Bill Text: CA AB1216 | 2015-2016 | Regular Session | Amended
Bill Title: Limitations on cost sharing: family coverage.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2016-11-30 - Died on Senate inactive file. [AB1216 Detail]
Download: California-2015-AB1216-Amended.html
BILL NUMBER: AB 1216 AMENDED
BILL TEXT
AMENDED IN SENATE MAY 31, 2016
AMENDED IN ASSEMBLY MAY 14, 2015
INTRODUCED BY Assembly Member Bonta
FEBRUARY 27, 2015
An act to amend Section 14100.3 of the Welfare and
Institutions Code, relating to Medi-Cal. An act to
amend Section 1367.006 of the Health and Safety Code, and to amend
Secti on 10112.28 of the Insurance Code, relating to
health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1216, as amended, Bonta. Medi-Cal: plan amendments and
waiver applications. Limitations on cost sharing:
family coverage.
Existing federal law, the Patient Protection and Affordable Care
Act (PPACA), enacts various health care coverage market reforms that
take effect January 1, 2014. Among other things, PPACA establishes
annual limits on specified forms of cost sharing, including
deductibles, on all essential health benefits for nongrandfathered
individual and group health insurance 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 and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires a plan contract or policy and, commencing
January 1, 2017, for a large group market health plan contract or
policy, for family coverage that includes a deductible and is a high
deductible health plan, as defined in federal law, to include a
deductible for each individual covered by the plan contract or policy
that is equal to either the amount set forth in a specified
provision of federal law or the deductible for individual coverage
under the plan contract or policy, whichever is greater.
This bill would instead prohibit a large group market health plan
contract or policy for family coverage that is a high deductible
health plan, as defined in federal law, and that includes a
deductible for individual coverage from subjecting an individual
covered by the plan contract or policy to a deductible that is
greater than the deductible for individual coverage under the plan
contract or policy if the deductible for individual coverage is
greater than or equal to the amount set forth in the provision of
federal law described above. Because a willful violation of this
prohibition 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 provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing law grants the department the
rights and duties necessary to conform to requirements for securing
approval of an agreement, or state plan, between the state and the
federal government under Title XIX of the federal Social Security Act
that describes the nature and scope of the Medi-Cal program.
Existing law requires the department to seek approval from the
federal Centers for Medicare and Medicaid Services (CMS) of any
amendments to the state plan or a waiver from the requirements of the
act for the purposes of continued federal financial participation
under the act. Existing law requires the department to post on its
Internet Web site all submitted state plan amendments and all federal
waiver applications and requests for new waivers, waiver amendments,
and waiver renewals and extensions, within 10 business days from the
date of submission of those documents to CMS. Existing law requires
the department to post on its Internet Web site all pending submitted
state plan amendments and federal waiver applications and requests
that the department submitted to CMS in 2009 and every year
thereafter.
This bill would instead require the department to post on its
Internet Web Site all submitted state plan amendments and all federal
waiver applications and requests for new waivers, waiver amendments,
and waiver renewals and extensions within 7 business days from the
date of submission, and would also require the department to post all
pending submitted state plan amendments and federal waiver
applications and requests. The bill would require the department to
accept public comment on all state plan amendments and waivers, as
specified, and would authorize use of information from the comments
to make amendments to those documents.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no yes .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.006 of the
Health and Safety Code is amended to read:
1367.006. (a) This section shall apply to nongrandfathered
individual and group health care service plan contracts that provide
coverage for essential health benefits, as defined in Section
1367.005, and that are issued, amended, or renewed on or after
January 1, 2015.
(b) (1) For nongrandfathered health care service plan contracts in
the individual or small group markets, a health care service plan
contract, except a specialized health care service plan contract,
that is issued, amended, or renewed on or after January 1, 2015,
shall provide for a limit on annual out-of-pocket expenses for all
covered benefits that meet the definition of essential health
benefits in Section 1367.005, including out-of-network emergency care
consistent with Section 1371.4.
(2) For nongrandfathered health care service plan contracts in the
large group market, a health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, or renewed on or after January 1, 2015, shall provide for a
limit on annual out-of-pocket expenses for covered benefits,
including out-of-network emergency care consistent with Section
1371.4. This limit shall only apply to essential health benefits, as
defined in Section 1367.005, that are covered under the plan to the
extent that this provision does not conflict with federal law or
guidance on out-of-pocket maximums for nongrandfathered health care
service plan contracts in the large group market.
(c) (1) The limit described in subdivision (b) shall not exceed
the limit described in Section 1302(c) of PPACA, and any subsequent
rules, regulations, or guidance issued under that section.
(2) The limit described in subdivision (b) shall result in a total
maximum out-of-pocket limit for all covered essential health
benefits equal to the dollar amounts in effect under Section 223(c)
(2)(A)(ii) of the Internal Revenue Code of 1986 with the dollar
amounts adjusted as specified in Section 1302(c)(1)(B) of PPACA.
(3) For family coverage, an individual within a family shall not
have a maximum out-of-pocket limit that is greater than the maximum
out-of-pocket limit for individual coverage for that product.
(d) Nothing in this section shall be construed to affect the
reduction in cost sharing for eligible enrollees described in Section
1402 of PPACA, and any subsequent rules, regulations, or guidance
issued under that section.
(e) If an essential health benefit is offered or provided by a
specialized health care service plan, the total annual out-of-pocket
maximum for all covered essential benefits shall not exceed the limit
in subdivision (b). This section shall not apply to a specialized
health care service plan that does not offer an essential health
benefit as defined in Section 1367.005.
(f) The maximum out-of-pocket limit shall apply to any copayment,
coinsurance, deductible, and any other form of cost sharing for all
covered benefits that meet the definition of essential health
benefits in Section 1367.005.
(g) (1) (A) Except as provided in paragraph (2), if a health care
service plan contract for family coverage includes a deductible, an
individual within a family shall not have a deductible that is
greater than the deductible limit for individual coverage for that
product.
(B) Except as provided in paragraph (2), if a large group market
health care service plan contract for family coverage that is issued,
amended, or renewed on or after January 1, 2017, includes a
deductible, an individual within a family shall not have a deductible
that is more than the deductible limit for individual coverage for
that product.
(2) (A) If For coverage in the individual
and small group markets, if a health care service plan contract
for family coverage includes a deductible and is a high deductible
health plan under the definition set forth in Section 223(c)(2) of
Title 26 of the United States Code, the plan contract shall include a
deductible for each individual covered by the plan that is equal to
either the amount set forth in Section 223(c)(2)(A)(i)(II) of Title
26 of the United States Code or the deductible for individual
coverage under the plan contract, whichever is greater.
(B) If a large group market health care service plan contract for
family coverage that is issued, amended, or renewed on or after
January 1, 2017, includes a deductible and is a
high deductible health plan under the definition set forth in Section
223(c)(2) of Title 26 of the United States Code, the plan
contract shall include a deductible for each individual covered by
the plan that is equal to either the amount set forth in Section 223
(c)(2)(A)(i)(II) of Title 26 of the United States Code or the
deductible for individual coverage under the plan contract, whichever
is greater. Code and includes a deductible for
individual coverage that is equal to or greater than the amount set
forth in Section 223(c)(2)(A)(i)(II) of Title 26 of the United States
Code and federal regulations thereunder, then no individual covered
by the plan may be subject to a deductible greater than the
deductible for individual coverage under the plan contract.
(h) For nongrandfathered health plan contracts in the group
market, "plan year" has the meaning set forth in Section 144.103 of
Title 45 of the Code of Federal Regulations. For nongrandfathered
health plan contracts sold in the individual market, "plan year"
means the calendar year.
(i) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.
SEC. 2. Section 10112.28 of the
Insurance Code is amended to read:
10112.28. (a) This section shall apply to nongrandfathered
individual and group health insurance policies that provide coverage
for essential health benefits, as defined in Section 10112.27, and
that are issued, amended, or renewed on or after January 1, 2015.
(b) (1) For nongrandfathered health insurance policies in the
individual or small group markets, a health insurance policy, except
a specialized health insurance policy, that is issued, amended, or
renewed on or after January 1, 2015, shall provide for a limit on
annual out-of-pocket expenses for all covered benefits that meet the
definition of essential health benefits in Section 10112.27,
including out-of-network emergency care.
(2) For nongrandfathered health insurance policies in the large
group market, a health insurance policy, except a specialized health
insurance policy, that is issued, amended, or renewed on or after
January 1, 2015, shall provide for a limit on annual out-of-pocket
expenses for covered benefits, including out-of-network emergency
care. This limit shall apply only to essential health benefits, as
defined in Section 10112.27, that are covered under the policy to the
extent that this provision does not conflict with federal law or
guidance on out-of-pocket maximums for nongrandfathered health
insurance policies in the large group market.
(c) (1) The limit described in subdivision (b) shall not exceed
the limit described in Section 1302(c) of PPACA and any subsequent
rules, regulations, or guidance issued under that section.
(2) The limit described in subdivision (b) shall result in a total
maximum out-of-pocket limit for all covered essential health
benefits that shall equal the dollar amounts in effect under Section
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 with the dollar
amounts adjusted as specified in Section 1302(c)(1)(B) of PPACA.
(3) For family coverage, an individual within a family shall not
have a maximum out-of-pocket limit that is greater than the maximum
out-of-pocket limit for individual coverage for that product.
(d) Nothing in this section shall be construed to affect the
reduction in cost sharing for eligible insureds described in Section
1402 of PPACA and any subsequent rules, regulations, or guidance
issued under that section.
(e) If an essential health benefit is offered or provided by a
specialized health insurance policy, the total annual out-of-pocket
maximum for all covered essential benefits shall not exceed the limit
in subdivision (b). This section shall not apply to a specialized
health insurance policy that does not offer an essential health
benefit as defined in Section 10112.27.
(f) The maximum out-of-pocket limit shall apply to any copayment,
coinsurance, deductible, and any other form of cost sharing for all
covered benefits that meet the definition of essential health
benefits, as defined in Section 10112.27.
(g) (1) (A) Except as provided in paragraph (2), if a health
insurance policy for family coverage includes a deductible, an
individual within a family shall not have a deductible that is
greater than the deductible limit for individual coverage for that
product.
(B) Except as provided in paragraph (2), for a large group market
health insurance policy for family coverage that is issued, amended,
or renewed on or after January 1, 2017, includes a deductible, an
individual within a family shall not have a deductible that is
greater than the deductible limit for individual coverage for that
product.
(2) (A) If
For coverage in the individual and small group
markets, if a health insurance policy for family coverage
includes a deductible and is a high deductible health plan under the
definition set forth in Section 223(c)(2) of Title 26 of the United
States Code, the policy shall include a deductible for each
individual covered by the policy that is equal to either the amount
set forth in Section 223(c)(2)(A)(i)(II) of Title 26 of the United
States Code or the deductible for individual coverage under the
policy, whichever is greater.
(B) If
If a large group market health insurance policy for
family coverage that is issued, amended, or renewed on or after
January 1, 2017, includes a deductible and is a
high deductible health plan under the definition set forth in Section
223(c)(2) of Title 26 of the United States Code, the policy
shall include a deductible for each individual covered by the policy
that is equal to either the amount set forth in Section 223(c)(2)(A)
(i)(II) of Title 26 of the United States Code or the deductible for
individual coverage under the policy, whichever is greater.
Code and includes a deductible for individual coverage that is
equal to or greater than the amount set forth in Section 223(c)(2)(A)
(i)(II) of Title 26 of the United States Code and federal regulations
thereunder, then no individual covered by the plan may be subject to
a deductible greater than the deductible for individual coverage
under the policy.
(h) For nongrandfathered health insurance policies in the group
market, "policy year" has the meaning set forth in Section 144.103 of
Title 45 of the Code of Federal Regulations. For nongrandfathered
health insurance policies sold in the individual market, "policy year"
means the calendar year.
(i) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.
SEC. 3. No reimbursement is required by this act
pursuant to Section 6 of Article XIII B of the California
Constitution because the only costs that may be incurred by a local
agency or school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction, or
changes the penalty for a crime or infraction, within the meaning of
Section 17556 of the Government Code, or changes the definition of a
crime within the meaning of Section 6 of Article XIII B of the
California Constitution.
SECTION 1. Section 14100.3 of the Welfare and
Institutions Code is amended to read:
14100.3. (a) (1) The State Department of Health Care Services
shall post on its Internet Web site all submitted state plan
amendments and all federal waiver applications and requests for new
waivers, waiver amendments, and waiver renewals and extensions,
within seven business days from the date the department submits these
documents for approval to the federal Centers for Medicare and
Medicaid Services (CMS).
(2) The department shall accept public comment on all submitted
state plan amendments and all federal waiver applications and
requests for new waivers, waiver amendments, and waiver renewals and
extensions, for a period of 30 days from the date the department
submits these documents for approval to CMS, and post the comments on
the department's Internet Web site. The department shall not be
required to respond to any comment submitted. However, the department
may use any information provided in the comments to make amendments
to any submitted state plan amendment or waiver, as the department
deems necessary.
(b) The department shall post on its Internet Web site final
approval or denial letters and accompanying documents for all
submitted state plan amendments and federal waiver applications and
requests within 10 business days from the date the department
receives notification of final approval or denial from CMS.
(c) If the department notifies CMS of the withdrawal of a
submitted state plan amendment or federal waiver application or
request, as described in subdivisions (a) and (b), the department
shall post on its Internet Web site the withdrawal notification
within 10 business days from the date the department notifies CMS of
the withdrawal.
(d) Unless already posted on the Internet Web site pursuant to
subdivisions (a) to (c), inclusive, the department shall post on its
Internet Web site all pending submitted state plan amendments and
federal waiver applications and requests.
