Bill Text: CA AB18 | 2013-2014 | Regular Session | Amended
Bill Title: Health care coverage: pediatric oral care benefits.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2014-02-03 - From committee: Filed with the Chief Clerk pursuant to Joint Rule 56. [AB18 Detail]
Download: California-2013-AB18-Amended.html
BILL NUMBER: AB 18 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 24, 2013
AMENDED IN ASSEMBLY MAY 24, 2013
AMENDED IN ASSEMBLY APRIL 16, 2013
AMENDED IN ASSEMBLY MARCH 19, 2013
INTRODUCED BY Assembly Member Pan
DECEMBER 3, 2012
An act to amend Sections 1367.005 and
Section 1385.02 of, and to add Sections 1367.013 and 1367.37
to, the Health and Safety Code, and to amend Sections
10112.27 and Section 10181.2 of, and to add
Sections 10112.35 and 10123.56 to, the Insurance Code, relating to
health care coverage, and declaring the urgency thereof, to take
effect immediately.
LEGISLATIVE COUNSEL'S DIGEST
AB 18, as amended, Pan. Health care coverage: pediatric oral
care. care benefits.
Existing law, the federal Patient Protection and Affordable Care
Act (PPACA), requires a health insurance issuer that offers coverage
in the small group or individual market to ensure that such coverage,
with respect to plan years on or after January 1, 2014, includes the
essential health benefits package, which is defined to include
pediatric oral care benefits. PPACA 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 requires
an exchange to allow an issuer to offer stand-alone dental plans in
the exchange, provided that the plans cover the pediatric oral care
benefits required under the essential health benefits package.
Existing law establishes the California Health Benefit Exchange
(Exchange) to facilitate the purchase of qualified health plans
through the Exchange by qualified individuals and qualified small
employers by January 1, 2014. Existing law requires carriers
participating in the Exchange that sell products outside the
Exchange to offer, market, and sell all products made available to
individuals and small employers through the Exchange to individuals
and small employers purchasing coverage outside the Exchange.
Existing law requires the board of the Exchange to establish the
Small Business Health Options Program (SHOP) to assist qualified
small employers in facilitating the enrollment of their employees in
qualified health plans offered through the Exchange.
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 also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires an individual or small group health
care service plan contract or health insurance policy issued,
amended, or renewed on or after January 1, 2014, to cover essential
health benefits and defines those benefits to include the pediatric
oral care benefits provided under a specified dental plan available
to subscribers of the Healthy Families Program.
This bill would exempt a plan contract or policy offered,
marketed, or sold through the SHOP or the small group market outside
the Exchange from covering those pediatric oral care benefits if the
SHOP or the small group market outside the Exchange offers a
stand-alone dental plan as described in PPACA and would require
stand-alone dental plans offered through the SHOP or the small group
market outside the Exchange to include coverage of those pediatric
oral care benefits. The bill would also require a plan contract or
policy covering pediatric oral care to waive the applicable dental
out-of-pocket maximum upon notification from a qualified health plan
that the applicable out-of-pocket maximum under the qualified health
plan has been satisfied, and would require qualified health plans to
develop a method for coordinating and tracking progress toward
satisfying the out-of-pocket maximum. The bill would also prohibit
those specialized plan contracts or policies from being regarded as
providing excepted benefits, as specified.
Existing law requires a health care service plan and a health
insurer to comply with minimum medical loss ratios and to provide an
annual rebate to each insured if the medical loss ratio is less than
a certain percentage, as specified.
This bill would require a specialized health care service plan
contract and specialized health insurance policy that provides
pediatric oral care benefits in the small group market
through the SHOP or the small group market outside the Exchange,
benefits, whether or not it is bundled with a
qualified health plan or standing alone, to also comply with minimum
medical loss ratios and provide an annual rebate, as specified.
Existing law requires the Department of Managed Health Care and
the Department of Insurance to promulgate regulations applicable to
health care service plans and specified health insurers,
respectively, to ensure that enrollees and insureds have the
opportunity to access needed health care services in a timely manner,
and to ensure adequacy of numbers of professional providers and
institutional providers. Existing law requires health care service
plans and health insurance policies to file specified rate
information with the Department of Managed Health Care and the
Department of Insurance, respectively, at least 60 days before
implementing a rate change.
This bill would specify that those provisions would also apply to
a specialized health care service plans
plan and specialized health insurance policies
policy that provide
provides pediatric oral care benefits through the SHOP
or the small group market outside the Exchange,
benefits, whether or not it is bundled with a qualified health
plan or standing alone. Because a willful violation of the bill's
provisions by a health care service plan would be a crime, this bill
would impose a state-mandated local program.
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.
This bill would declare that it is to take effect immediately as
an urgency statute.
Vote: 2/3. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.005 of the Health and
Safety Code is amended to read:
1367.005. (a) An individual or small group health care service
plan contract issued, amended, or renewed on or after January 1,
2014, shall, at a minimum, include coverage for essential health
benefits pursuant to PPACA and as outlined in this section. For
purposes of this section, "essential health benefits" means all of
the following:
(1) Health benefits within the categories identified in Section
1302(b) of PPACA: ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, including behavioral health
treatment, prescription drugs, rehabilitative and habilitative
services and devices, laboratory services, preventive and wellness
services and chronic disease management, and pediatric services,
including oral and vision care.
(2) (A) The health benefits covered by the Kaiser Foundation
Health Plan Small Group HMO 30 plan (federal health product
identification number 40513CA035) as this plan was offered during the
first quarter of 2012, as follows, regardless of whether the
benefits are specifically referenced in the evidence of coverage or
plan contract for that plan:
(i) Medically necessary basic health care services, as defined in
subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of
the California Code of Regulations.
(ii) The health benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in the following sections: Sections 1367.002, 1367.06, and 1367.35
(preventive services for children); Section 1367.25 (prescription
drug coverage for contraceptives); Section 1367.45 (AIDS vaccine);
Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section
1367.54 (alpha feto protein testing); Section 1367.6 (breast cancer
screening); Section 1367.61 (prosthetics for laryngectomy); Section
1367.62 (maternity hospital stay); Section 1367.63 (reconstructive
surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate
cancer); Section 1367.65 (mammography); Section 1367.66 (cervical
cancer); Section 1367.665 (cancer screening tests); Section 1367.67
(osteoporosis); Section 1367.68 (surgical procedures for jaw bones);
Section 1367.71 (anesthesia for dental); Section 1367.9 (conditions
attributable to diethylstilbestrol); Section 1368.2 (hospice care);
Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency
response ambulance or ambulance transport services); subdivision (b)
of Section 1373 (sterilization operations or procedures); Section
1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56
(phenylketonuria); Section 1374.17 (organ transplants for HIV);
Section 1374.72 (mental health parity); and Section 1374.73
(autism/behavioral health treatment).
(iii) Any other benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in those statutes.
(iv) The health benefits covered by the plan that are not
otherwise required to be covered under this chapter, to the extent
required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22,
1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the
California Code of Regulations.
(v) Any other health benefits covered by the plan that are not
otherwise required to be covered under this chapter.
(B) Where there are any conflicts or omissions in the plan
identified in subparagraph (A) as compared with the requirements for
health benefits under this chapter that were enacted prior to
December 31, 2011, the requirements of this chapter shall be
controlling, except as otherwise specified in this section.
(C) Notwithstanding subparagraph (B) or any other provision of
this section, the home health services benefits covered under the
plan identified in subparagraph (A) shall be deemed to not be in
conflict with this chapter.
(D) For purposes of this section, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
(Public Law 110-343) shall apply to a contract subject to this
section. Coverage of mental health and substance use disorder
services pursuant to this paragraph, along with any scope and
duration limits imposed on the benefits, shall be in compliance with
the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (Public Law 110-343), and all rules,
regulations, or guidance issued pursuant to Section 2726 of the
federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
(3) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (2), coverage shall
also be provided as required by federal rules, regulations, and
guidance issued pursuant to Section 1302(b) of PPACA. Habilitative
services shall be covered under the same terms and conditions applied
to rehabilitative services under the plan contract.
(4) With respect to pediatric vision care, the same health
benefits for pediatric vision care covered under the Federal
Employees Dental and Vision Insurance Program vision plan with the
largest national enrollment as of the first quarter of 2012. The
pediatric vision care benefits covered pursuant to this paragraph
shall be in addition to, and shall not replace, any vision services
covered under the plan identified in paragraph (2).
(5) (A) With respect to pediatric oral care, the same health
benefits for pediatric oral care covered under the dental plan
available to subscribers of the Healthy Families Program in 2011-12,
including the provision of medically necessary orthodontic care
provided pursuant to the federal Children's Health Insurance Program
Reauthorization Act of 2009. This subparagraph shall not apply to a
health care service plan contract that is a qualified health plan, as
defined in Section 100501 of the Government Code, that is offered,
marketed, or sold through the Small Business Health Options Program
(SHOP), pursuant to subdivision (m) of Section 100502 of the
Government Code, or the small group market outside the Exchange if a
specialized health care service plan contract described in
subdivision (c) is offered, marketed, or sold through the SHOP or the
small group market outside the Exchange.
(B) The pediatric oral care benefits covered pursuant to this
paragraph shall be in addition to, and shall not replace, any dental
or orthodontic services covered under the plan identified in
paragraph (2).
(C) Notwithstanding subparagraph (A), it is the intent of the
Legislature that all of the benefits described in Section 1302(b) of
PPACA be included as essential health benefits whether obtained
through a qualified health plan, or through a combination of a
qualified health plan and a specialized health care service plan as
described in subdivision (c). It is the intent of the Legislature
that pediatric essential health benefits purchased separately are
only essential health benefits for pediatric enrollees, to the extent
permitted by PPACA.
(b) Subdivision (a) shall not apply to any of the following:
(1) A specialized health care service plan contract.
(2) A Medicare supplement plan contract.
(3) A plan contract that qualifies as a grandfathered health plan
under Section 1251 of PPACA or any rules, regulations, or guidance
issued pursuant to that section.
(c) (1) A specialized health care service plan contract described
in Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)
(ii)) that is offered through the SHOP pursuant to Section 100502 of
the Government Code or the small group market outside the Exchange,
whether or not it is bundled with a qualified health plan or standing
alone, shall, at a minimum, include coverage of the health benefits
described in subparagraph (A) of paragraph (5) of subdivision (a).
(2) Beginning on January 1, 2015, a specialized health care
service plan contract described in paragraph (1) shall not be
regarded as providing excepted benefits under either the Public
Health Service Act or PPACA, for the purpose of determining the
applicability of Sections 2701 to 2706, inclusive, and Section 2708
of the Public Health Service Act, added by Section 1201 of PPACA,
relating to the following:
(A) The prohibition of preexisting condition exclusions or other
discrimination based on health status.
(B) Fair health insurance premiums.
(C) Guaranteed availability of coverage.
(D) Guaranteed renewability of coverage.
(E) Prohibition against discrimination against individual
participants and beneficiaries on the basis of health status.
(F) Nondiscrimination in health care.
(G) Prohibition of excessive waiting periods.
(3) Beginning on January 1, 2014, a specialized health care
service plan contract described in paragraph (1) shall not be
regarded as providing excepted benefits under either the Public
Health Service Act or PPACA, for the purpose of determining the
applicability of Section 2711 of the Public Health Service Act, added
by Section 1201 of PPACA.
(4) A specialized health care service plan contract described in
paragraph (1) shall waive the applicable dental out-of-pocket maximum
upon notification from a qualified health plan on behalf of an
enrollee that the applicable out-of-pocket maximum under the
qualified health plan has been satisfied. Beginning on January 1,
2015, the combined out-of-pocket maximums for dental and qualified
health plans shall not exceed those limits established in Section
1302(c) of PPACA. The plans shall develop a method for coordinating
and tracking progress toward satisfying the out-of-pocket maximum
limitation that limits the burden on subscribers and enrollees. This
paragraph shall be implemented only to the extent permitted by PPACA.
(d) Pediatric vision and oral care benefits described in
paragraphs (4) and (5) of subdivision (a) shall be provided for
individuals up to 22 years of age, to the extent permitted under
PPACA. Treatment limitations imposed on health benefits described in
this section shall be no greater than the treatment limitations
imposed by the corresponding plans identified in subdivision (a),
subject to the requirements set forth in paragraph (2) of subdivision
(a).
(e) Except as provided in subdivision (f), nothing in this section
shall be construed to permit a health care service plan to make
substitutions for the benefits required to be covered under this
section, regardless of whether those substitutions are actuarially
equivalent.
(f) To the extent permitted under Section 1302 of PPACA and any
rules, regulations, or guidance issued pursuant to that section, and
to the extent that substitution would not create an obligation for
the state to defray costs for any individual, a plan may substitute
its prescription drug formulary for the formulary provided under the
plan identified in subdivision (a) as long as the coverage for
prescription drugs complies with the sections referenced in clauses
(ii) and (iv) of subparagraph (A) of paragraph (2) of subdivision (a)
that apply to prescription drugs.
(g) No health care service plan, or its agent, solicitor, or
representative, shall issue, deliver, renew, offer, market,
represent, or sell any product, contract, or discount arrangement as
compliant with the essential health benefits requirement in federal
law, unless it includes coverage of the health benefits described in
subdivision (a), including the benefits described in subparagraph (A)
of paragraph (5) of subdivision (a), and meets the requirements of
subdivisions (d), (e), and (f).
(h) Except as otherwise provided in this section, this section
shall apply regardless of whether the plan contract is offered inside
or outside the Exchange.
(i) Nothing in this section shall be construed to exempt a plan or
a plan contract from meeting other applicable requirements of law.
(j) This section shall not be construed to prohibit a plan
contract from covering additional benefits, including, but not
limited to, spiritual care services that are tax deductible under
Section 213 of the Internal Revenue Code.
(k) Nothing in this section shall be implemented in a manner that
conflicts with a requirement of PPACA.
(l) This section shall be implemented only to the extent essential
health benefits are required pursuant to PPACA.
(m) An essential health benefit is required to be provided under
this section only to the extent that federal law does not require the
state to defray the costs of the benefit.
(n) Nothing in this section shall obligate the state to incur
costs for the coverage of benefits that are not essential health
benefits as defined in this section.
(o) A plan is not required to cover, under this section, changes
to health benefits that are the result of statutes enacted on or
after December 31, 2011.
(p) (1) The department may adopt emergency regulations
implementing this section. The department may, on a one-time basis,
readopt any emergency regulation authorized by this section that is
the same as, or substantially equivalent to, an emergency regulation
previously adopted under this section.
(2) The initial adoption of emergency regulations implementing
this section and the readoption of emergency regulations authorized
by this subdivision shall be deemed an emergency and necessary for
the immediate preservation of the public peace, health, safety, or
general welfare. The initial emergency regulations and the readoption
of emergency regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and each shall remain in effect for no more than
180 days, by which time final regulations may be adopted.
(3) The director shall consult with the Insurance Commissioner to
ensure consistency and uniformity in the development of regulations
under this subdivision.
(4) This subdivision shall become inoperative on March 1, 2016.
(q) For purposes of this section, the following definitions shall
apply:
(1) "Exchange" means the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(2) "Habilitative services" means medically necessary health care
services and health care devices that assist an individual in
partially or fully acquiring or improving skills and functioning and
that are necessary to address a health condition, to the maximum
extent practical. These services address the skills and abilities
needed for functioning in interaction with an individual's
environment. Examples of health care services that are not
habilitative services include, but are not limited to, respite care,
day care, recreational care, residential treatment, social services,
custodial care, or education services of any kind, including, but not
limited to, vocational training. Habilitative services shall be
covered under the same terms and conditions applied to rehabilitative
services under the plan contract.
(3) (A) "Health benefits," unless otherwise required to be defined
pursuant to federal rules, regulations, or guidance issued pursuant
to Section 1302(b) of PPACA, means health care items or services for
the diagnosis, cure, mitigation, treatment, or prevention of illness,
injury, disease, or a health condition, including a behavioral
health condition.
(B) "Health benefits" does not mean any cost-sharing requirements
such as copayments, coinsurance, or deductibles.
(4) "PPACA" 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), and
any rules, regulations, or guidance issued thereunder.
(5) "SHOP" means the Small Business Health Options Business
established pursuant to subdivision (m) of Section 100502 of the
Government Code.
(6) "Small group health care service plan contract" means a group
health care service plan contract issued to a small employer, as
defined in Section 1357.500.
SEC. 2. SECTION 1. Section 1367.013
is added to the Health and Safety Code, to read:
1367.013. (a) Beginning on January 1, 2014, a specialized health
care service plan contract described in Section 1311(d)(2)(B)(ii) of
PPACA (42 U.S.C. Sec. 18031(d)(2)(B)(ii)) that provides pediatric
oral care benefits through the Small Business Health Options
Program (SHOP), pursuant to subdivision (m) of Section 100502 of the
Government Code, or the small group market outside the Exchange,
benefits, whether or not it is bundled with a
qualified health plan or standing alone, shall be subject to Sections
1367, 1367.03, and 1342. 1367 and 1367.03.
(b) Beginning on January 1, 2015, a specialized health care
service plan contract described in Section 1311(d)(2)(B)(ii) of PPACA
(42 U.S.C. Sec. 18031(d)(2)(B)(ii)) that provides pediatric oral
care benefits through the SHOP or the small group market
outside the Exchange, benefits, whether or not
it is bundled with a qualified health plan or standing alone, shall
be subject to Article 6.2 (commencing with Section 1385.01).
SEC. 3. SEC. 2. Section 1367.37 is
added to the Health and Safety Code, to read:
1367.37. (a) (1) Notwithstanding Section 1367.003, beginning on
January 1, 2015, every specialized health care service plan contract
described in Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031
(d)(2)(B)(ii)), as defined in Section 1367.005, providing pediatric
oral care benefits in the small group market through the
Small Business Health Options Program (SHOP), pursuant to subdivision
(m) of Section 100502 of the Government Code, or the small group
market outside the Exchange, benefits, whether
or not it is bundled with a qualified health plan or standing alone,
shall provide an annual rebate to each enrollee under that coverage,
on a pro rata basis, if the ratio of the amount of premium revenue
expended by the specialized health care service plan on the costs for
reimbursement for services provided to enrollees under that coverage
and for activities that improve dental care quality to the total
amount of premium revenue, excluding federal and state taxes and
licensing or regulatory fees, and after accounting for payments or
receipts for risk adjustment, risk corridors, and reinsurance, is
less than 75 percent.
(2) Every specialized health care service plan contract described
in this subdivision shall maintain a minimum medical loss ratio of 75
percent.
(b) (1) The director 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 medical loss ratio as described
under Section 2718 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-18), and any federal rules or regulations issued
under that section.
(2) The director may also adopt 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) when it is necessary to implement the
applicable provisions of this section and to address specific
conflicts between state and federal law that prevent implementation
of federal law and guidance pursuant to Section 2718 of the federal
Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial
adoption of the emergency regulations shall be deemed to be an
emergency and necessary for the immediate preservation of the public
peace, health, safety, or general welfare.
(c) The department shall consult with the Department of Insurance
in adopting necessary regulations, and in taking any other action for
the purpose of implementing this section.
SEC. 4. SEC. 3. Section 1385.02 of
the Health and Safety Code is amended to read:
1385.02. This article shall apply to health care service plan
contracts offered in the individual or group market in California.
However, this article shall not apply to a specialized health care
service plan contract, other than one providing pediatric oral care
benefits through the Small Business Health Options Program,
pursuant to subdivision (m) of Section 100502 of the Government Code,
or the small group market outside the Exchange,
benefits, whether or not it is bundled with a qualified health
plan or standing alone, as described in Section 1367.013; a Medicare
supplement contract subject to Article 3.5 (commencing with Section
1358.1); a health care service plan contract offered in the Medi-Cal
program (Chapter 7 (commencing with Section 14000) of Part 3 of
Division 9 of the Welfare and Institutions Code); a health care
service plan contract offered in the Healthy Families Program (Part
6.2 (commencing with Section 12693) of Division 2 of the Insurance
Code), the Access for Infants and Mothers Program (Part 6.3
(commencing with Section 12695) of Division 2 of the Insurance Code),
the California Major Risk Medical Insurance Program (Part 6.5
(commencing with Section 12700) of Division 2 of the Insurance Code),
or the Federal Temporary High Risk Pool (Part 6.6 (commencing with
Section 12739.5) of Division 2 of the Insurance Code); a health care
service plan conversion contract offered pursuant to Section 1373.6;
or a health care service plan contract offered to a federally
eligible defined individual under Article 4.6 (commencing with
Section 1366.35) or Article 11.5 (commencing with Section 1399.801).
SEC. 5. Section 10112.27 of the Insurance Code
is amended to read:
10112.27. (a) An individual or small group health insurance
policy issued, amended, or renewed on or after January 1, 2014,
shall, at a minimum, include coverage for essential health benefits
pursuant to PPACA and as outlined in this section. This section shall
exclusively govern what benefits a health insurer must cover as
essential health benefits. For purposes of this section, "essential
health benefits" means all of the following:
(1) Health benefits within the categories identified in Section
1302(b) of PPACA: ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, including behavioral health
treatment, prescription drugs, rehabilitative and habilitative
services and devices, laboratory services, preventive and wellness
services and chronic disease management, and pediatric services,
including oral and vision care.
(2) (A) The health benefits covered by the Kaiser Foundation
Health Plan Small Group HMO 30 plan (federal health product
identification number 40513CA035) as this plan was offered during the
first quarter of 2012, as follows, regardless of whether the
benefits are specifically referenced in the plan contract or evidence
of coverage for that plan:
(i) Medically necessary basic health care services, as defined in
subdivision (b) of Section 1345 of the Health and Safety Code and in
Section 1300.67 of Title 28 of the California Code of Regulations.
(ii) The health benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in the following sections of the Health and Safety Code: Sections
1367.002, 1367.06, and 1367.35 (preventive services for children);
Section 1367.25 (prescription drug coverage for contraceptives);
Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing);
Section 1367.51 (diabetes); Section 1367.54 (alpha feto protein
testing); Section 1367.6 (breast cancer screening); Section 1367.61
(prosthetics for laryngectomy); Section 1367.62 (maternity hospital
stay); Section 1367.63 (reconstructive surgery); Section 1367.635
(mastectomies); Section 1367.64 (prostate cancer); Section 1367.65
(mammography); Section 1367.66 (cervical cancer); Section 1367.665
(cancer screening tests); Section 1367.67 (osteoporosis); Section
1367.68 (surgical procedures for jaw bones)
; Section 1367.71 (anesthesia for dental); Section
1367.9 (conditions attributable to diethylstilbestrol); Section
1368.2 (hospice care); Section 1370.6 (cancer clinical trials);
Section 1371.5 (emergency response ambulance or ambulance transport
services); subdivision (b) of Section 1373 (sterilization operations
or procedures); Section 1373.4 (inpatient hospital and ambulatory
maternity); Section 1374.56 (phenylketonuria); Section 1374.17 (organ
transplants for HIV); Section 1374.72 (mental health parity); and
Section 1374.73 (autism/behavioral health treatment).
(iii) Any other health benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in those statutes.
(iv) The health benefits covered by the plan that are not
otherwise required to be covered under Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code, to the
extent otherwise required pursuant to Sections 1367.18, 1367.21,
1367.215, 1367.22, 1367.24, and 1367.25 of the Health and Safety
Code, and Section 1300.67.24 of Title 28 of the California Code of
Regulations.
(v) Any other health benefits covered by the plan that are not
otherwise required to be covered under Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code.
(B) Where there are any conflicts or omissions in the plan
identified in subparagraph (A) as compared with the requirements for
health benefits under Chapter 2.2 (commencing with Section 1340) of
Division 2 of the Health and Safety Code that were enacted prior to
December 31, 2011, the requirements of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code shall be
controlling, except as otherwise specified in this section.
(C) Notwithstanding subparagraph (B) or any other provision of
this section, the home health services benefits covered under the
plan identified in subparagraph (A) shall be deemed to not be in
conflict with Chapter 2.2 (commencing with Section 1340) of Division
2 of the Health and Safety Code.
(D) For purposes of this section, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
(Public Law 110-343) shall apply to a policy subject to this section.
Coverage of mental health and substance use disorder services
pursuant to this paragraph, along with any scope and duration limits
imposed on the benefits, shall be in compliance with the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 (Public Law 110-343), and all rules, regulations, and
guidance issued pursuant to Section 2726 of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg-26).
(3) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (2), coverage shall
also be provided as required by federal rules, regulations, or
guidance issued pursuant to Section 1302(b) of PPACA. Habilitative
services shall be covered under the same terms and conditions applied
to rehabilitative services under the policy.
(4) With respect to pediatric vision care, the same health
benefits for pediatric vision care covered under the Federal
Employees Dental and Vision Insurance Program vision plan with the
largest national enrollment as of the first quarter of 2012. The
pediatric vision care services covered pursuant to this paragraph
shall be in addition to, and shall not replace, any vision services
covered under the plan identified in paragraph (2).
(5) (A) With respect to pediatric oral care, the same health
benefits for pediatric oral care covered under the dental plan
available to subscribers of the Healthy Families Program in 2011-12,
including the provision of medically necessary orthodontic care
provided pursuant to the federal Children's Health Insurance Program
Reauthorization Act of 2009. This subparagraph shall not apply to a
health insurance policy that is a qualified health plan, as defined
in Section 100501 of the Government Code, that is offered, marketed,
or sold through the Small Business Health Options Program (SHOP),
pursuant to subdivision (m) of Section 100502 of the Government Code,
or the small group market outside the Exchange if a specialized
health insurance policy described in subdivision (c) is offered,
marketed, or sold through the SHOP or the small group market outside
the Exchange.
(B) The pediatric oral care benefits covered pursuant to this
paragraph shall be in addition to, and shall not replace, any dental
or orthodontic services covered under the plan identified in
paragraph (2).
(C) Notwithstanding subparagraph (A), it is the intent of the
Legislature that all of the benefits described in Section 1302(b) of
PPACA be included as essential health benefits whether obtained
through a qualified health plan, or a combination of a qualified
health plan and a specialized health insurance policy as described in
subdivision (c). It is the intent of the Legislature that pediatric
essential health benefits purchased separately are only essential for
pediatric insureds, to the extent permitted by PPACA.
(b) Subdivision (a) shall not apply to any of the following:
(1) A policy that provides excepted benefits as described in
Sections 2722 and 2791 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91).
(2) A policy that qualifies as a grandfathered health plan under
Section 1251 of PPACA or any binding rules, regulations, or guidance
issued pursuant to that section.
(c) (1) A specialized health insurance policy described in Section
1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)(ii)) that
is offered through the SHOP or the small group market outside the
Exchange, whether or not it is bundled with a qualified health plan
or standing alone, shall, at a minimum, include coverage of the
health benefits described in subparagraph (A) of paragraph (5) of
subdivision (a).
(2) Beginning on January 1, 2015, a specialized health insurance
policy described in paragraph (1) providing pediatric oral care
benefits shall not be regarded as providing excepted benefits under
either the Public Health Service Act or PPACA, for the purpose of
determining the applicability of Sections 2701 to 2706, inclusive,
and Section 2708 of the Public Health Service Act, added by Section
1201 of PPACA, relating to the following:
(A) The prohibition of preexisting condition exclusions or other
discrimination based on health status.
(B) Fair health insurance premiums.
(C) Guaranteed availability of coverage.
(D) Guaranteed renewability of coverage.
(E) Prohibition against discrimination against individual
participants and beneficiaries on the basis of health status.
(F) Nondiscrimination in health care.
(G) Prohibition of excessive waiting periods.
(3) Beginning on January 1, 2014, a specialized health insurance
policy described in paragraph (1) providing pediatric oral care
benefits shall not be regarded as providing excepted benefits under
either the Public Health Service Act or PPACA, for the purpose of
determining the applicability of Section 2711 of the Public Health
Service Act, added by Section 1201 of PPACA.
(4) A specialized health insurance policy described in paragraph
(1) shall waive the applicable dental out-of-pocket maximum upon
notification from a qualified health plan on behalf of an insured
that the applicable out-of-pocket maximum under the qualified health
plan has been satisfied. Beginning on January 1, 2015, the combined
out-of-pocket maximums for dental and qualified health plans shall
not exceed those limits established in Section 1302(c) of PPACA.
Insurers shall develop a method for coordinating and tracking
progress toward satisfying the out-of-pocket maximum limitation that
limits the burden on policyholders and insureds. This paragraph shall
only be implemented to the extent permitted by PPACA.
(d) Pediatric vision and oral care benefits described in
paragraphs (4) and (5) of subdivision (a) shall be provided for
individuals up to 22 years of age, to the extent permitted under
PPACA. Treatment limitations imposed on health benefits described in
this section shall be no greater than the treatment limitations
imposed by the corresponding plans identified in subdivision (a),
subject to the requirements set forth in paragraph (2) of subdivision
(a).
(e) Except as provided in subdivision (f), nothing in this section
shall be construed to permit a health insurer to make substitutions
for the benefits required to be covered under this section,
regardless of whether those substitutions are actuarially equivalent.
(f) To the extent permitted under Section 1302 of PPACA and any
rules, regulations, or guidance issued pursuant to that section, and
to the extent that substitution would not create an obligation for
the state to defray costs for any individual, an insurer may
substitute its prescription drug formulary for the formulary provided
under the plan identified in subdivision (a) as long as the coverage
for prescription drugs complies with the sections referenced in
clauses (ii) and (iv) of subparagraph (A) of paragraph (2) of
subdivision (a) that apply to prescription drugs.
(g) No health insurer, or its agent, producer, or representative,
shall issue, deliver, renew, offer, market, represent, or sell any
product, policy, or discount arrangement as compliant with the
essential health benefits requirement in federal law, unless it
includes coverage of the health benefits described in subdivision
(a), including the benefits described in subparagraph (A) of
paragraph (5) of subdivision (a), and meets the requirements of
subdivisions (d), (e), and (f). This subdivision shall be enforced in
the same manner as Section 790.03, including through the means
specified in Sections 790.035 and 790.05.
(h) Except as otherwise provided in this section, this section
shall apply regardless of whether the policy is offered inside or
outside the Exchange.
(i) Nothing in this section shall be construed to exempt a health
insurer or a health insurance policy from meeting other applicable
requirements of law.
(j) This section shall not be construed to prohibit a policy from
covering additional benefits, including, but not limited to,
spiritual care services that are tax deductible under Section 213 of
the Internal Revenue Code.
(k) Nothing in this section shall be implemented in a manner that
conflicts with a requirement of PPACA.
(l) This section shall be implemented only to the extent essential
health benefits are required pursuant to PPACA.
(m) An essential health benefit is required to be provided under
this section only to the extent that federal law does not require the
state to defray the costs of the benefit.
(n) Nothing in this section shall obligate the state to incur
costs for the coverage of benefits that are not essential health
benefits as defined in this section.
(o) An insurer is not required to cover, under this section,
changes to health benefits that are the result of statutes enacted on
or after December 31, 2011.
(p) (1) The commissioner may adopt emergency regulations
implementing this section. The commissioner may, on a one-time basis,
readopt any emergency regulation authorized by this section that is
the same as, or substantially equivalent to, an emergency regulation
previously adopted under this section.
(2) The initial adoption of emergency regulations implementing
this section and the readoption of emergency regulations authorized
by this subdivision shall be deemed an emergency and necessary for
the immediate preservation of the public peace, health, safety, or
general welfare. The initial emergency regulations and the readoption
of emergency regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and each shall remain in effect for no more than
180 days, by which time final regulations may be adopted.
(3) The commissioner shall consult with the Director of the
Department of Managed Health Care to ensure consistency and
uniformity in the development of regulations under this subdivision.
(4) This subdivision shall become inoperative on March 1, 2016.
(q) Nothing in this section shall impose on health insurance
policies the cost sharing or network limitations of the plans
identified in subdivision (a) except to the extent otherwise required
to comply with provisions of this code, including this section, and
as otherwise applicable to all health insurance policies offered to
individuals and small groups.
(r) For purposes of this section, the following definitions shall
apply:
(1) "Exchange" means the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(2) "Habilitative services" means medically necessary health care
services and health care devices that assist an individual in
partially or fully acquiring or improving skills and functioning and
that are necessary to address a health condition, to the maximum
extent practical. These services address the skills and abilities
needed for functioning in interaction with an individual's
environment. Examples of health care services that are not
habilitative services include, but are not limited to, respite care,
day care, recreational care, residential treatment, social services,
custodial care, or education services of any kind, including, but not
limited to, vocational training. Habilitative services shall be
covered under the same terms and conditions applied to rehabilitative
services under the policy.
(3) (A) "Health benefits," unless otherwise required to be defined
pursuant to federal rules, regulations, or guidance issued pursuant
to Section 1302(b) of PPACA, means health care items or services for
the diagnosis, cure, mitigation, treatment, or prevention of illness,
injury, disease, or a health condition, including a behavioral
health condition.
(B) "Health benefits" does not mean any cost-sharing requirements
such as copayments, coinsurance, or deductibles.
(4) "PPACA" 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), and
any rules, regulations, or guidance issued thereunder.
(5) "SHOP" means the Small Business Health Options Program
established pursuant to subdivision (m) of Section 100502 of the
Government Code.
(6) "Small group health insurance policy" means a group health
care service insurance policy issued to a small employer, as defined
in Section 10753.
SEC. 6. SEC. 4. Section 10112.35 is
added to the Insurance Code, to read:
10112.35. (a) Beginning on January 1, 2014, a specialized health
insurance policy described in Section 1311(d)(2)(B)(ii) of PPACA (42
U.S.C. Sec. 18031(d)(2)(B)(ii)) that provides pediatric oral care
benefits through the Small Business Health Options Program
(SHOP), pursuant to subdivision (m) of Section 100502 of the
Government Code, or the small group market outside the Exchange,
benefits, whether or not it is bundled with a
qualified health plan or standing alone, shall be subject to Section
10133.5.
(b) Beginning on January 1, 2015, a specialized health insurance
policy described in Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C.
Sec. 18031(d)(2)(B)(ii)) that provides pediatric oral care
benefits through the SHOP or the small group market outside the
Exchange, benefits, whether or not it is bundled
with a qualified health plan or standing alone, shall be subject to
Article 4.5 (commencing with Section 10181).
SEC. 7. SEC. 5. Section 10123.56 is
added to the Insurance Code, to read:
10123.56. (a) (1) Notwithstanding Section 10112.25, beginning on
January 1, 2015, every specialized health insurance policy described
in Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)
(ii)), as defined in Section 10112.27, providing pediatric oral care
benefits in the small group market through the Small
Business Health Options Program (SHOP), pursuant to subdivision (m)
of Section 100502 of the Government Code, or the small group market
outside the Exchange, ben efits,
whether or not it is bundled with a qualified health plan or standing
alone, shall provide an annual rebate to each insured under that
coverage, on a pro rata basis, if the ratio of the amount of premium
revenue expended by the health insurer on the costs for reimbursement
for services provided to insureds under that coverage and for
activities that improve dental care quality to the total amount of
premium revenue, excluding federal and state taxes and licensing or
regulatory fees and after accounting for payments or receipts for
risk adjustment, risk corridors, and reinsurance, is less than 75
percent.
(2) Every specialized health insurance policy described in this
subdivision shall maintain a minimum medical loss ratio of 75
percent.
(b) (1) 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 medical loss ratio as
described under Section 2718 of the federal Public Health Service Act
(42 U.S.C. Sec. 300gg-18), and any federal rules or regulations
issued under that section.
(2) The commissioner may also adopt 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) when it is necessary to implement the
applicable provisions of this section and to address specific
conflicts between state and federal law that prevent implementation
of federal law and guidance pursuant to Section 2718 of the federal
Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial
adoption of the emergency regulations shall be deemed to be an
emergency and necessary for the immediate preservation of the public
peace, health, safety, or general welfare.
(c) The department shall consult with the Department of Managed
Health Care in adopting necessary regulations, and in taking any
other action for the purpose of implementing this section.
SEC. 8. SEC. 6. Section 10181.2 of
the Insurance Code is amended to read:
10181.2. This article shall apply to health insurance policies
offered in the individual or group market in California. However,
this article shall not apply to a specialized health insurance
policy, other than one providing pediatric oral care
benefits through the Small Business Health Options Program, pursuant
to subdivision (m) of Section 100502 of the Government Code, or the
small group market outside the Exchange, benefits,
whether or not it is bundled with a qualified health plan or
standing alone, as described in Section 10112.35; a Medicare
supplement policy subject to Article 6 (commencing with Section
10192.05); a health insurance policy offered in the Medi-Cal program
(Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of
the Welfare and Institutions Code); a health insurance policy
offered in the Healthy Families Program (Part 6.2 (commencing with
Section 12693)), the Access for Infants and Mothers Program (Part 6.3
(commencing with Section 12695)), the California Major Risk Medical
Insurance Program (Part 6.5 (commencing with Section 12700)), or the
Federal Temporary High Risk Pool (Part 6.6 (commencing with Section
12739.5)); a health insurance conversion policy offered pursuant to
Section 12682.1; or a health insurance policy offered to a federally
eligible defined individual under Chapter 9.5 (commencing with
Section 10900).
SEC. 9. SEC. 7. 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.
SEC. 10. SEC. 8. This act is an
urgency statute necessary for the immediate preservation of the
public peace, health, or safety within the meaning of Article IV of
the Constitution and shall go into immediate effect. The facts
constituting the necessity are:
In order to update state law consistent with federal requirements
at the earliest possible time, it is necessary that this bill take
effect immediately.
