BILL NUMBER: AB 2289 ENROLLED
BILL TEXT
PASSED THE ASSEMBLY AUGUST 25, 2004
PASSED THE SENATE AUGUST 24, 2004
AMENDED IN SENATE AUGUST 19, 2004
AMENDED IN SENATE JULY 14, 2004
AMENDED IN SENATE JUNE 22, 2004
AMENDED IN ASSEMBLY APRIL 20, 2004
AMENDED IN ASSEMBLY APRIL 15, 2004
INTRODUCED BY Assembly Member Chan
FEBRUARY 19, 2004
An act to add Section 1375 to the Health and Safety Code, and to
add Section 10123.671 to the Insurance Code, relating to health care.
LEGISLATIVE COUNSEL'S DIGEST
AB 2289, Chan. Health care information.
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 violation
of the act a crime. Existing law also provides for the licensure and
regulation of health insurers by the Department of Insurance. Under
existing law, a plan and a health insurer are required to provide
specified information to their respective regulatory departments
regarding their operations.
This bill would, except as specified, require a full-service
health care service plan and a health insurer to report on or before
July 1, 2005, to their respective regulatory departments certain
information about the plan or insurer's policy regarding specified
costs paid for benefits by, as applicable, enrollees, subscribers,
and insureds.
Because the bill would specify an additional requirement for a
health care service plan, the violation of which would be a crime, it
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.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1375 is added to the Health and Safety Code, to
read:
1375. (a) On or before July 1, 2005, on a one-time basis, each
full-service health care service plan shall file with the department
a written statement describing all of the following for the five
largest, defined by the total number of enrollees currently enrolled,
benefit plan designs in each of the small group market, the
individual market, and the noncustomized large group market,
currently being marketed or offered for enrollment:
(1) The plan's policy regarding share of premiums paid by
enrollees or subscribers, if any.
(2) The annual out-of-pocket maximums, if any.
(3) The annual deductibles, if any.
(4) The copayments for the following:
(A) Office or physician visits.
(B) Hospitalization.
(C) Prescription drugs.
(D) Outpatient services other than physician visits.
(E) Emergency health coverage.
(F) Ambulance services.
(G) Durable medical equipment.
(H) Mental health services.
(I) Chemical dependency services.
(J) Home health services.
(K) Skilled nursing facilities.
(5) An estimate of the number of enrollees covered by the plan.
(b) Enrollment information provided to the department by a plan
under this section shall be considered confidential and shall not be
disclosed, except that the department may report aggregate data.
(c) A plan shall also provide information required pursuant to
subdivision (a) about the five largest, defined by the total number
of enrollees enrolled on January 1, 2001, benefit plan designs in the
individual market, the small group market, and the noncustomized
large group market, that have been approved by the department since
January 1, 2000, but which the plan is not currently offering.
(d) If the plan requires different copayments for contracting
providers and noncontracting providers, or other categories of
providers, the plan shall provide the information by the category of
provider.
(e) The information required pursuant to this section shall be
reported in the format set forth for the uniform health plan benefits
and coverage matrix described in paragraph (1) of subdivision (b) of
Section 1363.
(f) The plan shall provide the department with copies of the
benefit plans described in subdivision (a).
(g) This section shall not apply to any of the following:
(1) Health care service plan contracts authorized under Article
5.6 (commencing with Section 1374.60).
(2) Health care service plan contracts for enrollees in Medi-Cal,
the Healthy Families Program, the Access for Infants and Mothers
Program, the California Major Risk Medical Insurance Program, the
California Public Employees' Retirement System, or Medicare.
(3) Health care service plan contracts provided to individuals
eligible for continued coverage under the Health Insurance
Portability and Accountability Act (HIPAA) or conversion plans.
(h) Nothing in this section requires a health care service plan to
cover services or provide benefits that are not otherwise covered
under the terms and conditions of the plan contract, nor to provide
services through a provider who is not under contract with the plan.
SEC. 2. Section 10123.671 is added to the Insurance Code, to read:
10123.671. (a) On or before July 1, 2005, on a one-time basis
every health insurer with a group health insurance policy that covers
hospital, medical, or surgical expenses that contracts with
providers for alternative rates pursuant to Section 10133 and that
limits payments under those policies to services secured by insureds
from providers charging alternative rates pursuant to the contracts,
shall file with the department a written statement describing all of
the following for the five largest, defined by the total number of
insureds currently insured, benefit plan designs in each of the small
group market, the individual market, and the noncustomized large
group market, currently being marketed or offered:
(1) The insurer's policy regarding share of premiums paid by
insureds, if any.
(2) The annual out-of-pocket maximums, if any.
(3) The annual deductibles or coinsurance, if any.
(4) The copayments for the following:
(A) Office or physician visits.
(B) Hospitalization.
(C) Prescription drugs.
(D) Outpatient services other than physician visits.
(E) Emergency health coverage.
(F) Ambulance services.
(G) Durable medical equipment.
(H) Mental health services.
(I) Chemical dependency services.
(J) Home health services.
(K) Skilled nursing facilities.
(5) An estimate of the number of insureds covered by the plan.
(b) Enrollment information provided to the department by an
insurer under this section shall be considered confidential and shall
not be disclosed, except that the department may report aggregate
data. The department shall maintain documents provided by insurers
pursuant to this section and make them available upon request in the
manner in which they were submitted. The department shall make the
documents available upon request subject to any applicable
confidentiality provisions.
(c) An insurer shall also provide information required pursuant to
subdivision (a) about the five largest, defined by the total number
of enrollees enrolled on January 1, 2001, benefit plan designs in the
individual market, the small group market, and the noncustomized
large group market, that have been approved by the department since
January 1, 2000, but which the insurer is not currently offering.
(d) If the insurer requires different copayments for contracting
providers and noncontracting providers, or other categories of
providers, the insurer shall provide the information by the category
of provider.
(e) The information required pursuant to this section shall be
reported in the format set forth for the uniform health plan benefits
and coverage matrix described in paragraph (1) of subdivision (b) of
Section 1363 of the Health and Safety Code.
(f) The insurer shall provide the department with copies of the
benefit plans described in subdivision (a).
(g) The written statement described in subdivision (a) shall be
filed only for purposes of information and is not subject to approval
or disapproval by the department.
(h) Nothing in this section shall require an insurer to cover
services or provide benefits that are not otherwise covered under the
terms and conditions of the policy, nor to provide services through
a provider who is not under contract with the insurer.
(i) This section shall not apply to health insurance policies
provided to individuals eligible for continued coverage under the
Health Insurance Portability and Accountability Act (HIPAA) or
conversion plans.
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.