BILL NUMBER: AB 2994 CHAPTERED 09/30/94 BILL TEXT CHAPTER 1282 FILED WITH SECRETARY OF STATE SEPTEMBER 30, 1994 APPROVED BY GOVERNOR SEPTEMBER 30, 1994 PASSED THE ASSEMBLY AUGUST 26, 1994 PASSED THE SENATE AUGUST 24, 1994 AMENDED IN SENATE AUGUST 9, 1994 AMENDED IN SENATE JUNE 21, 1994 AMENDED IN ASSEMBLY MAY 23, 1994 AMENDED IN ASSEMBLY MAY 2, 1994 AMENDED IN ASSEMBLY MARCH 24, 1994 INTRODUCED BY Assembly Member Brulte (Coauthor: Assembly Member Cortese) FEBRUARY 18, 1994 An act to add Section 1367.68 to the Health and Safety Code, and to add Sections 10123.21 and 11512.156 to the Insurance Code, relating to health insurance. LEGISLATIVE COUNSEL'S DIGEST AB 2994, Brulte. Health insurance: benefit coverage. Existing law does not prohibit health care service plans from excluding coverage for any surgical procedure for any condition directly affecting the upper or lower jawbone, or associated bone joints. It also does not prohibit group and individual policies of disability insurance, and individual and group nonprofit hospital service plan contracts that provide hospital, medical, or surgical coverage from excluding or denying coverage for the surgical procedure for those conditions directly affecting the upper or lower jawbone, or associated bone joints, as specified. This bill would provide that any provision of a prescribed health care service plan contract that excludes coverage for these surgical procedures shall have no force or effect if that provision results in any failure to provide medically-necessary services, as specified. It would also require certain individual and group policies of disability insurance and certain nonprofit hospital service plans to provide coverage for these procedures except with respect to dental services, if each procedure being considered for reimbursement is deemed medically-necessary pursuant to the plan's or policy's definition of medical necessity. A willful violation of this provision by a health care service plan is a misdemeanor. The bill would thus 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. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. Section 1367.68 is added to the Health and Safety Code, to read: 1367.68. (a) Any provision in a health care service plan contract entered into, amended, or renewed in this state on or after July 1, 1995, that excludes coverage for any surgical procedure for any condition directly affecting the upper or lower jawbone, or associated bone joints, shall have no force or effect as to any enrollee if that provision results in any failure to provide medically-necessary basic health care services to the enrollee pursuant to the plan's definition of medical necessity. (b) For purposes of this section, "plan contract" means every plan contract, except a specialized health care service plan contract, that covers hospital, medical, or surgical expenses. (c) Nothing in this section shall be construed to prohibit a plan from excluding coverage for dental services provided that any exclusion does not result in any failure to provide medically-necessary basic health care services. SEC. 2. Section 10123.21 is added to the Insurance Code, to read: 10123.21. On or after July 1, 1995, every individual or group policy of disability insurance that provides hospital, medical, or surgical coverage entered into, amended, or renewed in this state shall, subject to other terms and conditions as may be agreed upon between the group or individual policyholder and the insurer, provide coverage for the surgical procedure for those covered conditions directly affecting the upper or lower jawbone, or associated bone joints, if each procedure being considered for reimbursement is deemed medically-necessary by the insurer pursuant to the policy's definition of medical necessity. Nothing in this section shall be construed to require the provision of dental services if dental services are specifically excluded from coverage under the terms and conditions of the contract between the group or individual policyholder and insurer. SEC. 3. Section 11512.156 is added to the Insurance Code, to read: 11512.156. On or after July 1, 1995, every individual or group nonprofit hospital service plan contract that provides hospital, medical, or surgical benefits entered into, amended, or renewed in this state shall, subject to other terms and conditions as may be agreed upon between the group or individual subscriber and the plan, provide coverage for the surgical procedure for those covered conditions directly affecting the upper or lower jawbone, or associated bone joints, if each procedure being considered for reimbursement is deemed medically-necessary by the plan pursuant to the plan's definition of medical necessity. Nothing in this section shall be construed to require the provision of dental services if dental services are specifically excluded from coverage under the terms and conditions of the contract between the group or individual subscriber and the plan. SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs which may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, changes the definition of a crime or infraction, changes the penalty for a crime or infraction, or eliminates a crime or infraction. Notwithstanding Section 17580 of the Government Code, unless otherwise specified in this act, the provisions of this act shall become operative on the same date that the act takes effect pursuant to the California Constitution.