1. (a) To ensure proper application and implementation of the utilization review criteria required by Insurance Code section 10144.52 and this article, an insurer shall adopt formal education programs consistent with subdivision (e) of Insurance Code section 10144.52 that meet the following requirements:

   1. (1) Within six months of June 26, 2025, and at least every three years thereafter, an insurer shall sponsor formal education programs offered by the nonprofit professional associations identified in subdivision (a) of Section 2562.03, and the World Professional Association for Transgender Health, regarding the association's clinical criteria, to educate all its utilization review staff, including supervisors, and the staff and supervisors of any entity or contracting provider that performs utilization review or utilization management functions on an insurer's behalf, on proper application of the criteria in utilization review. For purposes of this subdivision (a)(1), sponsoring includes arranging and paying for the formal education program, provided that the education program is offered by the respective nonprofit professional association, or a third party designated or licensed by the association to conduct such a program.
   2. (2) An insurer shall ensure that all utilization review staff and supervisors subject to subdivision (a)(1) of this section are trained in the use and application of the most recent versions of the nonprofit professional association criteria required pursuant to Section 2562.03 before making any coverage determinations concerning service intensity, level of care placement, continued stay, or transfer or discharge, or before making coverage determinations with respect to health care benefits that are within the scope of clinical criteria developed by the World Professional Association for Transgender Health.

   3. (3) In accordance with Insurance Code section 10144.52(e)(2), an insurer shall provide the following stakeholders with access to the formal education programs, without limitation on frequency of access:

      1. (A) Network providers.
      2. (B) Group policyholders.
      3. (C) Insureds and their health care providers and authorized representatives.

      4. (D) Out-of-network providers delivering health care benefits to an insured pursuant to Section 2562.06 or a coverage document's out-of-network benefits.

         (b)(1) An insurer shall notify an insured or an insured's authorized representative, and the insured's health care provider, that all utilization review criteria, and training materials and resources that are part of the formal education programs described in subdivision (a) of this section, are available upon request at no cost. This notice shall be published on an insurer's website and disclosed in an insurer's coverage documents.

   4. (2) Method of Delivery. Upon request, an insurer shall provide all utilization review criteria, and all training materials and resources that are part of the formal education programs described in subdivision (a), to an insured or an insured's authorized representative, and an insured's health care provider, at no cost. An insurer shall provide the utilization review criteria and formal education program training materials and resources described in subdivision (b)(1) in one or more of the following ways:

      1. (A) In paper form delivered to the requestor's mailing address. Elements of a formal education program that cannot be provided in paper form shall instead be made available as provided in subdivision (b)(2)(C).
      2. (B) Electronically by email. An insurer shall notify the requestor in its response that a paper copy is available at no cost and describe the process for obtaining a paper copy. Elements of a formal education program that cannot be provided by email shall instead be made available as provided in subdivision (b)(2)(C).

      3. (C) Electronically on an insurer's website, or alternatively with respect to a formal education program's training materials and resources, on a host website directly linked from an insurer's website. In making the content available online, an insurer shall do the following:

         1. 1. Ensure the utilization review criteria and training materials and resources allow for electronic retention, such as saving and printing.
         2. 2. Ensure the content is accessible to people living with disabilities in accordance with section 508 of the federal Rehabilitation Act of 1973, as amended, and California Government Code sections 7405 and 11135.
         3. 3. Include notice that a paper copy is available at no cost and describe the process for obtaining a paper copy.
   5. (3) Timeframe for Delivery. An insurer shall send the utilization review criteria and formal education program training materials and resources described in subdivision (b)(1) to the requesting party within 30 calendar days of a request.

Note: Authority cited: Sections 10144.5, 10144.52 and 10144.57, Insurance Code. Reference: Sections 7405 and 11135, Government Code; and Sections 10123.135, 10144.5, 10144.52 and 10144.57, Insurance Code.

History

1. New section filed 6-26-2025; operative 6-26-2025 pursuant to Government Code section 11343.4(b)(3) (Register 2025, No. 26).