Free Medical Plans Study Guide
California Accident & Health Agent exam — Medical Plans.
Plan design (HMOs, PPOs, POS plans, deductibles, coinsurance, and out-of-pocket maximums) is covered in the national Medical Plans guide. California's Accident & Health exam weights medical expense insurance heavily, so it tests the state's regulator split, its benefit mandates, its ACA implementation through Covered California, and its claim-payment rules.
Who regulates what
- HMOs and POS plans are regulated mainly by the Department of Managed Health Care under the Knox-Keene Act (Health & Safety Code 1340).
- The California Department of Insurance regulates disability (health) insurers and most PPO and indemnity products. An entity paying medical expenses is presumed to be under CDI unless it shows another agency regulates it (CIC 740).
- In the Insurance Code, disability insurance covers sickness or bodily injury (CIC 106(a)). Health insurance means hospital, medical, or surgical coverage. AD&D, fixed indemnity, accident-only, and specified disease plans are excluded from that definition (CIC 106(b)).
ACA rules as California applies them
- Individual major medical coverage is guaranteed issue (CIC 10965.3), and preexisting condition exclusions are prohibited in group and nongrandfathered individual plans (CIC 10198.7).
- There are no lifetime or annual dollar limits on covered benefits (CIC 10112.1).
- Nongrandfathered plans cover evidence-based preventive services with no cost sharing (CIC 10112.2).
- Dependent coverage is available to age 26.
- Covered California is the state's exchange, an independent public entity (Gov. Code 100500).
- Premium tax credits are available only for qualified health plans bought there.
- Agents must complete Covered California's agreements and certification before writing exchange applications.
- Medi-Cal expansion covers adults 19 through 64 with household income up to 138% of the federal poverty level.
- The ACA medical loss ratio is 80% for individual and small group plans, and 85% for large group.
California benefit mandates
| Topic | California rule |
|---|---|
| Newborns | Covered from the moment of birth (CIC 10119) |
| Adopted children | Covered from the moment of placement in the insured's custody |
| Disabled dependents | Coverage continues past the limiting age while the child can't support themselves and depends on the insured (CIC 10277, 10278) |
| Maternity stays | At least 48 hours after vaginal delivery and 96 hours after cesarean (CIC 10123.87) |
| Maternity cost sharing | No higher than the most common amount for other inpatient care (CIC 10119.5) |
| Mastectomy | Length of stay set by the physician and patient, with no prior approval. Reconstruction and prostheses are covered (CIC 10123.86, 10123.8) |
| Mammography | Screening or diagnostic, on referral (CIC 10123.81) |
| Cervical screening | Annual, including a Pap test and an FDA-approved HPV test (CIC 10123.18) |
| Prostate screening | Including PSA testing when medically necessary (CIC 10123.835) |
| Contraceptives | All FDA-approved methods, when the plan covers outpatient prescription drugs (CIC 10123.196) |
| Diabetes | Supplies, equipment, and self-management training (CIC 10176.61) |
| Mental health parity | Medically necessary mental health and substance use treatment on the same terms as other care (CIC 10144.5) |
| Autism | Behavioral health treatment for pervasive developmental disorder or autism (CIC 10144.51) |
| Fertility (2026) | Large group policies issued or renewed on or after January 1, 2026 must cover infertility treatment, including up to three egg retrievals. Small group insurers must offer it (CIC 10119.6) |
Underwriting limits
- Health insurers may not deny, rate, or limit coverage based on genetic characteristics (CIC 10140(b)).
- Registered domestic partners must be covered on the same terms as spouses (CIC 381.5).
Claim payment
- Hospital, medical, and surgical claims must be paid or contested in writing within 30 calendar days (CIC 10123.13).
- The 40-day accept-or-deny rule in the Fair Claims regulations doesn't apply to these claims.
Common exam traps
- HMOs answer to DMHC. PPOs and indemnity plans answer to CDI.
- Health claims are decided in 30 days, not 40.
- Maternity stays: 48 hours vaginal, 96 hours cesarean.
- The 2026 fertility mandate applies to large group and must be offered to small group.
- Fixed indemnity and specified disease plans aren't "health insurance" under CIC 106(b).
Practice Medical Plans questions All Accident & Health Agent topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
