BILL NUMBER: AB 1976 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Cook
FEBRUARY 17, 2010
An act to add Article 12 (commencing with Section 1399.850) to
Chapter 2.2 of Division 2 of the Health and Safety Code, and to add
Chapter 7.5 (commencing with Section 10650) to Part 2 of Division 2
of the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1976, as introduced, Cook. Health care coverage: report of
claim information.
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. Existing law provides
for the regulation of health insurers by the Department of
Insurance.
Existing law, the federal Health Insurance Portability and
Accountability Act of 1996, establishes certain requirements relating
to the provision of health insurance and the protection of privacy
of individually identifiable health information. The act authorizes
group health plans to permit health insurance issuers, as defined, to
disclose protected health information to plan sponsors if specified
requirements are met.
This bill would, on and after July 1, 2011, require a health care
service plan or health insurer that receives a written request for a
written report of claim information from the group subscriber or
group policyholder of a group health care service plan contract or
health insurance policy issued by the plan or insurer, as specified,
to provide that report to the subscriber or policyholder no later
than 30 days after receipt of the request. The bill would require the
report to be provided in a specified manner and to include specified
information after removing any individually identifiable
information, as defined. The bill would prohibit the health care
service plan or health insurer from disclosing any information
protected under federal or state law. The bill would make a plan or
insurer that fails to comply with these requirements subject to
administrative penalties assessed by the departments.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Article 12 (commencing with Section 1399.850) is added
to Chapter 2.2 of Division 2 of the Health and Safety Code, to read:
Article 12. Reporting of Claim Information
1399.850. (a) For purposes of this article, except as provided in
subdivision (b), the following definitions apply:
(1) "Group health care service plan contract" means a group health
care service plan contract other than a contract issued to a small
employer, as defined in subdivision (l) of Section 1357.
(2) "Individually identifiable information" means both of the
following:
(A) Individually identifiable health information, as defined in
Section 160.103 of Title 45 of the Code of Federal Regulations.
(B) Medical information, as defined in Section 56.05 of the Civil
Code.
(b) A reference to a federal statute or regulation under
subdivision (a) refers to that statute or regulation as it existed on
January 1, 2010, except that the director may, by rule, in
consultation with the Insurance Commissioner, adopt a definition
based on a later amended, enacted, or adopted federal statute or
regulation if the director determines that use of the later amended,
enacted, or adopted statute or regulation is consistent with the
purposes of this article and promotes regulatory consistency.
1399.852. (a) A health care service plan that receives a written
request for a written report of claim information from the group
subscriber of a group health care service plan contract issued by the
plan shall provide that report, consistent with the requirements of
this section, to the group subscriber no later than 30 days after
receipt of the request. The health care service plan shall not be
required to provide a report under this subdivision regarding a
particular group health care service plan contract more than twice in
a 12-month period.
(b) A health care service plan shall provide the report of claim
information required pursuant to subdivision (a) by one of the
following means:
(1) In a written report.
(2) Through an electronic file transmitted by secure electronic
mail or a file transfer protocol site.
(3) By making the required information available through a secure
Internet Web site or Web portal accessible by the requesting group
subscriber.
(c) A report of claim information provided under this section
shall contain all information available to the health care service
plan for the 36-month period preceding the date of the report or the
entire period of coverage, whichever period is shorter, except as
provided in paragraph (5) and in subdivision (e). Except as provided
in subdivision (d), the report required by this section shall include
all of the following information, after removing any individually
identifiable information:
(1) Aggregate paid claims experience by month, including, but not
limited to, claims experience for medical, dental, and pharmacy
benefits, including capitation costs or payments in the case of
health maintenance organizations, as applicable. Twenty thousand
dollars ($20,000) shall be used as the pooling point for aggregate
reporting.
(2) Total premiums paid by month.
(3) The total number of covered employees on a monthly basis by
coverage tier, including whether the coverage was for one of the
following:
(A) An employee only.
(B) An employee with dependents only.
(C) An employee with a spouse only.
(D) An employee with a spouse and dependents.
(4) The total dollar amount of claims pending as of the date of
the report.
(5) A separate description and individual claims report for any
individual whose total paid claims exceed twenty thousand dollars
($20,000) during the 12-month period preceding the date of the
report. This report shall include both of the following related to
the claims for that individual:
(A) The amounts paid during the 12-month period.
(B) The applicable procedure codes and diagnosis codes.
(d) A health care service plan shall not disclose any information
in the report required under this section that the health care
service plan is prohibited from disclosing under another state or
federal law that imposes more stringent privacy restrictions than
those imposed under federal law under the Health Insurance
Portability and Accountability Act of 1996 (Public Law 104-191).
(e) If a health care service plan receives a request under
subdivision (a) after the date that coverage under the applicable
group health care service plan contract has terminated, the report
required under subdivision (a) shall contain all information
available to the health care service plan for the period described in
subdivision (c) preceding the date of termination of coverage or for
the entire period of coverage, whichever period is shorter. The
report shall include the information described in paragraphs (1) to
(5), inclusive, of subdivision (c), but shall not include any
individually identifiable health information.
(f) In order to be entitled to receive the report described in
this section, a group subscriber shall request that report on or
before the second anniversary of the date of termination of coverage
under a group health care service plan contract issued by the health
care service plan.
(g) A report of claim information provided under this section by
or to a state or local agency, as defined in Section 6252 of the
Government Code, is confidential and exempt from public disclosure
under Chapter 3.5 (commencing with Section 6250) of Division 7 of
Title 1 of the Government Code.
1399.853. For purposes of this article, Sections 1374.8 and 1390
shall not apply.
1399.854. A health care service plan that fails to comply with
this article is subject to administrative penalties assessed by the
department subject to appropriate notice of, and opportunity for, a
hearing in accordance with Section 1397.
1399.855. (a) This article applies only to a request for a
written report of claim information made on or after July 1, 2011.
(b) This article shall not apply to specialized health care
service plans.
SEC. 2. Chapter 7.5 (commencing with Section 10650) is added to
Part 2 of Division 2 of the Insurance Code, to read:
CHAPTER 7.5. REPORTING OF CLAIM INFORMATION
10650. (a) For purposes of this chapter, except as provided in
subdivision (b), the following definitions apply:
(1) "Group health insurance policy" means a group health insurance
policy other than a policy issued to a small employer, as defined in
subdivision (w) of Section 10700.
(2) "Individually identifiable information" means both of the
following:
(A) Individually identifiable health information, as defined in
Section 160.103 of Title 45 of the Code of Federal Regulations.
(B) Medical information, as defined in Section 56.05 of the Civil
Code.
(b) A reference to a federal statute or regulation under
subdivision (a) refers to that statute or regulation as it existed on
January 1, 2010, except that the commissioner may, by rule, in
consultation with the Director of Managed Health Care, adopt a
definition based on a later amended, enacted, or adopted federal
statute or regulation if the commissioner determines that use of the
later amended, enacted, or adopted statute or regulation is
consistent with the purposes of this chapter and promotes regulatory
consistency.
10652. (a) A health insurer that receives a written request for a
written report of claim information from the group policyholder of a
group health insurance policy issued by the insurer shall provide
that report, consistent with the requirements of this section, to the
group policyholder no later than 30 days after receipt of the
request. The health insurer shall not be required to provide a report
under this subdivision regarding a particular group health insurance
policy more than twice in a 12-month period.
(b) A health insurer shall provide the report of claim information
required pursuant to subdivision (a) by one of the following means:
(1) In a written report.
(2) Through an electronic file transmitted by secure electronic
mail or a file transfer protocol site.
(3) By making the required information available through a secure
Internet Web site or Web portal accessible by the requesting group
policyholder.
(c) A report of claim information provided under this section
shall contain all information available to the health insurer for the
36-month period preceding the date of the report or the entire
period of coverage, whichever period is shorter, except as provided
in paragraph (5) and in subdivision (e). Except as provided in
subdivision (d), the report required by this section shall include
all of the following information, after removing any individually
identifiable information:
(1) Aggregate paid claims experience by month, including, but not
limited to, claims experience for medical, dental, and pharmacy
benefits, including capitation costs or payments in the case of
contracts with providers at alternative rates pursuant to Section
10133, as applicable. Twenty thousand dollars ($20,000) shall be used
as the pooling point for aggregate reporting.
(2) Total premiums paid by month.
(3) The total number of covered employees on a monthly basis by
coverage tier, including whether the coverage was for one of the
following:
(A) An employee only.
(B) An employee with dependents only.
(C) An employee with a spouse only.
(D) An employee with a spouse and dependents.
(4) The total dollar amount of claims pending as of the date of
the report.
(5) A separate description and individual claims report for any
individual whose total paid claims exceed twenty thousand dollars
($20,000) during the 12-month period preceding the date of the
report. This report shall include both of the following related to
the claims for that individual:
(A) The amounts paid during the 12-month period.
(B) The applicable procedure codes and diagnosis codes.
(d) A health insurer shall not disclose any information in the
report required under this section that the health insurer is
prohibited from disclosing under another state or federal law that
imposes more stringent privacy restrictions than those imposed under
federal law under the Health Insurance Portability and Accountability
Act of 1996 (Public Law 104-191).
(e) If a health insurer receives a request under subdivision (a)
after the date that coverage under the applicable group health
insurance policy has terminated, the report required under
subdivision (a) shall contain all information available to the health
insurer for the period described in subdivision (c) preceding the
date of termination of coverage or for the entire policy period,
whichever period is shorter. The report shall include the information
described in paragraphs (1) to (5), inclusive, of subdivision (c),
but shall not include any individually identifiable health
information.
(f) In order to be entitled to receive the report described in
this section, a group policyholder shall request that report on or
before the second anniversary of the date of termination of coverage
under a group health insurance policy issued by the health insurer.
(g) A report of claim information provided under this section by
or to a state or local agency, as defined in Section 6252 of the
Government Code, is confidential and exempt from public disclosure
under Chapter 3.5 (commencing with Section 6250) of Division 7 of
Title 1 of the Government Code.
10653. For purposes of this chapter, Section 791.27 shall not
apply.
10654. A health insurer that fails to comply with this chapter is
subject to administrative penalties assessed by the department
subject to appropriate notice of, and opportunity for, a hearing.
10655. (a) This chapter applies only to a request for a written
report of claim information made on or after July 1, 2011.
(b) This chapter shall not apply to specialized health insurance
policies.
SEC. 3. The Legislature finds and declares that Sections 1 and 2
of this act, which add Section 1399.852 to the Health and Safety Code
and Section 10652 to the Insurance Code, respectively, impose a
limitation on the public's right of access to the meetings of public
bodies or the writings of public officials and agencies within the
meaning of Section 3 of Article I of the California Constitution.
Pursuant to that constitutional provision, the Legislature makes the
following findings to demonstrate the interest protected by this
limitation and the need for protecting that interest:
In order to protect personally identifiable health information, it
is necessary to ensure that the reports provided pursuant to this
act are kept confidential.