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. For exempt products under licensed plans, 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. Non-licensed companies 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 automatically provide notice of receipt to the company.
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