Health care coverage.

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 that the willful violation of provisions regulating health care service plans is a crime. Existing law provides for the licensing and regulation of health insurers by the Insurance Commissioner. Existing law requires health care service plans and health insurers to provide certain benefits, but generally does not require plans and insurers to cover prescription drugs. Existing law imposes various requirements on plans and insurers if they offer coverage for prescription drugs. Existing law, with respect to health care service plans, authorizes a plan to file information with the department to seek the approval of, among other things, a copayment, deductible, or exclusion to a plan's prescription drug benefit and specifies that an approved exclusion shall not be subject to review through the independent medical review process on the grounds of medical necessity. Existing federal law, the Patient Protection and Affordable Care Act, commencing January 1, 2014, imposes an annual limitation on cost sharing incurred under a health plan that shall not exceed a specified amount. This bill would, commencing January 1, 2014, require a health care service plan contract and a health insurance policy, except for a specialized plan or policy, to provide for a limit on annual out-of-pocket expenses for certain covered benefits, except as specified, and would provide that this limit shall not exceed that federal limit. The bill would also provide, commencing January 1, 2014, that these provisions shall not be construed to affect the reduction in cost sharing for eligible insureds described in federal law. Existing law provides that the obligation of a plan to comply with specified standards is not waived when the plan delegates any services that it is required to perform to its medical groups, independent practice associations, or other contracting entities. This bill would apply those provisions regarding waiver to the obligation of a plan to comply with the Knox-Keene Health Care Service Plan Act of 1975, rather than to the obligation of the plan to comply with specified standards. Because this bill would impose new requirements on health care service plans, the willful violation of which would be a crime, it would thereby 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.