BILL NUMBER: SB 227 AMENDED
BILL TEXT
AMENDED IN SENATE MAY 28, 2009
AMENDED IN SENATE APRIL 13, 2009
INTRODUCED BY Senator Alquist
FEBRUARY 23, 2009
An act to add Sections 1356.2, 1373.623, 1373.63, and 1399.807 to
the Health and Safety Code, and to amend Sections 12700, 12705,
12711, 12712, 12718, 12725, 12726, and 12739 of, to add Sections
1827.86, 10127.165, 10127.19, 10903, 12711.3, 12714.1, 12714.5, and
12738.5 to, to add Chapter 9 (commencing with Section 12739.5) to
Part 6.5 of Division 2 of, and to repeal and add Sections 12723 and
12737 of, the Insurance Code, relating to health care coverage, and
making an appropriation therefor.
LEGISLATIVE COUNSEL'S DIGEST
SB 227, as amended, Alquist. Health care coverage.
(1) Existing law establishes the California Major Risk Medical
Insurance Program (MRMIP) that is administered by the Managed Risk
Medical Insurance Board (MRMIB) to provide major risk medical
coverage to persons who, among other matters, have been rejected for
coverage by at least one private health plan. 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
a health care service plan and a health insurer to continue to
provide coverage to certain individuals who were members of a pilot
program that ended on December 31, 2007, and requires MRMIB to make
payments from the Major Risk Medical Insurance Fund, a continuously
appropriated fund, to health care service plans and insurers for the
provision of health services to those individuals.
This bill would require a health care service plan and a health
insurer to elect either to accept for coverage at rates set by MRMIB
and under specified conditions persons eligible for MRMIP that have
been assigned to the plan or insurer by MRMIB regardless of health
status or previous health care claims experience, or alternatively to
pay a fee set by MRMIB based on its market share, as specified.
Because the fee would be deposited in the fund, the bill would make
an appropriation by increasing the amount of revenue in a
continuously appropriated fund. The bill would authorize MRMIB, with
the approval of the Department of Finance, to obtain loans from the
General Fund for expenses related to administration of the fund.
The bill would require MRMIB to establish a voluntary reenrollment
program for persons enrolled in the former pilot program, would
implement benefit changes for MRMIP, and would establish limits on
MRMIP subscriber contribution amounts, as specified. The bill would
require MRMIB to appoint a panel to advise it on MRMIP, would
authorize MRMIB to apply for federal funding and take other actions,
as specified, and would require MRMIB to report to the Legislature on
or before July 1, 2012, as specified. The bill would require MRMIB
to report and make recommendations to the Legislature by September 1,
2010, regarding the status of benefits and premiums provided to
federally eligible defined individuals, based on data provided by
plans and insurers, as specified. The bill would enact other related
provisions. By imposing new requirements on health care service
plans, the willful violation of which would be a crime, the bill
would impose a state-mandated local program.
(2) Existing law requires specified amounts to be deposited in the
fund from the Cigarette and Tobacco Products Surtax Fund.
This bill would increase those amounts, thereby making an
appropriation. The bill would also specify that any money
in the fund attributable to monetary penalties imposed under MRMIP
shall not be continuously appropriated.
The bill would, until January 1, 2012, exempt MRMIB, the
Department of Managed Health Care, and the Department of Insurance
from certain procedural requirements necessary to adopt rules and
regulations.
(3) 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: yes. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1356.2 is added to the Health and Safety Code,
to read:
1356.2. (a) In addition to the other fees and reimbursements
required to be paid under this chapter, each licensed health care
service plan, except for a specialized health care service plan,
electing to pay the fee under Chapter 9 (commencing with Section
12739.5) of Part 6.5 of Division 2 of the Insurance Code shall pay
the fee to the director in the amount as determined by the Managed
Risk Medical Insurance Board. The timely payment of the fee and the
timely submission of information pursuant to Section 12739.7 of the
Insurance Code shall be deemed to be among the prerequisites for
obtaining and retaining a license as a health care service plan. The
director shall transmit fees collected pursuant to this section to
the Managed Risk Medical Insurance Board, in a manner determined by
that board, within 30 days after the date on which the director
receives those fees. The director shall permit health care service
plans subject to the fee to remit payment on a quarterly basis.
(b) A health care service plan that has elected not to pay the fee
under Chapter 9 (commencing with Section 12739.5) of Part 6.5 of
Division 2 of the Insurance Code shall demonstrate to the
satisfaction of the director that it is in compliance with
subdivision (a) of Section 1373.63.
(c) The fees paid pursuant to this section and Section 12739.7 of
the Insurance Code shall not be considered administrative costs for
the purposes of Section 1300.78 of Title 28 of the California Code of
Regulations or for purposes of calculating any medical loss ratio
imposed on health plans by statute or regulation.
SEC. 2. Section 1373.623 is added to the Health and Safety Code,
to read:
1373.623. (a) Commencing January 1, 2010, at least annually
thereafter, and at such other times as the Managed Risk Medical
Insurance Board shall request, health care service plans providing
continuation coverage pursuant to Section 1373.622 shall report to
the Managed Risk Medical Insurance Board the number of covered lives
remaining in the continuation coverage and such related information
as the board may require to implement subdivision (f) of Section
12725 of the Insurance Code.
(b) Health care service plans providing continuation coverage
shall provide to enrollees in continuation coverage the notice
developed by the Managed Risk Medical Insurance Board pursuant to
subdivision (f) of Section 12725 of the Insurance Code.
SEC. 3. Section 1373.63 is added to the Health and Safety Code, to
read:
1373.63. (a) On and after January 1, 2010, except as provided in
subdivision (e), every health care service plan, except for a
specialized health care service plan or a Medicare-only or
Medicare-supplement-only health care service plan, licensed in
California, that provides individual or group coverage, shall accept
for coverage persons eligible pursuant to Section 12725 of the
Insurance Code for the Major Risk Medical Insurance Program,
according to the assignment of eligible persons by the Managed Risk
Medical Insurance Board pursuant to Section 12712 of the Insurance
Code, regardless of the individual's health status or previous health
care claims experience. As used in this section, "board" means the
Managed Risk Medical Insurance Board.
(b) Health care service plans subject to this section shall
provide coverage to persons assigned by the board with the same level
of benefits as the Major Risk Medical Insurance Program, as
determined by the board, and shall charge those persons premium rates
determined by the board.
(c) For persons assigned for coverage to the health care service
plan, the health care service plan may impose only those coverage
exclusions or waiting periods as provided by the board in regulation
and pursuant to Section 12726 of the Insurance Code.
(d) Health plan contracts issued pursuant to this section shall be
guaranteed renewable.
(e) A health care service plan shall not be subject to the
requirements of this section if it instead elects to pay the fee
under Chapter 9 (commencing with Section 12739.5) of Part 6.5 of
Division 2 of the Insurance Code.
(f) The director may take all action authorized under this
chapter, including, but not limited to, the imposition of fines or
penalties against a health care service plan that does not comply
with this section or Section 1356.2.
SEC. 4. Section 1399.807 is added to the Health and Safety Code,
to read:
1399.807. On or before March 1, 2010, health care service plans
that offer, issue, or renew individual coverage pursuant to this
article shall provide to the department such data and information as
the department determines, in consultation with the Managed Risk
Medical Insurance Board and the Insurance Commissioner, are necessary
to be provided to the Managed Risk Medical Insurance Board for
purposes of the study required under Section 12714.5 of the Insurance
Code.
SEC. 5. Section 1827.86 is added to the Insurance Code, to read:
1827.86. (a) Every admitted health insurer that provides health
insurance and that elects to pay the fee under Chapter 9 (commencing
with Section 12739.5) of Part 6.5 shall pay the fee to the
commissioner in the amount as determined by the Managed Risk Medical
Insurance Board. The commissioner shall permit health insurers
subject to the fee to remit payment on a quarterly basis. The timely
payment of the fee and the timely submission of information pursuant
to Section 12739.7 shall be deemed to be among the prerequisites for
obtaining and retaining a certificate of authority or license issued
by the commissioner and, in addition, deficiencies with respect to
the timely payment or submission of information shall be grounds for
the imposition of sanctions or the institution of disciplinary
proceedings by the commissioner. The commissioner shall transmit fees
collected pursuant to this section to the Managed Risk Medical
Insurance Board, in a manner determined by that board, within 30 days
after the date on which the commissioner receives those fees.
(b) A health insurer that has elected not to pay the fee under
Chapter 9 (commencing with Section 12739.5) of Part 6.5 shall
demonstrate to the satisfaction of the commissioner that it is in
compliance with subdivision (a) of Section 10127.19.
(c) The requirements of this section shall not apply to Medicare
supplement, specialized health, or CHAMPUS supplement insurance, or
to hospital indemnity, hospital-only, accident-only, or specified
disease insurance that does not pay benefits on a fixed benefit, cash
payment only basis, or to short-term limited duration health
insurance.
(d) The fees paid pursuant to this section and Section 12739.7
shall not be considered administrative costs for the purposes of
Section 1300.78 of Title 28 of the California Code of Regulations or
for purposes of calculating any medical loss ratio imposed on health
insurers by statute or regulation.
SEC. 6. Section 10127.165 is added to the Insurance Code, to read:
10127.165. (a) Commencing January 1, 2010, at least annually
thereafter, and at such other times as the Managed Risk Medical
Insurance Board shall request, health insurers providing continuation
coverage pursuant to Section 10127.16 shall report to the Managed
Risk Medical Insurance Board the number of covered lives remaining in
the continuation coverage and such related information as the board
may require to implement subdivision (f) of Section 12725.
(b) Health insurers providing continuation coverage shall provide
to insureds in continuation coverage the notice developed by the
Managed Risk Medical Insurance Board pursuant to subdivision (f) of
Section 12725.
SEC. 7. Section 10127.19 is added to the Insurance Code, to read:
10127.19. (a) On and after January 1, 2010, except as provided in
subdivision (e), every health insurer that provides individual or
group health insurance, as defined in Section 106, to residents of
this state shall accept for coverage persons eligible pursuant to
Section 12725 for the Major Risk Medical Insurance Program, according
to the assignment of eligible persons by the Managed Risk Medical
Insurance Board, pursuant to Section 12712, regardless of the
individual's health status or previous health care claims experience.
As used in this section, "board" means the Managed Risk Medical
Insurance Board.
(b) Health insurers subject to this section shall provide coverage
to persons assigned by the board with the same level of benefits as
the Major Risk Medical Insurance Program, as determined by the board,
and shall charge those persons premium rates determined by the
board.
(c) For persons assigned for coverage to the insurer, the insurer
may impose only those coverage exclusions or waiting periods as
provided by the board in regulation and pursuant to Section 12726.
(d) Health insurance policies issued pursuant to this section
shall be guaranteed renewable.
(e) A health insurer shall not be subject to the requirements of
this section if it instead elects to pay the fee under Chapter 9
(commencing with Section 12739.5) of Part 6.5.
(f) The commissioner may take all action authorized under this
chapter, including, but not limited to, the imposition of fines or
penalties against a health insurer that does not comply with this
section or Section 1827.86.
(g) The requirements of this section shall not apply to Medicare
supplement, specialized health, or CHAMPUS supplement insurance, or
to hospital indemnity, hospital-only, accident-only, or specified
disease insurance that does not pay benefits on a fixed benefit, cash
payment only basis, or to short-term limited duration health
insurance.
SEC. 8. Section 10903 is added to the Insurance Code, to read:
10903. On or before March 1, 2010, health insurers that offer,
issue, or renew individual coverage pursuant to this chapter shall
provide to the commissioner such data and information as the
commissioner determines, in consultation with the Managed Risk
Medical Insurance Board and the Department of Managed Health Care,
are necessary to be provided to the Managed Risk Medical Insurance
Board for purposes of the study required under Section 12714.5.
SEC. 9. Section 12700 of the Insurance Code is amended to read:
12700. The Legislature finds and declares all of the following:
(a) That many Californians do not have employer-sponsored group
health care coverage and are unable to secure adequate health care
coverage for themselves and their dependents because of preexisting
medical conditions, and a number of employer-sponsored groups have
difficulty obtaining or maintaining their health care coverage
because some members of the group either have, or are viewed as being
at risk for having, high medical costs.
(b) That, even where uninsured persons with preexisting conditions
are able to secure coverage, the cost of coverage is prohibitively
high or is secured only by waiving coverage for the preexisting
conditions for which they are most likely to need care.
(c) That adverse selection precludes private health plans
regulated by the State of California from enrolling medically
uninsurable persons in the face of the escalating health care costs
and a highly competitive market.
(d) That left to face the cost of major medical care without
health care coverage, all but the extremely affluent uninsured
persons must ultimately look to publicly funded programs including
the Medi-Cal program or the Medically Indigent Services Program in
the event of severe illness or injury.
(e) That one prudent means of making comprehensive major medical
coverage available to individuals who are unable to purchase private
health care coverage when they are denied that coverage because of
their health risk, health history, or health status, is to arrange
for, and subsidize, private coverage using a combination of public
and private funding.
(f) That enrollment in affordable, comprehensive health care
coverage products compatible with their medical needs should be
available for purchase by all Californians, including those who are,
or are viewed by carriers as being, at high risk because of
preexisting medical conditions, and that information about these
coverage options should be readily available to consumers.
(g) That the structure of coverage for medically uninsurable
persons should encourage broad participation of private health care
service plans and health insurers in providing that coverage and
should, at a minimum, not create a disincentive for health care
service plans and health insurers to participate in the state's
program for high-risk and uninsurable persons.
(h) That on and after January 1, 2010, sufficient funding from a
combination of public and private sources shall be available so that
the program can provide health care coverage to eligible persons
willing to pay premiums and without the need for waiting lists.
SEC. 10. Section 12705 of the Insurance Code is amended to read:
12705. The following definitions apply for the purposes of this
part:
(a) "Applicant" means an individual who applies for major risk
medical coverage through the program.
(b) "Board" means the Managed Risk Medical Insurance Board.
(c) "Fund" means the Major Risk Medical Insurance Fund, from which
the program may authorize expenditures to pay for medically
necessary services that exceed subscribers' contributions, and for
administration of the program.
(d) "Major risk medical coverage" means the payment for
comprehensive, medically necessary services compatible with the
medical needs of medically uninsurable persons, provided by
institutional and professional providers and structured in a manner
that does not provide a disincentive for accessing needed health
care.
(e) "Participating health plan" means a health insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan as defined under
subdivision (f) of Section 1345 of the Health and Safety Code, that
contracts with the board to administer major risk medical coverage to
program subscribers and, pursuant to the terms of its contract with
the board, provides, arranges, pays for, or reimburses the costs of
health care services.
(f) "Payer" means an entity described in Section 1373.63 of the
Health and Safety Code or Section 10127.19 that elects to pay the
fee, as described in Chapter 9 (commencing with Section 12739.5).
(g) "Plan rates" means the total monthly amount charged by a
participating health plan for a category of risk.
(h) "Program" means the California Major Risk Medical Insurance
Program.
(i) "Program costs" means the anticipated costs of operating the
program for the year, including, but not limited to, the cost of
providing covered benefits to all prospective eligible subscribers;
administrative costs, including the costs of staff and overhead
operations for the program; and a reasonable amount to establish and
maintain a prudent reserve for the program. For purposes of this
section, administrative costs for the program may not be expended to
support any other program administered by the board.
(j) "Subscriber" means an individual who is eligible for and
receives major risk medical coverage through the program, and
includes a member of a federally recognized California Indian tribe.
(k) "Subscriber contribution" means the portion of participating
health plan rates paid by the subscriber, or paid on behalf of the
subscriber by a federally recognized California Indian tribal
government. If a federally recognized California Indian tribal
government makes a contribution on behalf of a member of the tribe,
the tribal government shall ensure that the subscriber is made aware
of all the health plan options available in the county where the
member resides.
SEC. 11. Section 12711 of the Insurance Code is amended to read:
12711. The board shall have the following authority:
(a) To determine the eligibility of applicants.
(b) To determine the major risk medical coverage to be provided to
program subscribers. The major risk medical coverage shall comply
with the provisions of Section 12718.
(c) To research and assess the needs of persons not adequately
covered by existing private and public health care delivery systems
and promote means of ensuring the availability of adequate health
care services.
(d) To approve subscriber contributions and plan rates, and to
establish program contribution amounts and the types of covered lives
that shall be reported by plans and insurers, and to administer fees
imposed pursuant to Chapter 9 (commencing with Section 12739.5).
(e) To provide major risk medical coverage for subscribers or to
contract with a participating health plan or plans to provide or
administer major risk medical coverage for subscribers.
(f) To authorize expenditures from the fund to pay program
expenses which exceed subscriber contributions.
(g) To contract for administration of the program or any portion
thereof with any public agency, including any agency of state
government, or with any private entity.
(h) To issue rules and regulations to carry out the purposes of
this part.
(i) To authorize expenditures from the fund or from other moneys
appropriated in the annual Budget Act for purposes relating to
Section 10127.15 of this code or Section 1373.62 of the Health and
Safety Code.
(j) To apply for any federal funding the board determines to be
cost effective, and to negotiate with the federal Centers for
Medicare and Medicaid Services to secure the federal funding.
(k) To contract with a reinsurer to obtain reinsurance or
stop-loss coverage for the program.
(l) To establish reasonable participation requirements for
subscribers.
(m) To assign persons eligible for the program pursuant to Section
12725 among health plans subject to Section 1373.63 of the Health
and Safety Code and health insurers subject to Section 10127.19,
except for plans and insurers that have elected instead to pay the
fee pursuant to those sections.
(n) To exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon it
under this part.
SEC. 12. Section 12711.3 is added to the Insurance Code, to read:
12711.3. The board, subject to the approval of the Department of
Finance, may obtain loans from the General Fund for all necessary and
reasonable expenses related to the administration of the fund. The
board shall repay principal and interest, using the pooled money
investment account rate of interest, to the General Fund no later
than January 1, 2017.
SEC. 13. Section 12712 of the Insurance Code is amended to read:
12712. The board shall perform the following functions:
(a) Establish the scope and content of adequate major medical
coverage to be offered by the program, including guidelines, as
appropriate, for disease management, case management, care
management, or other cost management strategies to ensure
cost-effective, high-quality health care services for subscribers.
(b) Determine reasonable minimum standards for participating
health plans.
(c) Determine the time, manner, method, and procedures for
withdrawing program approval from a plan or limiting subscriber
enrollment in a participating health plan.
(d) Research and assess the needs of persons without adequate
health coverage, and promote means of ensuring the availability of
adequate health care services.
(e) Administer the program so as to ensure that the program
subsidy amount does not exceed amounts transferred to the fund
pursuant to Chapter 8 (commencing with Section 12739).
(f) Issue appropriate rules and regulations for matters it may be
authorized or required to provide for by this part. In adopting these
rules and regulations, the board shall be guided by the needs and
welfare of persons unable to secure adequate health coverage for
themselves and their dependents, and prevailing practices among
private health plans.
(g) Implement strategies to ensure program integrity and to ensure
that the program serves the target population of uninsurable
individuals. Strategies may include, but are not limited to, ensuring
that applicants have provided adequate evidence of their inability
to obtain health care coverage and requiring subscribers to attest
that they do not have health care coverage that meets their medical
needs at a lower cost than coverage available in the program.
(h) Administer the program in a manner to maximize the program's
eligibility for any federal funds available for high-risk health
insurance pools consistent with the purposes of this part. The board
shall apply for or otherwise seek any available federal funds
consistent with the purposes of this part.
(i) In order to reduce or eliminate any waiting list for coverage
in the program, and to ensure the availability of a coverage option
for persons who have been denied private individual health coverage,
develop a process for and implement assignment of persons eligible
for the program to obtain their health coverage from health care
service plans subject to Section 1373.63 of the Health and Safety
Code and health insurers subject to Section 10127.19. The board shall
determine the benefit design that shall be provided by health care
service plans and health insurers to eligible persons assigned to
them by the board, consistent with the benefits provided to
subscribers. In developing the assignment process, the board shall
take into account the geographic service area of health plans and
health insurers who are available for assignment and the geographic
area where potential enrollees and insureds reside. To the greatest
extent possible, the board shall provide eligible persons with a
choice of health plan or health insurer. The board shall not assign
any eligible persons to health plans or health insurers that have
elected instead to pay the fee pursuant to Section 1373.63 of the
Health and Safety Code or Section 10127.19. The board shall determine
how many eligible persons it shall assign to each health care
service plan subject to Section 1373.63 of the Health and Safety Code
and each health insurer subject to Section 10127.19, consistent with
the purposes of this part, taking into consideration the costs of
providing coverage in the program and the fees paid by health care
service plans and health insurers who elect to pay the fee pursuant
to Section 1373.63 of the Health and Safety Code or Section 10127.19.
SEC. 14. Section 12714.1 is added to the Insurance Code, to read:
12714.1. (a) The board shall appoint an 11-member panel to advise
the board on the program. Appointments to the panel shall be
completed, and the panel shall be prepared to perform its duties,
prior to February 1, 2010.
(b) The membership of the panel shall be composed of all of the
following persons:
(1) Four representatives of health care service plans and health
insurers that provide health coverage in the individual health
insurance market, at least three of which shall be health plans
participating in the program.
(2) Two program subscribers.
(3) Two health care providers with expertise in the care and
treatment of chronic diseases, at least one of which shall be a
physician and surgeon.
(4) Three representatives of organizations representing the
interests of health care consumers and medically uninsurable persons.
(c) The Director of the Department of Managed Health Care, or his
or her designee, and the commissioner, or his or her designee, shall
participate in the panel as nonvoting members.
(d) The panel members shall have demonstrated expertise in the
provision of health-related services to medically uninsurable
individuals.
(e) The initial term of the panel members shall be staggered, with
six members being appointed for a two-year term and five members
being appointed for a four-year term. Upon the expiration of the
initial term, all panel members shall be appointed for a four-year
term.
(f) The panel shall elect, from among its members, its chair who
shall regularly report to the board, during the board's public
meetings, on behalf of the panel.
(g) The panel shall do all of the following:
(1) Make recommendations to improve the quality of health care
provided to subscribers in the program.
(2) Advise the board on policies and program operations.
(3) Make recommendations to ensure the affordability of coverage
for subscribers, especially low-income subscribers.
(4) Make recommendations to ensure the cost-effectiveness of
health care provided to subscribers in the program.
(5) Meet at least quarterly, unless deemed unnecessary by the
chair.
(h) The board shall consider all written recommendations of the
panel and respond to the panel in writing when the board rejects a
written recommendation made by the panel.
(i) All members of the advisory panel shall serve without
compensation. Members of the panel shall be reimbursed for all
necessary travel expenses associated with the activities of the
panel. Consumer representatives on the panel may receive per diem
compensation if they are otherwise economically unable to attend and
participate in panel activities.
SEC. 15. Section 12714.5 is added to the Insurance Code, to read:
12714.5. (a) On or before September 1, 2010, the board shall
report and make recommendations to the appropriate fiscal and policy
committees of the Legislature regarding the status of benefits and
premiums provided to federally eligible defined individuals under
Article 11.5 (commencing with Section 1399.801) of Chapter 2.2 of
Division 2 of the Health and Safety Code, and Chapter 9.5 (commencing
with Section 10900) of Part 2 of this division. The board shall
consult with the advisory panel established pursuant to Section
12714.1, the Department of Managed Health Care, and the Department of
Insurance in the preparation of this report.
(b) The board shall assess the products provided to federally
eligible defined individuals, and the premiums charged, in comparison
to coverage and subscriber contributions within the program, and
shall analyze the impact that any changes to benefits and subscriber
contributions in the program have had on coverage and premiums for
federally eligible defined individuals. The board shall obtain an
actuarial analysis and comparison between benefits and premiums in
the program and those in the individual market for federally eligible
defined individuals. The board shall make recommendations as to the
need for policy changes related to the premiums that health plans and
health insurers are required to charge for
coverage to federally eligible defined
individuals, in relationship to the contributions of subscribers in
the program, and shall discuss the impact of any changes in the
program on premium rates and coverage for federally eligible defined
individuals.
SEC. 16. Section 12718 of the Insurance Code is amended to read:
12718. (a) Benefits under this chapter or Chapter 5 (commencing
with Section 12720) shall be subject to required subscriber
copayments and deductibles as the board may authorize. Benefits in
the program shall provide comprehensive coverage, including,
effective January 1, 2011, lower subscriber cost sharing for primary
and preventive health care services and the medications necessary and
appropriate for the treatment and management of chronic health
conditions. Benefits, subscriber cost sharing, and out-of-pocket
costs shall be appropriate for a program serving high-risk and
medically uninsurable persons. To the greatest extent possible, the
board shall establish benefits that are compatible with comprehensive
coverage products available in the individual health insurance
market, but in no event shall the benefits for the program be less
than the minimum benefits required to be offered by health plans
licensed under the Knox-Keene Health Care Service Plan Act of 1975
(Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code) plus coverage for prescription drugs. The
board may offer more than one benefit design option with different
subscriber cost sharing in the form of copayments, deductibles, and
annual out-of-pocket costs. If the board contracts with participating
health plans pursuant to Chapter 5 (commencing with Section 12720),
copayments or deductibles shall be authorized in a manner consistent
with the basic method of operation of the participating health plans.
The aggregate amount of deductible and copayments payable annually
under this section shall not exceed two thousand five hundred dollars
($2,500) for an individual and four thousand dollars ($4,000) for a
family.
(b) Major risk medical coverage in the program shall have no
annual limits on total coverage or benefits and shall not have a
limit on covered benefits over the lifetime of each subscriber of
less than one million dollars ($1,000,000).
SEC. 17. Section 12723 of the Insurance Code is repealed.
SEC. 18. Section 12723 is added to the Insurance Code, to read:
12723. If the board contracts with participating health plans or
insurers to provide or administer major risk coverage, the board
shall contract with either health insurers holding valid, outstanding
certificates of authority from the commissioner, or health care
service plans licensed under the Knox-Keene Health Care Service Plan
Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2
of the Health and Safety Code).
SEC. 19. Section 12725 of the Insurance Code is amended to read:
12725. (a) Each resident of the state meeting the eligibility
criteria of this section and who is unable to secure adequate private
health coverage is eligible to apply for major risk medical coverage
through the program. For these purposes, "resident" includes a
member of a federally recognized California Indian tribe.
(b) To be eligible for enrollment in the program, an applicant
shall have been rejected for health care coverage by at least one
private health plan. An applicant shall be deemed to have been
rejected if the only private health coverage that the applicant could
secure would do one of the following:
(1) Impose substantial waivers that the program determines would
leave a subscriber without adequate coverage for medically necessary
services.
(2) Afford limited coverage that the program determines would
leave the subscriber without adequate coverage for medically
necessary services.
(3) Afford coverage only at an excessive price, which the board
determines is significantly above standard average individual
coverage rates.
(c) Rejection for policies or certificates of specified disease or
policies or certificates of hospital confinement indemnity, as
described in Section 10198.61, shall not be deemed to be rejection
for the purposes of eligibility for enrollment.
(d) The board may permit dependents of eligible subscribers to
enroll in major risk medical coverage through the program if the
board determines the enrollment can be carried out in an actuarially
and administratively sound manner.
(e) Notwithstanding the provisions of this section, the board may
by regulation prescribe a period of time during which an individual
is ineligible to apply for major risk medical coverage through the
program if the individual either voluntarily disenrolls from a
participating health plan or was terminated for nonpayment of the
premium unless the board determines that an individual applying for
the program had good cause for disenrolling from a participating
health plan and reapplying for coverage in the program.
(f) Notwithstanding the provisions of this section, the board
shall by regulation establish a process of eligibility and voluntary
reenrollment in the program for persons enrolled in guaranteed
coverage under the guaranteed issue pilot project established by
Chapter 794 of the Statutes of 2002. Individuals shall be voluntarily
enrolled in the program providing all of the following conditions
are met:
(1) There are currently no individuals on a waiting list for the
program because of insufficient funds available for the program.
(2) Persons are made eligible by the board under this subdivision
as funds allow, based on the date they were disenrolled from the
program pursuant to the pilot project, with those disenrolled first
made eligible first, and on a first-come-first-served basis.
(3) The program determines the maximum number of individuals who
may voluntarily reenroll from each health plan providing pilot
project coverage consistent with the proportion of pilot project
enrollees enrolled in each health plan as reported by the health
plans and health insurers pursuant to Section 1373.623 of the Health
and Safety Code and Section 10127.165 of this code.
(4) The board develops a notice that carriers participating in the
pilot project must provide to persons enrolled in the guaranteed
issue pilot program notifying the individuals of potential
eligibility for the program and option to be reenrolled.
SEC. 20. Section 12726 of the Insurance Code is amended to read:
12726. The board may permit the exclusion of coverage or benefits
for charges or expenses incurred by a subscriber during the first
six months of enrollment in the program for any condition for which,
during the six months immediately preceding enrollment in the program
medical advice, diagnosis, care, or treatment was recommended or
received as to the condition during that period.
However, the exclusion from coverage of this section shall be
waived to the extent to which the subscriber was covered under any
creditable coverage, as defined in Section 10900, that was
terminated, provided the subscriber has applied for enrollment in the
program not later than 63 days following termination of the prior
coverage, or within 180 days of termination of coverage if the
subscriber lost his or her previous creditable coverage because the
subscriber's employment ended, the availability of health coverage
offered through employment or sponsored by an employer terminated, or
an employer's contribution toward health coverage terminated. The
exclusion from coverage of this section shall also be waived as to
any condition of a subscriber previously receiving coverage under a
plan of another state similar to the program established by this part
if the subscriber was eligible for benefits under that other-state
coverage for the condition. The board may allow a participating
health plan that does not utilize a preexisting condition provision
to impose a waiting or affiliation period, not to exceed 90 days,
before the coverage issued becomes effective. During the waiting or
affiliation period a subscriber shall not be required to make the
contribution for program coverage.
SEC. 21. Section 12737 of the Insurance Code is repealed.
SEC. 22. Section 12737 is added to the Insurance Code, to read:
12737. (a) The board shall establish program contribution amounts
for coverage provided by each participating health plan.
(b) Subscriber contributions shall be established at no more than
150 percent of the standard average individual rate for comparable
coverage, as determined by the board. The board shall establish a
sliding scale with lower contribution requirements for subscribers at
or below 300 percent of the federal poverty level, but in no case
shall the subscriber contribution be lower than 110 percent of the
standard average individual rate for comparable individual coverage,
unless federal funds are received, pursuant to subdivision (j) of
Section 12711.
(c) Upon receipt of federal funds, and contingent upon the
allowable use and purpose of those funds, the board shall offer
enrollment to individuals who are on the waiting list for the
program. If no individuals are on the waiting list for the program,
the board shall use federal funds, contingent upon the allowable use
and purpose of those funds, to lower subscriber contributions for
subscribers at or below 300 percent of the federal poverty level. In
no case shall the board lower subscriber contributions for
subscribers at or below 300 percent of the federal poverty level to
less than 6 percent of income. The board may additionally lower
subscriber contributions for subscribers over 300 but less than 400
percent of the federal poverty level to no less than 6 percent of
income with any remaining federal funds. Any further available
federal funds shall be used to recalculate the fee described in
Section 12739.6 for the following year.
(d) In implementing subdivision (b) of Section 12718, the board
may exclude from the subscriber contribution that portion of the
standard average individual rate attributable to the elimination of
the annual benefit maximum and the increase in the lifetime benefit
maximum.
SEC. 23. Section 12738.5 is added to the Insurance Code, to read:
12738.5. (a) On or before July 1, 2012, the board shall report to
the Legislature on the implementation of this chapter, including the
number and type of persons enrolled in the program, program costs
and revenues, average per capita costs for program subscribers, and
annual increases in the costs of coverage provided to program
subscribers as a reflection of rate changes in the individual market.
(b) The board shall also include in the report an implementation
and transition plan for an alternative approach to ensuring quality
coverage for high-risk, potentially high-cost individuals, other than
a segregated high-risk pool, that may include a reinsurance
mechanism or a risk adjustment mechanism, or both. The transition
plan shall outline the steps the board will need to take in order to
replace the program with an alternative mechanism by January 1, 2014,
and shall take into account changes in costs and coverage in the
individual market. The plan developed by the board shall also take
into account any subsequent state or federal program that provides
broad-based or universal coverage and that includes guaranteed
coverage for high-risk or medically uninsurable persons.
SEC. 24. Section 12739 of the Insurance Code is
amended to read:
12739. (a) There is hereby created in the State Treasury a
special fund known as the Major Risk Medical Insurance Fund that is,
notwithstanding Section 13340 of the Government Code, continuously
appropriated to the board for the purposes specified in Sections
10127.15 and 12739.1, and Chapter 9 (commencing with Section
12739.5), and Section 1373.62 of the Health and Safety Code.
(b) The following amounts shall be deposited annually in the Major
Risk Medical Insurance Fund:
(1) Twenty-four million three hundred ninety-three thousand
dollars ($24,393,000) from the Hospital Services Account in the
Cigarette and Tobacco Products Surtax Fund.
(2) Fourteen million six hundred seven thousand dollars
($14,607,000) from the Physician Services Account in the Cigarette
and Tobacco Products Surtax Fund.
(3) One million dollars ($1,000,000) from the Unallocated Account
in the Cigarette and Tobacco Products Surtax Fund.
(4) Funds received as a result of the collection of the fees
imposed pursuant to Chapter 9 (commencing with Section 12739.5).
(c) Notwithstanding any other provision of law, any money in the
fund that is attributable to monetary penalties imposed pursuant to
this part shall not be continuously appropriated and shall be
available for expenditure as provided in this chapter only upon
appropriation by the Legislature.
SEC. 24. Section 12739 of the Insurance
Code is amended to read:
12739. (a) There is hereby created in the State Treasury a
special fund known as the Major Risk Medical Insurance Fund that is,
notwithstanding Section 13340 of the Government Code, continuously
appropriated to the board for the purposes specified in Sections
10127.15 and 12739.1 of, and Chapter 9 (commencing with Section
12739.5) of, this code, and Section 1373.62 of the Health and
Safety Code.
(b) After June 30, 1991, the The
following amounts shall be deposited annually in the Major Risk
Medical Insurance Fund:
(1) Eighteen million dollars ($18,000,000) from the Hospital
Services Account in the Cigarette and Tobacco Products Surtax Fund.
(2) (A) Eleven million
dollars ($11,000,000) from the Physician Services Account in the
Cigarette and Tobacco Products Surtax Fund.
(B) Notwithstanding subparagraph (A), for the 2007-08 fiscal year
only, the Controller shall reduce the amount deposited into the Major
Risk Medical Insurance Fund from the Physician Services Account in
the Cigarette and Tobacco Products Surtax Fund to one million dollars
($1,000,000).
(3) One million dollars ($1,000,000) from the Unallocated Account
in the Cigarette and Tobacco Products Surtax Fund.
(4) Funds received as a result of the collection of the fees
imposed pursuant to Chapter 9 (commencing with Section 12739.5).
(c) Notwithstanding any other provision of law, any money in the
fund that is attributable to monetary penalties imposed pursuant to
this part shall not be continuously appropriated and shall be
available for expenditure as provided in this chapter only upon
appropriation by the Legislature.
SEC. 25. Chapter 9 (commencing with Section 12739.5) is added to
Part 6.5 of Division 2 of the Insurance Code, to read:
CHAPTER 9. CONTRIBUTION REQUIREMENTS
12739.5. No later than February 1 of each year, commencing
February 1, 2010, each health care service plan subject to Section
1373.63 of the Health and Safety Code and each health insurer subject
to Section 10127.19 shall notify the board of its election to either
accept for coverage all eligible persons assigned to the health plan
or health insurer by the board in compliance with the limitations of
Section 1373.63 of the Health and Safety Code or Section 10127.19,
as applicable, or to be a payer. The board shall notify the Director
of the Department of Managed Health Care and the commissioner of the
entities that have elected to be a payer and, no later than May 1 of
each year, the amount of the fee each entity is required to pay.
12739.6. The board shall establish fees to be paid by health
plans and health insurers who have elected to be payers on a per
covered life per month basis. Each health plan and each health
insurer shall annually pay the fee determined by the board based on
the plan's or insurer's relative number of covered lives. The fee
charged by the board shall not exceed one dollar ($1) per covered
life per month.
12739.7. (a) On or before March 1 of each year, beginning in
2010, each health care service plan subject to Section 1373.63 of the
Health and Safety Code and each health insurer subject to Section
10127.19 shall report to the board the following information:
(1) The total number of covered lives as of the preceding December
31, as determined by the board.
(A) For purposes of this chapter, "covered lives" include
individuals who receive health care coverage provided, indemnified,
or administered by a health care service plan or health insurer
subject to this chapter, and individuals who receive health care
services pursuant to an agreement by which a health care service plan
or health insurer subject to this chapter rents or leases a
contracted network of providers. Each named enrollee, insured, or
covered individual, including primary subscribers or policyholders,
covered spouses, domestic partners, and dependents, shall count
separately as a covered life, except in the following instances:
(i) A health care service plan or health insurer providing,
indemnifying, or administering group health care coverage shall count
every 10 named enrollees, insureds, or covered individuals in a
group as one covered life.
(ii) In a group purchasing arrangement where more than 25 percent
of the enrollees or insureds are retirees and more than 25 percent of
the enrollees or insureds who are nonretirees can be considered
high-risk individuals, as defined by the health care service plan or
health insurer, the health care service plan or health insurer
providing, indemnifying, or administering health care coverage shall
exclude all of the covered lives in the group for the purposes of
reporting the total number of covered lives to the board.
(ii) A health care service plan or health insurer subject to this
chapter that rents or leases a contracted network of providers to a
group shall count every 10 individuals of the group as one covered
life.
(B) For purposes of this chapter, covered lives shall include
individuals described in subparagraph (A) covered by individual
coverage, conversion coverage, guaranteed issue coverage pursuant to
the federal Health Insurance Portability and Accountability Act of
1996, small group coverage, other group coverage, government employee
coverage, other government coverage, association coverage, services
provided by an administrator of health benefits coverage, and other
coverage. For purposes of this subparagraph, "administrator of health
benefits coverage" means a licensed health care service plan or a
health insurer holding a valid, outstanding certificate of authority
from the Insurance Commissioner, or any person or entity affiliated
with, or a subsidiary of, a licensed health care service plan or a
health insurer holding a valid, outstanding certificate of authority
from the Insurance Commissioner, that collects any charge or premium
from, or that adjusts or settles claims on behalf of, residents of
the state or that leases contracted provider networks to purchasers.
(C) For purposes of this chapter, notwithstanding subparagraph (A)
or (B), covered lives shall not include individuals covered under
the Medi-Cal program, Medicare, the Healthy Families Program (Part
6.2 (commencing with Section 12693)), this program, the
California Public Employees' Retirement System, continuation
coverage related to the pilot program established by Chapter 794 of
the Statutes of 2002 that sunsetted on December 31, 2007, the Access
for Infants and Mothers Program (Part 6.3 (commencing with Section
12695)), the California Children and Families Act of 1998 (Division
108 (commencing with Section 130100) of the Health and Safety Code),
accident-only, specified disease, long-term care, CHAMPUS supplement,
hospital indemnity, Medicare supplement, dental-only, or vision-only
insurance policies or specified disease insurance that does not pay
benefits on a fixed benefit, cash payment only basis or short-term
limited duration health insurance, or by a local, nonprofit program
or county serving children whose annual household income is below 400
percent of the federal poverty level who are under the age of 18
years and who are not eligible for the Medi-Cal program, the Access
for Infants and Mothers Program, or the Healthy Families Program.
(2) Other related information as the board, in consultation with
the advisory panel established by Section 12714.1, may require to
implement and administer this chapter. The board may specify form,
format, and other requirements for this report, in consultation with
the advisory panel established pursuant to Section 12714.1. The
absence of these specifications by the board does not relieve a
health care service plan or health insurer from reporting the
information in a timely fashion.
(b) The board may determine, at its discretion, an amount of
program costs to be covered by a health care service plan or health
insurer subject to this section that fails to report to the board by
March 1 of any year, the number of covered lives as required by this
section.
12739.8. No later than May 1 of each year, the board shall
produce a schedule showing the total fee due and payable for each
plan and insurer based on the fee level set by the board and the
number of covered lives reported by the health plan or health insurer
to the board. Each health plan and health insurer shall have the
affirmative duty to obtain that schedule from the board.
12739.9. (a) A health care service plan and a health insurer
shall either accept for coverage all persons eligible for the program
and assigned to the health plan or health insurer by the board as
required in Section 1373.63 of the Health and Safety Code or Section
10127.19 or be a payer, as elected pursuant to Section 12739.5.
(b) A health care service plan that is a payer and a health
insurer that is a payer shall pay the fee no later than June 1 of
each year. A health care service plan shall make its payment to the
Director of the Department of Managed Health Care, and a health
insurer shall make its payment to the commissioner.
12739.12. Each payer's fee imposed by the board pursuant to this
chapter shall constitute a fee payable in accordance with Section
1356.2 of the Health and Safety Code, for payers licensed by the
Department of Managed Health Care, or Section 1827.86, for payers
having a certificate of authority or license issued by the
commissioner.
12739.13. If revenues collected pursuant to this chapter exceed
the amount actually required for the operation of the program for any
fiscal year, the excess shall be retained in the fund and shall be
used by the board to reduce the fee paid by health care service plans
and health insurers in the subsequent fiscal year.
SEC. 26. Until January 1, 2012, the adoption and readoption of any
rules and regulations issued by the Managed Risk Medical Insurance
Board, the Department of Managed Health Care, or the Department of
Insurance to implement this act shall be deemed to be an emergency
and necessary for the immediate preservation of the public peace,
health and safety, or general welfare for purposes of Sections
11346.1 and 11349.6 of the Government Code, and the Managed Risk
Medical Insurance Board, the Department of Managed Health Care, and
the Department of Insurance are hereby exempted from the requirements
to describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law.
SEC. 27. 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.