Bill Text: CA SB780 | 2013-2014 | Regular Session | Amended
Bill Title: Health care coverage.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2014-08-14 - Set, second hearing. Held under submission. [SB780 Detail]
Download: California-2013-SB780-Amended.html
BILL NUMBER: SB 780 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 30, 2014
AMENDED IN SENATE MAY 8, 2013
AMENDED IN SENATE APRIL 24, 2013
INTRODUCED BY Senator Jackson
FEBRUARY 22, 2013
An act to amend Section 1373.65 of the Health and Safety Code, and
to amend Sections 10123.12, 10601, and 10604 of, and to add Section
10133.57 to, the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 780, as amended, Jackson. Health care coverage.
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 the act a crime.
Existing law requires a health care service plan to submit a
filing to the department at least 75 days prior to the termination
date of its contract with a provider group or a general acute care
hospital that includes the written notice the plan proposes to send
to its affected enrollees. The filing is required to be reviewed and
approved by the department prior to the notice being sent to
the enrollees. Existing law also requires the plan to provide
written notice to affected enrollees, as provided, prior to the
termination date of a contract between the plan and a provider group
or a general acute care hospital. A plan operating as a preferred
provider organization is only required to send the written notice to
all enrollees who reside within a 15-mile radius of a terminated
hospital if it is a general acute care hospital.
This bill would delete the requirements with regard to preferred
provider organizations. The bill would change the timing of the
75-day filing to 45 30 days prior to
the termination date for a contract between a health care service
plan that is not a health maintenance organization and a provider
group or general acute care hospital , and would not
prohibit the plan from sending the notice to the enrollees prior to
the filing being reviewed and approved by the department .
The bill would distinguish between enrollees of an assigned group
provider and enrollees of an unassigned group provider for purposes
of whether the filing is required to be submitted to the department.
The bill would also require that the plan send a department
approved department-approved written notice to
the enrollees, whether or not a filing was required, when a provider
group contract or a general acute care hospital contract is
terminated. The bill would distinguish between the enrollees of an
assigned or an unassigned provider group or general acute care
hospital with regard to the timing of the consumer notice and method
of delivery, and delivery. With respect to
the termination of a contract with an unassigned provider group or
general acute care hospital, the bill would impose specified
continued access to services requirements, billing requirements, and
requirements to obtain information on plans and providers
for the enrollees of an unassigned provider group or an unassigned
general acute care hospital. from the terminated
provider group or general acute care hospital regarding enrollees who
have services scheduled with the terminated provider group or
general acute care hospital for after the termination date using a
process agreed upon in the terminating contract. The bill would
authorize the department to develop a standard format for the
required notices. Because a willful violation of these
requirements with respect to health care service plans
would be a crime, the bill would impose a state-mandated
local program.
Existing law provides for the regulation of health insurers by the
Department of Insurance. Under existing law, a health insurer may
contract with providers for alternative rates of payment. Existing
law requires those insurers to file a policy with the department
describing how the insurer facilitates the continuity of care for new
insureds under group policies receiving services for an acute
condition from a noncontracting provider. Existing law also requires
those health insurers to, at the request of an insured, arrange for
the completion of covered services by a terminated provider if the
insured is undergoing treatment for certain conditions, as specified.
This bill would require, among other things, a health insurer to
submit a filing to the department, at least 45
30 days prior to the termination date of its contract with
a provider group or a general acute care hospital to provide
services at alternative rates of payment, that includes the written
notice the insurer proposes to send to its insureds. The bill would
require the filing to be reviewed and approved by the department
prior to the notice being sent to the insureds. The bill would set a
threshold for the number of insureds receiving health care services
from a group provider within the preceding 12 months for purposes of
whether the filing is required to be submitted to the department. The
bill would also require that the health insurer send a
department approved department-appr oved
written notice to specified insureds, whether or not a filing
was required, when a provider group contract or a general acute care
hospital contract is terminated, and would impose specified continued
access to services requirements, billing requirements, and
requirements to obtain information on insurers and providers
for insureds receiving health care services from a terminated
provider group or general acute care hospital. from
the terminated provider group or general acute care hospital
regarding insureds who have services scheduled with the terminated
provider group or general acute care hospital for after the
termination date using a process agreed upon in the terminating
contract. The bill would authorize the department to develop a
standard format for the required notices.
Existing law requires disability insurance policies to include a
disclosure form that contains specified information, including the
principal benefits and coverage of the policy, the exceptions,
reductions, and limitations that apply to the policy, and a
statement, with respect to health insurance policies, describing how
participation in the policy may affect the choice of physician,
hospital, or health care providers, and describing the extent of
financial liability that may be incurred if care is furnished by a
nonparticipating provider.
With respect to health insurance policies, this bill would require
the disclosure form to include additional information, including
conditions and procedures for cancellation, rescission, or
nonrenewal, a description of the limitations on the insured's choice
of provider, and, with respect to insurers that contract for
alternate rates of payment, a statement describing the basic method
of reimbursement made to its participating providers, as specified.
The bill would also require the first page of the disclosure form for
health insurance policies to include other specified information.
The bill would require a health insurer, medical group, or
participating provider that uses or receives financial bonuses or
other incentives to provide a written summary of specified
information to any requesting person.
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 1373.65 of the Health and Safety Code is
amended to read:
1373.65. (a) For the purposes of this section, the following
terms have the following meanings:
(1) "Assigned general acute care hospital" means a general acute
care hospital to which the health care service plan, either directly
or through its contracts with its delegated entities, directs
enrollees to receive nonemergency services.
(2) "Assigned provider group" means a provider group to which a
health care service plan directs its enrollees to receive specialty
physician services or a provider group that includes primary care
physicians to which a health care service plan assigns its members.
(3) "Provider group" means a medical group, independent practice
association, or any other similar organization.
(4) "Unassigned general acute care hospital" is a general acute
care hospital that is not an assigned general acute care hospital.
(5) "Unassigned provider group" means a provider group that is not
an assigned provider group.
(b) (1) Except as provided in paragraph (2), at least 75 days
prior to the termination date of its contract with a provider group
or a general acute care hospital, the health care service plan shall
submit a filing to the department that includes the written notice
the plan proposes to send to enrollees. The plan shall not send this
notice to enrollees until the department has reviewed and approved
the filing. If the department does not respond within seven days of
the date of its receipt of the filing, the filing shall be deemed
approved.
(2) At least 45 30 days prior to the
termination date of a contract between a health care service plan
that is not a health maintenance organization and a provider group or
a general acute care hospital, the health care service plan shall
submit a filing to the department that includes the written notice
the plan proposes to send to enrollees. The plan shall not send
this notice to enrollees until the department has reviewed
and approved the filing. If the department does not respond to the
plan within seven days of the date of its receipt of the filing, the
filing shall be deemed approved.
(3) For the purposes of a termination with an assigned provider
group or assigned general acute care hospital, the health care
service plan shall submit a filing to the department, as required by
paragraph (1), if 2,000 or more enrollees will be transferred or
redirected by the plan from the assigned provider group as a result
of the termination of the provider contract.
(4) For purposes of a termination with an unassigned provider
group, the health care service plan shall submit a filing to the
department, as required by paragraph (1) or (2), if 1,700 or more
enrollees were treated by the unassigned provider group within the 12
months preceding the filing date specified in paragraph (1) or (2).
(5) The director may adopt by regulation a different filing
threshold from the threshold stated in paragraphs (3) and (4), and in
consultation with the Department of Insurance, may adopt by
regulation a different filing threshold from the threshold stated in
paragraphs (3) and (4).
(c) (1) In the event of a contract termination between a health
care service plan and an assigned provider group or an assigned
general acute care hospital, the plan shall do all of the following:
(A) Send the written notice described in subdivision (b) by United
States mail at least 60 days prior to the termination date to
enrollees who are assigned to the terminated provider group or
general acute care hospital.
(B) A plan that is unable to comply with the timeframe in
subparagraph (A) because of exigent circumstances shall apply to the
department for a waiver. The plan shall be excused from complying
with the 60-day notice requirement only if its waiver application is
granted by the department or the department does not respond within
seven days of the date of its receipt of the waiver application.
(2) In the event of a contract termination between a health care
service plan and an unassigned provider group or an unassigned
general acute care hospital, the plan shall do all of the following:
(A) Send the written notice described in subdivision (b), within
five business days of the contract termination with an unassigned
provider group, to all of the following persons:
(i) Any unassigned enrollee who has received health care services
from the terminated provider group within the 12 months preceding the
date of termination.
(ii) Any unassigned enrollee who has any health care services
authorized, but not yet scheduled as of the date of termination, or
scheduled for after the date of termination with the terminated
provider group.
(B) Send the written notice described in subdivision (b), within
five business days of the contract termination with an unassigned
general acute care hospital, to all of the following persons:
(i) Any enrollee who has received health care services from the
terminated general acute care hospital within the 12 months preceding
the date of termination.
(ii) Any enrollee who is assigned to a provider group with any
physicians who have exclusive admitting privileges to the terminated
general acute care hospital.
(iii) Any enrollee who has health care services authorized, but
not yet scheduled as of the date of termination, or scheduled for
after the date of termination at the terminated general acute care
hospital.
(C) Allow enrollees to continue to access services that were
authorized or scheduled at the terminated unassigned provider group
or unassigned general acute care hospital prior to the date of either
the notice required by subdivisions (c) and (d), or the termination,
whichever is later, regardless of whether the enrollee has requested
completion of covered services. Those services shall be provided
from the date of the contract termination until completion of the
authorized or scheduled services for at least 60 days from the date
of either the notice or the termination, whichever is later. The
amount of, and the requirement for payment of, copayments,
deductibles, coinsurance, and other cost-sharing components by an
enrollee during the period of completion of authorized or scheduled
services with a terminated provider group or general acute care
hospital pursuant to this subparagraph shall be the same that would
be paid by the enrollee when receiving care from a provider currently
contracting with or employed by the plan.
(D) Provide reimbursement for services provided under subparagraph
(C) either at a rate agreed upon by the health
care service plan and the terminated provider group or general acute
care hospital or hospital. If there is not an
agreement, reimbursement shall be at the rate for those
services as provided in the terminating contract. In no event shall
the provider bill the patient for the cost of services beyond the
copayment, deductible, or other cost-sharing components of what the
enrollee would have been responsible for if the provider group or
general acute care hospital was currently contracted with the health
care service plan.
(E) Obtain information from the terminated provider group or
general acute care hospital regarding enrollees who have health care
services scheduled for after the date of termination with the
terminated provider group or general acute care hospital, including
the names of those enrollees and the dates on which their services
were scheduled. scheduled by using the
process agreed to in the terminating contract. Unless otherwise
prohibited by law, a terminated provider group or general acute care
hospital shall comply with a health care service plan's
request for that information. and the health care
service plan shall comply with the process in the terminating
contract.
(d) Even if a filing is not required to be submitted by
subdivision (b), a health care service plan shall send enrollee
notices as required by subdivision (c). A health care service plan
may only send enrollee notices for which a template has been filed
and approved by the department pursuant to Section 1373.95. The
department may develop a standard format for notices to be sent as
required by this section.
(e) If an individual provider terminates his or her contract or
employment with a provider group that contracts with a health care
service plan, the plan may require that the provider group send the
notices required by subdivisions (c) and (d).
(f) If, after sending the notices required by subdivisions (c) and
(d), a health care service plan reaches an agreement with any
terminated provider group or general acute care hospital to renew or
enter into a new contract or to not terminate their contract, the
plan shall send a subsequent written notice to all enrollees that
were sent the notices required by subdivisions (c) and (d) informing
them of the status. The plan shall offer each affected enrollee the
option to return to that provider group or general acute care
hospital. If an assigned enrollee does not exercise this option, the
plan shall reassign the enrollee to another provider group or general
acute care hospital.
(g) A health care service plan and a provider group or general
acute care hospital shall include in all written, printed, or
electronic communications sent to an enrollee that concern the
contract termination or block transfer, the following statement in
not less than 12-point type:
"If you have been receiving care from a health care provider, you
may have a right to keep your provider for a designated time period.
Please contact your HMO's customer service department, and if you
have further questions, you are encouraged to contact the Department
of Managed Health Care, which protects HMO consumers, by telephone at
its toll-free number, 1-888-HMO-2219, or at a TDD number for the
hearing impaired at 1-877-688-9891, or online at www.hmohelp.ca.gov."
(h) Nothing in this section shall be construed to limit the rights
or protections of enrollees under Section 1373.96.
SEC. 2. Section 10123.12 of the Insurance Code is amended to read:
10123.12. (a) Every health insurer, including those insurers that
contract for alternative rates of payment pursuant to Section 10133,
and every self-insured employee welfare benefit plan that will
affect the choice of physician, hospital, or other health care
providers, shall include within its disclosure form and within its
evidence or certificate of coverage a statement clearly describing
how participation in the policy or plan may affect the choice of
physician, hospital, or other health care providers, and describing
the nature and extent of the financial liability that is, or that may
be, incurred by the insured, enrollee, or covered dependents if care
is furnished by a provider that does not have a contract with the
insurer or plan to provide service at alternative rates of payment
pursuant to Section 10133. The form shall clearly inform prospective
insureds or plan enrollees that participation in the policy or plan
will affect the person's choice in this regard by placing the
following statement in a conspicuous place on all material required
to be given to prospective insureds or plan enrollees including
promotional and descriptive material, disclosure forms, and
certificates and evidences of coverage:
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED
It is not the intent of this section to require that the names of
individual health care providers be enumerated to prospective
insureds or enrollees.
If a health insurer providing coverage for hospital, medical, or
surgical expenses provides a list of facilities to patients or
contracting providers, the insurer shall include within the listing a
notification that insureds or enrollees may contact the insurer in
order to obtain a list of the facilities with which the health
insurer is contracting for subacute care and/or transitional
inpatient care.
(b) Every health insurer that contracts for alternative rates of
payment pursuant to Section 10133 shall include within its disclosure
form a statement clearly describing the basic method of
reimbursement, including the scope and general methods of payment,
made to its contracting providers of health care services, and
whether financial bonuses or any other incentives are used. The
disclosure form shall indicate that, if an insured wishes to know
more about these issues, the insured may request additional
information from the insurer, the insured's provider, or the provider'
s medical group regarding the information required pursuant to
subdivision (c).
(c) If a health insurer, medical group, or participating health
care provider uses or receives financial bonuses or any other
incentives, the insurer, medical group, or health care provider shall
provide a written summary to any person who requests it that
includes both of the following:
(1) A general description of the bonus and any other incentive
arrangements used in its compensation agreements. Nothing in this
paragraph shall be construed to require disclosure of trade secrets
or commercial or financial information that is privileged or
confidential, such as payment rates, as determined by the
commissioner, pursuant to state law.
(2) A description regarding whether, and in what manner, the
bonuses and any other incentives are related to a provider's use of
referral services.
(d) The statements and written information provided pursuant to
subdivisions (b) and (c) shall be communicated in clear and simple
language that enables consumers to evaluate and compare health
insurance policies.
SEC. 3. Section 10133.57 is added to the Insurance Code, to read:
10133.57. (a) For purposes of this section, "provider group"
means a medical group, independent practice association, or any other
similar organization.
(b) (1) At least 45 30 days prior to
the termination date of its contract with a provider group or a
general acute care hospital to provide services at alternative rates
of payment pursuant to Section 10133, the health insurer shall submit
a filing to the department that includes the written notice the
insurer proposes to send to the insureds. The insurer shall not send
this notice to the insureds until the department has reviewed and
approved the filing. If the department does not respond to the
insurer within seven days of the date of its receipt of the filing,
the filing shall be deemed approved.
(2) For purposes of a termination with a provider group, the
health insurer shall submit a filing to the department, as required
by paragraph (1), if 1,700 or more insureds were treated by the
provider group within the 12 months preceding the filing date
specified in paragraph (1).
(3) The department, in consultation with the Department of Managed
Health Care, may adopt by regulation a different filing threshold
from the threshold stated in paragraph (2).
(c) In the event of a contract termination between a health
insurer and a provider group or general acute care hospital, the
insurer shall do all of the following:
(1) Send the written notice described in subdivision (b), within
five business days of the contract termination with a provider group,
to all of the following persons:
(A) Any insured who has received health care services from the
terminated provider group within the 12 months preceding the date of
termination.
(B) Any insured who has any health care services authorized, but
not yet scheduled as of the date of termination, or scheduled for
after the date of termination with the terminated provider group.
(2) Send the written notice described in subdivision (b), within
five business days of the contract termination with a general acute
care hospital, to all of the following persons:
(A) Any insured who has received health care services from the
terminated general acute care hospital within the 12 months preceding
the date of termination.
(B) Any insured who has health care services authorized, but not
yet scheduled as of the date of termination, or scheduled for after
the date of termination at the terminated general acute care
hospital.
(3) Allow insureds to continue to access services that were
authorized or scheduled at the terminated provider group or general
acute care hospital prior to the date of either the notice required
by subdivisions (c) and (d), or the termination, whichever is later,
regardless of whether the insured has requested completion of covered
services. Those services shall be provided from the date of the
contract termination until completion of the authorized or scheduled
services for at least 60 days from the date of either the notice or
the termination, whichever is later. The amount of, and the
requirement for payment of, copayments, deductibles, coinsurance, and
other cost-sharing components by an insured during the period of
completion of authorized or scheduled services with a terminated
provider group or general acute care hospital pursuant to this
paragraph shall be the same that would be paid by the insured when
receiving care from a provider currently contracting with the
insurer.
(4) Provide reimbursement for services provided under paragraph
(3) either at a rate agreed upon by the insurer
and the terminated provider group or general acute care
hospital or hospital. If there is not an agreement,
reimbursement shall be at the rate for those services as
provided in the terminating contract. In no event shall the provider
bill the patient for the cost of services beyond the copayment,
deductible, or other cost-sharing components of what the insured
would have been responsible for if the provider group or general
acute care hospital was currently contracted with the insurer.
(5) Obtain information from the terminated provider group or
general acute care hospital regarding insureds who have health care
services scheduled for after the date of termination with the
terminated provider group or general acute care hospital, including
the names of those insureds and the dates on which their services
were scheduled. scheduled by using the
process agreed to in the terminating contract. Unless otherwise
prohibited by law, a terminated provider group or general acute care
hospital shall comply with a health insurer's request for
that information. and the health insurer shall comply
with the process in the terminating contract.
(d) Even if a filing is not required to be submitted by
subdivision (b), a health insurer shall send insured notices as
required by subdivision (c). A health insurer may only send insured
notices that have been filed and approved by the department pursuant
to this section. The department may develop a standard format
for notices to be sent as required by this section.
(e) If an individual provider terminates his or her contract or
employment with a provider group that contracts with a health
insurer, the insurer may require that the provider group send the
notices required by subdivisions (c) and (d).
(f) If, after sending the notices required by subdivisions (c) and
(d), a health insurer reaches an agreement with a terminated
provider group or general acute care hospital to renew or enter into
a new contract or to not terminate its contract, the insurer shall
send a subsequent written notice to all insureds that were sent the
notices required by subdivisions (c) and (d) informing those insureds
that the provider group or hospital remains in their provider
network.
(g) A health insurer or a provider group shall include in all
written, printed, or electronic communications sent to an insured
that concern the contract termination, the following statement in not
less than 12-point type:
"If you have been receiving care from a health care provider, you
may have a right to keep your provider for a designated time period.
Please contact your insurer's customer service department, and if you
have further questions, you are encouraged to contact the Department
of Insurance, which protects insurance consumers, by telephone at
its toll-free number, 800-927-HELP (4357), or at a TDD number for the
hearing impaired at 800-482-4833, or online at www.insurance.ca.gov."
(h) The commissioner may adopt 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)
that are necessary to implement the provisions of this section.
(i) Nothing in this section shall be construed to limit the rights
or protections of insureds under Section 10133.56.
SEC. 4. Section 10601 of the Insurance Code is amended to read:
10601. As used in this chapter:
(a) "Benefits and coverage" means the accident, sickness, or
disability indemnity available under a policy of disability
insurance.
(b) "Exception" means any provision in a policy whereby coverage
for a specified hazard or condition is entirely eliminated.
(c) "Reduction" means any provision in a policy that reduces the
amount of a policy benefit to some amount or period less than would
be otherwise payable for medically authorized expenses or services
had the reduction not been used.
(d) "Limitation" means any provision other than an exception or a
reduction that restricts coverage under the policy.
(e) "Presenting for examination or sale" means either (1)
publication and dissemination of any brochure, mailer, advertisement,
or form that constitutes a presentation of the provisions of the
policy and that provides a policy enrollment or application form, or
(2) consultations or discussions between prospective beneficiaries or
their contract agents and employees or agents of disability
insurers, when those consultations or discussions include
presentation of formal, organized information about the policy that
is intended to influence or inform the prospective insured or
beneficiary, such as brochures, summaries, charts, slides, or other
modes of information in lieu of or in addition to the policy itself.
(f) "Disability insurance" means every policy of disability
insurance and self-insured employee welfare benefit plan issued,
delivered, or entered into pursuant to or described in Chapter 1
(commencing with Section 10110) or Chapter 4 (commencing with Section
10270) of this part.
(g) "Insurer" means every insurer transacting disability insurance
and every self-insured employee welfare plan specified in
subdivision (f).
(h) "Disclosure form" means the standard supplemental disclosure
form required pursuant to Section 10603.
(i) "Small group health insurance policy" means a group health
insurance policy issued to a small employer, as defined in Section
10700, 10753, or 10755.
SEC. 5. Section 10604 of the Insurance Code is amended to read:
10604. The disclosure form shall include at least the following
information, in concise and specific terms, relative to the
disability insurance policy, together with additional information as
the commissioner may require in connection with the policy:
(a) The applicable category or categories of coverage provided by
the policy, from among the following:
(1) Basic hospital expense coverage.
(2) Basic medical-surgical expense coverage.
(3) Hospital confinement indemnity coverage.
(4) Major medical expense coverage.
(5) Disability income protection coverage.
(6) Accident only coverage.
(7) Specified disease or specified accident coverage.
(8) Other categories as the commissioner may prescribe.
(b) The principal benefits and coverage of the disability
insurance policy, including coverage for acute care and subacute care
if the policy is a health insurance policy, as defined in Section
106.
(c) The exceptions, reductions, and limitations that apply to the
policy.
(d) A summary, including a citation of the relevant contractual
provisions, of the process used to authorize, modify, delay, or deny
payments for services under the coverage provided by the policy
including coverage for subacute care, transitional inpatient care, or
care provided in skilled nursing facilities. This subdivision shall
only apply to policies of health insurance as defined in Section 106.
(e) The full premium cost of the policy.
(f) Any copayment, coinsurance, or deductible requirements that
may be incurred by the insured or his or her family in obtaining
coverage under the policy.
(g) The terms under which the policy may be renewed by the
insured, including any reservation by the insurer of any right to
change premiums.
(h) A statement that the disclosure form is a summary only, and
that the policy itself should be consulted to determine governing
contractual provisions.
(i) For a health insurance policy, as defined in Section 106, all
of the following:
(1) A notice on the first page of the disclosure form that
conforms with all of the following conditions:
(A) (i) States that the form discloses the terms and conditions of
coverage.
(ii) States, with respect to individual health insurance policies,
small group health insurance policies, and any group health
insurance policies, that the applicant has a right to view the
disclosure form and policy prior to beginning coverage under the
policy, and, if the policy does not accompany the disclosure form,
the notice shall specify where the policy can be obtained prior to
beginning coverage.
(B) Includes a statement that the disclosure and the policy should
be read completely and carefully and that individuals with special
health care needs should read carefully those sections that apply to
them.
(C) Includes the insurer's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the policy, or states where those telephone number or
numbers are located in the disclosure form.
(D) For individual health insurance policies and small group
health insurance policies, states where a health policy benefits and
coverage matrix is located.
(E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
(2) A statement as to when benefits shall cease in the event of
nonpayment of premium and the effect of nonpayment upon an insured
who is hospitalized or undergoing treatment for an ongoing condition.
(3) To the extent that the policy or insurer permits a free choice
of provider to its insureds, the statement shall disclose,
consistent with Section 10123.12, the nature and extent of choice
permitted and the financial liability that is, or may be, incurred by
the insured, covered dependents, or a third party by reason of the
exercise of that choice.
(4) For group health insurance policies, including small group
health insurance policies, a summary of the terms and conditions
under which insureds may remain in the policy in the event the group
ceases to exist, the group policy is terminated, an individual
insured leaves the group, or the insureds' eligibility status
changes.
(5) If the policy utilizes arbitration to settle disputes, a
statement of that fact. If the policy requires binding arbitration, a
disclosure pursuant to Section 10123.19.
(6) A description of any limitations on the insured's choice of
primary care physician, specialty care physician, or nonphysician
health care practitioner, based on service area and limitations on
the insured's choice of acute care hospital care, subacute or
transitional inpatient care, or skilled nursing facility.
(7) Conditions and procedures for cancellation, rescission, or
nonrenewal.
(8) A description as to how an insured may request continuity of
care as required by Sections 10133.55 and 10133.56, and request a
second opinion pursuant to Section 10123.68.
(9) Information concerning the right of an insured to request an
independent medical review in accordance with Article 3.5 (commencing
with Section 10169) of Chapter 1.
(10) A notice as required by Section 791.04.
SEC. 6. 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.
