Health care coverage: rate review.

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 provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer offering a contract or policy in the individual or small group market to file specified information, including total earned premiums and total incurred claims for each contract or policy form, with the appropriate department at least 120 days before implementing a rate change. Existing law requires a health plan that exclusively contracts with no more than 2 medical groups in the state to disclose actual trend experience information in lieu of disclosing specified annual medical trend factor assumptions and projected trends, as specified. Existing law requires the Department of Managed Health Care to conduct an annual public meeting regarding large group rates. This bill, commencing July 1, 2020, would expand those requirements to apply to large group health care service plan contracts and health insurance policies, and would impose additional rate filing requirements on large group contracts and policies. On and after July 1, 2020, the bill would require a plan or insurer to disclose with a rate filing specified information by geographic region for individual, grandfathered group, and nongrandfathered group contracts and policies, including the price paid compared to the price paid by the Medicare Program for the same services in each benefit category. The bill would eliminate separate reporting and disclosure requirements for a health plan that exclusively contracts with no more than 2 medical groups in the state. On and after July 1, 2020, the bill would require a health care service plan that fails to file specified information to disclose other information by market and by geographic region. If a plan or insurer fails to provide all the information required, the bill would specify that the filing is an unjustified rate on and after July 1, 2020. The bill would authorize a large group contractholder that has experience-rated or blended coverage and meets specified criteria to apply to the Department of Managed Health Care or Department of Insurance, as appropriate, within 60 days of receiving notice of a rate change to review a rate change and determine if it is unreasonable or not justified, and would require the appropriate department to use reasonable efforts to complete the review within 60 days of receiving all the information required to make a determination. The bill would require the Department of Managed Health Care to conduct a public meeting regarding large group rates in every even-numbered year. Because a willful violation of the bill's requirements relative 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.