BILL NUMBER: AB 18 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MARCH 19, 2013
INTRODUCED BY Assembly Member Pan
DECEMBER 3, 2012
An act to amend Section 1367.005 of the Health and Safety
Code, and to amend Section 10112.27 of the Insurance Code,
relating to health care coverage, and declaring the urgency thereof,
to take effect immediately.
LEGISLATIVE COUNSEL'S DIGEST
AB 18, as amended, Pan. Individual health care coverage.
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,
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.
Existing 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.
This 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.
This bill would declare that it is to take effect immediately as
an urgency statute.
Existing 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.
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 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.
This bill would state the intent of the Legislature to enact
legislation that would reform the individual health care coverage
market consistent with the PPACA.
This bill would declare that it is to take effect immediately as
an urgency statute.
Vote: 2/3. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. It is the intent of the Legislature
to enact legislation to reform the individual health care coverage
market consistent with 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).
SECTION 1. Section 1367.005 of the
Health and Safety Code is amended 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 pursuant to PPACA and as outlined in this section. For
purposes of this section, "essential health benefits" means all of
the following:
(1) Health benefits within the categories identified in Section
1302(b) of PPACA: 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 services,
including oral and vision care.
(2) (A) The health benefits covered by the Kaiser Foundation
Health Plan Small Group HMO 30 plan (federal health product
identification number 40513CA035) as this plan was offered during the
first quarter of 2012, as follows, regardless of whether the
benefits are specifically referenced in the evidence of coverage or
plan contract for that plan:
(i) Medically necessary basic health care services, as defined in
subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of
the California Code of Regulations.
(ii) The health benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in the following sections: Sections 1367.002, 1367.06, and 1367.35
(preventive services for children); Section 1367.25 (prescription
drug coverage for contraceptives); Section 1367.45 (AIDS vaccine);
Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section
1367.54 (alpha feto protein testing); Section 1367.6 (breast cancer
screening); Section 1367.61 (prosthetics for laryngectomy); Section
1367.62 (maternity hospital stay); Section 1367.63 (reconstructive
surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate
cancer); Section 1367.65 (mammography); Section 1367.66 (cervical
cancer); Section 1367.665 (cancer screening tests); Section 1367.67
(osteoporosis); Section 1367.68 (surgical procedures for jaw bones);
Section 1367.71 (anesthesia for dental); Section 1367.9 (conditions
attributable to diethylstilbestrol); Section 1368.2 (hospice care);
Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency
response ambulance or ambulance transport services); subdivision (b)
of Section 1373 (sterilization operations or procedures); Section
1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56
(phenylketonuria); Section 1374.17 (organ transplants for HIV);
Section 1374.72 (mental health parity); and Section 1374.73
(autism/behavioral health treatment).
(iii) Any other benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in those statutes.
(iv) The health benefits covered by the plan that are not
otherwise required to be covered under this chapter, to the extent
required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22,
1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the
California Code of Regulations.
(v) Any other health benefits covered by the plan that are not
otherwise required to be covered under this chapter.
(B) Where there are any conflicts or omissions in the plan
identified in subparagraph (A) as compared with the requirements for
health benefits under this chapter that were enacted prior to
December 31, 2011, the requirements of this chapter shall be
controlling, except as otherwise specified in this section.
(C) Notwithstanding subparagraph (B) or any other provision of
this section, the home health services benefits covered under the
plan identified in subparagraph (A) shall be deemed to not be in
conflict with this chapter.
(D) For purposes of this section, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
(Public Law 110-343) shall apply to a contract subject to this
section. Coverage of mental health and substance use disorder
services pursuant to this paragraph, along with any scope and
duration limits imposed on the benefits, shall be in compliance with
the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (Public Law 110-343), and all rules,
regulations, or guidance issued pursuant to Section 2726 of the
federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
(3) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (2), coverage shall
also be provided as required by federal rules, regulations, and
guidance issued pursuant to Section 1302(b) of PPACA. Habilitative
services shall be covered under the same terms and conditions applied
to rehabilitative services under the plan contract.
(4) With respect to pediatric vision care, the same health
benefits for pediatric vision care covered under the Federal
Employees Dental and Vision Insurance Program vision plan with the
largest national enrollment as of the first quarter of 2012. The
pediatric vision care benefits covered pursuant to this paragraph
shall be in addition to, and shall not replace, any vision services
covered under the plan identified in paragraph (2).
(5) (A) With respect to pediatric oral care,
the same health benefits for pediatric oral care covered under the
dental plan available to subscribers of the Healthy Families Program
in 2011-12, including the provision of medically necessary
orthodontic care provided pursuant to the federal Children's Health
Insurance Program Reauthorization Act of 2009. The pediatric
oral care benefits covered pursuant to this paragraph shall be in
addition to, and shall not replace, any dental or orthodontic
services covered under the plan identified in paragraph (2).
This subparagraph shall not apply to a health care
service plan contract offered through the Exchange if a specialized
health care service plan contract described in Section 1311(d)(2)(B)
(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)(ii)) is offered through
the Exchange.
(B) The pediatric oral care benefits covered pursuant to this
paragraph shall be in addition to, and shall not replace, any dental
or orthodontic services covered under the plan identified in
paragraph (2).
(b) Subdivision (a) shall not apply to any of the following:
(1) A specialized health care service plan contract.
(2) A Medicare supplement plan contract.
(3) A plan contract that qualifies as a grandfathered health plan
under Section 1251 of PPACA or any rules, regulations, or guidance
issued pursuant to that section.
(c) A specialized health care service plan contract described in
Section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)
(ii)) that is offered through the Exchange shall, at a minimum,
include coverage of the health benefits described in subparagraph (A)
of paragraph (5) of subdivision (a).
(b)
(d) Treatment limitations imposed on health benefits
described in this section shall be no greater than the treatment
limitations imposed by the corresponding plans identified in
subdivision (a), subject to the requirements set forth in paragraph
(2) of subdivision (a).
(c)
(e) Except as provided in subdivision (d),
(f), nothing in this section shall be construed
to permit a health care service plan to make substitutions for the
benefits required to be covered under this section, regardless of
whether those substitutions are actuarially equivalent.
(d)
(f) To the extent permitted under Section 1302 of PPACA
and any rules, regulations, or guidance issued pursuant to that
section, and to the extent that substitution would not create an
obligation for the state to defray costs for any individual, a plan
may substitute its prescription drug formulary for the formulary
provided under the plan identified in subdivision (a) as long as the
coverage for prescription drugs complies with the sections referenced
in clauses (ii) and (iv) of subparagraph (A) of paragraph (2) of
subdivision (a) that apply to prescription drugs.
(e)
(g) No health care service plan, or its agent,
solicitor, or representative, shall issue, deliver, renew, offer,
market, represent, or sell any product, contract, or discount
arrangement as compliant with the essential health benefits
requirement in federal law, unless it meets all of the
requirements of this section. includes coverage of the
health benefits described in subdivision (a), including the benefits
described in subparagraph (A) of paragraph (5) of subdivision (a),
and meets the requirements of subdivisions (d), (e), and (f).
(f)
(h) This Except as otherwise
provided in this section, 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 Exchange .
(g)
(i) Nothing in this section shall be construed to
exempt a plan or a plan contract from meeting other applicable
requirements of law.
(h)
(j) 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.
(i)
Subdivision (a) shall not apply to any of the following:
(1) A specialized health care service plan contract.
(2) A Medicare supplement plan.
(3) A plan contract that qualifies as a grandfathered health plan
under Section 1251 of PPACA or any rules, regulations, or guidance
issued pursuant to that section.
(j)
(k) Nothing in this section shall be implemented in a
manner that conflicts with a requirement of PPACA.
(k)
(l) This section shall be implemented only to the
extent essential health benefits are required pursuant to PPACA.
(l)
(m) An essential health benefit is required to be
provided under this section only to the extent that federal law does
not require the state to defray the costs of the benefit.
(m)
(n) Nothing in this section shall obligate the state to
incur costs for the coverage of benefits that are not essential
health benefits as defined in this section.
(n)
(o) A plan is not required to cover, under this
section, changes to health benefits that are the result of statutes
enacted on or after December 31, 2011.
(o)
(p) (1) The department may adopt emergency regulations
implementing this section. The department may, on a one-time basis,
readopt any emergency regulation authorized by this section that is
the same as, or substantially equivalent to, an emergency regulation
previously adopted under this section.
(2) The initial adoption of emergency regulations implementing
this section and the readoption of emergency regulations authorized
by this subdivision shall be deemed an emergency and necessary for
the immediate preservation of the public peace, health, safety, or
general welfare. The initial emergency regulations and the readoption
of emergency regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and each shall remain in effect for no more than
180 days, by which time final regulations may be adopted.
(3) The director shall consult with the Insurance Commissioner to
ensure consistency and uniformity in the development of regulations
under this subdivision.
(4) This subdivision shall become inoperative on March 1, 2016.
(p)
(q) For purposes of this section, the following
definitions shall apply:
(1) "Exchange" means the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(1)
(2) "Habilitative services" means medically necessary
health care services and health care devices that assist an
individual in partially or fully acquiring or improving skills and
functioning and that are necessary to address a health condition, to
the maximum extent practical. These services address the skills and
abilities needed for functioning in interaction with an individual's
environment. Examples of health care services that are not
habilitative services include, but are not limited to, respite care,
day care, recreational care, residential treatment, social services,
custodial care, or education services of any kind, including, but not
limited to, vocational training. Habilitative services shall be
covered under the same terms and conditions applied to rehabilitative
services under the plan contract.
(2)
(3) (A) "Health benefits," unless otherwise required to
be defined pursuant to federal rules, regulations, or guidance
issued pursuant to Section 1302(b) of PPACA, means health care items
or services for the diagnosis, cure, mitigation, treatment, or
prevention of illness, injury, disease, or a health condition,
including a behavioral health condition.
(B) "Health benefits" does not mean any cost-sharing requirements
such as copayments, coinsurance, or deductibles.
(3)
(4) "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.
(4)
(5) "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 1357.500
.
SEC. 2. Section 10112.27 of the
Insurance Code is amended 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
pursuant to PPACA and as outlined in this section. This section shall
exclusively govern what benefits a health insurer must cover as
essential health benefits. For purposes of this section, "essential
health benefits" means all of the following:
(1) Health benefits within the categories identified in Section
1302(b) of PPACA: 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 services,
including oral and vision care.
(2) (A) The health benefits covered by the Kaiser Foundation
Health Plan Small Group HMO 30 plan (federal health product
identification number 40513CA035) as this plan was offered during the
first quarter of 2012, as follows, regardless of whether the
benefits are specifically referenced in the plan contract or evidence
of coverage for that plan:
(i) Medically necessary basic health care services, as defined in
subdivision (b) of Section 1345 of the Health and Safety Code and in
Section 1300.67 of Title 28 of the California Code of Regulations.
(ii) The health benefits mandated to be covered by the plan
pursuant to statutes enacted before December 31, 2011, as described
in the following sections of the Health and Safety Code: Sections
1367.002, 1367.06, and 1367.35 (preventive services for children);
Section 1367.25 (prescription drug coverage for contraceptives);
Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing);
Section 1367.51 (diabetes); Section 1367.54 (alpha feto protein
testing); Section 1367.6 (breast cancer screening); Section 1367.61
(prosthetics for laryngectomy); Section 1367.62 (maternity hospital
stay); Section 1367.63 (reconstructive surgery); Section 1367.635
(mastectomies); Section 1367.64 (prostate cancer); Section 1367.65
(mammography); Section 1367.66 (cervical cancer); Section 1367.665
(cancer screening tests); Section 1367.67 (osteoporosis); Section
1367.68 (surgical procedures for jaw bones); Section 1367.71
(anesthesia for dental); Section 1367.9 (conditions attributable to
diethylstilbestrol); Section 1368.2 (hospice care); Section 1370.6
(cancer clinical trials); Section 1371.5 (emergency response
ambulance or ambulance transport services); subdivision (b) of
Section 1373 (sterilization operations or procedures); Section 1373.4
(inpatient hospital and ambulatory maternity); Section 1374.56
(phenylketonuria); Section 1374.17 (organ transplants for HIV);
Section 1374.72 (mental health parity); and Section 1374.73
(autism/behavioral health treatment).
(iii) Any other health benefits mandated to be covered
by the plan pursuant to statutes enacted before December 31, 2011, as
described in those statutes.
(iv) The health benefits covered by the plan that are not
otherwise required to be covered under Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code, to the
extent otherwise required pursuant to Sections 1367.18, 1367.21,
1367.215, 1367.22, 1367.24, and 1367.25 of the Health and Safety
Code, and Section 1300.67.24 of Title 28 of the California Code of
Regulations.
(v) Any other health benefits covered by the plan that are not
otherwise required to be covered under Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code.
(B) Where there are any conflicts or omissions in the plan
identified in subparagraph (A) as compared with the requirements for
health benefits under Chapter 2.2 (commencing with Section 1340) of
Division 2 of the Health and Safety Code that were enacted prior to
December 31, 2011, the requirements of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code shall be
controlling, except as otherwise specified in this section.
(C) Notwithstanding subparagraph (B) or any other provision of
this section, the home health services benefits covered under the
plan identified in subparagraph (A) shall be deemed to not be in
conflict with Chapter 2.2 (commencing with Section 1340) of Division
2 of the Health and Safety Code.
(D) For purposes of this section, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008
(Public Law 110-343) shall apply to a policy subject to this section.
Coverage of mental health and substance use disorder services
pursuant to this paragraph, along with any scope and duration limits
imposed on the benefits, shall be in compliance with the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 (Public Law 110-343), and all rules, regulations, and
guidance issued pursuant to Section 2726 of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg-26).
(3) With respect to habilitative services, in addition to any
habilitative services identified in paragraph (2), coverage shall
also be provided as required by federal rules, regulations, or
guidance issued pursuant to Section 1302(b) of PPACA. Habilitative
services shall be covered under the same terms and conditions applied
to rehabilitative services under the policy.
(4) With respect to pediatric vision care, the same health
benefits for pediatric vision care covered under the Federal
Employees Dental and Vision Insurance Program vision plan with the
largest national enrollment as of the first quarter of 2012. The
pediatric vision care services covered pursuant to this paragraph
shall be in addition to, and shall not replace, any vision services
covered under the plan identified in paragraph (2).
(5) (A) With respect to pediatric
oral care, the same health benefits for pediatric oral care covered
under the dental plan available to subscribers of the Healthy
Families Program in 2011-12, including the provision of medically
necessary orthodontic care provided pursuant to the federal Children'
s Health Insurance Program Reauthorization Act of 2009. The
pediatric oral care benefits covered pursuant to this paragraph shall
be in addition to, and shall not replace, any dental or orthodontic
services covered under the plan identified in paragraph (2).
This subparagraph shall not apply to a health
insurance policy offered through the Exchange if a specialized health
insurance policy described in Section 1311(d)(2)(B)(ii) of PPACA (42
U.S.C. Sec. 18031(d)(2)(B)(ii)) is offered through the Exchange.
(B) The pediatric oral care benefits covered pursuant to this
paragraph shall be in addition to, and shall not replace, any dental
or orthodontic services covered under the plan identified in
paragraph (2).
(b) Subdivision (a) shall not apply to any of the following:
(1) A policy that provides excepted benefits as described in
Sections 2722 and 2791 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91).
(2) A policy that qualifies as a grandfathered health plan under
Section 1251 of PPACA or any binding rules, regulation, or guidance
issued pursuant to that section.
(c) A specialized health insurance policy described in Section
1311(d)(2)(B)(ii) of PPACA (42 U.S.C. Sec. 18031(d)(2)(B)(ii)) that
is offered through the Exchange shall, at a minimum, include coverage
of the health benefits described in subparagraph (A) of paragraph
(5) of subdivision (a).
(b)
(d) Treatment limitations imposed on health benefits
described in this section shall be no greater than the treatment
limitations imposed by the corresponding plans identified in
subdivision (a), subject to the requirements set forth in paragraph
(2) of subdivision (a).
(c)
(e) Except as provided in subdivision (d),
(f), nothing in this section shall be construed
to permit a health insurer to make substitutions for the benefits
required to be covered under this section, regardless of whether
those substitutions are actuarially equivalent.
(d)
(f) To the extent permitted under Section 1302 of PPACA
and any rules, regulations, or guidance issued pursuant to that
section, and to the extent that substitution would not create an
obligation for the state to defray costs for any individual, an
insurer may substitute its prescription drug formulary for the
formulary provided under the plan identified in subdivision (a) as
long as the coverage for prescription drugs complies with the
sections referenced in clauses (ii) and (iv) of subparagraph (A) of
paragraph (2) of subdivision (a) that apply to prescription drugs.
(e)
(g) No health insurer, or its agent, producer, or
representative, shall issue, deliver, renew, offer, market,
represent, or sell any product, policy, or discount arrangement as
compliant with the essential health benefits requirement in federal
law, unless it meets all of the requirements of this
section. includes coverage of the health benefits
described in subdivision (a), including the benefits described in
subparagraph (A) of paragraph (5) of subdivision (a), and meets the
requirements of subdivisions (d), (e), and (f) .
This subdivision shall be enforced in the same manner as Section
790.03, including through the means specified in Sections 790.035 and
790.05.
(f) This
(h) Except as otherwise provided in
this section, 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 Exchange .
(g)
(i) Nothing in this section shall be construed to
exempt a health insurer or a health insurance policy from meeting
other applicable requirements of law.
(h)
(j) 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.
(i) Subdivision (a) shall not apply to any of the following:
(1) A policy that provides excepted benefits as described in
Sections 2722 and 2791 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91).
(2) A policy that qualifies as a grandfathered health plan under
Section 1251 of PPACA or any binding rules, regulation, or guidance
issued pursuant to that section.
(j)
(k) Nothing in this section shall be implemented in a
manner that conflicts with a requirement of PPACA.
(k)
(l) This section shall be implemented only to the
extent essential health benefits are required pursuant to PPACA.
(l)
(m) An essential health benefit is required to be
provided under this section only to the extent that federal law does
not require the state to defray the costs of the benefit.
(m)
(n) Nothing in this section shall obligate the state to
incur costs for the coverage of benefits that are not essential
health benefits as defined in this section.
(n)
(o) An insurer is not required to cover, under this
section, changes to health benefits that are the result of statutes
enacted on or after December 31, 2011.
(o)
(p) (1) The commissioner may adopt emergency
regulations implementing this section. The commissioner may, on a
one-time basis, readopt any emergency regulation authorized by this
section that is the same as, or substantially equivalent to, an
emergency regulation previously adopted under this section.
(2) The initial adoption of emergency regulations implementing
this section and the readoption of emergency regulations authorized
by this subdivision shall be deemed an emergency and
necessary for the immediate
preservation of the public peace, health, safety, or general welfare.
The initial emergency regulations and the readoption of emergency
regulations authorized by this section shall be submitted to the
Office of Administrative Law for filing with the Secretary of State
and each shall remain in effect for no more than 180 days, by which
time final regulations may be adopted.
(3) The commissioner shall consult with the Director of the
Department of Managed Health Care to ensure consistency and
uniformity in the development of regulations under this subdivision.
(4) This subdivision shall become inoperative on March 1, 2016.
(p)
(q) Nothing in this section shall impose on health
insurance policies the cost sharing or network limitations of the
plans identified in subdivision (a) except to the extent otherwise
required to comply with provisions of this code, including this
section, and as otherwise applicable to all health insurance policies
offered to individuals and small groups.
(q)
(r) For purposes of this section, the following
definitions shall apply:
(1) "Exchange" means the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(1)
(2) "Habilitative services" means medically necessary
health care services and health care devices that assist an
individual in partially or fully acquiring or improving skills and
functioning and that are necessary to address a health condition, to
the maximum extent practical. These services address the skills and
abilities needed for functioning in interaction with an individual's
environment. Examples of health care services that are not
habilitative services include, but are not limited to, respite care,
day care, recreational care, residential treatment, social services,
custodial care, or education services of any kind, including, but not
limited to, vocational training. Habilitative services shall be
covered under the same terms and conditions applied to rehabilitative
services under the policy.
(2)
(3) (A) "Health benefits," unless otherwise required to
be defined pursuant to federal rules, regulations, or guidance
issued pursuant to Section 1302(b) of PPACA, means health care items
or services for the diagnosis, cure, mitigation, treatment, or
prevention of illness, injury, disease, or a health condition,
including a behavioral health condition.
(B) "Health benefits" does not mean any cost-sharing requirements
such as copayments, coinsurance, or deductibles.
(3)
(4) "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.
(4)
(5) "Small group health insurance policy" means a group
health care service insurance policy issued to a small employer, as
defined in Section 10700 10753 .
SEC. 2. SEC. 3. This act is an
urgency statute necessary for the immediate preservation of the
public peace, health, or safety within the meaning of Article IV of
the Constitution and shall go into immediate effect. The facts
constituting the necessity are:
In order to update state law consistent with federal requirements
at the earliest possible time, it is necessary that this bill take
effect immediately.