Understanding Medical Insurance

Understanding California Health Insurance

State health insurance mandates are laws regulating the terms of coverage for insured health plans. Mandates can affect various parts of health insurance plans as follows:

  • Benefit mandates require health insurance plans to cover specific treatments, services or procedures. In some cases, however, benefit mandates only require issuers to offer coverage to employers for specific treatments, services or procedures.
  • Provider mandates require health insurance plans to pay for services provided by specific health care professionals. Often, provider mandates are in the form of nondiscrimination mandates that require coverage only if the health plan already reimburses services within the scope of the health care professional’s practice.
  • Person mandates require health insurance plans to cover specific categories of people.

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Additional mandates for health plans exist at the federal level. For example, the Affordable Care Act (ACA) requires non-grandfathered health plans in the small group and individual markets to provide coverage for certain items and services designated as “essential health benefits.” Health plan sponsors and issuers should work with their advisors to determine how to comply with applicable federal and state mandates.

California has a divided legal and regulatory system for health insurance plans. The Department of Managed Health Care (DMHC) regulates health care service plans, which include managed care plans such as health maintenance organizations (HMOs) and certain preferred provider organizations (PPOs). The California Department of Insurance (CDI) regulates health insurance policies. DMHC-regulated plan contracts and CDI-regulated policies may be subject to state benefit mandate laws, depending upon the exact wording of the law.

This Employment Law Summary contains a chart outlining California’s benefit, provider and person mandates for insured group health plans. Please keep in mind that the following chart does not address federal benefit mandates, such as those in the ACA.


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  • Human Resources Admin Portal specifically designed and tailored to your business.
  • Human Resource Hotline:  Access to Certified HR Professionals
  • Labor Law Attorneys:  Access to GDI’s network of HR/Employment Law Attorneys
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  • Follow-up Steps Include:  Access to OSHA and Safety Compliance Materials & Trainers
  • Many of the services are paid for by GDI Insurance Agency, Inc.

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    GDI Insurance Agency, Inc.

    At GDI Insurance Agency, Inc. we will do the work for you to ensure you have the best protection plan for your California business.  Not only that, but as you can see, we will go the extra mile to make sure your business is protected from the inside-out. 

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