Health care coverage: cost sharing: monitoring.

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. A willful violation of the act is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to limit annual out-of-pocket expenses for all covered benefits, as specified. This bill would require a health care service plan or health insurer to be responsible for monitoring the accrual of out-of-pocket costs toward the annual out-of-pocket limit. The bill would require a health care service plan or health insurer, for cost sharing attributed to in-network providers, including contracted vendors, that count toward the annual limit on out-of-pocket costs, to be solely responsible for monitoring the accrual of out-of-pocket costs and prohibit the health care service plan or health insurer from requiring the consumer to track or monitor the accumulation of cost sharing for covered essential health benefits attributed to in-network providers, including contracted vendors. The bill would require a health care service plan or health insurer to accept claims from the provider or information from the consumer with respect to cost sharing for out-of-network providers who are providing certain emergency services or otherwise providing covered benefits arranged by the health care service plan or health insurer subject to the annual limit on out-of-pocket expenses. The bill would also require the health care service plan or health insurer, if the cost sharing for covered essential health benefits attributable to an enrollee or insured exceeds the maximum annual out-of-pocket limits, to reimburse the enrollee or insured no later than 5 working days after the health care service plan or health insurer is required to reimburse the claim or notify the claimant that the claim is contested or denied. The bill would require that the enrollee or insured have the opportunity to review the accrual of cost sharing and provide additional information regarding cost sharing that should be accrued to the out-of-pocket limit. Because a willful violation of the bill's provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. This bill would make these provisions applicable to nongrandfathered individual and group health care service plans, specialized health care service plans that provide coverage for essential health benefits, nongrandfathered individual and group health insurers, and specialized health insurers that provide coverage for essential health benefits. 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.