BILL NUMBER: AB 1453 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 17, 2012
AMENDED IN ASSEMBLY MARCH 29, 2012
INTRODUCED BY Assembly Member Monning
JANUARY 5, 2012
An act to add Section 1367.005 to the Health and Safety Code, and
to add Section 10112.27 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1453, as amended, Monning. Essential health benefits.
Commencing January 1, 2014, 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 includes the essential
health benefits package, as defined. 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. PPACA defines a qualified
health plan as a plan that, among other requirements, provides the
essential health benefits package. Existing state law creates the
California Health Benefit Exchange (the Exchange) to facilitate the
purchase of qualified health plans by qualified individuals and
qualified small employers by January 1, 2014.
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 health care service plan contracts and health
insurance policies to cover various benefits.
This bill would require 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, which would be defined to include the benefits and services
covered by particular plans. The bill would specify that this
provision applies regardless of whether the contract or policy is
offered inside or outside the Exchange but would provide that it does
not apply to grandfathered plans or plans that offer excepted
benefits, as specified. The bill would prohibit a health care service
plan or health insurer, when offering, issuing, selling, or
marketing a plan contract or policy, from indicating or implying that
the contract or policy covers essential health benefits unless the
contract or policy covers essential health benefits as provided in
the bill.
Because a willful violation of the bill's provisions with respect
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.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature hereby finds and declares the
following:
(a) Commencing January 1, 2014, the federal Patient Protection and
Affordable Care Act (PPACA) requires a health insurance issuer that
offers coverage to small employers or individuals, both inside and
outside of an American Health Benefit Exchange, with the exception of
grandfathered plans, to provide minimum coverage that includes
essential health benefits, as defined.
(b) It is the intent of the Legislature to comply with federal law
and consistently implement the essential health benefits provisions
of PPACA and related federal guidance and regulations, by adopting
the uniform minimum essential benefits requirement in state-regulated
health care coverage regardless of whether the policy or contract is
regulated by the Department of Managed Health Care or the Department
of Insurance and regardless of whether the policy or contract is
offered to individuals or small employers inside or outside of the
California Health Benefit Exchange.
SEC. 2. Section 1367.005 is added to the Health and Safety Code,
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. For purposes of this section, "essential health benefits"
means all of the following:
(1) (A) The benefits and services covered by the Kaiser Small
Group HMO plan contract (product number 40513CA035) as of
December 31, 2011, this contract was offered during
the first quarter of 2012, including, but not limited to, all
of the following:
(i) The items and services covered by the plan contract within the
categories identified in subsection (b) of Section 1302 of PPACA,
including, but not limited to, 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 vision care.
(ii) The items and services covered by the plan contract within
the following categories: acupuncture services, chiropractic
services, skilled nursing facility services, hospice care, bariatric
surgery, nonsevere mental illness services, substance abuse services,
smoking cessation counseling, alcoholism treatment, applied behavior
analysis therapy for autism, smoking cessation drugs, pain
medication for terminally ill patients, rehabilitative services,
habilitative, physical, and occupational therapy, speech therapy,
orthotics and prosthetics, prosthetic devices for laryngectomy,
special footwear for persons suffering from foot disfigurement,
surgically implanted hearing devices, home health services, HIV/AIDS
services, osteoporosis services, and diabetes education.
(ii) Mandated benefits pursuant to statutes enacted before
December 31, 2011.
(B) The services and benefits described in this paragraph shall be
covered to the extent they are medically necessary. Scope and
duration limits imposed on the services and benefits described in
this paragraph shall be no greater than the scope and duration limits
imposed on those services and benefits by the plan contract
identified in subparagraph (A).
(2) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (1), the same services
as the plan contract covers for rehabilitative services. Habilitative
services shall be covered under the same terms and conditions
applied to rehabilitative services under the plan contract.
(3) With respect to pediatric oral care and pediatric vision
care , the same services and benefits for pediatric oral care
and pediatric vision care covered under the
federal Blue Cross and Blue Shield Standard Option Service Benefit
Plan available to enrollees through the Federal Employees Health
Benefit Plan (FEHB) as of December 31, 2011 Federal
Employees Dental and Vision Insurance Program dental plan and vision
plan with the largest national enrollment as of the first quarter of
2012 . Scope and duration limits imposed on the services and
benefits described in this paragraph shall be no greater than the
scope and duration limitations imposed on those benefits by the
federal Blue Cross and Blue Shield Standard Option Service
Benefit Plan available to enrollees through the FEHB as of December
31, 2011 Federal Employees Dental and Vision Insurance
Program dental plan and vision plan with the largest national
enrollment as of the first quarter of 2012 .
(4) Any other benefits required to be covered under this chapter.
(b) When offering, issuing, selling, or marketing a health care
service plan contract, a health care service plan shall not indicate
or imply that the plan contract covers essential health benefits
unless the plan contract covers essential health benefits as defined
in this section.
(c) This section shall apply regardless of whether the plan
contract is offered inside or outside the California Health Benefit
Exchange created by Section 100500 of the Government Code.
(d) A plan contract subject to this section shall also comply with
Section 1367.001.
(e) 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.
(f) Subdivision (a) shall not apply to any of the following:
(1) A plan contract that provides excepted benefits as described
in Section 2722 of the federal Public Health Service Act (42 U.S.C.
Sec. 300gg-21).
(2) A plan contract that qualifies as a grandfathered health plan
under Section 1251 of PPACA.
(g) This section shall be implemented only to the extent that
federal law or policy does not require the state to defray the costs
of benefits included within the definition of essential health
benefits under this section.
(h) For purposes of this section, the following definitions shall
apply:
(1) "Habilitative services" means health care services that help a
person keep, learn, or improve skills and functioning for daily
living.
(2) "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.
(3) "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.
SEC. 3. Section 10112.27 is added to the Insurance Code, 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.
For purposes of this section, "essential health benefits" means all
of the following:
(1) (A) The benefits and services covered by the Kaiser Small
Group HMO plan contract (product number 40513CA035) as of
December 31, 2011, this contract was offered during
the first quarter of 2012, including, but not limited to, all
of the following:
(i) The items and services covered by the plan contract within the
categories identified in subsection (b) of Section 1302 of PPACA,
including, but not limited to, 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 vision care.
(ii) The items and services covered by the plan contract within
the following categories: acupuncture services, chiropractic
services, skilled nursing facility services, hospice care, bariatric
surgery, nonsevere mental illness services, substance abuse services,
smoking cessation counseling, alcoholism treatment, applied behavior
analysis therapy for autism, smoking cessation drugs, pain
medication for terminally ill patients, rehabilitative services,
habilitative, physical, and occupational therapy, speech therapy,
orthotics and prosthetics, prosthetic devices for laryngectomy,
special footwear for persons suffering from foot disfigurement,
surgically implanted hearing devices, home health services, HIV/AIDS
services, osteoporosis services, and diabetes education.
(ii) Mandated benefits pursuant to statutes enacted before
December 31, 2011.
(B) The services and benefits described in this paragraph shall be
covered to the extent they are medically necessary. Scope and
duration limits imposed on the services and benefits described in
this paragraph shall be no greater than the scope and duration limits
imposed on those services and benefits by the health care service
plan contract identified in subparagraph (A).
(2) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (1), the same services
as the policy covers for rehabilitative services. Habilitative
services shall be covered under the same terms and conditions applied
to rehabilitative services under the policy.
(3) With respect to pediatric oral care and pediatric vision
care , the same services and benefits for pediatric oral care
and pediatric vision care covered under the
federal Blue Cross and Blue Shield Standard Option Service Benefit
Plan available to enrollees through the Federal Employees Health
Benefit Plan (FEHB) as of December 31, 2011 Federal
Employees Dental and Vision Insurance Program dental plan and vision
plan with the largest national enrollment as of the first quarter of
2012 . Scope and duration limits imposed on the services and
benefits described in this paragraph shall be no greater than the
scope and duration limitations imposed on those benefits by the
federal Blue Cross and Blue Shield Standard Option Service
Benefit Plan available to enrollees through the FEHB as of December
31, 2011 Federal Employees Dental and Vision Insurance
Program dental plan and vision plan with the largest national
enrollment as of the first quarter of 2012 .
(4) Any other benefits required to be covered under this part.
(b) When offering, issuing, selling, or marketing a health
insurance policy, a health insurer shall not indicate or imply that
the policy covers essential health benefits unless the policy covers
essential health benefits as defined in this section.
(c) This section shall apply regardless of whether the policy is
offered inside or outside the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(d) A health insurance policy subject to this section shall also
comply with Section 10112.1.
(e) 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.
(f) Subdivision (a) shall not apply to any of the following:
(1) A policy that provides excepted benefits as described in
Section 2722 of the federal Public Health Service Act (42 U.S.C. Sec.
300gg-21).
(2) A health insurance policy that qualifies as a grandfathered
health plan under Section 1251 of PPACA.
(g) This section shall be implemented only to the extent that
federal law or policy does not require the state to defray the costs
of benefits included within the definition of essential health
benefits under this section.
(h) For purposes of this section, the following definitions shall
apply:
(1) "Habilitative services" means health care services that help a
person keep, learn, or improve skills and functioning for daily
living.
(2) "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.
(3) "Small group health insurance policy" means a group health
insurance policy issued to a small employer, as defined in Section
10700.
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.