BILL NUMBER: SB 1053 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 9, 2014
INTRODUCED BY Senator Mitchell
FEBRUARY 18, 2014
An act to amend Sections 1367.005 and
Section 1367.25 of the Health and Safety Code, and to amend
Sections 10112.27 and Section 10123.196
of the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1053, as amended, Mitchell. Health care coverage:
contraceptives.
Existing law, the federal Patient Protection and Affordable Care
Act (PPACA), enacts various reforms to the health insurance market.
Among other things, PPACA requires a nongrandfathered group health
plan and a health insurance issuer offering group or individual
insurance coverage to provide coverage for and not impose cost
sharing requirements for certain preventive services, including those
preventive care and screenings for women provided in specified
guidelines. PPACA requires those plans and issuers to provide
coverage without cost-sharing cost sharing
for all federal Food and Drug Administration approved
contraceptive methods, sterilization procedures, and patient
education and counseling for all women with reproductive capacity, as
prescribed by a provider, except as specified.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan contract or health
insurance policy that provides coverage for outpatient prescription
drug benefits to provide coverage for a variety of federal Food and
Drug Administration (FDA) approved prescription contraceptive methods
designated by the plan or insurer, except as specified. Existing law
authorizes a religious employer, as defined, to request a contract
or policy without coverage of FDA approved contraceptive methods that
are contrary to the employer's religious tenets and, if so
requested, requires a contract or policy to be provided without that
coverage. 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, which are defined to include the health benefits
covered by particular benchmark plans.
This bill would require a health care service plan contract or
health insurance policy issued, amended, or renewed on or after
January 1, 2015, to provide coverage for all FDA approved
contraceptive drugs, devices, and products in each contraceptive
category outlined by the FDA, as well as voluntary
sterilization procedures and contraceptive education and counseling
, and would prohibit a plan or insurer from engaging in
unreasonable medical management, as defined, in providing that
coverage. The bill would specify that these benefits are included
within the definition of essential health benefits for contracts and
policies issued, amended, or renewed on or after January 1, 2015
. The bill would prohibit a nongrandfathered plan contract
or health insurance policy from imposing any cost-sharing
requirements or other restrictions or delays with respect
to this coverage, except as specified. The bill would also
prohibit authorize a plan or insurer
from requiring to require a prescription to
trigger coverage of FDA approved over-the-counter contraceptive
methods and supplies. The bill would retain the provision authorizing
a religious employer to request a contract or policy without
coverage of FDA approved contraceptive methods that are contrary to
the employer's religious tenets. Because a willful violation of the
bill's requirements by a health care service plan 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 all of the
following:
(a) California has a long history of expanding timely access to
birth control to prevent unintended pregnancy.
(b) The federal Patient Protection and Affordable Care Act
includes a contraceptive coverage guarantee as part of a broader
requirement for health insurance carriers and plans to cover key
preventive care services without out-of-pocket costs for patients.
(c) The Legislature intends to build on existing state and federal
law to ensure greater contraceptive coverage equity and timely
access to all Federal federal Food and
Drug Administration approved methods of birth control for all
individuals covered by health care service plan contracts and health
insurance policies in California.
SEC. 2. 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) 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).
(b) With respect to an individual or group health care service
plan contract issued, amended, or renewed on or after January 1,
2015, except for a specialized health care service plan contract,
"essential health benefits" also includes the benefits required to be
covered under subdivision (b) of Section 1367.25.
(c) Treatment limitations imposed on health benefits described in
subdivision (a) 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).
(d) Except as provided in subdivision (e), 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.
(e) 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.
(f) 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.
(g) 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.
(h) Nothing in this section shall be construed to exempt a plan or
a plan contract from meeting other applicable requirements of law.
(i) 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.
(j) 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.
(k) Nothing in this section shall be implemented in a manner that
conflicts with a requirement of PPACA.
(l) This section shall be implemented only to the extent essential
health benefits are required pursuant to PPACA.
(m) Except for the benefits required under subdivision (b), 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.
(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.
(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, except for the benefits required under
subdivision (b).
(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.
(q) For purposes of this section, the following definitions shall
apply:
(1) "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) (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) "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) "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. SEC. 2. Section 1367.25 of
the Health and Safety Code is amended to read:
1367.25. (a) A group health care service plan contract, except
for a specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2000,
through December 31, 2014, inclusive, and an individual health
care service plan contract that is amended, renewed, or delivered on
or after January 1, 2000, through December 31, 2014, inclusive,
except for a specialized health care service plan contract,
shall provide coverage for the following, under general terms and
conditions applicable to all benefits:
(1) A health care service plan contract that provides coverage
for outpatient prescription drug benefits shall include coverage for
a variety of federal Food and Drug Administration (FDA) approved
prescription contraceptive methods designated by the plan. In the
event the patient's participating provider, acting within his or her
scope of practice, determines that none of the methods designated by
the plan is medically appropriate for the patient's medical or
personal history, the plan shall also provide coverage for another
FDA approved, medically appropriate prescription contraceptive method
prescribed by the patient's provider.
(2) Outpatient prescription benefits
Benefits for an enrollee under this subdivision
shall be the same for an enrollee's covered spouse and covered
nonspouse dependents.
(b) (1) A group or individual health care service plan contract,
except for a specialized health care service plan contract, that is
issued, amended, renewed, or delivered on or after January 1, 2015,
shall provide coverage for all FDA of the
following:
(A) All FDA approved
contraceptive drugs, devices, and products in each contraceptive
category outlined by the FDA, as well as sterilization
procedures and contraceptive education and counseling. A health care
service plan shall not engage in unreasonable medical management in
providing the coverage required by this subdivision.
including drugs, devices, and products available over the counter, as
prescribed by the enrollee's provider.
(2) A nongrandfathered group or individual health care service
(B) Voluntary sterilization procedures.
(C) Patient education and counseling on contraception.
(2) (A) Except
for a grandfathered health plan, and subject to subparagraph (B), a
health care service plan contract subject to
this subdivision shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the coverage
provided pursuant to this subdivision.
(3) Notwithstanding paragraph (2), a plan may cover a generic drug
without cost sharing and impose cost sharing for equivalent branded
drugs. If a generic version of a drug is not available, a plan shall
provide coverage for the brand name drug in accordance with the
requirements of this subdivision. In addition, a plan shall
accommodate an enrollee for whom a generic drug would be medically
inappropriate under this subdivision, as determined by the enrollee's
participating provider in consultation with the enrollee, by having
a mechanism for waiving the otherwise applicable cost sharing for the
branded version.
(4) Notwithstanding paragraph (1), a health care service plan may
impose reasonable quantity limits on the number of contraceptive
supplies an enrollee may receive at a given time under this
subdivision.
(B) A health care service plan may cover a generic drug, device,
or product without cost sharing and impose cost sharing for
equivalent nonpreferred or branded drugs, devices, or products.
However, if a generic version of a drug, device, or product is not
available, or is deemed medically inadvisable by the enrollee's
provider, a health care service plan shall provide coverage for the
nonpreferred or brand name drug, device, or product without cost
sharing.
(5)
(3) A health care service plan shall not
may require a prescription to trigger coverage of
FDA approved over-the-counter contraceptive methods and supplies
under this subdivision.
(6) Outpatient drug benefits for
(4) Except as otherwise authorized under this section, a health
care service plan shall not impose any restrictions or delays on the
coverage required under this subdivision.
(5) Benefits for an enrollee
under this subdivision shall be the same for an enrollee's covered
spouse and covered nonspouse dependents.
(c) Notwithstanding any other provision of this section, a
religious employer may request a health care service plan contract
without coverage for FDA approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so
requested, a health care service plan contract shall be provided
without coverage for contraceptive methods.
(1) For purposes of this section, a "religious employer" is an
entity for which each of the following is true:
(A) The inculcation of religious values is the purpose of the
entity.
(B) The entity primarily employs persons who share the religious
tenets of the entity.
(C) The entity serves primarily persons who share the religious
tenets of the entity.
(D) The entity is a nonprofit organization as described in
Section 6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986,
as amended.
(2) Every religious employer that invokes the exemption provided
under this section shall provide written notice to prospective
enrollees prior to enrollment with the plan, listing the
contraceptive health care services the employer refuses to cover for
religious reasons.
(d) Nothing in this section shall be construed to exclude coverage
for contraceptive supplies ordered as
prescribed by a provider, acting within his or her scope of
practice, for reasons other than contraceptive purposes, such as
decreasing the risk of ovarian cancer or eliminating symptoms of
menopause, or for contraception that is necessary to preserve the
life or health of an enrollee.
(e) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for contraceptive
drugs , devices, and products .
(f) Nothing in this section shall be construed to require an
individual or group health care service plan contract to cover
experimental or investigational treatments.
(g) For purposes of this section, the following definitions apply:
(1) "Grandfathered health plan" has the meaning set forth in
Section 1251 of PPACA.
(2) "Nongrandfathered individual or group health care service plan
contract" means a health care service plan contract that is not a
grandfathered health plan.
(3)
(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.
(4)
(3) With respect to health care service plan contracts
issued, amended, or renewed on or after January 1, 2015, "provider"
means an individual who is certified or licensed pursuant to Division
2 (commencing with Section 500) of the Business and Professions
Code, or an initiative act referred to in that division, or Division
2.5 (commencing with Section 1797).
(5) "Reasonable quantity limits" means quantity limits placed by a
health care service plan on contraceptive supplies that would not
cause an undue burden or barrier to consistent, regular, and
effective use of the contraceptive method.
(6) "Unreasonable medical management" means techniques used by a
health care service plan that deny, tier, or condition enrollee
access to an FDA approved contraceptive drug, device, or product.
SEC. 4. 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 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) 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).
(b) With respect to an individual or group health insurance policy
issued, amended, or renewed on or after January 1, 2015, except for
a specialized health insurance policy, "essential health benefits"
also includes the benefits required to be covered under subdivision
(b) of Section 10123.196.
(c) Treatment limitations imposed on health benefits described in
subdivision (a) 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).
(d) Except as provided in subdivision (e), 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.
(e) 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.
(f) 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. 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.
(g) 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.
(h) Nothing in this section shall be construed to exempt a health
insurer or a health insurance policy from meeting other applicable
requirements of law.
(i) 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.
(j) 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.
(k) Nothing in this section shall be implemented in a manner that
conflicts with a requirement of PPACA.
(l) This section shall be implemented only to the extent essential
health benefits are required pursuant to PPACA.
(m) Except for the benefits required under subdivision (b), 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.
(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.
(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, except for the benefits required under
subdivision (b).
(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.
(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.
(r) For purposes of this section, the following definitions shall
apply:
(1) "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) (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) "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) "Small group health insurance policy" means a group health
care service insurance policy issued to a small employer, as defined
in Section 10700.
SEC. 5. SEC. 3. Section 10123.196 of
the Insurance Code is amended to read:
10123.196. (a) An individual or group policy of disability
insurance issued, amended, renewed, or delivered on or after January
1, 2000, through December 31, 2014, inclusive, that
provides coverage for hospital, medical, or surgical expenses, shall
provide coverage for the following, under the same terms and
conditions as applicable to all benefits:
(1) A disability insurance policy that provides coverage for
outpatient prescription drug benefits shall include coverage for a
variety of federal Food and Drug Administration (FDA) approved
prescription contraceptive methods, as designated by the insurer. If
an insured's health care provider determines that none of the methods
designated by the disability insurer is medically appropriate for
the insured's medical or personal history, the insurer shall, in the
alternative, provide coverage for some other FDA approved
prescription contraceptive method prescribed by the patient's health
care provider.
(2) Outpatient prescription coverage
Coverage with respect to an insured under this subdivision
shall be identical for an insured's covered spouse and covered
nonspouse dependents.
(b) (1) A group or individual policy of disability insurance,
except for a specialized health insurance policy, that is issued,
amended, renewed, or delivered on or after January 1, 2015, shall
provide coverage for all FDA approved contraceptive drugs,
devices, and products in each contraceptive category outlined by the
FDA, as well as sterilization procedures and contraceptive education
and counseling. A disability insurer shall not engage in unreasonable
medical management in providing the coverage required by this
subdivision. of the following:
(A) All FDA approved contraceptive drugs, devices, and products in
each contraceptive category outlined by the FDA, including drugs,
devices, and products available over the counter, as prescribed by
the insured's provider.
(B) Voluntary sterilization procedures.
(C) Patient education and counseling on contraception.
(2) A nongrandfathered group or individual policy of disability
insurance
(2) (A) Except
for a grandfathered health plan, and subject to subparagraph (B), a
disability insurer subject to this subdivision shall not impose
a deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this subdivision.
(3) Notwithstanding paragraph (2), an insurer may cover a generic
drug without cost sharing and impose cost sharing for equivalent
branded drugs. If a generic version of a drug is not available, an
insurer shall provide coverage for the brand name drug in accordance
with the requirements of this subdivision. In addition, an insurer
shall accommodate an insured for whom a generic drug would be
medically inappropriate under this subdivision, as determined by the
insured's health care provider in consultation with the insured, by
having a mechanism for waiving the otherwise applicable cost sharing
for the branded version.
(4) Notwithstanding paragraph (1), an insurer may impose
reasonable quantity limits on the number of contraceptive supplies an
insured may receive at a given time under this subdivision.
(B) A disability insurer may cover a generic drug, device, or
product without cost sharing and impose cost sharing for an
equivalent nonpreferred or branded drug, device, or product. However,
if a generic version of a drug, device, or product is not available,
or is deemed medically inadvisable by the insured's provider, a
disability insurer shall provide coverage for the nonpreferred or
brand name drug, device, or product without cost sharing.
(5)
(3) An insurer shall not may
require a prescription to trigger coverage of FDA approved
over-the-counter contraceptive methods and supplies under this
subdivision.
(4) Except as otherwise authorized under this section, an insurer
shall not impose any restrictions or delays on the coverage required
under this subdivision.
(6) Outpatient drug coverage
(5) Coverage with respect to an
insured under this subdivision shall be identical for an insured's
covered spouse and covered nonspouse dependents.
(c) Nothing in this section shall be construed to deny or restrict
in any way any existing right or benefit provided under law or by
contract.
(d) Nothing in this section shall be construed to require an
individual or group disability insurance policy to cover experimental
or investigational treatments.
(e) Notwithstanding any other provision of this section, a
religious employer may request a disability insurance policy without
coverage for contraceptive methods that are contrary to the religious
employer's religious tenets. If so requested, a disability insurance
policy shall be provided without coverage for contraceptive methods.
(1) For purposes of this section, a "religious employer" is an
entity for which each of the following is true:
(A) The inculcation of religious values is the purpose of the
entity.
(B) The entity primarily employs persons who share the religious
tenets of the entity.
(C) The entity serves primarily persons who share the religious
tenets of the entity.
(D) The entity is a nonprofit organization pursuant to Section
6033(a)(2)(A)(i) or (iii) of the Internal Revenue Code of 1986, as
amended.
(2) Every religious employer that invokes the exemption provided
under this section shall provide written notice to any prospective
employee once an offer of employment has been made, and prior to that
person commencing that employment, listing the contraceptive health
care services the employer refuses to cover for religious reasons.
(f) Nothing in this section shall be construed to exclude coverage
for contraceptive supplies ordered as
prescribed by a health care provider, acting
within his or her scope of practice, for reasons other than
contraceptive purposes, such as decreasing the risk of ovarian cancer
or eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an insured.
(g) This section shall only apply to disability insurance policies
or contracts that are defined as health benefit plans pursuant to
subdivision (a) of Section 10198.6, except that for accident only,
specified disease, or hospital indemnity coverage, coverage for
benefits under this section shall apply to the extent that the
benefits are covered under the general terms and conditions that
apply to all other benefits under the policy or contract. Nothing in
this section shall be construed as imposing a new benefit mandate on
accident only, specified disease, or hospital indemnity insurance.
(h) For purposes of this section, the following definitions apply:
(1) "Grandfathered health plan" has the meaning set forth in
Section 1251 of PPACA.
(2) "Nongrandfathered group or individual policy of disability
insurance" means a disability insurance policy that is not a
grandfathered health plan.
(3)
(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.
(4)
(3) With respect to policies of disability insurance
issued, amended, or renewed on or after January 1, 2015, "health care
provider" means an individual who is certified or licensed pursuant
to Division 2 (commencing with Section 500) of the Business and
Professions Code, or an initiative act referred to in that division,
or Division 2.5 (commencing with Section 1797) of the Health and
Safety Code.
(5) "Reasonable quantity limits" means quantity limits placed by a
disability insurer on contraceptive supplies that would not cause an
undue burden or barrier to consistent, regular, and effective use of
the contraceptive method.
(6) "Unreasonable medical management" means techniques used by a
disability insurer that deny, tier, or condition insured access to an
FDA approved contraceptive drug, device, or product.
SEC. 6. 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.