Dental benefits and 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's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services. This bill, on and after January 1, 2025, would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law establishes a process for the Department of Managed Health Care and the Department of Insurance to review proposed rate increases by health care service plans and health insurers in the individual or group market in California. Existing law excludes specialized health care service plan contracts and specialized health insurance policies, among others, from those provisions. This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program. This bill would require, on or after January 1, 2025, and at least annually thereafter, health care service plans and specialized health care service plans covering dental services or specialized health insurance policies covering dental services to file with the Department of Managed Health Care or Department of Insurance specified information, including, among other things, the type of plan or health insurer involved, such as for profit or not for profit. The bill would require the plan or health insurer to file with the respective departments the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. The bill would require the departments to issue a determination, for all plans or health insurers covering dental services, that the plan's or health insurer's rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to makes its determination. The bill would authorize the Director of the Department of Managed Health Care or the Insurance Commissioner, on or before July 1, 2024, to issue guidance to plans and health insurers regarding compliance with these provisions. Because a violation of these requirements by a health care service plan 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.