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 contract or health insurance policy to provide coverage for all generally medically accepted cancer screening tests. This bill would require a health care service plan contract or health insurance policy, except as specified, that is issued, amended, or renewed on or after January 1, 2027, to provide coverage for followup screening or diagnostic services for lung cancer, as specified. The bill would prohibit a contract or policy from imposing a copayment, coinsurance, deductible, or any other form of cost sharing for this coverage. If a health care service plan contract or health insurance policy is a high deductible health plan, the bill would prohibit the contract or policy from imposing a deductible, coinsurance, or any other cost sharing on this coverage unless not imposing the deductible, coinsurance, or cost sharing would conflict with the federal requirements for high deductible health plans. Because a willful violation of these provisions 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.
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 prohibits a contract between a plan or insurer and a dentist from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee's contract or the insured's policy. Existing law requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. Existing law requires a health care service plan or health insurer to comply with specified timely access requirements. Under existing law, a health care service plan is required to annually report to the Department of Managed Health Care on this compliance. Existing law authorizes the Department of Insurance to issue guidance to insurers regarding annual timely access and network reporting methodologies. This bill would require a plan or insurer, including a specialized plan or insurer, covering dental services, to pay a noncontracting dental provider, which includes a registered dental hygienist in alternative practice, directly for covered services rendered to the enrollee or insured in accordance with the benefit provided in the contract or policy when the noncontracting dental provider submits to the plan or insurer an assignment of benefits. The bill would require a noncontracting dental provider to obtain a signed and dated consent to collect an assignment of benefits from an enrollee or insured. The bill would prohibit a noncontracting dental provider collecting an enrollee's or insured's assignment of benefits from charging an enrollee or insured, prior to the plan or insurer payment, more than an estimate of the enrollee's or the insured's cost sharing for the treatment or a deposit that approximates that cost share. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program. This bill would require a plan or insurer to certify, under penalty of perjury, that specified information submitted to its regulator regarding network adequacy is true and correct, thus creating a crime and imposing a state-mandated local program. Existing law, the Dental Practice Act, provides for the licensure and regulation of dentists and dental assistants by the Dental Board of California and the licensure and regulation of dental hygienists by the Dental Hygiene Board of California, and defines unprofessional conduct by a licensee, including, among other things, the violation of any provision of the act. Existing law authorizes the respective board to discipline a licensee under the act by placing the licensee on probation under various specified terms and conditions. This bill would require a noncontracting dental provider, including a registered dental hygienist in alternative practice, to make specified disclosures to a patient before collecting the patient's signed and dated consent to an assignment of benefits. The bill would expand the definition of unprofessional conduct under the act to include the failure to comply with that disclosure requirement and the above-described prohibition relating to the charging of a patient more than an estimate of their cost sharing and the failure to maintain a signed and dated copy of the patient's consent. 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 measure would call upon Congress to reauthorize the enhanced premium tax credits and would urge Congress to continue exploring the concept of bolstering health savings accounts, as specified.
This measure would urge the United States Congress and the President of the United States to immediately restore and extend the enhanced Affordable Care Act premium tax credits.
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 contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals. Under existing law, mammography performed pursuant to those requirements or that meets the current recommendations of the United States Preventive Services Task Force is provided to an enrollee or an insured without cost sharing. This bill would require a health care service plan contract, a health insurance policy, or a self-insured employee welfare benefit plan issued, amended, or renewed on or after January 1, 2028, to provide coverage without imposing cost sharing for, among other things, screening mammography and medically necessary diagnostic breast imaging, including diagnostic breast imaging following an abnormal mammography result and for an enrollee or insured indicated to have a risk factor associated with breast cancer, except as specified. 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.
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 prohibits a contract between a plan or insurer and a dentist from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee's contract or the insured's policy. Existing law requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. Existing law requires a health care service plan or health insurer to comply with specified timely access requirements. For a specified plan or insurer offering coverage for dental services, existing law requires urgent dental appointments to be offered within 72 hours of a request, nonurgent dental appointments to be offered within 36 business days of a request, and preventive dental care appointments to be offered within 40 business days of a request, as specified. Existing law requires a contract between a health care service plan and health care provider to ensure compliance with network adequacy standards and to require reporting by providers to plans to ensure compliance. Under existing law, a health care service plan is required to annually report to the Department of Managed Health Care on this compliance. Existing law authorizes the Department of Insurance to issue guidance to insurers regarding annual timely access and network reporting methodologies. If a health care service plan or health insurer pays a contracting dental provider directly for covered services, this bill would require the plan or insurer to pay a noncontracting dental provider directly for covered services if the noncontracting provider submits to the plan or insurer a written assignment of benefits form signed by the enrollee or insured. The bill would require the plan or insurer to provide a predetermination or prior authorization to the dental provider and to reimburse the provider for not less than that amount, except as specified. The bill would require the plan or insurer to notify the enrollee or insured that the provider was paid and that the out-of-network cost may count towards their annual or lifetime maximum. The bill would require a noncontracting dental provider to make specified disclosures to an enrollee or insured before accepting an assignment of benefits. This bill would require specified plans and insurers that cover dental services to offer urgent dental appointments within 48 hours of a request, nonurgent dental appointments within 18 business days of a request, and preventive dental care appointments within 20 business days of a request, as specified. The bill would subject dentists to the relevant department's regulatory geographic accessibility standards. The bill would require plans and insurers to report comprehensive information regarding the networks that each dental provider serves. The bill would require the Department of Managed Health Care or the Department of Insurance to review the adequacy of an entire dental provider network, including the portions of the network serving plans and insurers not regulated by the respective department. Because a willful violation of the above-described provisions by a health care service plan would be a crime, this 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.
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 establishes the Independent Medical Review System within each department, under which an enrollee or insured may seek review if a health care service has been denied, modified, or delayed by a health care service plan or health insurer and the enrollee or insured has previously filed a grievance that remains unresolved after 30 days. This bill would require a health care service plan or health insurer to annually report to the appropriate department the total number of claims processed by the health care service plan or health insurer for the prior year and its number of treatment denials or modifications, separated and disaggregated as specified, commencing on or before June 1, 2026. The bill would require the departments to compare the number of a health care service plan's or health insurer's treatment denials and modifications to (1) the number of successful independent medical review overturns of the plan's or insurer's treatment denials or modifications and (2) the number of treatment denials or modifications reversed by a plan or insurer after an independent medical review for the denial or modification is requested, filed, or applied for. For a health care service plan or health insurer with 10 or more independent medical reviews in a given year, the bill would make the health care service plan or health insurer liable for an administrative penalty, as specified, if more than 50% of the independent medical reviews filed with a health care service plan or health insurer result in an overturning or reversal of a treatment denial or modification in any one individual category of specified general types of care. The bill would make a health care service plan or health insurer liable for additional administrative penalties for each independent medical review resulting in an additional overturned or reversed denial or modification in excess of that threshold. The bill would require the departments to annually include data, analysis, and conclusions relating to these provisions in specified reports. Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. Existing law creates the Managed Care Administrative Fines and Penalties Fund in the State Treasury for the deposit of fines and administrative penalties collected pursuant to provisions licensing and regulating health care service plans. This bill would create the Managed Care Independent Medical Review Administrative Penalties Subaccount in the Managed Care Administrative Fines and Penalties Fund for the receipt and deposit of moneys generated from the administrative penalties described above with respect to health care service plans. The bill would create the Health Insurance Independent Medical Review Administrative Penalties Fund in the State Treasury for the receipt and deposit of moneys generated from the administrative penalties described above with respect to health insurers. The bill would authorize the moneys in the Managed Care Independent Medical Review Administrative Penalties Subaccount and Health Insurance Independent Medical Review Administrative Penalties Fund to be expended, as specified, upon appropriation by the Legislature. This bill would declare that its provisions are severable. 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.
Existing law creates the California Health Benefit Exchange (Exchange) , also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under the federal Patient Protection and Affordable Care Act. Existing law requires the Exchange to enroll an individual in the lowest cost silver plan or another plan, as specified, upon receiving the individual's electronic account from an insurance affordability program. Existing law requires enrollment to occur before coverage through the insurance affordability program is terminated, and prohibits the premium due date from being sooner than the last day of the first month of enrollment. This bill would, commencing July 1, 2026, additionally authorize the Exchange to enroll an individual in the plan in which other members of the individual's household are enrolled, as specified, or the lowest cost plan available to an Indian who is eligible for specified reduced cost sharing, as determined by the Exchange, and would require the Exchange to enroll an individual in any of the plans described above upon receipt of a complete application for an insurance affordability program submitted through the Statewide Automated Welfare System. The bill would require the Exchange to enroll the individual either before coverage through the insurance affordability program is terminated as described above or upon the receipt of a complete application for an insurance affordability program through the Statewide Automated Welfare System as described above. Existing law requires the Exchange to provide an individual who is enrolled in a plan described above with a notice that includes specified information, including a statement that services received during the first month of enrollment will only be covered by the plan if the premium is paid by the due date. This bill would require the Exchange to provide the notice described above prior to the individual's effective date of coverage, and to provide, instead of the statement described above, instructions on how to effectuate coverage in the selected plan, including by paying the premium on or before the due date, or, if there is no premium due, instructions on how to opt into the selected plan.
Existing law establishes the Health Care Benefits Fund to support the University of California's implementation of the California Health Benefit Review Program. Under the program, the University of California assesses legislation proposing to repeal or mandate a benefit or service requirement on health care insurance plans or health insurers. Under the program, the University of California provides a written analysis that includes, among other data, financial impacts of legislation on publicly funded state health insurance programs, including the Medi-Cal program and the Healthy Families Program. Existing law imposes an annual charge on health care service plans and health insurers for the 2022–23 to 2026–27 fiscal years, inclusive, as specified, to be deposited into the fund. Existing law prohibits the total annual assessment on health care service plans and health insurers from exceeding $2,200,000. Under existing law, the fund and the program become inoperative on July 1, 2027, and are repealed as of January 1, 2028. This bill would extend the operation of the California Health Benefit Review Program and the Health Care Benefits Fund through July 1, 2033, and would authorize the continued assessment of the annual charge on health care service plans and health insurers for that purpose for the 2026–27 to 2032–33 fiscal years, inclusive. The bill would increase the allowable total annual assessment on health care service plans and health insurers to $3,200,000. The bill would remove the Healthy Families Program as an example of the publicly funded state health insurance programs within an analysis of financial impacts of legislation. This bill would make these provisions inoperative on July 1, 2033, and would repeal it as of January 1, 2034. This bill would include a change in state statute that would result in a taxpayer paying a higher tax within the meaning of Section 3 of Article XIIIA of the California Constitution, and thus would require for passage the approval of 23 of the membership of each house of the Legislature.
Existing law, for policy years beginning on or after January 1, 2024, requires student health insurance coverage, as defined, to be considered individual health insurance coverage. Existing law, except as specified, requires a blanket disability insurance policy that meets the definition of student health insurance coverage to comply with insurance provisions that are applicable to nongrandfathered individual health insurance, including, among others, essential health benefits requirements and annual limits on out-of-pocket expenses. Existing law exempts student health insurance coverage from certain requirements otherwise applicable to health insurers and health benefit plans, including the establishment of specified enrollment periods, guaranteed availability and renewability, specified coverage level requirements, and single risk pool rating requirements. Existing law requires a notice to be provided in the student health insurance enrollment materials stating that California requires residents and their dependents to obtain and maintain health coverage, either through student health insurance, or through a different method, including Medi-Cal, Covered California, or, if under 26 years of age, their parent's coverage. This bill would, commencing July 1, 2026, authorize a student certificate holder to request to terminate their student health insurance coverage during the policy year if the student graduates, takes a leave of absence, or is no longer enrolled at the institution of higher education. The bill would require the request to be provided to the institution of higher education at least 30 days before the effective date of termination and would, upon receipt of the request to terminate coverage, require the institution to terminate coverage effective within the same calendar month if feasible, but no later than the last day of the calendar month in which the 30-day period ends. The bill would authorize the student to pay only the premium through the date of the termination, as specified. The bill would require a student or dependent of a student to be notified of premium liability to them, if any, if they choose not to terminate coverage pursuant to these provisions. The bill would, commencing July 1, 2026, if a student requests a waiver from student health insurance coverage, require the waiver to be granted if the student obtains or maintains health coverage that is minimum essential coverage, as specified. The bill would prohibit charging the student a fee or premium if the waiver is granted. Existing law requires a health insurer to file with the Department of Insurance all required rate information for grandfathered individual and specified group health insurance policies at least 120 days before implementing any rate change. This bill would authorize the department to prohibit a requested rate change if the insurer fails to comply with the above-described timelines. This bill would also authorize the Insurance Commissioner to exercise their existing authority to enforce the above-described provisions and prohibits an administrative penalty, if assessed, from exceeding $5,000 for each violation, or $10,000 for a willful violation. The bill would also state the intent of the Legislature to encourage self-funded student health coverage offered by the University of California Student Health Insurance Plan and the University of California Voluntary Dependent Plan to maintain or exceed coverage standards of the federal Patient Protection and Affordable Care Act and to comply with the above described provisions.
