subdivision (b) of Section 106. The requirements of this section apply to all health care services covered by a health insurance policy.

(b)Notwithstanding Section 10133.5, a health insurer shall comply with the timely access requirements in this section, but a specialized health insurance policy as defined in subdivision (c) of Section 106, other than a specialized mental health insurance policy, is exempt from the provisions of this section, except as specified in paragraph (6) and subdivision (c).

(1)A health insurer shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the insured’s condition, consistent with good professional practice. An insurer shall establish and maintain provider networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. An insurer that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.

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Legislative history

Amended by Stats. 2022, Ch. 601, Sec. 3. (SB 225) Effective January 1, 2023.