AB 2115, as introduced, Wood. Health care service plans: levels of coverage.
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 establishes annual limits on deductibles for employer-sponsored plans and defines bronze, silver, gold, and platinum levels of coverage for the nongrandfathered individual and small group markets.
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, including defining levels of coverage. Existing law makes a willful violation of the act a crime.
This bill would make a technical, nonsubstantive change to these provisions.
Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 1367.009 of the Health and Safety Code
2 is amended to read:
(a) Levels of coverage for the nongrandfathered
2small group market are defined as follows:
3(1) Bronze level: A health care service plan contract in the
4bronze level shall provide a level of coverage that is actuarially
5equivalent to 60 percent of the full actuarial value of the benefits
6provided under the plan contract.
7(2) Silver level: A health care service plan contract in the silver
8level shall provide a level of coverage that is actuarially equivalent
9to 70 percent of the full actuarial value of the benefits provided
10under the plan contract.
11(3) Gold level: A health care service plan contract in the gold
12level shall provide a
level of coverage that is actuarially equivalent
13to 80 percent of the full actuarial value of the benefits provided
14under the plan contract.
15(4) Platinum level: A health care service plan contract in the
16platinum level shall provide a level of coverage that is actuarially
17equivalent to 90 percent of the full actuarial value of the benefits
18provided under the plan contract.
19(b) Actuarial value for nongrandfathered small employer health
20care service plan contracts shall be determined in accordance with
21begin insert all ofend insert the following:
22(1) Actuarial value shall not vary by more than plus or minus
232 percent.
24(2) Actuarial value shall be determined on the basis
of essential
25health benefits as defined in Section 1367.005 and as provided to
26a standard, nonelderly population. For this purpose, a standard
27population shall not include those receiving coverage through the
28Medi-Cal or Medicare programs.
29(3) The department may use the actuarial value methodology
30developed consistent with Section 1302(d) of PPACA.
31(4) The actuarial value for pediatric dental benefits, whether
32offered by a full service plan or a specialized plan, shall be
33consistent with federal law and guidance applicable to the plan
34type.
35(5) The department, in consultation with the Department of
36Insurance and the Exchange, shall consider whether to exercise
37state-level flexibility with respect to the actuarial value calculator
38in order to take into account the unique characteristics of the
39California health care
coverage market, including the prevalence
40of health care service plans, total cost of care paid for by the plan,
P3 1price of care, patterns of service utilization, and relevant
2demographic factors.
3(6) Employer contributions toward health reimbursement
4accounts and health savings accounts shall count toward the
5actuarial value of the product in the manner specified in federal
6rules and guidance.
7(c) “PPACA” means the federal Patient Protection and
8Affordable Care Act (Public Law 111-148), as amended by the
9federal Health Care and Education Reconciliation Act of 2010
10(Public Law 111-152), and any rules, regulations, or guidance
11issued thereunder.
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