California Senate Bill SB1052 Amended / Bill

 BILL NUMBER: SB 1052AMENDED BILL TEXT AMENDED IN SENATE MAY 27, 2014 AMENDED IN SENATE APRIL 29, 2014 AMENDED IN SENATE MARCH 28, 2014 INTRODUCED BY Senator Torres FEBRUARY 18, 2014 An act  to amend Section 100503 of, and  to add Section 100503.1  to,   to  the Government Code, to amend Sections 1363.01 and 1368.016 of, and to add Section 1367.205 to, the Health and Safety Code, and to amend Section 10123.199 of, and to add Section 10123.192 to, the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGEST SB 1052, as amended, Torres. Health care coverage. Existing law, the Knox-Keene Health Care Service Plan Act (Knox-Keene 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. The Knox-Keene Act requires a health care service plan that provides prescription drug benefits and maintains one or more drug formularies to provide to members of the public, upon request, a copy of the most current list of prescription drugs on the formulary, as specified. This bill would require a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies to post those formularies on its Internet Web site, update that posting within 24 hours after making any formulary changes, use a standard template to display formularies, and include in any published formulary, among other information, the prior authorization or step edit requirements for, and the range of cost sharing for, each drug included on the formulary. The bill would authorize the Department of Managed Health Care and the Department of Insurance to develop a standard formulary template and would require plans and insurers to use that template to comply with specified provisions of the bill. The bill would make other related conforming changes. Because a willful 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 the California Health Benefit Exchange within state government, specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of qualified health plans through the Exchange by qualified individuals and small employers.  Existing law requires the board to undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange and to undertake outreach and enrollment activities that seek to assist with enrolling in the Exchange in the least burdensome manner. Existing law also requires the board of the Exchange to annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, as specified, and requires that this report be submitted to the Legislature and the Governor and be made available to the public on the Internet Web site of the Exchange.   This bill, would also require the report to include the total number of uninsured Californians as a percentage of the state population and an independent evaluation of the marketing and outreach and enrollment activities undertaken by the Exchange.  Existing law requires the board  of the Exchange  to determine the minimum requirements a  carrier   health care service plan or health insurer  must meet to be considered for participation in the Exchange and the standards and criteria for selecting qualified health plans to be offered through the Exchange that are in the best interests of qualified individuals and qualified small employers. This bill would require the board of the Exchange to ensure that its Internet Web site provides a direct link to the formularies for each qualified health plan offered through the Exchange that are posted by  carriers   plans and insurers  pursuant to the bill's provisions. The bill would also require the board  , on or before January 1, 2016,  to create a search tool on its Internet Web site that allows potential enrollees to search for qualified health plans by a particular drug and by a particular therapeutic condition. 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. Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:  SECTION 1.   Section 100503 of the Government Code, as amended by Section 4 of Chapter 5 of the First Extraordinary Session of the Statutes of 2013, is amended to read: 100503. In addition to meeting the minimum requirements of Section 1311 of the federal act, the board shall do all of the following: (a) Determine the criteria and process for eligibility, enrollment, and disenrollment of enrollees and potential enrollees in the Exchange and coordinate that process with the state and local government entities administering other health care coverage programs, including the State Department of Health Care Services, the Managed Risk Medical Insurance Board, and California counties, in order to ensure consistent eligibility and enrollment processes and seamless transitions between coverage. (b) Develop processes to coordinate with the county entities that administer eligibility for the Medi-Cal program and the entity that determines eligibility for the Healthy Families Program, including, but not limited to, processes for case transfer, referral, and enrollment in the Exchange of individuals applying for assistance to those entities, if allowed or required by federal law. (c) Determine the minimum requirements a carrier must meet to be considered for participation in the Exchange, and the standards and criteria for selecting qualified health plans to be offered through the Exchange that are in the best interests of qualified individuals and qualified small employers. The board shall consistently and uniformly apply these requirements, standards, and criteria to all carriers. In the course of selectively contracting for health care coverage offered to qualified individuals and qualified small employers through the Exchange, the board shall seek to contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service. (d) Provide, in each region of the state, a choice of qualified health plans at each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act. (e) Require, as a condition of participation in the Exchange, carriers to fairly and affirmatively offer, market, and sell in the Exchange at least one product within each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act. The board may require carriers to offer additional products within each of those five levels of coverage. This subdivision shall not apply to a carrier that solely offers supplemental coverage in the Exchange under paragraph (10) of subdivision (a) of Section 100504. (f) (1) Except as otherwise provided in this section and Section 100504.5, require, as a condition of participation in the Exchange, carriers that sell any products outside the Exchange to do both of the following: (A) Fairly and affirmatively offer, market, and sell all products made available to individuals in the Exchange to individuals purchasing coverage outside the Exchange. (B) Fairly and affirmatively offer, market, and sell all products made available to small employers in the Exchange to small employers purchasing coverage outside the Exchange. (2) For purposes of this subdivision, "product" does not include contracts entered into pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code between the Managed Risk Medical Insurance Board and carriers for enrolled Healthy Families beneficiaries or contracts entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code between the State Department of Health Care Services and carriers for enrolled Medi-Cal beneficiaries. "Product" also does not include a bridge plan product offered pursuant to Section 100504.5. (3) Except as required by Section 1301(a)(1)(C)(ii) of the federal act, a carrier offering a bridge plan product in the Exchange may limit the products it offers in the Exchange solely to a bridge plan product contract. (g) Determine when an enrollee's coverage commences and the extent and scope of coverage. (h) Provide for the processing of applications and the enrollment and disenrollment of enrollees. (i) Determine and approve cost-sharing provisions for qualified health plans. (j) Establish uniform billing and payment policies for qualified health plans offered in the Exchange to ensure consistent enrollment and disenrollment activities for individuals enrolled in the Exchange. (k) Undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange. The board shall also undertake outreach and enrollment activities that seek to assist enrollees and potential enrollees with enrolling and reenrolling in the Exchange in the least burdensome manner, including populations that may experience barriers to enrollment, such as the disabled and those with limited English language proficiency. (l) Select and set performance standards and compensation for navigators selected under subdivision (l) of Section 100502. (m) Employ necessary staff. (1) The board shall hire a chief fiscal officer, a chief operations officer, a director for the SHOP Exchange, a director of Health Plan Contracting, a chief technology and information officer, a general counsel, and other key executive positions, as determined by the board, who shall be exempt from civil service. (2) (A) The board shall set the salaries for the exempt positions described in paragraph (1) and subdivision (i) of Section 100500 in amounts that are reasonably necessary to attract and retain individuals of superior qualifications. The salaries shall be published by the board in the board's annual budget. The board's annual budget shall be posted on the Internet Web site of the Exchange. To determine the compensation for these positions, the board shall cause to be conducted, through the use of independent outside advisors, salary surveys of both of the following: (i) Other state and federal health insurance exchanges that are most comparable to the Exchange. (ii) Other relevant labor pools. (B) The salaries established by the board under subparagraph (A) shall not exceed the highest comparable salary for a position of that type, as determined by the surveys conducted pursuant to subparagraph (A). (C) The Department of Human Resources shall review the methodology used in the surveys conducted pursuant to subparagraph (A). (3) The positions described in paragraph (1) and subdivision (i) of Section 100500 shall not be subject to otherwise applicable provisions of the Government Code or the Public Contract Code and, for those purposes, the Exchange shall not be considered a state agency or public entity. (n) Assess a charge on the qualified health plans offered by carriers that is reasonable and necessary to support the development, operations, and prudent cash management of the Exchange. This charge shall not affect the requirement under Section 1301 of the federal act that carriers charge the same premium rate for each qualified health plan whether offered inside or outside the Exchange. (o) Authorize expenditures, as necessary, from the California Health Trust Fund to pay program expenses to administer the Exchange. (p) Keep an accurate accounting of all activities, receipts, and expenditures, and annually submit to the United States Secretary of Health and Human Services a report concerning that accounting. Commencing January 1, 2016, the board shall conduct an annual audit. (q) (1) (A) Annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, including, at a minimum, all of the following: (i) The manner in which funds were expended and the progress toward, and the achievement of, the requirements of this title. (ii) Data provided by health care service plans and health insurers offering bridge plan products regarding the extent of health care provider and health facility overlap in their Medi-Cal networks as compared to the health care provider and health facility networks contracting with the plan or insurer in their bridge plan contracts. (iii) The total number of uninsured Californians as a percentage of the state population. (iv) An evaluation of the effectiveness of the activities undertaken pursuant to subdivision (k). This evaluation shall be conducted by an independent entity selected by the board. (B) The report required by this paragraph shall be transmitted to the Legislature and the Governor and shall be made available to the public on the Internet Web site of the Exchange. A report made to the Legislature pursuant to this paragraph shall be submitted pursuant to Section 9795. (2) The Exchange shall prepare, or contract for the preparation of, an evaluation of the bridge plan program using the first three years of experience with the program. The evaluation shall be provided to the health policy and fiscal committees of the Legislature in the fourth year following federal approval of the bridge plan option. The evaluation shall include, but not be limited to, all of the following: (A) The number of individuals eligible to participate in the bridge plan program each year by category of eligibility. (B) The number of eligible individuals who elect a bridge plan option each year by category of eligibility. (C) The average length of time, by region and statewide, that individuals remain in the bridge plan option each year by category of eligibility. (D) The regions of the state with a bridge plan option, and the carriers in each region that offer a bridge plan, by year. (E) The premium difference each year, by region, between the bridge plan and the first and second lowest cost plan for individuals in the Exchange who are not eligible for the bridge plan. (F) The effect of the bridge plan on the premium subsidy amount for bridge plan eligible individuals each year by each region. (G) Based on a survey of individuals enrolled in the bridge plan: (i) Whether individuals enrolling in the bridge plan product are able to keep their existing health care providers. (ii) Whether individuals would want to retain their bridge plan product, buy a different Exchange product, or decline to purchase health insurance if there was no bridge plan product available. The Exchange may include questions designed to elicit the information in this subparagraph as part of an existing survey of individuals receiving coverage in the Exchange. (3) In addition to the evaluation required by paragraph (2), the Exchange shall post the items in subparagraphs (A) to (F), inclusive, on its Internet Web site each year. (4) In addition to the report described in paragraph (1), the board shall be responsive to requests for additional information from the Legislature, including providing testimony and commenting on proposed state legislation or policy issues. The Legislature finds and declares that activities including, but not limited to, responding to legislative or executive inquiries, tracking and commenting on legislation and regulatory activities, and preparing reports on the implementation of this title and the performance of the Exchange, are necessary state requirements and are distinct from the promotion of legislative or regulatory modifications referred to in subdivision (d) of Section 100520. (r) Maintain enrollment and expenditures to ensure that expenditures do not exceed the amount of revenue in the fund, and if sufficient revenue is not available to pay estimated expenditures, institute appropriate measures to ensure fiscal solvency. (s) Exercise all powers reasonably necessary to carry out and comply with the duties, responsibilities, and requirements of this act and the federal act. (t) Consult with stakeholders relevant to carrying out the activities under this title, including, but not limited to, all of the following: (1) Health care consumers who are enrolled in health plans. (2) Individuals and entities with experience in facilitating enrollment in health plans. (3) Representatives of small businesses and self-employed individuals. (4) The State Medi-Cal Director. (5) Advocates for enrolling hard-to-reach populations. (u) Facilitate the purchase of qualified health plans in the Exchange by qualified individuals and qualified small employers no later than January 1, 2014. (v) Report, or contract with an independent entity to report, to the Legislature by December 1, 2018, on whether to adopt the option in Section 1312(c)(3) of the federal act to merge the individual and small employer markets. In its report, the board shall provide information, based on at least two years of data from the Exchange, on the potential impact on rates paid by individuals and by small employers in a merged individual and small employer market, as compared to the rates paid by individuals and small employers if a separate individual and small employer market is maintained. A report made pursuant to this subdivision shall be submitted pursuant to Section 9795. (w) With respect to the SHOP Program, collect premiums and administer all other necessary and related tasks, including, but not limited to, enrollment and plan payment, in order to make the offering of employee plan choice as simple as possible for qualified small employers. (x) Require carriers participating in the Exchange to immediately notify the Exchange, under the terms and conditions established by the board when an individual is or will be enrolled in or disenrolled from any qualified health plan offered by the carrier. (y) Ensure that the Exchange provides oral interpretation services in any language for individuals seeking coverage through the Exchange and makes available a toll-free telephone number for the hearing and speech impaired. The board shall ensure that written information made available by the Exchange is presented in a plainly worded, easily understandable format and made available in prevalent languages. (z) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.   SEC. 2.   Section 100503 of the Government Code, as added by Section 5 of Chapter 5 of the First Extraordinary Session of the Statutes of 2013, is amended to read: 100503. In addition to meeting the minimum requirements of Section 1311 of the federal act, the board shall do all of the following: (a) Determine the criteria and process for eligibility, enrollment, and disenrollment of enrollees and potential enrollees in the Exchange and coordinate that process with the state and local government entities administering other health care coverage programs, including the State Department of Health Care Services, the Managed Risk Medical Insurance Board, and California counties, in order to ensure consistent eligibility and enrollment processes and seamless transitions between coverage. (b) Develop processes to coordinate with the county entities that administer eligibility for the Medi-Cal program and the entity that determines eligibility for the Healthy Families Program, including, but not limited to, processes for case transfer, referral, and enrollment in the Exchange of individuals applying for assistance to those entities, if allowed or required by federal law. (c) Determine the minimum requirements a carrier must meet to be considered for participation in the Exchange, and the standards and criteria for selecting qualified health plans to be offered through the Exchange that are in the best interests of qualified individuals and qualified small employers. The board shall consistently and uniformly apply these requirements, standards, and criteria to all carriers. In the course of selectively contracting for health care coverage offered to qualified individuals and qualified small employers through the Exchange, the board shall seek to contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service. (d) Provide, in each region of the state, a choice of qualified health plans at each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act. (e) Require, as a condition of participation in the Exchange, carriers to fairly and affirmatively offer, market, and sell in the Exchange at least one product within each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act. The board may require carriers to offer additional products within each of those five levels of coverage. This subdivision shall not apply to a carrier that solely offers supplemental coverage in the Exchange under paragraph (10) of subdivision (a) of Section 100504. (f) (1) Require, as a condition of participation in the Exchange, carriers that sell any products outside the Exchange to do both of the following: (A) Fairly and affirmatively offer, market, and sell all products made available to individuals in the Exchange to individuals purchasing coverage outside the Exchange. (B) Fairly and affirmatively offer, market, and sell all products made available to small employers in the Exchange to small employers purchasing coverage outside the Exchange. (2) For purposes of this subdivision, "product" does not include contracts entered into pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code between the Managed Risk Medical Insurance Board and carriers for enrolled Healthy Families beneficiaries or contracts entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code between the State Department of Health Care Services and carriers for enrolled Medi-Cal beneficiaries. (g) Determine when an enrollee's coverage commences and the extent and scope of coverage. (h) Provide for the processing of applications and the enrollment and disenrollment of enrollees. (i) Determine and approve cost-sharing provisions for qualified health plans. (j) Establish uniform billing and payment policies for qualified health plans offered in the Exchange to ensure consistent enrollment and disenrollment activities for individuals enrolled in the Exchange. (k) Undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange. The board shall also undertake outreach and enrollment activities that seek to assist enrollees and potential enrollees with enrolling and reenrolling in the Exchange in the least burdensome manner, including populations that may experience barriers to enrollment, such as the disabled and those with limited English language proficiency. (l) Select and set performance standards and compensation for navigators selected under subdivision (l) of Section 100502. (m) Employ necessary staff. (1) The board shall hire a chief fiscal officer, a chief operations officer, a director for the SHOP Exchange, a director of Health Plan Contracting, a chief technology and information officer, a general counsel, and other key executive positions, as determined by the board, who shall be exempt from civil service. (2) (A) The board shall set the salaries for the exempt positions described in paragraph (1) and subdivision (i) of Section 100500 in amounts that are reasonably necessary to attract and retain individuals of superior qualifications. The salaries shall be published by the board in the board's annual budget. The board's annual budget shall be posted on the Internet Web site of the Exchange. To determine the compensation for these positions, the board shall cause to be conducted, through the use of independent outside advisors, salary surveys of both of the following: (i) Other state and federal health insurance exchanges that are most comparable to the Exchange. (ii) Other relevant labor pools. (B) The salaries established by the board under subparagraph (A) shall not exceed the highest comparable salary for a position of that type, as determined by the surveys conducted pursuant to subparagraph (A). (C) The Department of Human Resources shall review the methodology used in the surveys conducted pursuant to subparagraph (A). (3) The positions described in paragraph (1) and subdivision (i) of Section 100500 shall not be subject to otherwise applicable provisions of the Government Code or the Public Contract Code and, for those purposes, the Exchange shall not be considered a state agency or public entity. (n) Assess a charge on the qualified health plans offered by carriers that is reasonable and necessary to support the development, operations, and prudent cash management of the Exchange. This charge shall not affect the requirement under Section 1301 of the federal act that carriers charge the same premium rate for each qualified health plan whether offered inside or outside the Exchange. (o) Authorize expenditures, as necessary, from the California Health Trust Fund to pay program expenses to administer the Exchange. (p) Keep an accurate accounting of all activities, receipts, and expenditures, and annually submit to the United States Secretary of Health and Human Services a report concerning that accounting. Commencing January 1, 2016, the board shall conduct an annual audit. (q) (1) (A) Annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, including, at a minimum, all of the following: (i) The manner in which funds were expended and the progress toward, and the achievement of, the requirements of this title. (ii) The total number of uninsured Californians as a percentage of the state population. (iii) An evaluation of the effectiveness of the activities undertaken pursuant to subdivision (k). This evaluation shall be conducted by an independent entity selected by the board. (B) The report required by this paragraph shall be transmitted to the Legislature and the Governor and shall be made available to the public on the Internet Web site of the Exchange. A report made to the Legislature pursuant to this paragraph shall be submitted pursuant to Section 9795. (2) In addition to the report described in paragraph (1), the board shall be responsive to requests for additional information from the Legislature, including providing testimony and commenting on proposed state legislation or policy issues. The Legislature finds and declares that activities including, but not limited to, responding to legislative or executive inquiries, tracking and commenting on legislation and regulatory activities, and preparing reports on the implementation of this title and the performance of the Exchange, are necessary state requirements and are distinct from the promotion of legislative or regulatory modifications referred to in subdivision (d) of Section 100520. (r) Maintain enrollment and expenditures to ensure that expenditures do not exceed the amount of revenue in the fund, and if sufficient revenue is not available to pay estimated expenditures, institute appropriate measures to ensure fiscal solvency. (s) Exercise all powers reasonably necessary to carry out and comply with the duties, responsibilities, and requirements of this act and the federal act. (t) Consult with stakeholders relevant to carrying out the activities under this title, including, but not limited to, all of the following: (1) Health care consumers who are enrolled in health plans. (2) Individuals and entities with experience in facilitating enrollment in health plans. (3) Representatives of small businesses and self-employed individuals. (4) The State Medi-Cal Director. (5) Advocates for enrolling hard-to-reach populations. (u) Facilitate the purchase of qualified health plans in the Exchange by qualified individuals and qualified small employers no later than January 1, 2014. (v) Report, or contract with an independent entity to report, to the Legislature by December 1, 2018, on whether to adopt the option in Section 1312(c)(3) of the federal act to merge the individual and small employer markets. In its report, the board shall provide information, based on at least two years of data from the Exchange, on the potential impact on rates paid by individuals and by small employers in a merged individual and small employer market, as compared to the rates paid by individuals and small employers if a separate individual and small employer market is maintained. A report made pursuant to this subdivision shall be submitted pursuant to Section 9795. (w) With respect to the SHOP Program, collect premiums and administer all other necessary and related tasks, including, but not limited to, enrollment and plan payment, in order to make the offering of employee plan choice as simple as possible for qualified small employers. (x) Require carriers participating in the Exchange to immediately notify the Exchange, under the terms and conditions established by the board when an individual is or will be enrolled in or disenrolled from any qualified health plan offered by the carrier. (y) Ensure that the Exchange provides oral interpretation services in any language for individuals seeking coverage through the Exchange and makes available a toll-free telephone number for the hearing and speech impaired. The board shall ensure that written information made available by the Exchange is presented in a plainly worded, easily understandable format and made available in prevalent languages. (z) This section shall become operative only if Section 4 of the act that added this section becomes inoperative pursuant to subdivision (z) of that Section 4.   SEC. 3.   SECTION 1.  Section 100503.1 is added to the Government Code, to read: 100503.1. (a) The board shall ensure that the Internet Web site maintained under subdivision (c) of Section 100502 provides a direct link to the formulary, or formularies, for each qualified health plan offered through the Exchange that is posted by the carrier pursuant to Section 1367.205 of the Health and Safety Code or Section 10123.192 of the Insurance Code. (b)  The   On or before January 1, 2016, the  board shall create a search tool on the Internet Web site maintained under subdivision (c) of Section 100502 that allows potential enrollees to search for qualified health plans by a particular drug and by a particular therapeutic condition.  SEC. 4.   SEC. 2.  Section 1363.01 of the Health and Safety Code is amended to read: 1363.01. (a) Every plan that covers prescription drug benefits shall provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary. The notice shall be in language that is easily understood and in a format that is easy to understand. The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary. (b) Every plan that covers prescription drug benefits shall provide to members of the public, upon request, information regarding whether a specific drug or drugs are on the plan's formulary. Notice of the opportunity to secure this information from the plan, including the plan's telephone number for making a request of this nature and the Internet Web site where the formulary is posted under Section 1367.205, shall be included in the evidence of coverage and disclosure form to enrollees. (c) Every plan shall notify enrollees, and members of the public who request formulary information, that the presence of a drug on the plan's formulary does not guarantee that an enrollee will be prescribed that drug by his or her prescribing provider for a particular medical condition.  SEC. 5.   SEC. 3.  Section 1367.205 is added to the Health and Safety Code, to read: 1367.205. (a) In addition to the list required to be provided under Section 1367.20, a health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following: (1) Post the formulary or formularies for each product offered by the plan on the plan's Internet Web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers. (2) Update the formularies posted pursuant to paragraph (1) with any change to those formularies within 24 hours after making the change. (3) Use a standard template to display the formulary or formularies for each product offered by the plan. This template shall do both of the following: (A) Use the United States Pharmacopeia classification system. (B) Organize drugs by therapeutic class, listing drugs alphabetically. (4) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (1) and the list provided pursuant to Section 1367.20: (A) Any prior authorization or step edit requirements for each specific drug included on the formulary. (B) The range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows: (i) Under $100 - $. (ii) $100-$250 - $$. (iii) $251-$500 - $$$. (iv) Over $500 - $$$$. (C) Identification of any drugs on the formulary that are preferred over other drugs on the formulary. (D) The notification described in subdivision (c) of Section 1363.01. (b) The department may develop a standard formulary template provided that the department consults with the Department of Insurance on the template design. If the department develops this template, a health care service plan shall use the template to comply with paragraph (3) of subdivision (a). (c) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under a health care service plan product and includes the drugs covered under both the pharmacy benefit of the product and the medical benefit of the product.  SEC. 6.   SEC. 4.  Section 1368.016 of the Health and Safety Code is amended to read: 1368.016. (a) A health care service plan that provides coverage for professional mental health services, including a specialized health care service plan that provides coverage for professional mental health services, shall, pursuant to subdivision (f) of Section 1368.015, include on its Internet Web site, or provide a link to, the following information: (1) A telephone number that the enrollee or provider can call, during normal business hours, for assistance obtaining mental health benefits coverage information, including the extent to which benefits have been exhausted, in-network provider access information, and claims processing information. (2) A link to prescription drug formularies posted pursuant to Section 1367.205, or instructions on how to obtain the formulary, as described in Section 1367.20. (3) A detailed summary that describes the process by which the plan reviews and authorizes or approves, modifies, or denies requests for health care services as described in Sections 1363.5 and 1367.01. (4) Lists of providers or instructions on how to obtain the provider list, as required by Section 1367.26. (5) A detailed summary of the enrollee grievance process as described in Sections 1368 and 1368.015. (6) A detailed description of how an enrollee may request continuity of care pursuant to subdivisions (a) and (b) of Section 1373.95. (7) Information concerning the right, and applicable procedure, of an enrollee to request an independent medical review pursuant to Section 1374.30. (b) Any modified material described in subdivision (a) shall be updated at least quarterly. (c) The information described in subdivision (a) may be made available through a secured Internet Web site that is only accessible to enrollees. (d) The material described in subdivision (a) shall also be made available to enrollees in hard copy upon request. (e) Nothing in this article shall preclude a health care service plan from including additional information on its Internet Web site for applicants, enrollees or subscribers, or providers, including, but not limited to, the cost of procedures or services by health care providers in a plan's network. (f) The department shall include on the department's Internet Web site a link to the Internet Web site of each health care service plan and specialized health care service plan described in subdivision (a). (g) This section shall not apply to Medicare supplement insurance, Employee Assistance Programs, short-term limited duration health insurance, Champus-supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, and specified disease insurance. This section shall also not apply to specialized health care service plans, except behavioral health-only plans. (h) This section shall not apply to a health care service plan that contracts with a specialized health care service plan, insurer, or other entity to cover professional mental health services for its enrollees, provided that the health care service plan provides a link on its Internet Web site to an Internet Web site operated by the specialized health care service plan, insurer, or other entity with which it contracts, and that plan, insurer, or other entity complies with this section or Section 10123.199 of the Insurance Code.  SEC. 7.   SEC. 5.  Section 10123.192 is added to the Insurance Code, to read: 10123.192. (a) A health insurer that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following: (1) Post the formulary or formularies for each product offered by the insurer on the insurer's Internet Web site in a manner that is accessible and searchable by potential insureds, insureds, and providers. (2) Update the formularies posted pursuant to paragraph (1) with any change to those formularies within 24 hours after making the change. (3) Use a standard template to display the formulary or formularies for each product offered by the insurer. This template shall do both of the following: (A) Use the United States Pharmacopeia classification system. (B) Organize drugs by therapeutic class, listing drugs alphabetically. (4) Include all of the following on any published formulary for any product offered by the insurer, including, but not limited to, the formulary or formularies posted pursuant to paragraph (1): (A) Any prior authorization or step edit requirements for each specific drug included on the formulary. (B) The range of cost sharing for a potential insured of each specific drug included on the formulary, as follows: (i) Under $100 - $. (ii) $100-$250 - $$. (iii) $251-$500 - $$$. (iv) Over $500 - $$$$. (C) Identification of any drugs on the formulary that are preferred over other drugs on the formulary. (D) A notification that the presence of a drug on the insurer's formulary does not guarantee that an insured will be prescribed that drug by his or her prescribing provider for a particular medical condition. (b) The department may develop a standard formulary template provided that the department consults with the Department of Managed Health Care on the template design. If the department develops this template, a health insurer shall use the template to comply with paragraph (3) of subdivision (a). (c) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under a health insurance product and includes the drugs covered under both the pharmacy benefit of the product and the medical benefit of the product.  SEC. 8.   SEC. 6.  Section 10123.199 of the Insurance Code is amended to read: 10123.199. (a) A health insurer that provides coverage for professional mental health services shall establish an Internet Web site. Each Internet Web site shall include, or provide a link to, the following information: (1) A telephone number that the insured or provider can call, during normal business hours, for assistance obtaining mental health benefits coverage information, including the extent to which benefits have been exhausted, in-network provider access information, and claims processing information. (2) A link to prescription drug formularies posted pursuant to Section 10123.192, or instructions on how to obtain formulary information. (3) A detailed summary description of the process by which the insurer reviews and approves, modifies, or denies requests for health care services as described in Section 10123.135. (4) Lists of providers or instructions on how to obtain a provider list as required by Section 10133.1. (5) A detailed summary of the health insurer's grievance process. (6) A detailed description of how the insured may request continuity of care as described in Section 10133.55. (7) Information concerning the right, and applicable procedure, of the insured to request an independent medical review pursuant to Section 10169. (b) Except as otherwise specified, the material described in subdivision (a) shall be updated at least quarterly. (c) The information described in subdivision (a) may be made available through a secured Internet Web site that is only accessible to the insured. (d) The material described in subdivision (a) shall also be made available to insureds in hard copy upon request. (e) Nothing in this article shall preclude an insurer from including additional information on its Internet Web site for applicants or insureds, including, but not limited to, the cost of procedures or services by health care providers in an insurer's network. (f) The department shall include on the department's Internet Web site, a link to the Internet Web site of each health insurer described in subdivision (a). (g) This section shall not apply to Medicare supplement insurance, Employee Assistance Programs, short-term limited duration health insurance, Champus-supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, and specified disease insurance. This section shall also not apply to specialized health insurance policies, except behavioral health-only policies. (h) This section shall not apply to a health insurer that contracts with a specialized health care service plan, insurer, or other entity to cover professional mental health services for its insureds, provided that the health insurer provides a link on its Internet Web site to an Internet Web site operated by the specialized health care service plan, insurer, or other entity with which it contracts, and that plan, insurer, or other entity complies with this section or Section 1368.016 of the Health and Safety Code.  SEC. 9.   SEC. 7.  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.