BILL NUMBER: AB 895 CHAPTERED
BILL TEXT
CHAPTER 164
FILED WITH SECRETARY OF STATE JULY 30, 2007
APPROVED BY GOVERNOR JULY 30, 2007
PASSED THE SENATE JULY 9, 2007
PASSED THE ASSEMBLY JULY 20, 2007
AMENDED IN SENATE JULY 5, 2007
AMENDED IN SENATE JUNE 21, 2007
AMENDED IN ASSEMBLY APRIL 30, 2007
AMENDED IN ASSEMBLY APRIL 12, 2007
INTRODUCED BY Assembly Member Aghazarian
FEBRUARY 22, 2007
An act to add Section 1374.19 to the Health and Safety Code, and
to add Section 10120.2 to the Insurance Code, relating to health care
coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 895, Aghazarian. Health care coverage: dental care.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
the willful violation of which is a crime, provides for the
licensure and regulation of health care service plans and specialized
health care service plans, including plans covering dental services.
Existing law provides for the regulation of insurers by the
Department of Insurance. Existing law imposes specified coverage and
disclosure requirements on health care service plans and insurers.
Existing law provides for, but does not require, a coordination of
benefits in instances where coverage for a claim is available from
more than one insurer or plan, as specified.
This bill would require a health care service plan or a
specialized health care service plan contract covering dental
services, or a disability insurer that issues a dental insurance
policy, to declare its coordination of benefits policy, as defined,
prominently in its evidence of coverage documents or in its contracts
or policies with both enrollees or insureds and subscribers or
policyholders. The bill would require an enrollee's or insured's
primary dental benefit plan, as defined, that is coordinating dental
benefits with one or more other plans or insurers to pay the maximum
amount required by its contract or policy with the enrollee or
insured or the subscriber or policyholder. The bill would require a
secondary dental benefit plan, as defined, to pay the lesser of
either the amount that it would have paid in the absence of any other
dental benefit coverage or the enrollee's or insured's total
out-of-pocket cost payable under the primary dental benefit plan for
benefits covered under the secondary dental benefit plan.
Because a willful violation of the bill's requirements with regard
to health care service plans would be a crime, the 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.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. It is the intent of the Legislature that a health care
service plan covering dental services, a specialized health care
service plan contract covering dental services, and a disability
insurer that issues a dental insurance policy, when acting as a
secondary plan or insurer, shall pay the lesser of either the amount
that it would have paid in the absence of any other dental benefit
coverage, or the enrollee's or insured's total out-of-pocket cost
payable under the primary dental benefit plan or policy for benefits
covered under the secondary plan or policy.
SEC. 2. Section 1374.19 is added to the Health and Safety Code, to
read:
1374.19. (a) This section shall only apply to a health care
service plan covering dental services or a specialized health care
service plan contract covering dental service pursuant to this
chapter.
(b) For purposes of this section, the following terms have the
following meanings:
(1) "Coordination of benefits" means the method by which a health
care service plan covering dental services or a specialized health
care service plan contract, covering dental services, and one or more
other health care service plans, specialized health care service
plans, or disability insurers, covering dental services, pay their
respective reimbursements for dental benefits when an enrollee is
covered by multiple health care service plans or specialized health
care services plan contracts, or a combination thereof, or a
combination of health care service plans or specialized health care
service plan contracts and disability insurers.
(2) "Primary dental benefit plan" means a health care service plan
or specialized health care service plan contract regulated pursuant
to this chapter or a dental insurance policy issued by a disability
insurer regulated pursuant to Part 2 (commencing with Section 10110)
of Division 2 of the Insurance Code that provides an enrollee or
insured with primary dental coverage.
(3) "Secondary dental benefit plan" means a health care service
plan or specialized health care service plan contract regulated
pursuant to this chapter or a dental insurance policy issued by a
disability insurer regulated pursuant to Part 2 (commencing with
Section 10110) of Division 2 of the Insurance Code that provides an
enrollee or insured with secondary dental coverage.
(c) A health care service plan covering dental services or a
specialized health care service plan issuing a specialized health
care service plan contract covering dental services shall declare its
coordination of benefits policy prominently in its evidence of
coverage or contract with both enrollee and subscriber.
(d) When a primary dental benefit plan is coordinating its
benefits with one or more secondary dental benefits plans, it shall
pay the maximum amount required by its contract with the enrollee or
subscriber.
(e) A health care service plan covering dental services or a
specialized health care service plan contract covering dental
services, when acting as a secondary dental benefit plan, shall pay
the lesser of either the amount that it would have paid in the
absence of any other dental benefit coverage, or the enrollee's total
out-of-pocket cost payable under the primary dental benefit plan for
benefits covered under the secondary plan.
(f) Nothing in this section is intended to conflict with or modify
the way in which a health care service plan covering dental services
or a specialized health care service plan covering dental services
determines which dental benefit plan is primary and which is
secondary in coordinating benefits with another plan or insurer
pursuant to existing state law or regulation.
SEC. 3. Section 10120.2 is added to the Insurance Code, to read:
10120.2. (a) This section shall only apply to a disability
insurer that issues a dental insurance policy pursuant to this part.
(b) For purposes of this section, the following terms have the
following meanings:
(1) "Coordination of benefits" means the method by which a
disability insurer and one or more other disability insurers, health
care service plans covering dental services, or specialized health
care service plans, covering dental services, pay their respective
reimbursements for dental benefits when an insured is covered by
multiple disability insurers, or a combination of disability insurers
and health care service plans or specialized health care service
plans.
(2) "Primary dental benefit plan" means a dental insurance policy
issued by a disability insurer regulated pursuant to this part or a
health care service plan or specialized health care service plan
contract regulated pursuant to Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code that provides an
insured or enrollee with primary dental coverage.
(3) "Secondary dental benefit plan" means a dental insurance
policy issued by a disability insurer regulated pursuant to this part
or a health care service plan or specialized health care service
plan contract regulated pursuant to Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code that
provides an insured or enrollee with secondary dental coverage.
(c) A disability insurer that issues a dental insurance policy
shall declare its coordination of benefits policy prominently in its
evidence of coverage or insurance policy with both insured and
policyholder.
(d) When a primary dental benefit plan is coordinating its
benefits with one or more secondary dental benefit plans, it shall
pay the maximum amount required by its policy with the insured or
policyholder.
(e) A disability insurer that issues a dental insurance policy,
when acting as a secondary dental benefit plan or insurer, shall pay
the lesser of either the amount it would have paid in the absence of
any other dental benefit coverage, or the insured's total
out-of-pocket cost payable under the primary dental benefit plan for
benefits covered under the secondary plan or policy.
(f) Nothing in this section is intended to conflict with or modify
the way in which a disability insurer that issues a dental insurance
policy determines which dental benefit plan is primary and which is
secondary in coordinating benefits with another insurer or plan
pursuant to existing state law or regulation.
SEC. 4. 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.