Bill Text: CA SB1176 | 2013-2014 | Regular Session | Amended
Bill Title: Health care coverage: cost sharing: monitoring.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2014-08-21 - Ordered to inactive file on request of Assembly Member V. Manuel Pérez. [SB1176 Detail]
Download: California-2013-SB1176-Amended.html
BILL NUMBER: SB 1176 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 24, 2014
AMENDED IN SENATE APRIL 30, 2014
AMENDED IN SENATE APRIL 7, 2014
INTRODUCED BY Senator Steinberg
FEBRUARY 20, 2014
An act to add Section 1367.0061 to the Health and Safety Code, and
to add Section 10112.281 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1176, as amended, Steinberg. Health care coverage: cost
sharing: tracking. monitoring.
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. A willful violation
of the act is a crime. Existing law provides for the regulation of
health insurers by the Department of Insurance. Existing law requires
a health care service plan or health insurer
to limit annual out-of-pocket expenses for all covered benefits, as
specified.
This bill would require a health care service plan or health
insurer to be responsible for monitoring the accrual of out-of-pocket
costs. The bill would require a health care service plan or health
insurer to track the accumulation of cost sharing for covered
essential health benefits attributed to in-network providers, and
would prohibit those entities from requiring consumers to track or
monitor those costs. The bill would require a plan or insurer to
accept claims from the provider or the consumer with respect to cost
sharing for out-of-network providers who are providing certain
emergency services or otherwise providing covered benefits. The bill
would also require a plan or insurer to notify each enrollee or
insured, within 30 days, when his or her cost sharing has reached the
maximum annual out-of-pocket limit for covered essential health
benefits and to reimburse an enrollee or insured within 30 days of
receiving a claim for cost sharing paid in excess of the maximum
annual out-of-pocket limit. The bill would require that the enrollee
or insured have the opportunity to review the accrual of cost sharing
and provide additional information regarding cost sharing that
should be credited to the out-of-pocket limit. Because a willful
violation of the bill's provisions by a health care service plan
would be a crime, the bill would impose a state-mandated local
program.
This bill would require a health care service plan or health
insurer to be responsible for monitoring the accrual of out-of-pocket
costs toward the annual out-of-pocket limit. The bill would require
a health care service plan or health insurer, for cost sharing
attributed to in-network providers, including contracted vendors,
that count toward the annual limit on out-of-pocket costs, to be
solely responsible for monitoring the accrual of out-of-pocket costs
and prohibit the health care service plan or health insurer from
requiring the consumer to track or monitor the accumulation of cost
sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors. The bill would
require a health care service plan or health insurer to accept claims
from the provider or information from the consumer with respect to
cost sharing for out-of-network providers who are providing certain
emergency services or otherwise providing covered benefits arranged
by the health care service plan or health insurer subject to the
annual limit on out-of-pocket expenses. The bill would also require
the health care service plan or health insurer, if the cost sharing
for covered essential health benefits attributable to an enrollee or
insured exceeds the maximum annual out-of-pocket limits, to reimburse
the enrollee or insured no later than 5 working days after the
health care service plan or health insurer is required to reimburse
the claim or notify the claimant that the claim is contested or
denied. The bill would require that the enrollee or insured have the
opportunity to review the accrual of cost sharing and provide
additional information regarding cost sharing that should be accrued
to the out-of-pocket limit. Because a willful violation of the bill's
provisions by a health care service plan would be a crime, the bill
would impose a state-mandated local program.
This bill would make these provisions applicable to
nongrandfathered individual and group health care service plans,
specialized health care service plans that provide coverage for
essential health benefits, nongrandfathered individual and group
health insurers, and specialized health insurers that provide
coverage for essential health benefits.
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: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.0061 is added to the Health and Safety
Code, immediately following Section 1367.006, to read:
1367.0061. (a) This section shall apply to nongrandfathered
individual and group health care service plans and to specialized
health care service plans that provide coverage for essential health
benefits, as defined in Section 1367.005, and that are issued,
amended, or renewed on or after January 1, 2015.
(b) The health care service plan shall be responsible for
monitoring the accrual of out-of-pocket costs as
defined toward the annual limit on
out-of-pocket costs as provided in Section 1367.006.
(c) The health care service plan shall track the accumulation of
cost sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors. The plan shall
not require consumers to track or monitor the accumulation of cost
sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors.
(1) For cost sharing attributed to in-network providers, including
contracted vendors, that count toward the annual limit on
out-of-pocket costs, the health care service plan shall be solely
responsible for monitoring the accrual of out-of-pocket costs and
shall not require consumers to track or monitor the accumulation of
cost sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors.
(d)
(2) For cost sharing attributed to out-of-network
providers who are providing emergency services consistent with
Section 1371.4 or cost sharing for out-of-network providers
otherwise providing covered benefits,
benefits arranged by the health care service plan, subject to
the annual limit on out-of-pocket expenses as specified in Section
1367.006, the health care service plan shall accept claims from the
provider or information from the consumer with respect to
cost sharing.
(e)
(c) If the cost sharing for covered essential health
benefits attributable to an enrollee exceeds the maximum annual
out-of-pocket limits, the health care service plan shall be
responsible for reimbursing the individual within 30 days of receipt
of claims information. reimburse the enrollee no later
than five working days after the health care service plan is
required to reimburse the claim or notify the claimant that the claim
is contested or denied, as specified in Section 1371.
(f) Within 30 days, the health care service plan shall notify each
enrollee when the enrollee's cost sharing has reached the maximum
annual out-of-pocket limit for covered essential health benefits.
(d) If the cost sharing for covered essential health benefits
attributable to an enrollee meets or exceeds the maximum annual
out-of-pocket limits, the health care service plan shall notify the
enrollee no later than five working days after the health care
service plan is required to reimburse the claim or notify the
claimant that the claim is contested or denied, as specified in
Section 1371.
(g)
(e) The enrollee shall have the opportunity to review
the accrual of cost sharing and provide additional information
regarding cost sharing that should be accrued to the annual
out-of-pocket limit.
(h)
(f) Nothing in this section shall be construed as
requiring the enrollee to determine or identify when the maximum
annual out-of-pocket limit for covered benefits has been reached.
SEC. 2. Section 10112.281 is added to the Insurance Code,
immediately following Section 10112.28, to read:
10112.281. (a) This section shall apply to nongrandfathered
individual and group health insurers and to specialized health
insurers that provide coverage for essential health benefits, as
defined in Section 10112.27, and that are issued, amended, or renewed
on or after January 1, 2015.
(b) The health insurer shall be responsible for monitoring
the accrual of out-of-pocket costs as defined
toward the annual limit on out-of-pocket costs as
provided in Section 10112.28.
(c) The health insurer shall track the accumulation of cost
sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors. The insurer shall
not require consumers to track or monitor the accumulation of cost
sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors.
(1) For cost sharing attributed to in-network providers, including
contracted vendors, that count toward the annual limit on
out-of-pocket costs, the health insurer shall be solely responsible
for monitoring the accrual of out-of-pocket costs and shall not
require consumers to track or monitor the accumulation of cost
sharing for covered essential health benefits attributed to
in-network providers, including contracted vendors.
(d)
(2) For cost sharing attributed to out-of-network
providers who are providing emergency services consistent with
Section 10112.7 or otherwise providing covered benefits,
benefits arranged by the health insurer, subject
to the annual limit on out-of-pocket expenses as specified in
Section 10112.28, the health insurer shall accept claims from the
provider or information from the consumer with respect to
cost sharing.
(e)
(c) If the cost sharing for covered essential health
benefits attributable to an insured exceeds the maximum annual
out-of-pocket limits, the health insurer shall be
responsible for reimbursing the individual within 30 days of receipt
of claims information. reimburse the insured no later
than five working days after the health insurer is required to
reimburse the claim or notify the claimant that the claim is
contested or denied, as specified in Section 10123.13.
(f) Within 30 days, the health insurer shall notify each insured
when the insured's cost sharing has reached the maximum annual
out-of-pocket limit for covered essential health benefits.
(d) If the cost sharing for covered essential health benefits
attributable to an insured meets or exceeds the maximum annual
out-of-pocket limits, the health insurer shall notify the insured no
later than five working days after the health insurer is required to
reimburse the claim or notify the claimant that the claim is
contested or denied, as specified in Section 10123.13.
(g)
(e) The insured shall have the opportunity to review
the accrual of cost sharing and provide additional information
regarding cost sharing that should be accrued to the annual
out-of-pocket limit.
(h)
(f) Nothing in this section shall be construed as
requiring the insured to determine or identify when the maximum
annual out-of-pocket limit for covered benefits has been reached.
SEC. 3. 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.
