BILL NUMBER: SB 1091	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  AUGUST 18, 2016
	AMENDED IN ASSEMBLY  JUNE 15, 2016
	AMENDED IN SENATE  APRIL 19, 2016
	AMENDED IN SENATE  APRIL 4, 2016

INTRODUCED BY   Senator Liu

                        FEBRUARY 17, 2016

   An act to add Sections 10231.3 and 10235.9a to the Insurance Code,
relating to insurance.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1091, as amended, Liu. Long-term care insurance.
   Under existing law, the Department of Insurance, headed by the
Insurance Commissioner, licenses and regulates insurers. Existing law
divides insurance into various classes, including long-term care
insurance, which includes an insurance policy, certificate, or rider
advertised, marketed, offered, solicited, or designed to provide
coverage for diagnostic, preventive, therapeutic, rehabilitative,
maintenance, or personal care services that are provided in a setting
other than an acute care unit of a hospital. Existing law defines
"policy" for these purposes.
    This bill would, among other things, define "alternate plan of
care" as a plan of care  authorized by a provision in a
policy, rider, endorsement, or amendment that allows benefits for
long-term care services   developed by a licensed health
care practitioner that includes a specification of long-term care
services required by an insured  that are not specifically
defined as a covered service under the policy.  The bill would
also define "alternate-plan-of-care provision" to mean a provision in
a policy, rider, endorsement, or amendment that allows benefits for
services specified in an alternate plan of care. 
    The bill would authorize, for policies issued on or after January
1, 2017, the insured or an insurer to propose an alternate plan of
care. The bill would  also  prohibit the maximum benefit
available under the contract from being changed based on an insured
utilizing an alternate plan of care but would authorize the maximum
benefit to be reduced by  any approved alternate plan of care
costs.   the amount of any benefits paid under an
alternate plan of care. The bill would also require coverage for
services under an alternate plan of care to be in addition to, not in
lieu of, coverage for services specifically defined as covered
services under the policy.  The bill would also require an
 insurer   insurer, within 60 days,  to
provide a written explanation to the policyholder or certificate
holder as to the specific reason an agreement cannot be reached for
policies or certificates that contain an alternate plan of care
provision, as specified.
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  The Legislature finds and declares  both
  all  of the following:
   (a) Long-term care insurance is a vital lifeline for many of
California's aging population.
   (b) Ensuring that the insurance available to consumers is fair and
accessible is essential to our aging community's quality of life.

   (c) Because long-term care insurance is often purchased many years
before a claim is anticipated, it is necessary to give insurers and
insureds the flexibility needed to adapt policy coverage to meet
contemporary needs.  
   (d) An alternate plan of care may provide insureds access to
benefits for services not available at the time the policy was
purchased and insurers a way to offer cost-effective alternatives to
the benefits explicitly covered under the policy. 
  SEC. 2.  It is the intent of the Legislature to ensure that
insurance products provide appropriate benefits that fit consumers'
needs.
  SEC. 3.  Section 10231.3 is added to the Insurance Code, to read:
   10231.3.  (a) For the purposes of this section, the following
 terms   definitions  apply:
   (1) An "alternate plan of care" means a plan of care 
authorized by a provision in a policy, rider, endorsement, or
amendment that allows benefits for long-term care services 
 developed by a licensed health care practitioner that includes a
specification of long-term   care services required by an
insured that are not specifically defined as  a covered
service   covered services  under the policy. 
   (2) An "alternate-plan-of-care provision" means a provision in a
policy, rider, endorsement, or amendment that allows benefits for
services specified in an alternate plan of care.  
   (2) 
    (3)  "Licensed health care practitioner" means a
physician, registered nurse, licensed social worker, or other
individual whom the United States Secretary of the Treasury may
prescribe by regulation. 
   (3) 
    (4)  "Plan of care" means a written description of the
insured's needs and a specification of the type, frequency, and
providers of all formal and informal long-term care services required
by the insured and the cost, if any. 
   (b) An alternate-plan-of-care provision shall provide for all of
the following:  
   (b) 
    (1)  An alternate plan of care may be proposed by the
insured or the insurer. Adoption, amendment, or replacement of an
alternate plan of care shall be agreed to by the insured, the
insurer, and a licensed health care  practitioner. 
 practitioner that is independent of the insurer.  Consent
or agreement to an alternate plan of care shall be free and mutual.

   (c) 
    (2)  The maximum benefit available under the contract
shall not change based on an insured utilizing an alternate plan of
care, but that benefit will be reduced by  any alternate plan
of care costs that are approved. Nothing in this section shall
prohibit an insurer from requiring that an alternate plan of care be
a cost-effective alternative.   the amount of any
benefits paid under an alternate plan of care.  
   (3) Coverage for services under an alternate plan of care shall be
in addition to, not in lieu of, coverage for services that are
specifically defined as covered services under the policy. The
insured may switch between services that are specifically defined as
covered services under the policy and services under the alternate
plan of care and back if there is agreement from the licensed health
care practitioner and the insurer.  
   (d) 
    (c)  Nothing in this section shall be construed to
require an insurer to include a provision authorizing an alternate
plan of care. 
   (e) 
    (d)  This section shall apply to policies issued on or
after January 1, 2017.
  SEC. 4.  Section 10235.9a is added to the Insurance Code,
immediately following Section 10235.9, to read:
   10235.9a.  For policies or certificates issued on or after January
1, 2017, that contain an alternate plan of care provision pursuant
to Section 10231.3, if an insurer and insured cannot agree on the
terms of an alternate plan of care, the insurer shall provide a
written explanation to the policyholder or certificate holder as to
the specific reason or reasons why the agreement cannot be reached.
 The insurer shall provide the written explanation within 60 days
of the insurer's determination that an agreement cannot be reached.