Health care coverage: federally eligible defined individuals: preferred provider products: premium rates.

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 or a health insurer offering individual plan contracts or individual health insurance policies to fairly and affirmatively offer, market, and sell certain individual contracts and policies to all federally eligible defined individuals, as defined, in each service area in which the plan or insurer provides or arranges for the provision of health care services. For those contracts and policies that offer services through a preferred provider arrangement, existing law requires that the premium not exceed the average premium paid by a similar subscriber of the Major Risk Medical Insurance Program (MRMIP) , as specified. This bill would define the "average premium paid" for purposes of this provision as an amount calculated on an annual basis by the Managed Risk Medical Insurance Board using a weighted average based on each plan's or insurer's enrollment in MRMIP, as specified. The bill would require plans and insurers to include a statement regarding those maximum premium rates in certain solicitation and sales materials. Existing law requires plans and insurers to file a specified notice with the Department of Managed Health Care or the Department of Insurance prior to renewing or amending a contract or policy issued to a federally eligible defined individual and prior to changing the premium rates applicable to that contract or policy. Existing law requires the notice or amendment to include a certification of compliance with specified premium requirements. This bill would specify that this certification binds the plan or insurer to the representation of compliance and subjects the plan or insurer to all remedies available to the Director of the Department of Managed Health Care or the Insurance Commissioner, as specified. Because a willful violation of the bill's requirements with respect to health care service plans 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. This bill would declare that it is to take effect immediately as an urgency statute.