BILL NUMBER: SB 1431 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 9, 2012
INTRODUCED BY Senator De León
FEBRUARY 24, 2012
An act to amend Section 10705 of the Insurance Code,
relating to health insurance. An act to add Chapter
8.1 (commencing with Section 10750) to Part 2 of Division 2 of the
Insurance Code, relating to insurance.
LEGISLATIVE COUNSEL'S DIGEST
SB 1431, as amended, De León. Health insurance.
Stop-loss insurance coverage.
Existing law prohibits a person from transacting any class of
insurance business, including health insurance, in this state without
first being an admitted insurer. Under existing law, admission is
secured by procuring a certificate of authority from the Insurance
Commissioner. Existing law prohibits a health insurance policy from
being issued or delivered to any person in this state unless
specified requirements have been met, including that a copy of the
form and premium rates are filed with the commissioner. Under
existing law, if the commissioner notifies the health insurer that
the filed form does not comply with specified requirements, it is
unlawful for that health insurer to issue any health insurance policy
in that form.
Existing law, with respect to small employer health insurance,
requires a carrier providing aggregate or specific stop-loss coverage
or any other assumption of risk with reference to a health benefit
plan, as defined, to provide that the plan meets specified
requirements concerning preexisting condition provisions, waiting or
affiliation periods, and late enrollees.
Existing law, the federal Patient Protection and Affordable Care
Act (PPACA), commencing January 1, 2014, prohibits a group health
plan and a health insurance issuer offering group or individual
health insurance coverage from imposing any preexisting condition
exclusion with respect to the plan or coverage.
This bill would require a stop-loss carrier, as defined, to offer
coverage to all employees and dependents of a small employer to
which it issues a stop-loss insurance policy and would prohibit the
carrier from excluding any employee or dependent on the basis of
actual or expected health status-related factors, as specified.
Except as specified, the bill would require a stop-loss carrier to
renew, at the option of the small employer, all stop-loss insurance
policies. The bill would prohibit a stop-loss carrier from issuing a
stop-loss insurance policy to a small employer that contains certain
individual or aggregate attachment points for a policy year or
provides direct coverage, as defined, of an employee's health claims.
The bill would make a stop-loss carrier in violation of these
provisions subject to administrative penalties and would direct those
fine and penalty moneys received to the General Fund to be available
upon appropriation by the Legislature.
Existing law provides for licensing and regulation of health
insurers by the Insurance Commissioner. Existing law, with respect to
health insurance for small employers, requires a health insurer to
file a copy of the form of the health insurance policy, contract,
certificate, or statement of coverage with the commissioner for
approval prior to issuance or delivery to the purchaser.
This bill would require the filing to be done electronically.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Chapter 8.1 (commencing with Section
10750) is added to Part 2 of Division 2 of the Insurance
Code , to read:
CHAPTER 8.1. STOP-LOSS INSURANCE
10750. As used in this chapter, the following definitions shall
apply:
(a) "Association" has the same meaning as described in paragraph
(4) of subdivision (a) of Section 10270.5.
(b) "Attachment point" means the total amount of health claims
incurred by a small employer in a policy year for its employees and
their dependents above which the stop-loss carrier incurs a liability
for payment.
(1) "Individual attachment point" means the total amount of health
claims incurred by a small employer in a policy year for an
individual employee or dependent of an employee above which the
stop-loss carrier incurs a liability for payment. For purposes of
this chapter, "specific attachment point" shall have the same meaning
as "individual attachment point."
(2) "Aggregate attachment point" means the total amount of health
claims incurred by a small employer in a policy year for all covered
employees and their dependents above which the stop-loss carrier
incurs a liability for payment.
(c) "Dependent" means the spouse, registered domestic partner as
described in Section 297 of the Family Code, or child of an employee.
(d) "Direct coverage" means that an insurance company assumes a
direct obligation to an employee under an insurance policy to pay or
indemnify the employee for health claims incurred by the employee or
the employee's dependents.
(e) "Expected claims" means the total amount of health claims
that, in the absence of a stop-loss insurance policy or other
insurance, are projected to be incurred by a small employer for its
employees and their dependents.
(f) "Policy year" means the 12-month period that is designated as
the policy year for the stop-loss insurance policy. If the stop-loss
insurance policy does not designate a policy year, the policy year is
the year in which the total amount of health claims incurred by a
small employer for an individual employee or dependent of an
employee, or the aggregate amount for all covered employees and their
dependents, are added together for the purposes of determining
whether the claims have exceeded the attachment point.
(g) "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 pursuant to that law.
(h) "Small employer" has the same meaning as defined in
subdivision (w) of Section 10700.
(i) "Stop-loss carrier" means an insurance company or other entity
providing individual or aggregate stop-loss insurance coverage, or
any other assumption of risk, to a small employer for the health
claims of its employees and their dependents, regardless of the situs
of the contract or master policyholder.
(j) "Stop-loss insurance policy" means a policy, contract,
certificate, or statement of coverage between a stop-loss carrier and
small employer providing individual or aggregate stop-loss insurance
coverage, or any other assumption of risk, to a small employer for
the health claims of its employees and their dependents, regardless
of the situs of the contract or master policyholder.
10750.1. A stop-loss carrier shall offer coverage to all
employees and dependents of employees of a small employer to which it
issues a stop-loss insurance policy and shall not exclude any
employee or dependent on the basis of an actual or expected health
status-related factor. Health status-related factors include, but are
not limited to, any of the following: health status; medical
condition, including both physical and mental illnesses; claims
experience; medical history; receipt of health care; genetic
information; disability; evidence of insurability, including
conditions arising out of acts of domestic violence of the employee
or dependent; or any other health status-related factor as determined
by the department.
10750.2. A stop-loss carrier shall renew, at the option of the
small employer, all stop-loss insurance policies written, issued,
administered, or renewed on or after the effective date of this
chapter, and all stop-loss insurance policies in force on or after
the effective date of this chapter, except as follows:
(a) (1) For nonpayment of the required premiums by the small
employer, if the small employer has been duly notified and billed for
the charge and at least a 30-day grace period has elapsed since the
date of notification or, if longer, the period of time required for
notice and any other requirements pursuant to Section 2703, 2712, or
2742 of the federal Public Health Service Act (42 U.S.C. Sec.
300gg-2, 300gg-12, or 300gg-42) and any subsequent rules or
regulations has elapsed.
(2) A stop-loss carrier shall continue to provide coverage as
required by the small employer's policy during the grace period
described in paragraph (1). Nothing in this section shall be
construed to affect or impair the small employer's or carrier's other
rights and responsibilities pursuant to the policy.
(b) Where the stop-loss carrier demonstrates fraud or an
intentional misrepresentation of material fact by the small employer
under the terms of the stop-loss insurance policy.
(c) Where the stop-loss carrier has been determined by the
commissioner to be financially impaired.
(d) Where the stop-loss carrier ceases to write, issue, or
administer new stop-loss insurance policies in this state; provided,
however, that the following conditions are satisfied:
(1) Notice of the decision to cease writing, issuing, or
administering new or existing stop-loss insurance policies in this
state is provided to the commissioner, and to the small employer, at
least 180 days prior to the discontinuation of the coverage.
(2) Stop-loss insurance policies subject to this chapter shall not
be canceled until 180 days after the date of the notice required
under paragraph (1). During that time, the stop-loss carrier shall
continue to comply with this chapter.
10750.3. (a) A stop-loss carrier shall not issue a stop-loss
insurance policy to a small employer that does any of the following:
(1) Contains an individual attachment point for a policy year that
is lower than ninety-five thousand dollars ($95,000).
(2) Contains an aggregate attachment point for a policy year that
is lower than the greater of one of the following:
(A) Nineteen thousand dollars ($19,000) times the total number of
covered employees and dependents.
(B) One hundred twenty percent of expected claims.
(C) Ninety-five thousand dollars ($95,000).
(3) Provides direct coverage of an employee's health claims.
(b) For the purposes of determining the dollar amounts set forth
in subdivision (a), and upon consideration of the medical components
of the Consumer Price Index, the commissioner may amend, by
regulation, the dollar amounts at least six months prior to their
effective dates.
10750.4. The commissioner may adopt regulations as may be
necessary to carry out the purposes of this chapter. In adopting
regulations, the commissioner shall comply with Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code.
10750.5. A stop-loss carrier that violates the provisions of this
chapter shall be subject to the remedies and administrative
penalties pertaining to carriers in Sections 10718 and 10718.5. All
fine and penalty moneys received pursuant to this section shall be
deposited in the General Fund and shall be available for expenditure
by the commissioner upon appropriation by the Legislature.
10750.6. The provisions of this section are severable. If any
provision of this section or its application is held invalid, that
invalidity shall not affect other provisions or applications that can
be given effect without the invalid provision or application.
All matter omitted in this version of the bill appears in the bill as
introduced in the Senate, February 24, 2012. (JR11)