| Old | New | Differences | |
|---|---|---|---|
| 1 | - | Amended IN Assembly March | |
| 1 | + | Amended IN Assembly March 13, 2017 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 1353Introduced by Assembly Member WaldronFebruary 17, 2017 An act to amend Section 1367.005 of add Sections 1367.245 and 1367.246 to the Health and Safety Code, and to add Sections 10123.203 and 10123.204 to the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 1353, as amended, Waldron. Health care coverage: essential health benefits. prescription drugs: continuity of care.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. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plans or health insurers step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plans prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was previously prescribed the prescription drug either prior to enrollment or if the prescription drug was previously approved for coverage by the plan or insurer. The bill would require a plan or health insurer to respond to an exception request within 72 hours, or within 24 hours if exigent circumstances exist, following receipt of the exception request. The bill would require a plan or health insurer that denies an exception request to provide the reasons for the denial in a notice provided to the enrollee or insured, as specified.The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug that was previously included on a formulary or formularies maintained by the plan or health insurer if specified conditions are satisfied, including that the enrollees or insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or insured or represents a significant health risk to the enrollee or insured.By imposing new requirements on a health care service plan, the willful violation of which is 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 federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires a health insurance issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined. PPACA requires each state, by January 1, 2014, to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers.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 requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to, at a minimum, cover essential health benefits, and defines essential health benefits to include health benefits covered by other particular benchmark plans, including a certain plan offered during the first quarter of 2014.This bill would make a technical, nonsubstantive change to this provision.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NOYES Local Program: NOYES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read:1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02.SEC. 2. Section 1367.246 is added to the Health and Safety Code, immediately following Section 1367.245, to read:1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee.SEC. 3. Section 10123.203 is added to the Insurance Code, to read:10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial.SEC. 4. Section 10123.204 is added to the Insurance Code, to read:10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured.SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.SECTION 1.Section 1367.005 of the Health and Safety Code is amended to read:1367.005.(a)An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall, at a minimum, include coverage for essential health benefits pursuant to PPACA and as outlined in this section. For purposes of this section, essential health benefits means all of the following:(1)Health benefits within the categories identified in Section 1302(b) of PPACA: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.(2)(A)The health benefits covered by the Kaiser Foundation Health Plan Small Group HMO 30 plan (federal health product identification number 40513CA035) as this plan was offered during the first quarter of 2014, as follows, regardless of whether the benefits are specifically referenced in the evidence of coverage or plan contract for that plan:(i)Medically necessary basic health care services, as defined in subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of the California Code of Regulations.(ii)The health benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in the following sections: Sections 1367.002, 1367.06, and 1367.35 (preventive services for children); Section 1367.25 (prescription drug coverage for contraceptives); Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section 1367.54 (alpha-fetoprotein testing); Section 1367.6 (breast cancer screening); Section 1367.61 (prosthetics for laryngectomy); Section 1367.62 (maternity hospital stay); Section 1367.63 (reconstructive surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate cancer); Section 1367.65 (mammography); Section 1367.66 (cervical cancer); Section 1367.665 (cancer screening tests); Section 1367.67 (osteoporosis); Section 1367.68 (surgical procedures for jaw bones); Section 1367.71 (anesthesia for dental); Section 1367.9 (conditions attributable to diethylstilbestrol); Section 1368.2 (hospice care); Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency response ambulance or ambulance transport services); subdivision (b) of Section 1373 (sterilization operations or procedures); Section 1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56 (phenylketonuria); Section 1374.17 (organ transplants for HIV); Section 1374.72 (mental health parity); and Section 1374.73 (autism/behavioral health treatment).(iii)Any other benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in those statutes.(iv)The health benefits covered by the plan that are not otherwise required to be covered under this chapter, to the extent required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22, 1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the California Code of Regulations.(v)Any other health benefits covered by the plan that are not otherwise required to be covered under this chapter.(B)If there are any conflicts or omissions in the plan identified in subparagraph (A) as compared with the requirements for health benefits under this chapter that were enacted prior to December 31, 2011, the requirements of this chapter shall be controlling, except as otherwise specified in this section.(C)Notwithstanding subparagraph (B) or any other provision of this section, the home health services benefits covered under the plan identified in subparagraph (A) shall be deemed to not be in conflict with this chapter.(D)For purposes of this section, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343) shall apply to a contract subject to this section. Coverage of mental health and substance use disorder services pursuant to this paragraph, along with any scope and duration limits imposed on the benefits, shall be in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all rules, regulations, or guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).(3)With respect to habilitative services, in addition to any habilitative services and devices identified in paragraph (2), coverage shall also be provided as required by federal rules, regulations, and guidance issued pursuant to Section 1302(b) of PPACA. Habilitative services and devices shall be covered under the same terms and conditions applied to rehabilitative services and devices under the plan contract. Limits on habilitative and rehabilitative services and devices shall not be combined.(4)With respect to pediatric vision care, the same health benefits for pediatric vision care covered under the Federal Employees Dental and Vision Insurance Program vision plan with the largest national enrollment as of the first quarter of 2014. The pediatric vision care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any vision services covered under the plan identified in paragraph (2).(5)With respect to pediatric oral care, the same health benefits for pediatric oral care covered under the dental benefit received by children under the Medi-Cal program as of 2014, including the provision of medically necessary orthodontic care provided pursuant to the federal Childrens Health Insurance Program Reauthorization Act of 2009. The pediatric oral care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any dental or orthodontic services covered under the plan identified in paragraph (2).(b)Treatment limitations imposed on health benefits described in this section shall be no greater than the treatment limitations imposed by the corresponding plans identified in subdivision (a), subject to the requirements set forth in paragraph (2) of subdivision (a).(c)Except as provided in subdivision (d),this section shall not be construed to permit a health care service plan to make substitutions for the benefits required to be covered under this section, regardless of whether those substitutions are actuarially equivalent.(d)To the extent permitted under Section 1302 of PPACA and any rules, regulations, or guidance issued pursuant to that section, and to the extent that substitution would not create an obligation for the state to defray costs for any individual, a plan may substitute its prescription drug formulary for the formulary provided under the plan identified in subdivision (a) as long as the coverage for prescription drugs complies with the sections referenced in clauses (ii) and (iv) of subparagraph (A) of paragraph (2) of subdivision (a) that apply to prescription drugs.(e)A health care service plan, or its agent, solicitor, or representative, shall not issue, deliver, renew, offer, market, represent, or sell any product, contract, or discount arrangement as compliant with the essential health benefits requirement in federal law, unless it meets all of the requirements of this section.(f)This section applies regardless of whether the plan contract is offered inside or outside the California Health Benefit Exchange created by Section 100500 of the Government Code.(g)This section shall not be construed to exempt a plan or a plan contract from meeting other applicable requirements of law.(h)This section shall not be construed to prohibit a plan contract from covering additional benefits, including, but not limited to, spiritual care services that are tax deductible under Section 213 of the Internal Revenue Code.(i)Subdivision (a) does not apply to any of the following:(1)A specialized health care service plan contract.(2)A Medicare supplement plan.(3)A plan contract that qualifies as a grandfathered health plan under Section 1251 of PPACA or any rules, regulations, or guidance issued pursuant to that section.(j)This section shall not be implemented in a manner that conflicts with a requirement of PPACA.(k)This section shall be implemented only to the extent essential health benefits are required pursuant to PPACA.(l)An essential health benefit is required to be provided under this section only to the extent that federal law does not require the state to defray the costs of the benefit.(m)This section does not obligate the state to incur costs for the coverage of benefits that are not essential health benefits as defined in this section.(n)A plan is not required to cover, under this section, changes to health benefits that are the result of statutes enacted on or after December 31, 2011.(o)(1)The department may adopt emergency regulations implementing this section. The department may, on a one-time basis, readopt any emergency regulation authorized by this section that is the same as, or substantially equivalent to, an emergency regulation previously adopted under this section.(2)The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.(3)The initial adoption of emergency regulations implementing this section made during the 201516 Regular Session of the Legislature and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.(4)The director shall consult with the Insurance Commissioner to ensure consistency and uniformity in the development of regulations under this subdivision.(5)This subdivision shall become inoperative on July 1, 2018.(p)For purposes of this section, the following definitions apply:(1)Habilitative services means health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings, or both. Habilitative services shall be covered under the same terms and conditions applied to rehabilitative services under the plan contract.(2)(A)Health benefits, unless otherwise required to be defined pursuant to federal rules, regulations, or guidance issued pursuant to Section 1302(b) of PPACA, means health care items or services for the diagnosis, cure, mitigation, treatment, or prevention of illness, injury, disease, or a health condition, including a behavioral health condition.(B)Health benefits does not mean any cost-sharing requirements such as copayments, coinsurance, or deductibles.(3)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.(4)Small group health care service plan contract means a group health care service plan contract issued to a small employer, as defined in Section 1357.500. | |
| 2 | 2 | ||
| 3 | - | Amended IN Assembly March | |
| 3 | + | Amended IN Assembly March 13, 2017 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 1353Introduced by Assembly Member WaldronFebruary 17, 2017 An act to amend Section 1367.005 of add Sections 1367.245 and 1367.246 to the Health and Safety Code, and to add Sections 10123.203 and 10123.204 to the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 1353, as amended, Waldron. Health care coverage: essential health benefits. prescription drugs: continuity of care.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. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plans or health insurers step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plans prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was previously prescribed the prescription drug either prior to enrollment or if the prescription drug was previously approved for coverage by the plan or insurer. The bill would require a plan or health insurer to respond to an exception request within 72 hours, or within 24 hours if exigent circumstances exist, following receipt of the exception request. The bill would require a plan or health insurer that denies an exception request to provide the reasons for the denial in a notice provided to the enrollee or insured, as specified.The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug that was previously included on a formulary or formularies maintained by the plan or health insurer if specified conditions are satisfied, including that the enrollees or insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or insured or represents a significant health risk to the enrollee or insured.By imposing new requirements on a health care service plan, the willful violation of which is 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 federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires a health insurance issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined. PPACA requires each state, by January 1, 2014, to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers.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 requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to, at a minimum, cover essential health benefits, and defines essential health benefits to include health benefits covered by other particular benchmark plans, including a certain plan offered during the first quarter of 2014.This bill would make a technical, nonsubstantive change to this provision.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NOYES Local Program: NOYES | |
| 4 | 4 | ||
| 5 | - | ||
| 5 | + | Amended IN Assembly March 13, 2017 | |
| 6 | 6 | ||
| 7 | - | Amended IN Assembly March 23, 2017 | |
| 8 | 7 | Amended IN Assembly March 13, 2017 | |
| 9 | 8 | ||
| 10 | 9 | CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION | |
| 11 | 10 | ||
| 12 | 11 | Assembly Bill No. 1353 | |
| 13 | 12 | ||
| 14 | 13 | Introduced by Assembly Member WaldronFebruary 17, 2017 | |
| 15 | 14 | ||
| 16 | 15 | Introduced by Assembly Member Waldron | |
| 17 | 16 | February 17, 2017 | |
| 18 | 17 | ||
| 19 | - | An act to add Sections 1367.245 and 1367.246 to the Health and Safety Code, and to add Sections 10123.203 and 10123.204 to the Insurance Code, relating to health care coverage. | |
| 18 | + | An act to amend Section 1367.005 of add Sections 1367.245 and 1367.246 to the Health and Safety Code, and to add Sections 10123.203 and 10123.204 to the Insurance Code, relating to health care coverage. | |
| 20 | 19 | ||
| 21 | 20 | LEGISLATIVE COUNSEL'S DIGEST | |
| 22 | 21 | ||
| 23 | 22 | ## LEGISLATIVE COUNSEL'S DIGEST | |
| 24 | 23 | ||
| 25 | - | AB 1353, as amended, Waldron. Health care coverage: prescription drugs: continuity of care. | |
| 24 | + | AB 1353, as amended, Waldron. Health care coverage: essential health benefits. prescription drugs: continuity of care. | |
| 26 | 25 | ||
| 27 | - | 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. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plans or health insurers step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plans prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was | |
| 26 | + | 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. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plans or health insurers step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plans prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was previously prescribed the prescription drug either prior to enrollment or if the prescription drug was previously approved for coverage by the plan or insurer. The bill would require a plan or health insurer to respond to an exception request within 72 hours, or within 24 hours if exigent circumstances exist, following receipt of the exception request. The bill would require a plan or health insurer that denies an exception request to provide the reasons for the denial in a notice provided to the enrollee or insured, as specified.The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug that was previously included on a formulary or formularies maintained by the plan or health insurer if specified conditions are satisfied, including that the enrollees or insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or insured or represents a significant health risk to the enrollee or insured.By imposing new requirements on a health care service plan, the willful violation of which is 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 federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires a health insurance issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined. PPACA requires each state, by January 1, 2014, to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers.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 requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to, at a minimum, cover essential health benefits, and defines essential health benefits to include health benefits covered by other particular benchmark plans, including a certain plan offered during the first quarter of 2014.This bill would make a technical, nonsubstantive change to this provision. | |
| 28 | 27 | ||
| 29 | 28 | 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. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plans or health insurers step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plans prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. | |
| 30 | 29 | ||
| 31 | - | This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was | |
| 30 | + | This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees and insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was previously prescribed the prescription drug either prior to enrollment or if the prescription drug was previously approved for coverage by the plan or insurer. The bill would require a plan or health insurer to respond to an exception request within 72 hours, or within 24 hours if exigent circumstances exist, following receipt of the exception request. The bill would require a plan or health insurer that denies an exception request to provide the reasons for the denial in a notice provided to the enrollee or insured, as specified. | |
| 32 | 31 | ||
| 33 | - | The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug that was | |
| 32 | + | The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug that was previously included on a formulary or formularies maintained by the plan or health insurer if specified conditions are satisfied, including that the enrollees or insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or insured or represents a significant health risk to the enrollee or insured. | |
| 34 | 33 | ||
| 35 | 34 | By imposing new requirements on a health care service plan, the willful violation of which is a crime, this bill would impose a state-mandated local program. | |
| 36 | 35 | ||
| 37 | 36 | 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. | |
| 38 | 37 | ||
| 39 | 38 | This bill would provide that no reimbursement is required by this act for a specified reason. | |
| 40 | 39 | ||
| 40 | + | Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires a health insurance issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined. PPACA requires each state, by January 1, 2014, to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers. | |
| 41 | + | ||
| 42 | + | ||
| 43 | + | ||
| 44 | + | 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 requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to, at a minimum, cover essential health benefits, and defines essential health benefits to include health benefits covered by other particular benchmark plans, including a certain plan offered during the first quarter of 2014. | |
| 45 | + | ||
| 46 | + | ||
| 47 | + | ||
| 48 | + | This bill would make a technical, nonsubstantive change to this provision. | |
| 49 | + | ||
| 50 | + | ||
| 51 | + | ||
| 41 | 52 | ## Digest Key | |
| 42 | 53 | ||
| 43 | 54 | ## Bill Text | |
| 44 | 55 | ||
| 45 | - | The people of the State of California do enact as follows:SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read:1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 56 | + | The people of the State of California do enact as follows:SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read:1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02.SEC. 2. Section 1367.246 is added to the Health and Safety Code, immediately following Section 1367.245, to read:1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee.SEC. 3. Section 10123.203 is added to the Insurance Code, to read:10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial.SEC. 4. Section 10123.204 is added to the Insurance Code, to read:10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured.SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.SECTION 1.Section 1367.005 of the Health and Safety Code is amended to read:1367.005.(a)An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall, at a minimum, include coverage for essential health benefits pursuant to PPACA and as outlined in this section. For purposes of this section, essential health benefits means all of the following:(1)Health benefits within the categories identified in Section 1302(b) of PPACA: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.(2)(A)The health benefits covered by the Kaiser Foundation Health Plan Small Group HMO 30 plan (federal health product identification number 40513CA035) as this plan was offered during the first quarter of 2014, as follows, regardless of whether the benefits are specifically referenced in the evidence of coverage or plan contract for that plan:(i)Medically necessary basic health care services, as defined in subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of the California Code of Regulations.(ii)The health benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in the following sections: Sections 1367.002, 1367.06, and 1367.35 (preventive services for children); Section 1367.25 (prescription drug coverage for contraceptives); Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section 1367.54 (alpha-fetoprotein testing); Section 1367.6 (breast cancer screening); Section 1367.61 (prosthetics for laryngectomy); Section 1367.62 (maternity hospital stay); Section 1367.63 (reconstructive surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate cancer); Section 1367.65 (mammography); Section 1367.66 (cervical cancer); Section 1367.665 (cancer screening tests); Section 1367.67 (osteoporosis); Section 1367.68 (surgical procedures for jaw bones); Section 1367.71 (anesthesia for dental); Section 1367.9 (conditions attributable to diethylstilbestrol); Section 1368.2 (hospice care); Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency response ambulance or ambulance transport services); subdivision (b) of Section 1373 (sterilization operations or procedures); Section 1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56 (phenylketonuria); Section 1374.17 (organ transplants for HIV); Section 1374.72 (mental health parity); and Section 1374.73 (autism/behavioral health treatment).(iii)Any other benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in those statutes.(iv)The health benefits covered by the plan that are not otherwise required to be covered under this chapter, to the extent required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22, 1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the California Code of Regulations.(v)Any other health benefits covered by the plan that are not otherwise required to be covered under this chapter.(B)If there are any conflicts or omissions in the plan identified in subparagraph (A) as compared with the requirements for health benefits under this chapter that were enacted prior to December 31, 2011, the requirements of this chapter shall be controlling, except as otherwise specified in this section.(C)Notwithstanding subparagraph (B) or any other provision of this section, the home health services benefits covered under the plan identified in subparagraph (A) shall be deemed to not be in conflict with this chapter.(D)For purposes of this section, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343) shall apply to a contract subject to this section. Coverage of mental health and substance use disorder services pursuant to this paragraph, along with any scope and duration limits imposed on the benefits, shall be in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all rules, regulations, or guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).(3)With respect to habilitative services, in addition to any habilitative services and devices identified in paragraph (2), coverage shall also be provided as required by federal rules, regulations, and guidance issued pursuant to Section 1302(b) of PPACA. Habilitative services and devices shall be covered under the same terms and conditions applied to rehabilitative services and devices under the plan contract. Limits on habilitative and rehabilitative services and devices shall not be combined.(4)With respect to pediatric vision care, the same health benefits for pediatric vision care covered under the Federal Employees Dental and Vision Insurance Program vision plan with the largest national enrollment as of the first quarter of 2014. The pediatric vision care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any vision services covered under the plan identified in paragraph (2).(5)With respect to pediatric oral care, the same health benefits for pediatric oral care covered under the dental benefit received by children under the Medi-Cal program as of 2014, including the provision of medically necessary orthodontic care provided pursuant to the federal Childrens Health Insurance Program Reauthorization Act of 2009. The pediatric oral care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any dental or orthodontic services covered under the plan identified in paragraph (2).(b)Treatment limitations imposed on health benefits described in this section shall be no greater than the treatment limitations imposed by the corresponding plans identified in subdivision (a), subject to the requirements set forth in paragraph (2) of subdivision (a).(c)Except as provided in subdivision (d),this section shall not be construed to permit a health care service plan to make substitutions for the benefits required to be covered under this section, regardless of whether those substitutions are actuarially equivalent.(d)To the extent permitted under Section 1302 of PPACA and any rules, regulations, or guidance issued pursuant to that section, and to the extent that substitution would not create an obligation for the state to defray costs for any individual, a plan may substitute its prescription drug formulary for the formulary provided under the plan identified in subdivision (a) as long as the coverage for prescription drugs complies with the sections referenced in clauses (ii) and (iv) of subparagraph (A) of paragraph (2) of subdivision (a) that apply to prescription drugs.(e)A health care service plan, or its agent, solicitor, or representative, shall not issue, deliver, renew, offer, market, represent, or sell any product, contract, or discount arrangement as compliant with the essential health benefits requirement in federal law, unless it meets all of the requirements of this section.(f)This section applies regardless of whether the plan contract is offered inside or outside the California Health Benefit Exchange created by Section 100500 of the Government Code.(g)This section shall not be construed to exempt a plan or a plan contract from meeting other applicable requirements of law.(h)This section shall not be construed to prohibit a plan contract from covering additional benefits, including, but not limited to, spiritual care services that are tax deductible under Section 213 of the Internal Revenue Code.(i)Subdivision (a) does not apply to any of the following:(1)A specialized health care service plan contract.(2)A Medicare supplement plan.(3)A plan contract that qualifies as a grandfathered health plan under Section 1251 of PPACA or any rules, regulations, or guidance issued pursuant to that section.(j)This section shall not be implemented in a manner that conflicts with a requirement of PPACA.(k)This section shall be implemented only to the extent essential health benefits are required pursuant to PPACA.(l)An essential health benefit is required to be provided under this section only to the extent that federal law does not require the state to defray the costs of the benefit.(m)This section does not obligate the state to incur costs for the coverage of benefits that are not essential health benefits as defined in this section.(n)A plan is not required to cover, under this section, changes to health benefits that are the result of statutes enacted on or after December 31, 2011.(o)(1)The department may adopt emergency regulations implementing this section. The department may, on a one-time basis, readopt any emergency regulation authorized by this section that is the same as, or substantially equivalent to, an emergency regulation previously adopted under this section.(2)The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.(3)The initial adoption of emergency regulations implementing this section made during the 201516 Regular Session of the Legislature and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.(4)The director shall consult with the Insurance Commissioner to ensure consistency and uniformity in the development of regulations under this subdivision.(5)This subdivision shall become inoperative on July 1, 2018.(p)For purposes of this section, the following definitions apply:(1)Habilitative services means health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings, or both. Habilitative services shall be covered under the same terms and conditions applied to rehabilitative services under the plan contract.(2)(A)Health benefits, unless otherwise required to be defined pursuant to federal rules, regulations, or guidance issued pursuant to Section 1302(b) of PPACA, means health care items or services for the diagnosis, cure, mitigation, treatment, or prevention of illness, injury, disease, or a health condition, including a behavioral health condition.(B)Health benefits does not mean any cost-sharing requirements such as copayments, coinsurance, or deductibles.(3)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.(4)Small group health care service plan contract means a group health care service plan contract issued to a small employer, as defined in Section 1357.500. | |
| 46 | 57 | ||
| 47 | 58 | The people of the State of California do enact as follows: | |
| 48 | 59 | ||
| 49 | 60 | ## The people of the State of California do enact as follows: | |
| 50 | 61 | ||
| 51 | - | SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read:1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 62 | + | SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read:1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02. | |
| 52 | 63 | ||
| 53 | 64 | SECTION 1. Section 1367.245 is added to the Health and Safety Code, immediately following Section 1367.244, to read: | |
| 54 | 65 | ||
| 55 | 66 | ### SECTION 1. | |
| 56 | 67 | ||
| 57 | - | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 68 | + | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02. | |
| 58 | 69 | ||
| 59 | - | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 70 | + | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02. | |
| 60 | 71 | ||
| 61 | - | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 72 | + | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs.(b) A health care service plan shall grant an exception request under this section if both of the following are met:(1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee.(2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02. | |
| 62 | 73 | ||
| 63 | 74 | ||
| 64 | 75 | ||
| 65 | 76 | 1367.245. (a) Notwithstanding Section 1367.24, 1367.241, or any other law, a health care service plan that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which enrollees, enrollees designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan for medically necessary prescription drugs. | |
| 66 | 77 | ||
| 67 | 78 | (b) A health care service plan shall grant an exception request under this section if both of the following are met: | |
| 68 | 79 | ||
| 69 | - | (1) Either the enrollee was previously prescribed the prescription drug prior to | |
| 80 | + | (1) Either the enrollee was previously prescribed the prescription drug prior to enrollment in the health care service plan or the prescription drug had been previously approved for coverage by the plan for a medical condition of the enrollee. | |
| 70 | 81 | ||
| 71 | - | (2) The enrollee is medically stable and the enrollees prescribing provider continues | |
| 82 | + | (2) The enrollee is medically stable and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. | |
| 72 | 83 | ||
| 73 | 84 | (c) (1) A health care service plan shall respond to an exception request within 72 hours following receipt of the exception request. A plan that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed. | |
| 74 | 85 | ||
| 75 | 86 | (2) A health care service plan shall provide that an exception request may be obtained within 24 hours if an enrollee is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an enrollee is undergoing a current course of treatment using that prescription drug. A plan that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed. | |
| 76 | 87 | ||
| 77 | 88 | (d) If a health care service plan fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted. | |
| 78 | 89 | ||
| 79 | 90 | (e) A health care service plan that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the plan for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the enrollee. The notice shall indicate that the enrollee may file a grievance with the plan if the enrollee objects to the denial. The notice shall comply with subdivision (b) of Section 1368.02. | |
| 80 | 91 | ||
| 81 | - | SEC. 2. Section 1367.246 is added to the Health and Safety Code, immediately following Section 1367.245, to read:1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 92 | + | SEC. 2. Section 1367.246 is added to the Health and Safety Code, immediately following Section 1367.245, to read:1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee. | |
| 82 | 93 | ||
| 83 | 94 | SEC. 2. Section 1367.246 is added to the Health and Safety Code, immediately following Section 1367.245, to read: | |
| 84 | 95 | ||
| 85 | 96 | ### SEC. 2. | |
| 86 | 97 | ||
| 87 | - | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 98 | + | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee. | |
| 88 | 99 | ||
| 89 | - | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 100 | + | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee. | |
| 90 | 101 | ||
| 91 | - | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 102 | + | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied:(a) The enrollee was previously prescribed that nonformulary prescription drug.(b) The enrollee is medically stable.(c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition.(d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee. | |
| 92 | 103 | ||
| 93 | 104 | ||
| 94 | 105 | ||
| 95 | - | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 106 | + | 1367.246. Notwithstanding subdivision (c) of Section 1367.22, Section 1367.24, or any other law, a health care service plan contract issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the plan if all of the following conditions are satisfied: | |
| 96 | 107 | ||
| 97 | - | (a) The enrollee was | |
| 108 | + | (a) The enrollee was previously prescribed that nonformulary prescription drug. | |
| 98 | 109 | ||
| 99 | 110 | (b) The enrollee is medically stable. | |
| 100 | 111 | ||
| 101 | - | (c) The drug previously had been approved for coverage by the plan for a | |
| 112 | + | (c) The drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the enrollees prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollees medical condition. | |
| 102 | 113 | ||
| 103 | 114 | (d) The enrollees prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or represents a significant health risk to the enrollee. | |
| 104 | 115 | ||
| 105 | - | SEC. 3. Section 10123.203 is added to the Insurance Code, to read:10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug | |
| 116 | + | SEC. 3. Section 10123.203 is added to the Insurance Code, to read:10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial. | |
| 106 | 117 | ||
| 107 | 118 | SEC. 3. Section 10123.203 is added to the Insurance Code, to read: | |
| 108 | 119 | ||
| 109 | 120 | ### SEC. 3. | |
| 110 | 121 | ||
| 111 | - | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug | |
| 122 | + | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial. | |
| 112 | 123 | ||
| 113 | - | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug | |
| 124 | + | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial. | |
| 114 | 125 | ||
| 115 | - | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug | |
| 126 | + | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs.(b) A health insurer shall grant an exception request under this section if both of the following are met:(1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured.(2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed.(2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed.(d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted.(e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial. | |
| 116 | 127 | ||
| 117 | 128 | ||
| 118 | 129 | ||
| 119 | 130 | 10123.203. (a) Notwithstanding Section 10123.191 or any other law, a health insurer that provides coverage for outpatient prescription drugs shall establish an expeditious process, as described in this section, by which insureds, insureds designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the health insurer for medically necessary prescription drugs. | |
| 120 | 131 | ||
| 121 | 132 | (b) A health insurer shall grant an exception request under this section if both of the following are met: | |
| 122 | 133 | ||
| 123 | - | (1) Either the insured was previously prescribed the prescription drug | |
| 134 | + | (1) Either the insured was previously prescribed the prescription drug prior to enrollment or the prescription drug had been previously approved for coverage by the health insurer for a medical condition of the insured. | |
| 124 | 135 | ||
| 125 | - | (2) The insured is medically stable and the insureds prescribing provider continues | |
| 136 | + | (2) The insured is medically stable and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition. | |
| 126 | 137 | ||
| 127 | 138 | (c) (1) A health insurer shall respond to an exception request within 72 hours following receipt of the exception request. A health insurer that grants an exception request under this subdivision shall provide coverage of the prescription drug for the duration of the medical condition for which the medication was prescribed. | |
| 128 | 139 | ||
| 129 | 140 | (2) A health insurer shall provide that an exception request may be obtained within 24 hours if an insured is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function or if an insured is undergoing a current course of treatment using that prescription drug. A health insurer that grants an exception request under this subdivision based on exigent circumstances shall provide coverage for the duration of the medical condition for which the medication was prescribed. | |
| 130 | 141 | ||
| 131 | 142 | (d) If a health insurer fails to respond within 72 hours, or within 24 hours if exigent circumstances exist, upon receipt of a completed exception request, the exception request shall be deemed to have been granted. | |
| 132 | 143 | ||
| 133 | 144 | (e) A health insurer that denies a request made pursuant to this section to obtain an exception to any prior authorization process or any other reasonable utilization management or medical management practices utilized by the health insurer for a medically necessary prescription drug shall provide the reasons for the denial in a notice provided to the insured. The notice shall indicate that the insured may file a grievance with the health insurer if the insured objects to the denial. | |
| 134 | 145 | ||
| 135 | - | SEC. 4. Section 10123.204 is added to the Insurance Code, to read:10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 146 | + | SEC. 4. Section 10123.204 is added to the Insurance Code, to read:10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured. | |
| 136 | 147 | ||
| 137 | 148 | SEC. 4. Section 10123.204 is added to the Insurance Code, to read: | |
| 138 | 149 | ||
| 139 | 150 | ### SEC. 4. | |
| 140 | 151 | ||
| 141 | - | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 152 | + | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured. | |
| 142 | 153 | ||
| 143 | - | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 154 | + | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured. | |
| 144 | 155 | ||
| 145 | - | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 156 | + | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied:(a) The insured was previously prescribed that nonformulary prescription drug.(b) The insured is medically stable.(c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition.(d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured. | |
| 146 | 157 | ||
| 147 | 158 | ||
| 148 | 159 | ||
| 149 | - | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was | |
| 160 | + | 10123.204. Notwithstanding any other law, a health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs shall provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary prescription drug that was previously included on a formulary or formularies for outpatient prescription drugs maintained by the health insurer if all of the following conditions are satisfied: | |
| 150 | 161 | ||
| 151 | - | (a) The insured was | |
| 162 | + | (a) The insured was previously prescribed that nonformulary prescription drug. | |
| 152 | 163 | ||
| 153 | 164 | (b) The insured is medically stable. | |
| 154 | 165 | ||
| 155 | - | (c) The drug previously had been approved for coverage by the health insurer for a | |
| 166 | + | (c) The drug previously had been approved for coverage by the health insurer for a medical condition of the insured and the insureds prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the insureds medical condition. | |
| 156 | 167 | ||
| 157 | 168 | (d) The insureds prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the insured or represents a significant health risk to the insured. | |
| 158 | 169 | ||
| 159 | 170 | SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 160 | 171 | ||
| 161 | 172 | SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 162 | 173 | ||
| 163 | 174 | SEC. 5. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution. | |
| 164 | 175 | ||
| 165 | 176 | ### SEC. 5. | |
| 177 | + | ||
| 178 | + | ||
| 179 | + | ||
| 180 | + | ||
| 181 | + | ||
| 182 | + | (a)An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall, at a minimum, include coverage for essential health benefits pursuant to PPACA and as outlined in this section. For purposes of this section, essential health benefits means all of the following: | |
| 183 | + | ||
| 184 | + | ||
| 185 | + | ||
| 186 | + | (1)Health benefits within the categories identified in Section 1302(b) of PPACA: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. | |
| 187 | + | ||
| 188 | + | ||
| 189 | + | ||
| 190 | + | (2)(A)The health benefits covered by the Kaiser Foundation Health Plan Small Group HMO 30 plan (federal health product identification number 40513CA035) as this plan was offered during the first quarter of 2014, as follows, regardless of whether the benefits are specifically referenced in the evidence of coverage or plan contract for that plan: | |
| 191 | + | ||
| 192 | + | ||
| 193 | + | ||
| 194 | + | (i)Medically necessary basic health care services, as defined in subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of the California Code of Regulations. | |
| 195 | + | ||
| 196 | + | ||
| 197 | + | ||
| 198 | + | (ii)The health benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in the following sections: Sections 1367.002, 1367.06, and 1367.35 (preventive services for children); Section 1367.25 (prescription drug coverage for contraceptives); Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section 1367.54 (alpha-fetoprotein testing); Section 1367.6 (breast cancer screening); Section 1367.61 (prosthetics for laryngectomy); Section 1367.62 (maternity hospital stay); Section 1367.63 (reconstructive surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate cancer); Section 1367.65 (mammography); Section 1367.66 (cervical cancer); Section 1367.665 (cancer screening tests); Section 1367.67 (osteoporosis); Section 1367.68 (surgical procedures for jaw bones); Section 1367.71 (anesthesia for dental); Section 1367.9 (conditions attributable to diethylstilbestrol); Section 1368.2 (hospice care); Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency response ambulance or ambulance transport services); subdivision (b) of Section 1373 (sterilization operations or procedures); Section 1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56 (phenylketonuria); Section 1374.17 (organ transplants for HIV); Section 1374.72 (mental health parity); and Section 1374.73 (autism/behavioral health treatment). | |
| 199 | + | ||
| 200 | + | ||
| 201 | + | ||
| 202 | + | (iii)Any other benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in those statutes. | |
| 203 | + | ||
| 204 | + | ||
| 205 | + | ||
| 206 | + | (iv)The health benefits covered by the plan that are not otherwise required to be covered under this chapter, to the extent required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22, 1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the California Code of Regulations. | |
| 207 | + | ||
| 208 | + | ||
| 209 | + | ||
| 210 | + | (v)Any other health benefits covered by the plan that are not otherwise required to be covered under this chapter. | |
| 211 | + | ||
| 212 | + | ||
| 213 | + | ||
| 214 | + | (B)If there are any conflicts or omissions in the plan identified in subparagraph (A) as compared with the requirements for health benefits under this chapter that were enacted prior to December 31, 2011, the requirements of this chapter shall be controlling, except as otherwise specified in this section. | |
| 215 | + | ||
| 216 | + | ||
| 217 | + | ||
| 218 | + | (C)Notwithstanding subparagraph (B) or any other provision of this section, the home health services benefits covered under the plan identified in subparagraph (A) shall be deemed to not be in conflict with this chapter. | |
| 219 | + | ||
| 220 | + | ||
| 221 | + | ||
| 222 | + | (D)For purposes of this section, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343) shall apply to a contract subject to this section. Coverage of mental health and substance use disorder services pursuant to this paragraph, along with any scope and duration limits imposed on the benefits, shall be in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all rules, regulations, or guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26). | |
| 223 | + | ||
| 224 | + | ||
| 225 | + | ||
| 226 | + | (3)With respect to habilitative services, in addition to any habilitative services and devices identified in paragraph (2), coverage shall also be provided as required by federal rules, regulations, and guidance issued pursuant to Section 1302(b) of PPACA. Habilitative services and devices shall be covered under the same terms and conditions applied to rehabilitative services and devices under the plan contract. Limits on habilitative and rehabilitative services and devices shall not be combined. | |
| 227 | + | ||
| 228 | + | ||
| 229 | + | ||
| 230 | + | (4)With respect to pediatric vision care, the same health benefits for pediatric vision care covered under the Federal Employees Dental and Vision Insurance Program vision plan with the largest national enrollment as of the first quarter of 2014. The pediatric vision care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any vision services covered under the plan identified in paragraph (2). | |
| 231 | + | ||
| 232 | + | ||
| 233 | + | ||
| 234 | + | (5)With respect to pediatric oral care, the same health benefits for pediatric oral care covered under the dental benefit received by children under the Medi-Cal program as of 2014, including the provision of medically necessary orthodontic care provided pursuant to the federal Childrens Health Insurance Program Reauthorization Act of 2009. The pediatric oral care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any dental or orthodontic services covered under the plan identified in paragraph (2). | |
| 235 | + | ||
| 236 | + | ||
| 237 | + | ||
| 238 | + | (b)Treatment limitations imposed on health benefits described in this section shall be no greater than the treatment limitations imposed by the corresponding plans identified in subdivision (a), subject to the requirements set forth in paragraph (2) of subdivision (a). | |
| 239 | + | ||
| 240 | + | ||
| 241 | + | ||
| 242 | + | (c)Except as provided in subdivision (d),this section shall not be construed to permit a health care service plan to make substitutions for the benefits required to be covered under this section, regardless of whether those substitutions are actuarially equivalent. | |
| 243 | + | ||
| 244 | + | ||
| 245 | + | ||
| 246 | + | (d)To the extent permitted under Section 1302 of PPACA and any rules, regulations, or guidance issued pursuant to that section, and to the extent that substitution would not create an obligation for the state to defray costs for any individual, a plan may substitute its prescription drug formulary for the formulary provided under the plan identified in subdivision (a) as long as the coverage for prescription drugs complies with the sections referenced in clauses (ii) and (iv) of subparagraph (A) of paragraph (2) of subdivision (a) that apply to prescription drugs. | |
| 247 | + | ||
| 248 | + | ||
| 249 | + | ||
| 250 | + | (e)A health care service plan, or its agent, solicitor, or representative, shall not issue, deliver, renew, offer, market, represent, or sell any product, contract, or discount arrangement as compliant with the essential health benefits requirement in federal law, unless it meets all of the requirements of this section. | |
| 251 | + | ||
| 252 | + | ||
| 253 | + | ||
| 254 | + | (f)This section applies regardless of whether the plan contract is offered inside or outside the California Health Benefit Exchange created by Section 100500 of the Government Code. | |
| 255 | + | ||
| 256 | + | ||
| 257 | + | ||
| 258 | + | (g)This section shall not be construed to exempt a plan or a plan contract from meeting other applicable requirements of law. | |
| 259 | + | ||
| 260 | + | ||
| 261 | + | ||
| 262 | + | (h)This section shall not be construed to prohibit a plan contract from covering additional benefits, including, but not limited to, spiritual care services that are tax deductible under Section 213 of the Internal Revenue Code. | |
| 263 | + | ||
| 264 | + | ||
| 265 | + | ||
| 266 | + | (i)Subdivision (a) does not apply to any of the following: | |
| 267 | + | ||
| 268 | + | ||
| 269 | + | ||
| 270 | + | (1)A specialized health care service plan contract. | |
| 271 | + | ||
| 272 | + | ||
| 273 | + | ||
| 274 | + | (2)A Medicare supplement plan. | |
| 275 | + | ||
| 276 | + | ||
| 277 | + | ||
| 278 | + | (3)A plan contract that qualifies as a grandfathered health plan under Section 1251 of PPACA or any rules, regulations, or guidance issued pursuant to that section. | |
| 279 | + | ||
| 280 | + | ||
| 281 | + | ||
| 282 | + | (j)This section shall not be implemented in a manner that conflicts with a requirement of PPACA. | |
| 283 | + | ||
| 284 | + | ||
| 285 | + | ||
| 286 | + | (k)This section shall be implemented only to the extent essential health benefits are required pursuant to PPACA. | |
| 287 | + | ||
| 288 | + | ||
| 289 | + | ||
| 290 | + | (l)An essential health benefit is required to be provided under this section only to the extent that federal law does not require the state to defray the costs of the benefit. | |
| 291 | + | ||
| 292 | + | ||
| 293 | + | ||
| 294 | + | (m)This section does not obligate the state to incur costs for the coverage of benefits that are not essential health benefits as defined in this section. | |
| 295 | + | ||
| 296 | + | ||
| 297 | + | ||
| 298 | + | (n)A plan is not required to cover, under this section, changes to health benefits that are the result of statutes enacted on or after December 31, 2011. | |
| 299 | + | ||
| 300 | + | ||
| 301 | + | ||
| 302 | + | (o)(1)The department may adopt emergency regulations implementing this section. The department may, on a one-time basis, readopt any emergency regulation authorized by this section that is the same as, or substantially equivalent to, an emergency regulation previously adopted under this section. | |
| 303 | + | ||
| 304 | + | ||
| 305 | + | ||
| 306 | + | (2)The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted. | |
| 307 | + | ||
| 308 | + | ||
| 309 | + | ||
| 310 | + | (3)The initial adoption of emergency regulations implementing this section made during the 201516 Regular Session of the Legislature and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The initial emergency regulations and the readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted. | |
| 311 | + | ||
| 312 | + | ||
| 313 | + | ||
| 314 | + | (4)The director shall consult with the Insurance Commissioner to ensure consistency and uniformity in the development of regulations under this subdivision. | |
| 315 | + | ||
| 316 | + | ||
| 317 | + | ||
| 318 | + | (5)This subdivision shall become inoperative on July 1, 2018. | |
| 319 | + | ||
| 320 | + | ||
| 321 | + | ||
| 322 | + | (p)For purposes of this section, the following definitions apply: | |
| 323 | + | ||
| 324 | + | ||
| 325 | + | ||
| 326 | + | (1)Habilitative services means health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings, or both. Habilitative services shall be covered under the same terms and conditions applied to rehabilitative services under the plan contract. | |
| 327 | + | ||
| 328 | + | ||
| 329 | + | ||
| 330 | + | (2)(A)Health benefits, unless otherwise required to be defined pursuant to federal rules, regulations, or guidance issued pursuant to Section 1302(b) of PPACA, means health care items or services for the diagnosis, cure, mitigation, treatment, or prevention of illness, injury, disease, or a health condition, including a behavioral health condition. | |
| 331 | + | ||
| 332 | + | ||
| 333 | + | ||
| 334 | + | (B)Health benefits does not mean any cost-sharing requirements such as copayments, coinsurance, or deductibles. | |
| 335 | + | ||
| 336 | + | ||
| 337 | + | ||
| 338 | + | (3)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. | |
| 339 | + | ||
| 340 | + | ||
| 341 | + | ||
| 342 | + | (4)Small group health care service plan contract means a group health care service plan contract issued to a small employer, as defined in Section 1357.500. |