AB 18, as amended, Pan. Individual health care coverage.
begin insertExisting 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, with respect to plan years on or after January 1, 2014, includes the essential health benefits package, which is defined to include pediatric oral care benefits. 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, as specified, and requires an exchange to allow an issuer to offer stand-alone dental plans in the exchange, provided that the plans cover the pediatric oral care benefits required under the essential health benefits package.
end insertbegin insertExisting law establishes the California Health Benefit Exchange (Exchange) to facilitate the purchase of qualified health plans through the Exchange by qualified individuals and qualified small employers by January 1, 2014. Existing law requires carriers participating in the Exchange that sell products outside the Exchange to offer, market, and sell all products made available to individuals and small employers through the Exchange to individuals and small employers purchasing coverage outside the Exchange. 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 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 and defines those benefits to include the pediatric oral care benefits covered under a specified dental plan available to subscribers of the Healthy Families Program.
end insertbegin insertThis bill would exempt a plan contract or policy offered through the Exchange from covering those pediatric oral care benefits if the Exchange offers a stand-alone dental plan as described in PPACA and would require stand-alone dental plans offered through the Exchange to include coverage of those pediatric oral care benefits.
end insertbegin insertThis bill would declare that it is to take effect immediately as an urgency statute.
end insertExisting federal law, the federal Patient Protection and Affordable Care Act (PPACA) enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires each health insurance issuer that offers health insurance coverage in the individual or group market in a state to accept every employer and individual in the state that applies for that coverage and to renew that coverage at the option of the plan sponsor or the individual. PPACA 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 that plan or coverage. PPACA allows the premium rate charge by a health insurance issuer offering small group or individual coverage to vary only by family composition, rating area, age, and tobacco use, as specified, and prohibits discrimination against individuals based on health status.
end deleteExisting 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 the regulation of health insurers by the Insurance Commissioner. Existing law requires plans and insurers offering coverage in the individual market to comply with certain requirements, including that they offer coverage for a child on a guarantee issue basis.
end deleteThis bill would state the intent of the Legislature to enact legislation that would reform the individual health care coverage market consistent with the PPACA.
end deleteThis bill would declare that it is to take effect immediately as an urgency statute.
end deleteVote: 2⁄3.
Appropriation: no.
Fiscal committee: begin deleteno end deletebegin insertyesend insert.
State-mandated local program: no.
The people of the State of California do enact as follows:
It is the intent of the Legislature to enact
2legislation to reform the individual health care coverage market
3consistent with the federal Patient Protection and Affordable Care
4Act (Public Law 111-148), as amended by the federal Health Care
5and Education Reconciliation Act of 2010 (Public Law 111-152).
begin insertSection 1367.005 of the end insertbegin insertHealth and Safety Codeend insert
7begin insert is amended to read:end insert
(a) An individual or small group health care service
9plan contract issued, amended, or renewed on or after January 1,
102014, shall, at a minimum, include coverage for essential health
11benefits pursuant to PPACA and as outlined in this section. For
12purposes of this section, “essential health benefits” means all of
13the following:
14(1) Health benefits within the categories identified in Section
151302(b) of PPACA: ambulatory patient services, emergency
16services, hospitalization, maternity and newborn care, mental health
17and substance use disorder services, including behavioral health
18treatment, prescription drugs, rehabilitative and habilitative services
19and devices, laboratory services, preventive and wellness services
20and chronic disease management, and pediatric services, including
21oral and vision care.
22(2) (A) The health benefits covered by the Kaiser Foundation
23Health Plan Small Group HMO 30 plan (federal health product
24identification number 40513CA035) as this plan was offered during
25the first quarter of 2012, as follows, regardless of whether the
26benefits are specifically referenced in the evidence of coverage or
27plan contract for that plan:
P4 1(i) Medically necessary basic health care services, as defined
2in subdivision (b) of Section 1345 and in Section 1300.67 of Title
328 of the California Code of Regulations.
4(ii) The health benefits mandated to be covered by the plan
5pursuant to statutes enacted before December 31, 2011, as
6described in the following sections: Sections 1367.002, 1367.06,
7and 1367.35 (preventive services for children); Section 1367.25
8(prescription drug coverage for contraceptives); Section 1367.45
9(AIDS vaccine); Section 1367.46 (HIV testing); Section 1367.51
10(diabetes); Section 1367.54 (alpha feto protein testing); Section
111367.6 (breast cancer screening); Section 1367.61 (prosthetics for
12laryngectomy); Section 1367.62 (maternity hospital stay); Section
131367.63 (reconstructive surgery); Section 1367.635 (mastectomies);
14Section 1367.64 (prostate cancer); Section 1367.65
15(mammography); Section 1367.66 (cervical cancer); Section
161367.665 (cancer screening tests); Section 1367.67 (osteoporosis);
17Section 1367.68 (surgical procedures for jaw bones); Section
181367.71 (anesthesia for dental); Section 1367.9 (conditions
19attributable to diethylstilbestrol); Section 1368.2 (hospice care);
20Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency
21response ambulance or ambulance transport services); subdivision
22(b) of Section 1373 (sterilization operations or procedures); Section
231373.4 (inpatient hospital and ambulatory maternity); Section
241374.56 (phenylketonuria); Section 1374.17 (organ transplants for
25HIV); Section 1374.72 (mental health parity); and Section 1374.73
26(autism/behavioral health treatment).
27(iii) Any other benefits mandated to be covered by the plan
28pursuant to statutes enacted before December 31, 2011, as
29described in those statutes.
30(iv) The health benefits covered by the plan that are not
31otherwise required to be covered under this chapter, to the extent
32required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22,
331367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the
34California Code of Regulations.
35(v) Any other health benefits covered by the plan that are not
36otherwise required to be covered under this chapter.
37(B) Where there are any conflicts or omissions in the plan
38identified in subparagraph (A) as compared with the requirements
39for health benefits under this chapter that were enacted prior to
P5 1December 31, 2011, the requirements of this chapter shall be
2controlling, except as otherwise specified in this section.
3(C) Notwithstanding subparagraph (B) or any other provision
4of this section, the home health services benefits covered under
5the plan identified in subparagraph (A) shall be deemed to not be
6in conflict with this chapter.
7(D) For purposes of this section, the Paul Wellstone and Pete
8Domenici Mental Health Parity and Addiction Equity Act of 2008
9(Public Law 110-343) shall apply to a contract subject to this
10section. Coverage of mental health and substance use disorder
11services pursuant to this paragraph, along with any scope and
12duration limits imposed on the benefits, shall be in compliance
13with the Paul Wellstone and Pete Domenici Mental Health Parity
14and Addiction Equity Act of 2008 (Public Law 110-343), and all
15rules, regulations, or guidance issued pursuant to Section 2726 of
16the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
17(3) With respect to habilitative services, in addition to any
18habilitative services identified in paragraph (2), coverage shall
19also be provided as required by federal rules, regulations, and
20guidance issued pursuant to Section 1302(b) of PPACA.
21Habilitative services shall be covered under the same terms and
22conditions applied to rehabilitative services under the plan contract.
23(4) With respect to pediatric vision care, the same health benefits
24for pediatric vision care covered under the Federal Employees
25Dental and Vision Insurance Program vision plan with the largest
26national enrollment as of the first quarter of 2012. The pediatric
27vision care benefits covered pursuant to this paragraph shall be in
28addition to, and shall not replace, any vision services covered under
29the plan identified in paragraph (2).
30(5) begin insert(A)end insertbegin insert end insert With respect to pediatric oral care, the same health
31benefits for pediatric oral care covered under the dental plan
32available to subscribers of the Healthy Families Program in
332011-12, including the provision of medically necessary
34orthodontic care provided pursuant to the federal Children’s Health
35Insurance Program Reauthorization Act of 2009.begin delete The pediatric begin insert This
36oral care benefits covered pursuant to this paragraph shall be in
37addition to, and shall not replace, any dental or orthodontic services
38covered under the plan identified in paragraph (2).end delete
39subparagraph shall not apply to a health care service plan contract
40offered through the Exchange if a specialized health care service
P6 1plan contract described in Section 1311(d)(2)(B)(ii) of PPACA
2(42 U.S.C. Sec. 18031(d)(2)(B)(ii)) is offered through the
3Exchange. end insert
4(B) The pediatric oral care benefits covered pursuant to this
5paragraph shall be in addition to, and shall not replace, any dental
6or orthodontic services covered under the plan identified in
7paragraph (2).
8(b) Subdivision (a) shall not apply to any of the following:
end insertbegin insert9(1) A specialized health care service plan contract.
end insertbegin insert10(2) A Medicare supplement plan contract.
end insertbegin insert
11(3) A plan contract that qualifies as a grandfathered health plan
12under Section 1251 of PPACA or any rules, regulations, or
13guidance issued pursuant to that section.
14(c) A specialized health care service plan contract described in
15Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec.
1618031(d)(2)(B)(ii)) that is offered through the Exchange shall, at
17a minimum, include coverage of the health benefits described in
18subparagraph (A) of paragraph (5) of subdivision (a).
19(b)
end delete
20begin insert(d)end insert Treatment limitations imposed on health benefits described
21in this section shall be no greater than the treatment limitations
22imposed by the corresponding plans identified in subdivision (a),
23subject to the requirements set forth in paragraph (2) of subdivision
24(a).
25(c)
end delete
26begin insert(e)end insert Except as provided in subdivisionbegin delete (d),end deletebegin insert (f),end insert nothing in this
27section shall be construed to permit a health care service plan to
28make substitutions for the benefits required to be covered under
29this section, regardless of whether those substitutions are actuarially
30equivalent.
31(d)
end delete
32begin insert(f)end insert To the extent permitted under Section 1302 of PPACA and
33any rules, regulations, or guidance issued pursuant to that section,
34and to the extent that substitution would not create an obligation
35for the state to defray costs for any individual, a plan may substitute
36its prescription drug formulary for the formulary provided under
37the plan identified in subdivision (a) as long as the coverage for
38prescription drugs complies with the sections referenced in clauses
39(ii) and (iv) of subparagraph (A) of paragraph (2) of subdivision
40(a) that apply to prescription drugs.
P7 1(e)
end delete
2begin insert(g)end insert No health care service plan, or its agent, solicitor, or
3representative, shall issue, deliver, renew, offer, market, represent,
4or sell any product, contract, or discount arrangement as compliant
5with the essential health benefits requirement in federal law, unless
6itbegin delete meets all of the requirements of this section.end deletebegin insert includes coverage
7of the health benefits described in subdivision (a), including the
8benefits described in subparagraph (A) of paragraph (5) of
9subdivision (a), and meets the requirements of subdivisions (d),
10(e), and (f). end insert
11(f)
end delete
12begin insert(h)end insert begin deleteThis end deletebegin insertExcept as otherwise provided in this section, this end insertsection
13shall apply regardless of whether the plan contract is offered inside
14or outside thebegin delete California Health Benefit Exchange created by begin insert Exchangeend insert.
15Section 100500 of the Government Codeend delete
16(g)
end delete
17begin insert(i)end insert Nothing in this section shall be construed to exempt a plan
18or a plan contract from meeting other applicable requirements of
19law.
20(h)
end delete
21begin insert(j)end insert This section shall not be construed to prohibit a plan contract
22from covering additional benefits, including, but not limited to,
23spiritual care services that are tax deductible under Section 213 of
24the Internal Revenue Code.
25(i)
end delete26 Subdivision (a) shall not apply to any of the following:
end delete27(1) A specialized health care service plan contract.
end delete28(2) A Medicare supplement plan.
end delete
29(3) A plan contract that qualifies as a grandfathered health plan
30under Section 1251 of PPACA or any rules, regulations, or
31guidance issued pursuant to that section.
32(j)
end delete
33begin insert(k)end insert Nothing in this section shall be implemented in a manner
34that conflicts with a requirement of PPACA.
35(k)
end delete
36begin insert(l)end insert This section shall be implemented only to the extent essential
37health benefits are required pursuant to PPACA.
38(l)
end delete
P8 1begin insert(m)end insert An essential health benefit is required to be provided under
2this section only to the extent that federal law does not require the
3state to defray the costs of the benefit.
4(m)
end delete
5begin insert(n)end insert Nothing in this section shall obligate the state to incur costs
6for the coverage of benefits that are not essential health benefits
7as defined in this section.
8(n)
end delete
9begin insert(o)end insert A plan is not required to cover, under this section, changes
10to health benefits that are the result of statutes enacted on or after
11December 31, 2011.
12(o)
end delete
13begin insert(p)end insert (1) The department may adopt emergency regulations
14implementing this section. The department may, on a one-time
15basis, readopt any emergency regulation authorized by this section
16that is the same as, or substantially equivalent to, an emergency
17regulation previously adopted under this section.
18(2) The initial adoption of emergency regulations implementing
19this section and the readoption of emergency regulations authorized
20by this subdivision shall be deemed an emergency and necessary
21for the immediate preservation of the public peace, health, safety,
22or general welfare. The initial emergency regulations and the
23readoption of emergency regulations authorized by this section
24shall be submitted to the Office of Administrative Law for filing
25with the Secretary of State and each shall remain in effect for no
26more than 180 days, by which time final regulations may be
27adopted.
28(3) The director shall consult with the Insurance Commissioner
29to ensure consistency and uniformity in the development of
30regulations under this subdivision.
31(4) This subdivision shall become inoperative on March 1, 2016.
32(p)
end delete
33begin insert(q)end insert For purposes of this section, the following definitions shall
34apply:
35(1) “Exchange” means the California Health Benefit Exchange
36created by Section 100500 of the Government Code.
37(1)
end delete
38begin insert(2)end insert “Habilitative services” means medically necessary health
39care services and health care devices that assist an individual in
40partially or fully acquiring or improving skills and functioning and
P9 1that are necessary to address a health condition, to the maximum
2extent practical. These services address the skills and abilities
3needed for functioning in interaction with an individual’s
4environment. Examples of health care services that are not
5habilitative services include, but are not limited to, respite care,
6day care, recreational care, residential treatment, social services,
7custodial care, or education services of any kind, including, but
8not limited to, vocational training. Habilitative services shall be
9covered under the same terms and conditions applied to
10rehabilitative services under the plan contract.
11(2)
end delete
12begin insert(3)end insert (A) “Health benefits,” unless otherwise required to be
13defined pursuant to federal rules, regulations, or guidance issued
14pursuant to Section 1302(b) of PPACA, means health care items
15or services for the diagnosis, cure, mitigation, treatment, or
16prevention of illness, injury, disease, or a health condition,
17including a behavioral health condition.
18(B) “Health benefits” does not mean any cost-sharing
19requirements such as copayments, coinsurance, or deductibles.
20(3)
end delete
21begin insert(4)end insert “PPACA” means the federal Patient Protection and
22Affordable Care Act (Public Law 111-148), as amended by the
23federal Health Care and Education Reconciliation Act of 2010
24(Public Law 111-152), and any rules, regulations, or guidance
25issued thereunder.
26(4)
end delete
27begin insert(5)end insert “Small group health care service plan contract” means a
28group health care service plan contract issued to a small employer,
29as defined in Sectionbegin delete 1357end deletebegin insert 1357.500end insert.
begin insertSection 10112.27 of the end insertbegin insertInsurance Codeend insertbegin insert is amended
31to read:end insert
(a) An individual or small group health insurance
33policy issued, amended, or renewed on or after January 1, 2014,
34shall, at a minimum, include coverage for essential health benefits
35pursuant to PPACA and as outlined in this section. This section
36shall exclusively govern what benefits a health insurer must cover
37as essential health benefits. For purposes of this section, “essential
38health benefits” means all of the following:
39(1) Health benefits within the categories identified in Section
401302(b) of PPACA: ambulatory patient services, emergency
P10 1services, hospitalization, maternity and newborn care, mental health
2and substance use disorder services, including behavioral health
3treatment, prescription drugs, rehabilitative and habilitative services
4and devices, laboratory services, preventive and wellness services
5and chronic disease management, and pediatric services, including
6oral and vision care.
7(2) (A) The health benefits covered by the Kaiser Foundation
8Health Plan Small Group HMO 30 plan (federal health product
9identification number 40513CA035) as this plan was offered during
10the first quarter of 2012, as follows, regardless of whether the
11benefits are specifically referenced in the plan contract or evidence
12of coverage for that plan:
13(i) Medically necessary basic health care services, as defined
14in subdivision (b) of Section 1345 of the Health and Safety Code
15and in Section 1300.67 of Title 28 of the California Code of
16Regulations.
17(ii) The health benefits mandated to be covered by the plan
18pursuant to statutes enacted before December 31, 2011, as
19described in the following sections of the Health and Safety Code:
20Sections 1367.002, 1367.06, and 1367.35 (preventive services for
21children); Section 1367.25 (prescription drug coverage for
22contraceptives); Section 1367.45 (AIDS vaccine); Section 1367.46
23(HIV testing); Section 1367.51 (diabetes); Section 1367.54 (alpha
24feto protein testing); Section 1367.6 (breast cancer screening);
25Section 1367.61 (prosthetics for laryngectomy); Section 1367.62
26(maternity hospital stay); Section 1367.63 (reconstructive surgery);
27Section 1367.635 (mastectomies); Section 1367.64 (prostate
28cancer); Section 1367.65 (mammography); Section 1367.66
29(cervical cancer); Section 1367.665 (cancer screening tests);
30Section 1367.67 (osteoporosis); Section 1367.68 (surgical
31procedures for jaw bones); Section 1367.71 (anesthesia for dental);
32Section 1367.9 (conditions attributable to diethylstilbestrol);
33Section 1368.2 (hospice care); Section 1370.6 (cancer clinical
34trials); Section 1371.5 (emergency response ambulance or
35ambulance transport services); subdivision (b) of Section 1373
36(sterilization operations or procedures); Section 1373.4 (inpatient
37hospital and ambulatory maternity); Section 1374.56
38(phenylketonuria); Section 1374.17 (organ transplants for HIV);
39Section 1374.72 (mental health parity); and Section 1374.73
40(autism/behavioral health treatment).
P11 1(iii) Any otherbegin insert healthend insert benefits mandated to be covered by the
2plan pursuant to statutes enacted before December 31, 2011, as
3described in those statutes.
4(iv) The health benefits covered by the plan that are not
5otherwise required to be covered under Chapter 2.2 (commencing
6with Section 1340) of Division 2 of the Health and Safety Code,
7to the extent otherwise required pursuant to Sections 1367.18,
81367.21, 1367.215, 1367.22, 1367.24, and 1367.25 of the Health
9and Safety Code, and Section 1300.67.24 of Title 28 of the
10California Code of Regulations.
11(v) Any other health benefits covered by the plan that are not
12otherwise required to be covered under Chapter 2.2 (commencing
13with Section 1340) of Division 2 of the Health and Safety Code.
14(B) Where there are any conflicts or omissions in the plan
15identified in subparagraph (A) as compared with the requirements
16for health benefits under Chapter 2.2 (commencing with Section
171340) of Division 2 of the Health and Safety Code that were
18enacted prior to December 31, 2011, the requirements of Chapter
192.2 (commencing with Section 1340) of Division 2 of the Health
20and Safety Code shall be controlling, except as otherwise specified
21in this section.
22(C) Notwithstanding subparagraph (B) or any other provision
23of this section, the home health services benefits covered under
24the plan identified in subparagraph (A) shall be deemed to not be
25in conflict with Chapter 2.2 (commencing with Section 1340) of
26Division 2 of the Health and Safety Code.
27(D) For purposes of this section, the Paul Wellstone and Pete
28Domenici Mental Health Parity and Addiction Equity Act of 2008
29(Public Law 110-343) shall apply to a policy subject to this section.
30Coverage of mental health and substance use disorder services
31pursuant to this paragraph, along with any scope and duration
32limits imposed on the benefits, shall be in compliance with the
33Paul Wellstone and Pete Domenici Mental Health Parity and
34Addiction Equity Act of 2008 (Public Law 110-343), and all rules,
35regulations, and guidance issued pursuant to Section 2726 of the
36federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
37(3) With respect to habilitative services, in addition to any
38habilitative services identified in paragraph (2), coverage shall
39also be provided as required by federal rules, regulations, or
40guidance issued pursuant to Section 1302(b) of PPACA.
P12 1Habilitative services shall be covered under the same terms and
2conditions applied to rehabilitative services under the policy.
3(4) With respect to pediatric vision care, the same health benefits
4for pediatric vision care covered under the Federal Employees
5Dental and Vision Insurance Program vision plan with the largest
6national enrollment as of the first quarter of 2012. The pediatric
7vision care services covered pursuant to this paragraph shall be in
8addition to, and shall not replace, any vision services covered under
9the plan identified in paragraph (2).
10(5)begin insert end insertbegin insert(A)end insertbegin insert end insert With respect to pediatric oral care, the same health
11benefits for pediatric oral care covered under the dental plan
12available to subscribers of the Healthy Families Program in
132011-12, including the provision of medically necessary
14orthodontic care provided pursuant to the federal Children’s Health
15Insurance Program Reauthorization Act of 2009.begin delete The pediatric begin insert This
16oral care benefits covered pursuant to this paragraph shall be in
17addition to, and shall not replace, any dental or orthodontic services
18covered under the plan identified in paragraph (2).end delete
19subparagraph shall not apply to a health insurance policy offered
20through the Exchange if a specialized health insurance policy
21described in Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec.
2218031(d)(2)(B)(ii)) is offered through the Exchange. end insert
23(B) The pediatric oral care benefits covered pursuant to this
24paragraph shall be in addition to, and shall not replace, any dental
25or orthodontic services covered under the plan identified in
26paragraph (2).
27(b) Subdivision (a) shall not apply to any of the following:
end insertbegin insert
28(1) A policy that provides excepted benefits as described in
29Sections 2722 and 2791 of the federal Public Health Service Act
30(42 U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91).
31(2) A policy that qualifies as a grandfathered health plan under
32Section 1251 of PPACA or any binding rules, regulation, or
33guidance issued pursuant to that section.
34(c) A specialized health insurance policy described in Section
351311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)(ii))
36that is offered through the Exchange shall, at a minimum, include
37coverage of the health benefits described in subparagraph (A) of
38paragraph (5) of subdivision (a).
39(b)
end delete
P13 1begin insert(d)end insert Treatment limitations imposed on health benefits described
2in this section shall be no greater than the treatment limitations
3imposed by the corresponding plans identified in subdivision (a),
4subject to the requirements set forth in paragraph (2) of subdivision
5(a).
6(c)
end delete
7begin insert(e)end insert Except as provided in subdivisionbegin delete (d),end deletebegin insert (f),end insert nothing in this
8section shall be construed to permit a health insurer to make
9substitutions for the benefits required to be covered under this
10section, regardless of whether those substitutions are actuarially
11equivalent.
12(d)
end delete
13begin insert(f)end insert To the extent permitted under Section 1302 of PPACA and
14any rules, regulations, or guidance issued pursuant to that section,
15and to the extent that substitution would not create an obligation
16for the state to defray costs for any individual, an insurer may
17substitute its prescription drug formulary for the formulary
18provided under the plan identified in subdivision (a) as long as the
19coverage for prescription drugs complies with the sections
20referenced in clauses (ii) and (iv) of subparagraph (A) of paragraph
21(2) of subdivision (a) that apply to prescription drugs.
22(e)
end delete
23begin insert(g)end insert No health insurer, or its agent, producer, or representative,
24shall issue, deliver, renew, offer, market, represent, or sell any
25product, policy, or discount arrangement as compliant with the
26essential health benefits requirement in federal law, unless itbegin delete meets begin insert includes coverage of the
27all of the requirements of this section.end delete
28health benefits described in subdivision (a), including the benefits
29described in subparagraph (A) of paragraph (5) of subdivision
30(a), and meets the requirements of subdivisions (d), (e), and (f)end insertbegin insert.end insert
31 This subdivision shall be enforced in the same manner as Section
32790.03, including through the means specified in Sections 790.035
33and 790.05.
34(f) This
end delete
35begin insert(h)end insertbegin insert end insertbegin insertExcept as otherwise provided in this section, this end insertsection
36shall apply regardless of whether the policy is offered inside or
37outside thebegin delete California Health Benefit Exchange created by Section begin insert Exchangeend insert.
38100500 of the Government Codeend delete
39(g)
end delete
P14 1begin insert(i)end insert Nothing in this section shall be construed to exempt a health
2insurer or a health insurance policy from meeting other applicable
3requirements of law.
4(h)
end delete
5begin insert(j)end insert This section shall not be construed to prohibit a policy from
6covering additional benefits, including, but not limited to, spiritual
7care services that are tax deductible under Section 213 of the
8Internal Revenue Code.
9(i) Subdivision (a) shall not apply to any of the following:
end delete
10(1) A policy that provides excepted benefits as described in
11Sections 2722 and 2791 of the federal Public Health Service Act
12(42 U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91).
13(2) A policy that qualifies as a grandfathered health plan under
14Section 1251 of PPACA or any binding rules, regulation, or
15guidance issued pursuant to that section.
16(j)
end delete
17begin insert(k)end insert Nothing in this section shall be implemented in a manner
18that conflicts with a requirement of PPACA.
19(k)
end delete
20begin insert(l)end insert This section shall be implemented only to the extent essential
21health benefits are required pursuant to PPACA.
22(l)
end delete
23begin insert(m)end insert An essential health benefit is required to be provided under
24this section only to the extent that federal law does not require the
25state to defray the costs of the benefit.
26(m)
end delete
27begin insert(n)end insert Nothing in this section shall obligate the state to incur costs
28for the coverage of benefits that are not essential health benefits
29as defined in this section.
30(n)
end delete
31begin insert(o)end insert An insurer is not required to cover, under this section,
32changes to health benefits that are the result of statutes enacted on
33or after December 31, 2011.
34(o)
end delete
35begin insert(p)end insert (1) The commissioner may adopt emergency regulations
36implementing this section. The commissioner may, on a one-time
37basis, readopt any emergency regulation authorized by this section
38that is the same as, or substantially equivalent to, an emergency
39regulation previously adopted under this section.
P15 1(2) The initial adoption of emergency regulations implementing
2this section and the readoption of emergency regulations authorized
3by this subdivision shall be deemed an emergency and necessary
4for the immediate preservation of the public peace, health, safety,
5or general welfare. The initial emergency regulations and the
6readoption of emergency regulations authorized by this section
7shall be submitted to the Office of Administrative Law for filing
8with the Secretary of State and each shall remain in effect for no
9more than 180 days, by which time final regulations may be
10adopted.
11(3) The commissioner shall consult with the Director of the
12Department of Managed Health Care to ensure consistency and
13uniformity in the development of regulations under this
14subdivision.
15(4) This subdivision shall become inoperative on March 1, 2016.
16(p)
end delete
17begin insert(q)end insert Nothing in this section shall impose on health insurance
18policies the cost sharing or network limitations of the plans
19identified in subdivision (a) except to the extent otherwise required
20to comply with provisions of this code, including this section, and
21as otherwise applicable to all health insurance policies offered to
22individuals and small groups.
23(q)
end delete
24begin insert(r)end insert For purposes of this section, the following definitions shall
25apply:
26(1) “Exchange” means the California Health Benefit Exchange
27created by Section 100500 of the Government Code.
28(1)
end delete
29begin insert(2)end insert “Habilitative services” means medically necessary health
30care services and health care devices that assist an individual in
31partially or fully acquiring or improving skills and functioning and
32that are necessary to address a health condition, to the maximum
33extent practical. These services address the skills and abilities
34needed for functioning in interaction with an individual’s
35environment. Examples of health care services that are not
36habilitative services include, but are not limited to, respite care,
37day care, recreational care, residential treatment, social services,
38custodial care, or education services of any kind, including, but
39not limited to, vocational training. Habilitative services shall be
P16 1covered under the same terms and conditions applied to
2rehabilitative services under the policy.
3(2)
end delete
4begin insert(3)end insert (A) “Health benefits,” unless otherwise required to be
5defined pursuant to federal rules, regulations, or guidance issued
6pursuant to Section 1302(b) of PPACA, means health care items
7or services for the diagnosis, cure, mitigation, treatment, or
8prevention of illness, injury, disease, or a health condition,
9including a behavioral health condition.
10(B) “Health benefits” does not mean any cost-sharing
11requirements such as copayments, coinsurance, or deductibles.
12(3)
end delete
13begin insert(4)end insert “PPACA” means the federal Patient Protection and
14Affordable Care Act (Public Law 111-148), as amended by the
15federal Health Care and Education Reconciliation Act of 2010
16(Public Law 111-152), and any rules, regulations, or guidance
17issued thereunder.
18(4)
end delete
19begin insert(5)end insert “Small group health insurance policy” means a group health
20care service insurance policy issued to a small employer, as defined
21in Sectionbegin delete 10700end deletebegin insert 10753end insert.
This act is an urgency statute necessary for the
24immediate preservation of the public peace, health, or safety within
25the meaning of Article IV of the Constitution and shall go into
26immediate effect. The facts constituting the necessity are:
27In order to update state law consistent with federal requirements
28at the earliest possible time, it is necessary that this bill take effect
29immediately.
O
98