The following definitions apply:
- Client: The employee or a family member of the employee
- Sessions: Any in-person or telephone consultation with the client in connection with the client's health, mental health, alcohol or substance abuse problems. Excluding a consultation that occurs in an acute emergency situation, a consultation after referral for motivation or re-referral or a consultation due to a management, state licensing agency or union request for information or assessment regarding work performance issues.
Obtain An Exemption
A health care service plan (plan) or company may request an exemption from the provisions of the Knox-Keene Act for its EAP product if it complies with each of the following provisions:
- Services are provided to improve employee efficiency through identification and referrals of issues with health, mental health, and alcohol substance abuse problems.
- Services consist of identification of problems and referral to appropriate health care providers or organizations for treatment, and the plan or company does not provide for counseling, treatment or therapy.
- The plan or company does not charge any client (directly or indirectly) any premium or copayment for services.
- If the plan or company refers a member for counseling, treatment or therapy to an entity with which it has a financial interest, it must disclose this relationship to the contract holder (group) and the individual being referred.
- The number of sessions with any individual/client cannot exceed three within any six month period.
- The plan or company must maintain a record of client sessions for not less than two years. Records must be available for inspection by the Department as designated in Health and Safety Code section 1381.
- The plan or company, staff, facilities, and equipment must be licensed or certified when required by applicable law.
- Unless licensed under the Knox-Keene Act, prepaid fees cannot be collected more than 45 days in advance.
Relevant Laws
- Knox Keene Act (Health and Safety Code) sections - 1360, 1360.1, 1368, 1381
- California Code of Regulations (Title 28) section - 1300.43.14
Instructions
If the preceding requirements have all been met, the plan or company may submit an Exemption Form (Form) to the Department. Companies currently not licensed under the Knox-Keene Act may mail or scan/email the Form to the Department. If mailing, it is a good idea to send the Form via certified mail for a record of receipt. The Department will not automatically provide notice of receipt to the company.
For plans already licensed by the Department that want to submit a Form for an exempt product, the Form must be filed through the eFiling system using the exhibit type “Exhibit EAP01 – Form 1300.43.14 Emp Assist Prg Exemption” (near the top of the drop-down menu for selecting exhibits). Licensed plans must also file an Exhibit E-1 (Summary of Information), as this is required for all filings.
Resources
Exemption Criteria
EAP Exemption Form
Obtain or Modify A License
A plan or company whose EAP product is not eligible for an exemption pursuant to California Code of Regulations, title 28, section 1300.43.14, is required to submit a filing or application to the DMHC, respectively. To obtain a license, please refer to Health Plan Licensing homepage.
Contacts
Mail:
Department of Managed Health Care
Office of Plan Licensing
Attention: EAP Coordinator
980 9th Street, Suite 500
Sacramento, CA 95814
Contact:
For questions regarding the EAP Exemptions Form or process, please contact the EAP Coordinator 916-324-9046 or at EAPfiling@dmhc.ca.gov