Bill Text: CA SB1176 | 2013-2014 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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

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BILL NUMBER: SB 1176	AMENDED
	BILL TEXT

	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.
   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 plan or 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 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)  The   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 accrual of out-of-pocket costs as
defined in Section 1367.006. 
   (b)
    (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.

   (c) 
   (d)  For cost sharing attributed to out-of-network
providers who are providing emergency services consistent with
Section 1371.4 or otherwise providing covered benefits,  subject
to the annual limit on out-o   f-pocket expenses as
specified in Section 1367.006,  the health care service plan
shall accept claims from the provider or the consumer with respect to
cost sharing. 
   (d) 
    (e)  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. 
   (e) The 
    (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. 
   (g) 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.
 
   (f) 
    (h)  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)  The   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 accrual of out-of-pocket costs as defined
in Section 10112.28. 
   (b) 
    (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. 
   (c) 
    (d)  For cost sharing attributed to out-of-network
providers who are providing emergency services consistent with
Section 10112.7 or otherwise providing covered benefits,  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 the consumer with respect to cost sharing. 
   (d) 
    (e)  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. 
   (e) The 
    (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. 
   (g) 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.
 
   (f) 
    (h)  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.