Bill Text: CA AB1602 | 2009-2010 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: California Health Benefit Exchange.
Spectrum: Partisan Bill (Democrat 5-0)
Status: (Passed) 2010-09-30 - Chaptered by Secretary of State - Chapter 655, Statutes of 2010. [AB1602 Detail]
Download: California-2009-AB1602-Amended.html
Bill Title: California Health Benefit Exchange.
Spectrum: Partisan Bill (Democrat 5-0)
Status: (Passed) 2010-09-30 - Chaptered by Secretary of State - Chapter 655, Statutes of 2010. [AB1602 Detail]
Download: California-2009-AB1602-Amended.html
BILL NUMBER: AB 1602 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 2, 2010
AMENDED IN SENATE JUNE 24, 2010
AMENDED IN ASSEMBLY APRIL 15, 2010
AMENDED IN ASSEMBLY APRIL 8, 2010
INTRODUCED BY Assembly Member John A. Perez
(Principal coauthors: Assembly Members Bass and Monning)
JANUARY 5, 2010
An act to add Title 22 (commencing with Section 100500) to
the Government Code, to amend Sections 1357.06, 1357.51, and
1373 of, and to add Section Sections 1346.2
and 1367.001 to, the Health and Safety Code, and to amend
Sections 10198.7, 10277, and 10708 of, and to add Section
10112.1 Sections 10112.1 and 10112.2 to, the
Insurance Code, relating to health care coverage, and making an
appropriation therefor.
LEGISLATIVE COUNSEL'S DIGEST
AB 1602, as amended, John A. Perez. Health care coverage.
(1) Existing law provides various programs to provide health care
coverage to persons with limited financial resources, including the
Medi-Cal program and the Healthy Families Program.
Existing law, the federal Patient Protection and Affordable Care
Act, requires each state to, by January 1, 2014, establish an
American Health Benefit Exchange that facilitates the purchase of
qualified health plans by qualified individuals and qualified small
employers, as specified, and meets certain other requirements.
This bill would enact the California Patient Protection and
Affordable Care Act. The bill would create the California Health
Benefit Exchange (the Exchange) in state government to be governed by
an executive board with 5 members, including the Secretary of
California Health and Human Services and 4 other members appointed by
the Governor and the Legislature. The bill would specify the powers
and duties of the board relative to determining eligibility for
enrollment in the Exchange and arranging for coverage with qualified
health plans, and would require the Exchange
board to facilitate the purchase of qualified health plans
through the Exchange by qualified individuals and qualified
small employers by January 1, 2014. The bill would prohibit a
carrier that is not participating in the Exchange from offering a
catastrophic plan, as defined, in the individual market. The
bill would create the California Health Trust Fund as a continuously
appropriated fund and would enact other related provisions.
The bill would also state the intent of the Legislature to enact the
necessary statutory changes relative to specified federal health care
reforms.
The bill would require the Director of the Department of Managed
Health Care and the Insurance Commissioner to review an Internet
portal developed by the United States Department of Health and Human
Services and to jointly develop and maintain an electronic
clearinghouse of coverage available in the individual and small group
markets if the federal Internet portal does not adequately achieve
certain purposes.
(2) Existing law, the Knox-Keene Health Care Service Plan Act of
1975, provides for the licensure and regulation of health care
service plans by the Department of Managed Health Care and makes a
willful violation of that act a crime. Existing law also provides for
the regulation of health insurers by the Department of Insurance.
Existing law requires every health care service plan contract that
provides for termination of coverage of a dependent child upon the
attainment of the limiting age for dependent children to also provide
that attainment of the limiting age shall not terminate the coverage
of a child under certain conditions. Existing law establishes
similar requirements for group health insurance policies that provide
coverage of dependent children.
This bill would prohibit the limiting age in group or individual
contracts or policies from being less than 26 years of age for
dependent children covered by those plan contracts and insurance
policies.
The bill would modify certain of the requirements applicable to
group or individual health care service plan contracts and health
insurance policies issued, amended, renewed, or delivered on or after
September 23, 2010, consistent with requirements of the federal
Patient Protection and Affordable Care Act. The bill would prohibit
lifetime limits on the dollar value of benefits and would authorize
annual limits on the dollar value of benefits only in specified
circumstances. The bill would require coverage, and prohibit
cost-sharing requirements applicable to enrollees or insureds, for
certain health care benefits. The bill would also prohibit
preexisting condition exclusions for enrollees or insureds under 19
years of age.
Because a willful violation of these requirements with respect to
a health care service plan would be a crime, the bill would impose a
state-mandated local program.
(3) The California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
Vote: majority. Appropriation: yes. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. This act shall be known and may be cited as the
California Patient Protection and Affordable Care Act.
SEC. 2. It is the intent of the Legislature to enact the necessary
statutory changes to California law in order to be consistent with
the federal Patient Protection and Affordable Care Act (Public Law
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), hereafter the
federal act. In doing so, it is the intent of the Legislature to do
all of the following:
(a) Reduce the number of uninsured Californians by creating an
organized, transparent marketplace for Californians to purchase
affordable, quality health care coverage, to claim available federal
tax credits and cost-sharing subsidies, and to meet the personal
responsibility requirements imposed under the federal act.
(b) Leverage available federal funds to the greatest extent
possible.
(c)
(b) Strengthen the health care delivery system.
(d)
(c) Guarantee the availability and renewability of
health care coverage through the private health insurance market to
qualified individuals and qualified small employers.
(e)
(d) Require that health care service plans and health
insurers issuing coverage in the individual and small employer
markets compete on the basis of price, quality, and service, and not
on risk selection.
(f)
(e) Meet the requirements of the federal act.
SEC. 3. (a) There is in state government the California Health
SEC. 3. Title 22 (commencing with Section 100500)
is added to the Government Code , to read:
TITLE 22. CALIFORNIA HEALTH BENEFIT EXCHANGE
100500. For purposes of this division, the following definitions
shall apply:
(a) "Board" means the board described in subdivision (a) of
Section 100501.
(b) "Carrier" means either a private health insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan, as defined under
subdivision (f) of Section 1345 of the Health and Safety Code,
licensed by the Department of Managed Health Care.
(c) "Exchange" means the California Health Benefit Exchange
established by Section 100501.
(d) "Federal act" means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the federal
Health Care and Education Reconciliation Act of 2010 (Public Law
111-152).
(e) "Fund" means the California Health Trust Fund established by
Section 100520.
(f) "SHOP Program" means the Small Business Health Options Program
established by subdivision (m) of Section 100502.
100501. (a) There is in
state government the California Health Benefit Exchange, an
independent public entity, which shall be known as the Exchange. The
Exchange shall be governed by an executive board consisting of five
members who are residents of California . Of the members
of the board, two shall be appointed by the Governor, one shall be
appointed by the Senate Committee on Rules, and one shall be
appointed by the Speaker of the Assembly. The Secretary of California
Health and Human Services or his or her designee shall serve as a
voting, ex officio member of the board.
(b) Members of the board , other than an ex officio member,
shall be appointed for a term of four years. Vacancies shall be
filled by appointment for the unexpired term.
(c) Each person appointed to the board shall have demonstrated and
acknowledged expertise in at least two of the following areas:
(1) The health care coverage market.
(2) The small group health care coverage market.
(1) Individual health care coverage.
(2) Small group health care coverage.
(3) Health benefits plan administration.
(4) Health care finance.
(5) Administering a public or private health care delivery system.
(6) Health plan purchasing.
(d) Each member of the board shall have the responsibility and
duty to meet the requirements of this act and the federal act, to
serve the public interest of the individuals and small businesses
seeking health care coverage through the Exchange, and to ensure the
operational well-being and fiscal solvency of the Exchange.
(e) In making appointments to the board, the appointing
authorities shall take into consideration the cultural, ethnic, and
geographical diversity of the state so that the board's composition
reflects the communities of California.
(e)
(f) A member of the board or of the staff of the
Exchange shall not be employed by, a consultant to, a member of the
board of directors of, affiliated with , an agent of, or
otherwise a representative of, a carrier or other insurer, an agent
or broker, a health care provider, or a health care facility or
health clinic while serving on the board and during the first
year following his or her service on the board . A board member
shall not receive compensation for his or her service on the board
but may receive a per diem and reimbursement for travel and other
necessary expenses, as provided in Section 103 of the Business and
Professions Code, while engaged in the performance of official duties
of the board.
(g) No member of the board shall make, participate in making, or
in any way attempt to use his or her official position to influence
the making of any decision that he or she knows or has reason to know
will have a reasonably foreseeable material financial effect,
distinguishable from its effect on the public generally, on him or
her or a member of his or her immediate family, or on either of the
following:
(1) Any source of income, other than gifts and other than loans by
a commercial lending institution in the regular course of business
on terms available to the public without regard to official status
aggregating two hundred fifty dollars ($250) or more in value
provided to, received by, or promised to the member within 12 months
prior to the time when the decision is made.
(2) Any business entity in which the member is a director,
officer, partner, trustee, employee, or holds any position of
management.
(h) There shall not be any liability in a private capacity on the
part of the board or any member of the board, or any officer or
employee of the board, for or on account of any act performed or
obligation entered into in an official capacity, when done in good
faith, without intent to defraud, and in connection with the
administration, management, or conduct of this title or affairs
related to this title.
(f)
(i) The board shall hire an executive director to
organize, administer, and manage the operations of the
Exchange and to serve as secretary to the board. The executive
director shall serve as an ex officio, nonvoting member of the board.
Exchange. The executive director shall serve at the
pleasure of the board.
(g)
(j) The board shall be subject to the Bagley-Keene Open
Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1
of Part 1 of Division 3 of Title 2 of the Government Code
), except that the board may hold closed sessions when
considering matters related to litigation, personnel, contracting,
and rates.
(h)
(k) The board shall apply for planning and
establishment grants made available to the Exchange pursuant to
Section 1311 of the federal act. If an executive director has not
been hired under subdivision (f) (i)
when the United States Secretary of Health and Human Services makes
the initial planning and establishment grants available, the
California Health and Human Services Agency shall, upon request of
the board, submit the initial application for planning and
establishment grants to the United States Secretary of Health and
Human Services. If a majority of the board has not been
appointed when the United States Secretary of Health and Human
Services makes the initial planning and establishment grants
available, the California Health and Human Services Agency shall
submit the initial application for planning and establishment grants
to the United States Secretary of Health and Human Services.
The board shall be responsible for using the funds awarded by the
United States Secretary of Health and Human Services for the planning
and establishment of the Exchange, consistent with subdivision (b)
of Section 1311 of the federal act.
(i) The board shall, at a minimum, do all of the following to
100502. The board shall, at a minimum, do all of
the following to implement Section 1311 of the federal act:
(1)
(a) Implement procedures for the certification,
recertification, and decertification, consistent with guidelines
established by the United States Secretary of Health and Human
Services, of health plans as qualified health plans. The board shall
require health plans seeking certification as qualified health plans
to do all of the following:
(A)
(1) Submit a justification for any premium increase
prior to implementation of the increase. The plans shall prominently
post that information on their Internet Web sites. The board shall
take this information, and the information and the recommendations
provided to the board by the Department of Insurance or the
Department of Managed Health Care under paragraph (1) of subdivision
(b) of Section 2794 of the federal Public Health Service Act, into
consideration when determining whether to make the health plan
available through the Exchange. The board shall take into account any
excess of premium growth outside the Exchange as compared to the
rate of that growth inside the Exchange, including information
reported by the Department of Insurance and the Department of Managed
Health Care.
(B) (i)
(2) (A) Make available
to the public and submit to the board, the United States Secretary
of Health and Human Services, and the Insurance Commissioner or the
Department of Managed Health Care, as applicable, accurate and timely
disclosure of the following information:
(I)
(i) Claims payment policies and practices.
(II)
(ii) Periodic financial disclosures.
(III)
(iii) Data on enrollment.
(IV)
(iv) Data on disenrollment.
(V)
(v) Data on the number of claims that are denied.
(VI)
(vi) Data on rating practices.
(VII)
(vii) Information on cost sharing and payments with
respect to any out-of-network coverage.
(VIII)
(viii) Information on enrollee and participant rights
under Title I of the federal act.
(IX)
(ix) Other information as determined appropriate by the
United States Secretary of Health and Human Services.
(ii)
(B) The information required under clause (i)
subparagraph (A) shall be provided in plain
language, as defined in subparagraph (B) of paragraph (3) of
subdivision (e) of Section 1311 of the federal act.
(C)
(3) Permit individuals to learn, in a timely manner
upon the request of the individual, the amount of cost sharing,
including, but not limited to, deductibles, copayments, and
coinsurance, under the individual's plan or coverage that the
individual would be responsible for paying with respect to the
furnishing of a specific item or service by a participating provider.
At a minimum, this information shall be made available to the
individual through an Internet Web site and through other means for
individuals without access to the Internet.
(2)
(b) Provide for the operation of a toll-free telephone
hotline to respond to requests for assistance.
(3)
(c) Maintain an Internet Web site through which
enrollees and prospective enrollees of qualified health plans may
obtain standardized comparative information on those plans.
In developing the Internet Web site, the board shall ensure that
information is presented in a plainly worded and easily
understandable format to assist enrollees and potential enrollees in
making an informed coverage choice.
(4)
(d) Assign a rating to each qualified health plan
offered through the Exchange in accordance with the criteria
developed by the United States Secretary of Health and Human
Services.
(5)
(e) Utilize a standardized format for presenting health
benefits plan options in the Exchange, including the use of the
uniform outline of coverage established under Section 2715 of the
federal Public Health Service Act.
(6)
(f) Inform individuals of eligibility requirements for
the Medi-Cal program, the Healthy Families Program, or any applicable
state or local public program and, if, through screening of the
application by the Exchange, the Exchange determines that an
individual is eligible for any such program, enroll that individual
in the program.
(7)
(g) Establish and make available by electronic means a
calculator to determine the actual cost of coverage after the
application of any premium tax credit under Section 36B of the
Internal Revenue Code of 1986 and any cost-sharing reduction under
Section 1402 of the federal act.
(8)
(h) Grant a certification attesting that, for purposes
of the individual responsibility penalty under Section 5000A of the
Internal Revenue Code of 1986, an individual is exempt from the
individual requirement or from the penalty imposed by that section
because of any either of the following:
(A)
(1) There is no affordable qualified health plan
available through the Exchange or the individual's employer covering
the individual.
(B)
(2) The individual meets the requirements for any other
exemption from the individual responsibility requirement or penalty.
(9)
(i) Transfer to the Secretary of the Treasury all of
the following:
(A)
(1) A list of the individuals who are issued a
certification under paragraph (8) subdivision
(h) , including the name and taxpayer identification number of
each individual.
(B)
(2) The name and taxpayer identification number of each
individual who was an employee of an employer but who was determined
to be eligible for the premium tax credit under Section 36B of the
Internal Revenue Code of 1986 because of either of the following:
(i)
(A) The employer did not provide minimum essential
coverage.
(ii)
(B) The employer provided the minimum essential coverage
but it was determined under subparagraph (C) of paragraph (2) of
subsection (c) of Section 36B of the Internal Revenue Code of 1986 to
either be unaffordable to the employee or not provide the required
minimum actuarial value.
(C)
(3) The name and taxpayer identification number of each
individual who notifies the Exchange under paragraph (4) of
subsection (b) of Section 1411 of the federal act that they have
changed employers and of each individual who ceases coverage under a
qualified health plan during a plan year and the effective date of
that cessation.
(10)
(j) Provide to each employer the name of each employee
of the employer described in subparagraph (B) of paragraph
(9) paragraph (2) of subdivision (i) who ceases
coverage under a qualified health plan during a plan year and the
effective date of that cessation.
(11)
(k) Perform duties required of, or delegated to, the
Exchange by the United States Secretary of Health and Human Services
or the Secretary of the Treasury related to determining eligibility
for premium tax credits, reduced cost sharing, or individual
responsibility exemptions.
(12)
(l) Establish the navigator program in accordance with
subdivision (i) of Section 1311 of the federal act. Any entity chosen
by the Exchange as a navigator shall do all of the following:
(A)
(1) Conduct public education activities to raise
awareness of the availability of qualified health plans.
(B)
(2) Distribute fair and impartial information
concerning enrollment in qualified health plans, and the availability
of premium tax credits under Section 36B of the Internal Revenue
Code of 1986 and cost-sharing reductions under Section 1402 of the
federal act.
(C)
( 3 ) Facilitate enrollment in
qualified health plans.
(D)
(4) Provide referrals to any applicable office of
health insurance consumer assistance or health insurance ombudsman
established under Section 2793 of the federal Public Health Service
Act, or any other appropriate state agency or agencies, for any
enrollee with a grievance, complaint, or question regarding his or
her health plan, coverage, or a determination under that
plan or coverage.
(E)
(5) Provide information in a manner that is culturally
and linguistically appropriate to the needs of the population being
served by the Exchange.
(13)
(m) Establish the Small Business Health Options
Program, separate from the activities of the board related to the
individual market, to assist qualified small employers in
facilitating the enrollment of their employees in qualified
health plans offered in the small group market.
(j) In addition to
meeting the minimum requirements of Section enrollment
of their employees in qualified health plans offered through the
Exchange in the small group market in a manner consistent with
paragraph (2) of subdivision (a) of Section 1312 of the federal act.
100503. In addition to meeting the minimum
requirements of Section 1311 of the federal act, the board shall
do all of the following:
(1) Determine eligibility, enrollment, and disenrollment criteria
and processes for enrollees and potential enrollees in the Exchange.
(a) Determine the criteria and process for eligibility,
enrollment, and disenrollment of enrollees and potential enrollees in
the Exchange.
(b) Develop processes to coordinate with the county entities that
administer eligibility for the Medi-Cal program and the entity that
determines eligibility for the Healthy Families Program, including,
but not limited to, processes for case transfer, referral, and
enrollment in the Exchange of individuals applying for assistance to
those entities, if allowed or required by federal law.
(2)
(c) Determine the minimum requirements a health plan
must meet to be considered for participation in the Exchange as a
qualified health plan, and the standards and criteria for selecting
qualified health plans to be offered through the Exchange. In the
course of selectively contracting for health care coverage offered to
qualified individuals and qualified small employers through the
Exchange, the board shall seek to contract with carriers to provide
health insurance choices that offer the optimal choice, value,
quality, and service.
(3)
(d) Provide, in each region of the state, a choice of
qualified health plans at each of the five levels of coverage
contained in subdivisions (d) and (e) of Section 1302 of the federal
act.
(4)
(e) Require, as a condition of participation in the
Exchange, carriers to fairly and affirmatively offer, market, and
sell in the Exchange the five levels of coverage contained in
subdivisions (d) and (e) of Section 1302 of the federal act.
(f) Require, as a condition of participation in the Exchange,
carriers that sell any products outside the Exchange to do both of
the following:
(A)
(1) Fairly and affirmatively offer, market, and sell
all products made available to individuals in the Exchange to
individuals purchasing coverage outside the Exchange.
(B)
(2) Fairly and affirmatively offer, market, and sell
all products made available to small employers in the Exchange to
small employers purchasing coverage outside the Exchange.
(5) Require, as a condition of participation in the Exchange,
carriers that sell any products outside the Exchange to do both of
the following:
(6)
(g) Determine when an enrollee's coverage commences and
the extent and scope of coverage.
(6)
(h) Provide for the processing of applications and the
enrollment and disenrollment of enrollees.
(7)
(i) Determine and approve cost-sharing provisions for
qualified health plans.
(7) Develop and maintain an electronic clearinghouse of
information regarding all health benefits products offered by
carriers in the individual and small employer markets to facilitate
fair and affirmative marketing of all individual and small employer
plans inside and outside the Exchange. In performing this function,
the board shall routinely monitor individual and small employer
benefits filings with the Department of Managed Health Care and the
Department of Insurance and complaints submitted by individuals and
small employers with those regulatory agencies, and shall use any
other available means to maintain the clearinghouse.
(8)
(j) Undertake activities necessary to market and
publicize the availability of health care coverage through
the Exchange. availability of health care coverage and
federal subsidies through the Exchange. The board shall also
undertake outreach and enrollment activities that seek to assist
enrollees and potential enrollees with enrolling and reenrolling in
the Exchange in the least burdensome manner, including populations
that may experience barriers to enrollment, such as the disabled and
those with limited English language proficiency.
(9)
(k) Select and set performance standards and
compensation for navigators selected under paragraph (12) of
subdivision (i) subdivision (l) of Section 100502
.
(10)
(l) Employ necessary staff.
(11) Assess a charge as a part of the premium, at the lowest
possible rate, on carriers participating in the Exchange, to support
(m) Assess a charge, at the lowest
possible rate, on the qualified health plans offered by carriers to
support the development, operations, and prudent cash
management of the Exchange. This charge shall not affect the
requirement under Section 1301 of the federal act that carriers
charge the same premium rate for each qualified health plan whether
offered inside or outside the Exchange.
(12)
(n) Authorize expenditures, as necessary, from the
California Health Trust Fund to pay program expenses to administer
the Exchange.
(13)
(o) Keep an accurate accounting of all activities,
receipts, and expenditures, and annually submit to the United States
Secretary of Health and Human Services a report concerning that
accounting.
(14)
(p) Maintain enrollment and expenditures to ensure that
expenditures do not exceed the amount of revenue in the fund, and if
sufficient revenue is not available to pay estimated expenditures,
institute appropriate measures to ensure fiscal solvency.
(15)
(q) Exercise all powers reasonably necessary to carry
out the powers and responsibilities expressly granted or imposed by
this act.
(16)
(r) Consult with stakeholders relevant to carrying out
the activities under this section title
, including, but not limited to, all of the following:
(A)
(1) Health care consumers who are enrolled in health
plans.
(B)
(2) Individuals and entities with experience in
facilitating enrollment in health plans.
(C)
(3) Representatives of small businesses and
self-employed individuals.
(D)
(4) The Director of Health Care Services.
(E)
(5) Advocates for enrolling hard-to-reach populations.
(18)
(s) Facilitate the purchase of qualified health plans
in the Exchange by qualified individuals and qualified
small employers no later than January 1, 2014.
(k) The board may do the following:
(1) Collect premiums and assist in the administration of
subsidies.
(2) Report, or contract with an independent entity to report, to
the Legislature on whether to adopt the option in subdivision (b) of
Section 1311 of the federal act to provide a single exchange for
providing services to both qualified individuals and qualified small
employers in the Exchange. In its report, the board shall provide
data on the potential impact on rates paid by individuals and by
(t) Report, or contract with an
independent entity to report, to the Legislature by December 1, 2018,
on whether to adopt the option in paragraph (3) of subdivision (c)
of Section 1312 of the federal act to merge the individual and small
group markets. In its report, the board shall provide information,
based on at least two years of data from the Exchange, on the
potential impact on rates paid by individuals and by small
employers in a merged individual and small group market, as compared
to the rates paid by individuals and small employers if a separate
individual and small group market is maintained. A report made
pursuant to this paragraph shall be submitted pursuant to Section
9795 of the Government Code .
(u) With respect to the SHOP Program, collect premiums and
administer all other necessary and related tasks, including, but not
limited to, enrollment and plan payment, in order to make the
offering of employee plan choice as simple as possible for qualified
small employers.
(v) Require carriers participating in the Exchange to immediately
notify the Exchange, under the terms and conditions established by
the board when an individual is or will be enrolled in or disenrolled
from any qualified health plan
offered by the carrier.
(w) Ensure that the Exchange provides oral interpretation services
in any language for individuals seeking coverage through the
Exchange and makes available a toll-free telephone number for the
hearing and speech impaired. The board shall ensure that written
information made available by the Exchange is presented in a plainly
worded, easily understandable format and made available in prevalent
languages.
100504. (a) The board may do the following:
(1) With respect to individual coverage made available in the
Exchange, collect premiums and assist in the administration of
subsidies.
(3)
(2) Enter into contracts.
(4)
(3) Sue and be sued.
(5)
(4) Receive and accept gifts, grants, or donations of
moneys from any agency of the United States, any agency of the state,
any municipality, county, or other political subdivision of the
state.
(6)
(5) Receive and accept gifts, grants, or donations from
individuals, associations, private foundations, or corporations,
subject to the adoption by the board at a public meeting of conflict
of interest provisions.
(7)
(6) Adopt rules and regulations, as necessary. Until
January 1, 2014 2016 , any necessary
rules and regulations may be adopted as emergency regulations in
accordance with the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2
of the Government Code ). The adoption of these
regulations shall be deemed to be an emergency and necessary for the
immediate preservation of the public peace, health and safety, or
general welfare.
(l) As used in this section, "federal act" means the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152).
SEC. 4. (a) The California Health Trust is hereby created
(7) Collaborate with the State Department of Health Care Services,
to the extent possible, to allow an individual the option to remain
enrolled with his or her carrier and provider network in the event
the individual experiences a loss of eligibility of premium tax
credits and becomes eligible for the Medi-Cal program or the Healthy
Families Program, or loses eligibility for the Medi-Cal program or
the Healthy Families Program and becomes eligible for premium tax
credits through the Exchange.
(8) Share information with relevant state departments, consistent
with the confidentiality provisions in Section 1411 of the federal
act, necessary for the administration of the Exchange.
(9) Require carriers participating in the Exchange to make
available to the Exchange and regularly update an electronic
directory of contracting health care providers so that individuals
seeking coverage through the Exchange can search by health care
provider name to determine which health plans in the Exchange include
that health care provider in their network. The board may also
require a carrier to provide regularly updated information to the
Exchange as to whether a health care provider is accepting new
patients for a particular health plan. The Exchange may provide an
integrated and uniform consumer directory of health care providers
indicating which carriers the providers contract with and whether the
providers are currently accepting new patients. The Exchange may
also establish methods by which health care providers may transmit
relevant information directly to the Exchange, rather than through a
carrier.
(b) The Exchange shall only collect information from individuals
or designees of individuals necessary to administer the Exchange and
consistent with Section 1411 of the federal act.
100505. A carrier that is not participating in the Exchange shall
not offer, market, or sell a catastrophic plan, as defined in
subdivision (e) of Section 1302 of the federal act, in the individual
market.
100520. (a) The California
Health Trust Fund is hereby created in the State Treasury for
the purpose of this section and Section 3 of this act
title . Notwithstanding Section 13340
of the Government Code , all moneys in the fund shall be
continuously appropriated without regard to fiscal year for the
purposes of this section and Section 3 of this act
title . Any moneys in the fund that are unexpended or
unencumbered at the end of a fiscal year may be carried forward to
the next succeeding fiscal year.
(b) Notwithstanding any other provision of law, moneys deposited
in the fund shall not be loaned to, or borrowed by, any other special
fund or the General Fund, or a county general fund or any other
county fund.
(c) The board of the California Health Benefit Exchange shall
establish and maintain a prudent reserve in the fund.
(d) The board or staff of the Exchange shall not utilize any funds
intended for the administrative and operational expenses of the
Exchange for staff retreats, promotional giveaways, excessive
executive compensation, or promotion of federal or state legislative
or regulatory modifications.
(e) Notwithstanding Section 16305.7 of the Government
Code , all interest earned on the moneys that have been
deposited into the fund shall be retained in the fund and used for
purposes consistent with the fund.
SEC. 5. Section 1346.2 is added to the
Health and Safety Code , to read:
1346.2. The director shall, in coordination with the Insurance
Commissioner, review the Internet portal developed by the United
States Secretary of Health and Human Services under subdivision (a)
of Section 1103 of the federal Patient Protection and Affordable Care
Act (Public Law 111-148) and paragraph (5) of subdivision (c) of
Section 1311 of that act, and any enhancements to that portal
expected to be implemented by the secretary on or before January 1,
2015. The review shall examine whether the Internet portal provides
sufficient information regarding all health benefit products offered
by health care service plans and health insurers in the individual
and small employer markets in California to facilitate fair and
affirmative marketing of all individual and small employer plans,
particularly outside the California Health Benefit Exchange created
under Title 22 (commencing with Section 100500) of the Government
Code. If the director and the Insurance Commissioner jointly
determine that the Internet portal does not adequately achieve those
purposes, they shall jointly develop and maintain an electronic
clearinghouse to achieve those purposes. In performing this function,
the director and the Insurance Commissioner shall routinely monitor
individual and small employer benefit filings and complaints
submitted by individuals and small employers with their respective
departments, and shall use any other available means to maintain the
clearinghouse.
SEC. 5. SEC. 6. Section 1357.06 of
the Health and Safety Code is amended to read:
1357.06. (a) Preexisting condition provisions of a plan contract
shall not exclude coverage for a period beyond six months following
the individual's effective date of coverage and may only relate to
conditions for which medical advice, diagnosis, care, or treatment,
including prescription drugs, was recommended or received from a
licensed health practitioner during the six months immediately
preceding the effective date of coverage.
(b) A plan that does not utilize a preexisting condition provision
may impose a waiting or affiliation period, not to exceed 60 days,
before the coverage issued subject to this article shall become
effective. During the waiting or affiliation period no premiums shall
be charged to the enrollee or the subscriber.
(c) In determining whether a preexisting condition provision or a
waiting or affiliation period applies to any person, a plan shall
credit the time the person was covered under creditable coverage,
provided the person becomes eligible for coverage under the
succeeding plan contract within 62 days of termination of prior
coverage, exclusive of any waiting or affiliation period, and applies
for coverage with the succeeding plan contract within the applicable
enrollment period. A plan shall also credit any time an eligible
employee must wait before enrolling in the plan, including any
affiliation or employer-imposed waiting or affiliation period.
However, if a person's employment has ended, the availability of
health coverage offered through employment or sponsored by an
employer has terminated, or an employer's contribution toward health
coverage has terminated, a plan shall credit the time the person was
covered under creditable coverage if the person becomes eligible for
health coverage offered through employment or sponsored by an
employer within 180 days, exclusive of any waiting or affiliation
period, and applies for coverage under the succeeding plan contract
within the applicable enrollment period.
(d) In addition to the preexisting condition exclusions authorized
by subdivision (a) and the waiting or affiliation period authorized
by subdivision (b), health plans providing coverage to a guaranteed
association may impose on employers or individuals purchasing
coverage who would not be eligible for guaranteed coverage if they
were not purchasing through the association a waiting or affiliation
period, not to exceed 60 days, before the coverage issued subject to
this article shall become effective. During the waiting or
affiliation period, no premiums shall be charged to the enrollee or
the subscriber.
(e) An individual's period of creditable coverage shall be
certified pursuant to subdivision (e) of Section 2701 of Title XXVII
of the federal Public Health Services Act (42 U.S.C. Sec. 300gg(e)).
(f) A health care service plan issuing group coverage may not
impose a preexisting condition exclusion to any of the following:
(1) To a newborn individual, who, as of the last day of the 30-day
period beginning with the date of birth, has applied for coverage
through the employer-sponsored plan.
(2) To a child who is adopted or placed for adoption before
attaining 18 years of age and who, as of the last day of the 30-day
period beginning with the date of adoption or placement for adoption,
is covered under creditable coverage and applies for coverage
through the employer-sponsored plan. This provision shall not apply
if, for 63 continuous days, the child is not covered under any
creditable coverage.
(3) To a condition relating to benefits for pregnancy or maternity
care.
(g) Notwithstanding any other provision of this chapter, a group
health care service plan contract that is issued, amended, renewed,
or delivered on or after September 23, 2010, may not impose any
preexisting condition exclusion with respect to coverage under the
contract of any enrollee under 19 years of age.
SEC. 6. SEC. 7. Section 1357.51 of
the Health and Safety Code is amended to read:
1357.51. (a) No plan contract that covers three or more enrollees
shall exclude coverage for any individual on the basis of a
preexisting condition provision for a period greater than six months
following the individual's effective date of coverage. Preexisting
condition provisions contained in plan contracts may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the six months immediately
preceding the effective date of coverage.
(b) No plan contract that covers one or two individuals shall
exclude coverage on the basis of a preexisting condition provision
for a period greater than 12 months following the individual's
effective date of coverage, nor shall the plan limit or exclude
coverage for a specific enrollee by type of illness, treatment,
medical condition, or accident, except for satisfaction of a
preexisting condition clause pursuant to this article. Preexisting
condition provisions contained in plan contracts may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the 12 months immediately
preceding the effective date of coverage.
(c) A plan that does not utilize a preexisting condition provision
may impose a waiting or affiliation period not to exceed 60 days,
before the coverage issued subject to this article shall become
effective. During the waiting or affiliation period, the plan is not
required to provide health care services and no premium shall be
charged to the subscriber or enrollee.
(d) A plan that does not utilize a preexisting condition provision
in plan contracts that cover one or two individuals may impose a
contract provision excluding coverage for waivered conditions. No
plan may exclude coverage on the basis of a waivered condition for a
period greater than 12 months following the individual's effective
date of coverage. A waivered condition provision contained in plan
contracts may relate only to conditions for which medical advice,
diagnosis, care, or treatment, including use of prescription drugs,
was recommended or received from a licensed health practitioner
during the 12 months immediately preceding the effective date of
coverage.
(e) In determining whether a preexisting condition provision, a
waivered condition provision, or a waiting or affiliation period
applies to any enrollee, a plan shall credit the time the enrollee
was covered under creditable coverage, provided that the enrollee
becomes eligible for coverage under the succeeding plan contract
within 62 days of termination of prior coverage, exclusive of any
waiting or affiliation period, and applies for coverage under the
succeeding plan within the applicable enrollment period. A plan shall
also credit any time that an eligible employee must wait before
enrolling in the plan, including any postenrollment or
employer-imposed waiting or affiliation period.
However, if a person's employment has ended, the availability of
health coverage offered through employment or sponsored by an
employer has terminated, or an employer's contribution toward health
coverage has terminated, a plan shall credit the time the person was
covered under creditable coverage if the person becomes eligible for
health coverage offered through employment or sponsored by an
employer within 180 days, exclusive of any waiting or affiliation
period, and applies for coverage under the succeeding plan contract
within the applicable enrollment period.
(f) No plan shall exclude late enrollees from coverage for more
than 12 months from the date of the late enrollee's application for
coverage. No plan shall require any premium or other periodic charge
to be paid by or on behalf of a late enrollee during the period of
exclusion from coverage permitted by this subdivision.
(g) A health care service plan issuing group coverage may not
impose a preexisting condition exclusion upon the following:
(1) A newborn individual, who, as of the last day of the 30-day
period beginning with the date of birth, has applied for coverage
through the employer-sponsored plan.
(2) A child who is adopted or placed for adoption before attaining
18 years of age and who, as of the last day of the 30-day period
beginning with the date of adoption or placement for adoption, is
covered under creditable coverage and applies for coverage through
the employer-sponsored plan. This provision shall not apply if, for
63 continuous days, the child is not covered under any creditable
coverage.
(3) A condition relating to benefits for pregnancy or maternity
care.
(h) An individual's period of creditable coverage shall be
certified pursuant to subsection (e) of Section 2701 of Title XXVII
of the federal Public Health Services Act (42 U.S.C. Sec. 300gg(e)).
(i) Notwithstanding any other provision of this chapter, a health
benefit plan, as defined in Section 1357.50, that is issued, amended,
renewed, or delivered on or after September 23, 2010, may not impose
any preexisting condition exclusion with respect to coverage under
the plan of any enrollee under 19 years of age.
SEC. 7. SEC. 8. Section 1367.001 is
added to the Health and Safety Code, to read:
1367.001. (a) (1) A group or individual health care service plan
contract that is issued, amended, renewed, or delivered on or after
September 23, 2010, may not establish lifetime limits on the dollar
value of benefits for any participant or beneficiary.
(2) With respect to plan years beginning prior to January 1, 2014,
a group or individual health care service plan contract that is
issued, amended, renewed, or delivered on or after September 23,
2010, may only establish a restricted annual limit on the dollar
value of benefits for any participant or beneficiary with respect to
the scope of benefits that are essential health benefits under
subsection (b) of Section 1302 of the federal Patient Protection and
Affordable Care Act, as determined by the United States Secretary of
Health and Human Services.
(b) (1) Subject to the minimum interval established by the United
States Secretary of Health and Human Services pursuant to subsection
(b) of Section 2713 of Section 1001 of the federal Patient Protection
and Affordable Care Act, a group or individual health care service
plan contract that is issued, amended, renewed, or delivered on or
after September 23, 2010, shall, at a minimum, provide coverage for,
and shall not impose any cost sharing requirements for, all of the
following:
(A) Evidence-based items or services that have in effect a rating
of "A" or "B" in the current recommendations of the United States
Preventive Services Task Force.
(B) Immunizations that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the federal Centers
for Disease Control and Prevention with respect to the individual
involved.
(C) With respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for in the
comprehensive guidelines supported by the federal Health Resources
and Services Administration.
(D) With respect to women, any additional preventive care and
screenings not described in subparagraph (A) as provided for in
comprehensive guidelines supported by the federal Health Resources
and Services Administration.
(2) For purposes of this subdivision, the current recommendations
of the United States Preventive Services Task Force regarding breast
cancer screening, mammography, and prevention shall be considered
the most current, other than recommendations issued by the task force
in November of 2009, or within 30 days of that month.
(3) Nothing in this subdivision shall be construed to prohibit a
plan from providing coverage for services in addition to those
recommended by the United States Preventive Services Task Force or to
deny coverage for services that are not recommended by the task
force.
(c) This section shall not apply to Medicare supplement
plans plan contracts or to specialized health
care service plans plan contracts .
(d) This section shall apply notwithstanding any other provision
of this chapter.
SEC. 8. SEC. 9. Section 1373 of the
Health and Safety Code is amended to read:
1373. (a) A plan contract may not provide an exception for other
coverage if the other coverage is entitlement to Medi-Cal benefits
under Chapter 7 (commencing with Section 14000) or Chapter 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code, or Medicaid benefits under Subchapter
19 (commencing with Section 1396) of Chapter 7 of Title 42 of the
United States Code.
Each plan contract shall be interpreted not to provide an
exception for the Medi-Cal or Medicaid benefits.
A plan contract shall not provide an exemption for enrollment
because of an applicant's entitlement to Medi-Cal benefits under
Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing
with Section 14200) of Part 3 of Division 9 of the Welfare and
Institutions Code, or Medicaid benefits under Subchapter 19
(commencing with Section 1396) of Chapter 7 of Title 42 of the United
States Code.
A plan contract may not provide that the benefits payable
thereunder are subject to reduction if the individual insured has
entitlement to the Medi-Cal or Medicaid benefits.
(b) A plan contract that provides coverage, whether by specific
benefit or by the effect of general wording, for sterilization
operations or procedures shall not impose any disclaimer, restriction
on, or limitation of, coverage relative to the covered individual's
reason for sterilization.
As used in this section, "sterilization operations or procedures"
shall have the same meaning as that specified in Section 10120 of the
Insurance Code.
(c) Every plan contract that provides coverage to the spouse or
dependents of the subscriber or spouse shall grant immediate accident
and sickness coverage, from and after the moment of birth, to each
newborn infant of any subscriber or spouse covered and to each minor
child placed for adoption from and after the date on which the
adoptive child's birth parent or other appropriate legal authority
signs a written document, including, but not limited to, a health
facility minor release report, a medical authorization form, or a
relinquishment form, granting the subscriber or spouse the right to
control health care for the adoptive child or, absent this written
document, on the date there exists evidence of the subscriber's or
spouse's right to control the health care of the child placed for
adoption. No plan may be entered into or amended if it contains any
disclaimer, waiver, or other limitation of coverage relative to the
coverage or insurability of newborn infants of, or children placed
for adoption with, a subscriber or spouse covered as required by this
subdivision.
(d) (1) Every plan contract that provides that coverage of a
dependent child of a subscriber shall terminate upon attainment of
the limiting age for dependent children specified in the plan, shall
also provide that attainment of the limiting age shall not operate to
terminate the coverage of the child while the child is and continues
to meet both of the following criteria:
(A) Incapable of self-sustaining employment by reason of a
physically or mentally disabling injury, illness, or condition.
(B) Chiefly dependent upon the subscriber for support and
maintenance.
(2) The plan shall notify the subscriber that the dependent child'
s coverage will terminate upon attainment of the limiting age unless
the subscriber submits proof of the criteria described in
subparagraphs (A) and (B) of paragraph (1) to the plan within 60 days
of the date of receipt of the notification. The plan shall send this
notification to the subscriber at least 90 days prior to the date
the child attains the limiting age. Upon receipt of a request by the
subscriber for continued coverage of the child and proof of the
criteria described in subparagraphs (A) and (B) of paragraph (1), the
plan shall determine whether the child meets that criteria before
the child attains the limiting age. If the plan fails to make the
determination by that date, it shall continue coverage of the child
pending its determination.
(3) The plan may subsequently request information about a
dependent child whose coverage is continued beyond the limiting age
under this subdivision but not more frequently than annually after
the two-year period following the child's attainment of the limiting
age.
(4) If the subscriber changes carriers to another plan or to a
health insurer, the new plan or insurer shall continue to provide
coverage for the dependent child. The new plan or insurer may request
information about the dependent child initially and not more
frequently than annually thereafter to determine if the child
continues to satisfy the criteria in subparagraphs (A) and (B) of
paragraph (1). The subscriber shall submit the information requested
by the new plan or insurer within 60 days of receiving the request.
(5) Except as specified in this section and except as necessary to
be consistent with the regulations promulgated by the United States
Secretary of Health and Human Services that define "dependent" for
purposes of the limiting age, under no circumstances shall the
limiting age be less than 26 years of age.
(e) A plan contract that provides coverage, whether by specific
benefit or by the effect of general wording, for both an employee and
one or more covered persons dependent upon the employee and provides
for an extension of the coverage for any period following a
termination of employment of the employee shall also provide that
this extension of coverage shall apply to dependents upon the same
terms and conditions precedent as applied to the covered employee,
for the same period of time, subject to payment of premiums, if any,
as required by the terms of the policy and subject to any applicable
collective bargaining agreement.
(f) A group contract shall not discriminate against handicapped
persons or against groups containing handicapped persons. Nothing in
this subdivision shall preclude reasonable provisions in a plan
contract against liability for services or reimbursement of the
handicap condition or conditions relating thereto, as may be allowed
by rules of the director.
(g) Every group contract shall set forth the terms and conditions
under which subscribers and enrollees may remain in the plan in the
event the group ceases to exist, the group contract is terminated or
an individual subscriber leaves the group, or the enrollees'
eligibility status changes.
(h) (1) A health care service plan or specialized health care
service plan may provide for coverage of, or for payment for,
professional mental health services, or vision care services, or for
the exclusion of these services. If the terms and conditions include
coverage for services provided in
a general acute care hospital or an acute psychiatric
hospital as defined in Section 1250 and do not restrict or modify the
choice of providers, the coverage shall extend to care provided by a
psychiatric health facility as defined in Section 1250.2 operating
pursuant to licensure by the State Department of Mental Health. A
health care service plan that offers outpatient mental health
services but does not cover these services in all of its group
contracts shall communicate to prospective group contractholders as
to the availability of outpatient coverage for the treatment of
mental or nervous disorders.
(2) No plan shall prohibit the member from selecting any
psychologist who is licensed pursuant to the Psychology Licensing Law
(Chapter 6.6 (commencing with Section 2900) of Division 2 of the
Business and Professions Code), any optometrist who is the holder of
a certificate issued pursuant to Chapter 7 (commencing with Section
3000) of Division 2 of the Business and Professions Code or, upon
referral by a physician and surgeon licensed pursuant to the Medical
Practice Act (Chapter 5 (commencing with Section 2000) of Division 2
of the Business and Professions Code), (A) any marriage and family
therapist who is the holder of a license under Section 4980.50 of the
Business and Professions Code, (B) any licensed clinical social
worker who is the holder of a license under Section 4996 of the
Business and Professions Code, (C) any registered nurse licensed
pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of
the Business and Professions Code, who possesses a master's degree
in psychiatric-mental health nursing and is listed as a
psychiatric-mental health nurse by the Board of Registered Nursing,
or (D) any advanced practice registered nurse certified as a clinical
nurse specialist pursuant to Article 9 (commencing with Section
2838) of Chapter 6 of Division 2 of the Business and Professions Code
who participates in expert clinical practice in the specialty of
psychiatric-mental health nursing, to perform the particular services
covered under the terms of the plan, and the certificate holder is
expressly authorized by law to perform these services.
(3) Nothing in this section shall be construed to allow any
certificate holder or licensee enumerated in this section to perform
professional mental health services beyond his or her field or fields
of competence as established by his or her education, training and
experience.
(4) For the purposes of this section, "marriage and family
therapist" means a licensed marriage and family therapist who has
received specific instruction in assessment, diagnosis, prognosis,
and counseling, and psychotherapeutic treatment of premarital,
marriage, family, and child relationship dysfunctions that is
equivalent to the instruction required for licensure on January 1,
1981.
(5) Nothing in this section shall be construed to allow a member
to select and obtain mental health or psychological or vision care
services from a certificate or licenseholder who is not directly
affiliated with or under contract to the health care service plan or
specialized health care service plan to which the member belongs. All
health care service plans and individual practice associations that
offer mental health benefits shall make reasonable efforts to make
available to their members the services of licensed psychologists.
However, a failure of a plan or association to comply with the
requirements of the preceding sentence shall not constitute a
misdemeanor.
(6) As used in this subdivision, "individual practice association"
means an entity as defined in subsection (5) of Section 1307 of the
federal Public Health Service Act (42 U.S.C. Sec. 300e-1 (5)).
(7) Health care service plan coverage for professional mental
health services may include community residential treatment services
that are alternatives to inpatient care and that are directly
affiliated with the plan or to which enrollees are referred by
providers affiliated with the plan.
(i) If the plan utilizes arbitration to settle disputes, the plan
contracts shall set forth the type of disputes subject to
arbitration, the process to be utilized, and how it is to be
initiated.
(j) A plan contract that provides benefits that accrue after a
certain time of confinement in a health care facility shall specify
what constitutes a day of confinement or the number of consecutive
hours of confinement that are requisite to the commencement of
benefits.
(k) If a plan provides coverage for a dependent child who is over
26 years of age and enrolled as a full-time student at a secondary or
postsecondary educational institution, the following shall apply:
(1) Any break in the school calendar shall not disqualify the
dependent child from coverage.
(2) If the dependent child takes a medical leave of absence, and
the nature of the dependent child's injury, illness, or condition
would render the dependent child incapable of self-sustaining
employment, the provisions of subdivision (d) shall apply if the
dependent child is chiefly dependent on the subscriber for support
and maintenance.
(3) (A) If the dependent child takes a medical leave of absence
from school, but the nature of the dependent child's injury, illness,
or condition does not meet the requirements of paragraph (2), the
dependent child's coverage shall not terminate for a period not to
exceed 12 months or until the date on which the coverage is scheduled
to terminate pursuant to the terms and conditions of the plan,
whichever comes first. The period of coverage under this paragraph
shall commence on the first day of the medical leave of absence from
the school or on the date the physician determines the illness
prevented the dependent child from attending school, whichever comes
first. Any break in the school calendar shall not disqualify the
dependent child from coverage under this paragraph.
(B) Documentation or certification of the medical necessity for a
leave of absence from school shall be submitted to the plan at least
30 days prior to the medical leave of absence from the school, if the
medical reason for the absence and the absence are foreseeable, or
30 days after the start date of the medical leave of absence from
school and shall be considered prima facie evidence of entitlement to
coverage under this paragraph.
(4) This subdivision shall not apply to a specialized health care
service plan or to a Medicare supplement plan.
SEC. 9. SEC. 10. Section 10112.1 is
added to the Insurance Code, to read:
10112.1. (a) (1) A group or individual health insurance policy
that is issued, amended, renewed, or delivered on or after September
23, 2010, may not establish lifetime limits on the dollar value of
benefits for any participant or beneficiary.
(2) With respect to plan years beginning prior to January 1, 2014,
a group or individual health insurance policy that is issued,
amended, renewed, or delivered on or after September 23, 2010, may
only establish a restricted annual limit on the dollar value of
benefits for any participant or beneficiary with respect to the scope
of benefits that are essential health benefits under subsection (b)
of Section 1302 of the federal Patient Protection and Affordable Care
Act, as determined by the United States Secretary of Health and
Human Services.
(b) (1) Subject to the minimum interval established by the United
States Secretary of Health and Human Services pursuant to subsection
(b) of Section 2713 of Section 1001 of the federal Patient Protection
and Affordable Care Act, a group or individual health insurance
policy that is issued, amended, renewed, or delivered on or after
September 23, 2010, shall, at a minimum, provide coverage for, and
shall not impose any cost sharing requirements for, all of the
following:
(A) Evidence-based items or services that have in effect a rating
of "A" or "B" in the current recommendations of the United States
Preventive Services Task Force.
(B) Immunizations that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the federal Centers
for Disease Control and Prevention with respect to the individual
involved.
(C) With respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for in the
comprehensive guidelines supported by the federal Health Resources
and Services Administration.
(D) With respect to women, any additional preventive care and
screenings not described in subparagraph (A) as provided for in
comprehensive guidelines supported by the federal Health Resources
and Services Administration.
(2) For purposes of this subdivision, the current recommendations
of the United States Preventive Services Task Force regarding breast
cancer screening, mammography, and prevention shall be considered
the most current, other than recommendations issued by the task force
in November of 2009, or within 30 days of that month.
(3) Nothing in this subdivision shall be construed to prohibit a
health insurer from providing coverage for services in addition to
those recommended by the United States Preventive Services Task Force
or to deny coverage for services that are not recommended by the
task force.
(c) This section shall not apply to specialized health insurance
policies, Medicare supplement policies, CHAMPUS-supplement insurance
policies, TRICARE-supplement insurance policies, accident-only
insurance policies, or insurance policies excluded from the
definition of "health insurance" under subdivision (b) of Section
106.
(d) This section shall apply notwithstanding any other provision
of this part.
SEC. 11. Section 10112.2 is added to the
Insurance Code , to read:
10112.2. The commissioner shall, in coordination with the
Director of the Department of Managed Health Care, review the
Internet portal developed by the United States Secretary of Health
and Human Services under subdivision (a) of Section 1103 of the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and paragraph (5) of subdivision (c) of Section 1311 of that
act, and any enhancements to that portal expected to be implemented
by the Secretary on or before January 1, 2015. The review shall
examine whether the Internet portal provides sufficient information
regarding all health benefit products offered by health care service
plans and health insurers in the individual and small employer
markets in California to facilitate fair and affirmative marketing of
all individual and small employer plans, particularly outside the
Health Benefit Exchange created under Title 22 (commencing with
Section 100500) of the Government Code. If the commissioner and the
Director of the Department of Managed Health Care jointly determine
that the Internet portal does not adequately achieve those purposes,
they shall jointly develop and maintain an electronic clearinghouse
to achieve those purposes. In performing this function, the
commissioner and the Director of the Department of Managed Health
Care shall routinely monitor individual and small employer benefit
filings and complaints submitted by individuals and small employers
with their respective departments, and shall use any other available
means to maintain the clearinghouse.
SEC. 10. SEC. 12. Section 10198.7 of
the Insurance Code is amended to read:
10198.7. (a) No health benefit plan that covers three or more
persons and that is issued, renewed, or written by any insurer,
nonprofit hospital service plan, self-insured employee welfare
benefit plan, fraternal benefits society, or any other entity shall
exclude coverage for any individual on the basis of a preexisting
condition provision for a period greater than six months following
the individual's effective date of coverage, nor shall limit or
exclude coverage for a specific insured person by type of illness,
treatment, medical condition, or accident except for satisfaction of
a preexisting clause pursuant to this article. Preexisting condition
provisions contained in health benefit plans may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the six months immediately
preceding the effective date of coverage.
(b) No health benefit plan that covers one or two individuals and
that is issued, renewed, or written by any insurer, self-insured
employee welfare benefit plan, fraternal benefits society, or any
other entity shall exclude coverage on the basis of a preexisting
condition provision for a period greater than 12 months following the
individual's effective date of coverage, nor shall limit or exclude
coverage for a specific insured person by type of illness, treatment,
medical condition, or accident, except for satisfaction of a
preexisting condition clause pursuant to this article. Preexisting
condition provisions contained in health benefit plans may relate
only to conditions for which medical advice, diagnosis, care, or
treatment, including use of prescription drugs, was recommended or
received from a licensed health practitioner during the 12 months
immediately preceding the effective date of coverage.
(c) A carrier that does not utilize a preexisting condition
provision may impose a waiting or affiliation period not to exceed 60
days, before the coverage issued subject to this article shall
become effective. During the waiting or affiliation period, the
carrier is not required to provide health care services and no
premium shall be charged to the subscriber or enrollee.
(d) A carrier that does not utilize a preexisting condition
provision in health plans that cover one or two individuals may
impose a contract provision excluding coverage for waivered
conditions. No carrier may exclude coverage on the basis of a
waivered condition for a period greater than 12 months following the
individual's effective date of coverage. A waivered condition
provision contained in health benefit plans may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the 12 months immediately
preceding the effective date of coverage.
(e) In determining whether a preexisting condition provision, a
waivered condition provision, or a waiting or affiliation period
applies to any person, all health benefit plans shall credit the time
the person was covered under creditable coverage, provided the
person becomes eligible for coverage under the succeeding health
benefit plan within 62 days of termination of prior coverage,
exclusive of any waiting or affiliation period, and applies for
coverage under the succeeding plan within the applicable enrollment
period. A health benefit plan shall also credit any time an eligible
employee must wait before enrolling in the health benefit plan,
including any affiliation or employer-imposed waiting period.
However, if a person's employment has ended, the availability of
health coverage offered through employment or sponsored by an
employer has terminated or, an employer's contribution toward health
coverage has terminated, a carrier shall credit the time the person
was covered under creditable coverage if the person becomes eligible
for health coverage offered through employment or sponsored by an
employer within 180 days, exclusive of any waiting or affiliation
period, and applies for coverage under the succeeding plan within the
applicable enrollment period.
(f) No health benefit plan that covers three or more persons and
that is issued, renewed, or written by any insurer, nonprofit
hospital service plan, self-insured employee welfare benefit plan,
fraternal benefits society, or any other entity may exclude late
enrollees from coverage for more than 12 months from the date of the
late enrollee's application for coverage. No insurer, nonprofit
hospital service plan, self-insured employee welfare benefit plan,
fraternal benefits society, or any other entity shall require any
premium or other periodic charge to be paid by or on behalf of a late
enrollee during the period of exclusion from coverage permitted by
this subdivision.
(g) An individual's period of creditable coverage shall be
certified pursuant to subdivision (e) of Section 2701 of Title XXVII
of the federal Public Health Services Act. (42 U.S.C. Sec. 300gg(e).
(h) A group health benefit plan may not impose a preexisting
condition exclusion to any of the following:
(1) To a newborn individual, who, as of the last day of the 30-day
period beginning with the date of birth, applied for coverage
through the employer-sponsored plan.
(2) To a child who is adopted or placed for adoption before
attaining 18 years of age and who, as of the last day of the 30-day
period beginning with the date of adoption or placement for adoption,
is covered under creditable coverage and applies for coverage
through the employer-sponsored plan. This provision shall not apply
if, for 63 continuous days, the child is not covered under any
creditable coverage.
(3) To a condition relating to benefits for pregnancy or maternity
care.
(i) Any entity providing aggregate or specific stop loss coverage
or any other assumption of risk with reference to a health benefit
plan shall provide that the plan meets all requirements of this
article concerning waiting periods, preexisting condition provisions,
and late enrollees.
(j) Notwithstanding any other provision of this code, a health
benefit plan that is issued, amended, renewed, or delivered on or
after September 23, 2010, may not impose any preexisting condition
exclusion with respect to coverage under the plan of any insured
under 19 years of age.
SEC. 11. SEC. 13. Section 10277 of
the Insurance Code is amended to read:
10277. (a) A group health insurance policy that provides that
coverage of a dependent child of an employee or other member of the
covered group shall terminate upon attainment of the limiting age for
dependent children specified in the policy, shall also provide that
attainment of the limiting age shall not operate to terminate the
coverage of the child while the child is and continues to meet both
of the following criteria:
(1) Incapable of self-sustaining employment by reason of a
physically or mentally disabling injury, illness, or condition.
(2) Chiefly dependent upon the employee or member for support and
maintenance.
(b) The insurer shall notify the employee or member that the
dependent child's coverage will terminate upon attainment of the
limiting age unless the employee or member submits proof of the
criteria described in paragraphs (1) and (2) of subdivision (a) to
the insurer within 60 days of the date of receipt of the
notification. The insurer shall send this notification to the
employee or member at least 90 days prior to the date the child
attains the limiting age. Upon receipt of a request by the employee
or member for continued coverage of the child and proof of the
criteria described in paragraphs (1) and (2) of subdivision (a), the
insurer shall determine whether the dependent child meets that
criteria before the child attains the limiting age. If the insurer
fails to make the determination by that date, it shall continue
coverage of the child pending its determination.
(c) The insurer may subsequently request information about a
dependent child whose coverage is continued beyond the limiting age
under subdivision (a), but not more frequently than annually after
the two-year period following the child's attainment of the limiting
age.
(d) If the employee or member changes carriers to another insurer
or to a health care service plan, the new insurer or plan shall
continue to provide coverage for the dependent child. The new plan or
insurer may request information about the dependent child initially
and not more frequently than annually thereafter to determine if the
child continues to satisfy the criteria in paragraphs (1) and (2) of
subdivision (a). The employee or member shall submit the information
requested by the new plan or insurer within 60 days of receiving the
request.
(e) Except as specified in this subdivision and except as
necessary to be consistent with the regulations promulgated by the
United States Secretary of Health and Human Services that define
"dependent" for purposes of the limiting age, under no circumstances
shall the limiting age be less than 26 years of age under a group or
individual health insurance policy that provides coverage of a
dependent child.
(f) If a group health insurance policy provides coverage for a
dependent child who is over 26 years of age and enrolled as a
full-time student at a secondary or postsecondary educational
institution, the following shall apply:
(1) Any break in the school calendar shall not disqualify the
dependent child from coverage.
(2) If the dependent child takes a medical leave of absence, and
the nature of the dependent child's injury, illness, or condition
would render the dependent child incapable of self-sustaining
employment, the provisions of subdivision (a) shall apply if the
dependent child is chiefly dependent on the policyholder for support
and maintenance.
(3) (A) If the dependent child takes a medical leave of absence
from school, but the nature of the dependent child's injury, illness,
or condition does not meet the requirements of paragraph (2), the
dependent child's coverage shall not terminate for a period not to
exceed 12 months or until the date on which the coverage is scheduled
to terminate pursuant to the terms and conditions of the policy,
whichever comes first. The period of coverage under this paragraph
shall commence on the first day of the medical leave of absence from
the school or on the date the physician determines the illness
prevented the dependent child from attending school, whichever comes
first. Any break in the school calendar shall not disqualify the
dependent child from coverage under this paragraph.
(B) Documentation or certification of the medical necessity for a
leave of absence from school shall be submitted to the insurer at
least 30 days prior to the medical leave of absence from the school,
if the medical reason for the absence and the absence are
foreseeable, or 30 days after the start date of the medical leave of
absence from school and shall be considered prima facie evidence of
entitlement to coverage under this paragraph.
(4) This subdivision shall not apply to a policy of specialized
health insurance, Medicare supplement insurance, CHAMPUS-supplement,
or TRICARE-supplement insurance policies, or to hospital-only,
accident-only, or specified disease insurance policies that reimburse
for hospital, medical, or surgical benefits.
SEC. 12. SEC. 14. Section 10708 of
the Insurance Code is amended to read:
10708. (a) Preexisting condition provisions of health benefit
plans shall not exclude coverage for a period beyond six months
following the individual's effective date of coverage and may only
relate to conditions for which medical advice, diagnosis, care, or
treatment, including the use of prescription medications, was
recommended by or received from a licensed health practitioner during
the six months immediately preceding the effective date of coverage.
(b) A carrier that does not utilize a preexisting condition
provision may impose a waiting or affiliation period, not to exceed
60 days, before the coverage issued subject to this chapter shall
become effective. During the waiting or affiliation period, the
carrier is not required to provide health care benefits and no
premiums shall be charged to the subscriber or enrollee.
(c) In determining whether a preexisting condition provision or a
waiting period applies to any person, a plan shall credit the time
the person was covered under creditable coverage, provided the person
becomes eligible for coverage under the succeeding plan contract
within 62 days of termination of prior coverage, exclusive of any
waiting or affiliation period, and applies for coverage with the
succeeding health benefit plan contract within the applicable
enrollment period. A plan shall also credit any time an eligible
employee must wait before enrolling in the health benefit plan,
including any postenrollment or employer-imposed waiting or
affiliation period. However, if a person's employment has ended, the
availability of health coverage offered through employment or
sponsored by an employer has terminated, or an employer's
contribution toward health coverage has terminated, a plan shall
credit the time the person was covered under creditable coverage if
the person becomes eligible for health coverage offered through
employment or sponsored by an employer within 180 days, exclusive of
any waiting or affiliation period, and applies for coverage under the
succeeding health benefit plan within the applicable enrollment
period.
(d) Group health benefit plans may not impose a preexisting
conditions exclusion to the following:
(1) To a newborn individual, who, as of the last day of the 30-day
period beginning with the date of birth, applied for coverage
through the employer-sponsored plan.
(2) To a child who is adopted or placed for adoption before
attaining 18 years of age and who, as of the last day of the 30-day
period beginning with the date of adoption or placement for adoption,
is covered under creditable coverage and applies for coverage
through the employer-sponsored plan. This provision shall not apply
if, for 63 continuous days, the child is not covered under any
creditable coverage.
(3) To a condition relating to benefits for pregnancy or maternity
care.
(e) A carrier providing aggregate or specific stop loss coverage
or any other assumption of risk with reference to a health benefit
plan shall provide that the plan meets all requirements of this
section concerning preexisting condition provisions and waiting or
affiliation periods.
(f) In addition to the preexisting condition exclusions authorized
by subdivision (a) and the waiting or affiliation period authorized
by subdivision (b), carriers providing coverage to a guaranteed
association may impose on employers or individuals purchasing
coverage who would not be eligible for guaranteed coverage if they
were not purchasing through the association a waiting or affiliation
period, not to exceed 60 days, before the coverage issued
subject to this chapter shall
become effective. During the waiting or affiliation period, the
carrier is not required to provide health care benefits and no
premiums shall be charged to the insured.
(g) Notwithstanding any other provision of this code, a group
health benefit plan that is issued, amended, renewed, or delivered on
or after September 23, 2010, may not impose any preexisting
condition exclusion with respect to coverage under the plan of any
insured under 19 years of age.
SEC. 13. SEC. 15. No reimbursement
is required by this act pursuant to Section 6 of Article XIII B of
the California Constitution because the only costs that may be
incurred by a local agency or school district will be incurred
because this act creates a new crime or infraction, eliminates a
crime or infraction, or changes the penalty for a crime or
infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIII B of the California Constitution.
