Amended IN Senate April 10, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Senate Bill No. 1008Introduced by Senator SkinnerFebruary 06, 2018 An act to amend Section 1367.004 of the Health and Safety Code, and to amend Section 10112.26 of the Insurance Code, amend Sections 1367.003 and 1367.004 of, and to add Sections 1363.04 and 1367.013 to, the Health and Safety Code, and to amend Sections 10112.25 and 10112.26 of, and to add Sections 10112.255 and 10603.04 to, the Insurance Code, relating to dental services. LEGISLATIVE COUNSEL'S DIGESTSB 1008, as amended, Skinner. Health insurance: dental services: medical loss ratio. ratios: out-of-network coverage information: disclosures.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.The federal Patient Protection and Affordable Care Act requires a health insurance issuer issuing health insurance coverage to comply with minimum medical loss ratios and to provide an annual rebate to each insured if the medical loss ratio of the amount of the revenue expended by the issuer on costs to the total amount of premium revenue is less than a certain percentage, as specified.Existing law requires a health care service plan that issues, sells, renews, or offers a specialized health care service plan, and a health insurer that issues, sells, renews, or offers a specialized health insurance policy, covering dental services, to annually file a report that is organized by market and product type and contains the same information required in a specified federal medical loss ratio annual reporting form. Existing law expresses the intent of the Legislature that the data reported be considered by the Legislature in adopting a medical loss ratio standard for health care service plans and specialized health insurance policies that cover dental services that was to take effect no later than January 1, 2018. Existing law requires a health care service plan or health insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy.This bill would require a health care service plan or a health insurer that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services in California, in addition to any other applicable disclosure requirements, to utilize a uniform benefit disclosure form, with specified contents. The bill also would require a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services, and that offers a dental discount product, to fully disclose the type of discount product that the purchaser will receive on the plans Internet Web site and on the unified benefit disclosure form. The bill would require the Department of Managed Health Care and the Department of Insurance to implement the bills provisions relating to disclosure through emergency regulations, as specified.Existing law requires a health care service plan or health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies, as applicable, for health care coverage in this state, to provide an annual rebate to each enrollee or insured, as applicable, under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan or health insurer on the costs for reimbursement for clinical services provided to enrollees or insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, as specified, is less than 85% with respect to a plan or insurer in the large group market or less than 80% with respect to a plan or insurer in the small group or individual market. Existing law governs the calculation of the total amount of the annual rebate based in part on these ratios. Existing law also requires a health care service plan and a health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies for health care coverage in this state to comply with specified minimum medical loss ratios. Existing law specifically exempts a specialized health care service plan contract or specialized health insurance policy from the requirement to provide an annual rebate.This bill would instead express the intent of the Legislature to enact a medical loss ratio standard enact similar provisions that would require, for specialized health care service plans and specialized health insurance policies policies that cover dental services no later than January 1, 2019. The bill would also make technical changes. services, an annual rebate amount that would be calculated based on a specified ratio, and to comply with specified minimum medical loss ratios that would differ from the minimum medical loss ratios applicable to other health care service plans and health insurers. The bill would also revise related annual reporting requirements. The bill would express the intent of the Legislature to enact legislation, by 2024, to incrementally increase these minimum medical loss ratios until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers. The bill would also require a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan or specialized health insurance policy that provides out-of-network dental services as a covered benefit to provide to a billing and treating provider, on behalf of the enrollee or insured, as applicable, specified information regarding the enrollees or insureds benefits.Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.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 1363.04 is added to the Health and Safety Code, to read:1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.SEC. 2. Section 1367.003 of the Health and Safety Code is amended to read:1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).SEC. 3. Section 1367.004 of the Health and Safety Code is amended to read:1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.SEC. 4. Section 1367.013 is added to the Health and Safety Code, to read:1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.SEC. 5. Section 10112.25 of the Insurance Code is amended to read:10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).SEC. 6. Section 10112.255 is added to the Insurance Code, to read:10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.SEC. 7. Section 10112.26 of the Insurance Code is amended to read:10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.SEC. 8. Section 10603.04 is added to the Insurance Code, to read:10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.SEC. 9. It is the intent of the Legislature to enact legislation, by 2024, to incrementally increase the minimum medical loss ratios applicable to specialized health care service plans and specialized health insurance policies that cover dental services, as established by the amendments to Section 1367.003 of the Health and Safety Code and Section 10112.25 of the Insurance Code made by this act, until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers.SEC. 10. 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 1367.004 of the Health and Safety Code is amended to read:1367.004.(a)A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c)If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d)The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e)The department shall make available to the public all of the data provided to the department pursuant to this section.(f)This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health care service plans that cover dental services no later than January 1, 2019.SEC. 2.Section 10112.26 of the Insurance Code is amended to read:10112.26.(a)A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c)If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d)The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e)The department shall make available to the public all of the data provided to the department pursuant to this section.(f)This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g)This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health insurance policies that cover dental services no later than January 1, 2019.
Amended IN Senate April 10, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Senate Bill No. 1008Introduced by Senator SkinnerFebruary 06, 2018 An act to amend Section 1367.004 of the Health and Safety Code, and to amend Section 10112.26 of the Insurance Code, amend Sections 1367.003 and 1367.004 of, and to add Sections 1363.04 and 1367.013 to, the Health and Safety Code, and to amend Sections 10112.25 and 10112.26 of, and to add Sections 10112.255 and 10603.04 to, the Insurance Code, relating to dental services. LEGISLATIVE COUNSEL'S DIGESTSB 1008, as amended, Skinner. Health insurance: dental services: medical loss ratio. ratios: out-of-network coverage information: disclosures.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.The federal Patient Protection and Affordable Care Act requires a health insurance issuer issuing health insurance coverage to comply with minimum medical loss ratios and to provide an annual rebate to each insured if the medical loss ratio of the amount of the revenue expended by the issuer on costs to the total amount of premium revenue is less than a certain percentage, as specified.Existing law requires a health care service plan that issues, sells, renews, or offers a specialized health care service plan, and a health insurer that issues, sells, renews, or offers a specialized health insurance policy, covering dental services, to annually file a report that is organized by market and product type and contains the same information required in a specified federal medical loss ratio annual reporting form. Existing law expresses the intent of the Legislature that the data reported be considered by the Legislature in adopting a medical loss ratio standard for health care service plans and specialized health insurance policies that cover dental services that was to take effect no later than January 1, 2018. Existing law requires a health care service plan or health insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy.This bill would require a health care service plan or a health insurer that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services in California, in addition to any other applicable disclosure requirements, to utilize a uniform benefit disclosure form, with specified contents. The bill also would require a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services, and that offers a dental discount product, to fully disclose the type of discount product that the purchaser will receive on the plans Internet Web site and on the unified benefit disclosure form. The bill would require the Department of Managed Health Care and the Department of Insurance to implement the bills provisions relating to disclosure through emergency regulations, as specified.Existing law requires a health care service plan or health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies, as applicable, for health care coverage in this state, to provide an annual rebate to each enrollee or insured, as applicable, under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan or health insurer on the costs for reimbursement for clinical services provided to enrollees or insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, as specified, is less than 85% with respect to a plan or insurer in the large group market or less than 80% with respect to a plan or insurer in the small group or individual market. Existing law governs the calculation of the total amount of the annual rebate based in part on these ratios. Existing law also requires a health care service plan and a health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies for health care coverage in this state to comply with specified minimum medical loss ratios. Existing law specifically exempts a specialized health care service plan contract or specialized health insurance policy from the requirement to provide an annual rebate.This bill would instead express the intent of the Legislature to enact a medical loss ratio standard enact similar provisions that would require, for specialized health care service plans and specialized health insurance policies policies that cover dental services no later than January 1, 2019. The bill would also make technical changes. services, an annual rebate amount that would be calculated based on a specified ratio, and to comply with specified minimum medical loss ratios that would differ from the minimum medical loss ratios applicable to other health care service plans and health insurers. The bill would also revise related annual reporting requirements. The bill would express the intent of the Legislature to enact legislation, by 2024, to incrementally increase these minimum medical loss ratios until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers. The bill would also require a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan or specialized health insurance policy that provides out-of-network dental services as a covered benefit to provide to a billing and treating provider, on behalf of the enrollee or insured, as applicable, specified information regarding the enrollees or insureds benefits.Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NOYES Local Program: NOYES
Amended IN Senate April 10, 2018
Amended IN Senate April 10, 2018
CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION
Senate Bill No. 1008
Introduced by Senator SkinnerFebruary 06, 2018
Introduced by Senator Skinner
February 06, 2018
An act to amend Section 1367.004 of the Health and Safety Code, and to amend Section 10112.26 of the Insurance Code, amend Sections 1367.003 and 1367.004 of, and to add Sections 1363.04 and 1367.013 to, the Health and Safety Code, and to amend Sections 10112.25 and 10112.26 of, and to add Sections 10112.255 and 10603.04 to, the Insurance Code, relating to dental services.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
SB 1008, as amended, Skinner. Health insurance: dental services: medical loss ratio. ratios: out-of-network coverage information: disclosures.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.The federal Patient Protection and Affordable Care Act requires a health insurance issuer issuing health insurance coverage to comply with minimum medical loss ratios and to provide an annual rebate to each insured if the medical loss ratio of the amount of the revenue expended by the issuer on costs to the total amount of premium revenue is less than a certain percentage, as specified.Existing law requires a health care service plan that issues, sells, renews, or offers a specialized health care service plan, and a health insurer that issues, sells, renews, or offers a specialized health insurance policy, covering dental services, to annually file a report that is organized by market and product type and contains the same information required in a specified federal medical loss ratio annual reporting form. Existing law expresses the intent of the Legislature that the data reported be considered by the Legislature in adopting a medical loss ratio standard for health care service plans and specialized health insurance policies that cover dental services that was to take effect no later than January 1, 2018. Existing law requires a health care service plan or health insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy.This bill would require a health care service plan or a health insurer that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services in California, in addition to any other applicable disclosure requirements, to utilize a uniform benefit disclosure form, with specified contents. The bill also would require a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services, and that offers a dental discount product, to fully disclose the type of discount product that the purchaser will receive on the plans Internet Web site and on the unified benefit disclosure form. The bill would require the Department of Managed Health Care and the Department of Insurance to implement the bills provisions relating to disclosure through emergency regulations, as specified.Existing law requires a health care service plan or health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies, as applicable, for health care coverage in this state, to provide an annual rebate to each enrollee or insured, as applicable, under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan or health insurer on the costs for reimbursement for clinical services provided to enrollees or insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, as specified, is less than 85% with respect to a plan or insurer in the large group market or less than 80% with respect to a plan or insurer in the small group or individual market. Existing law governs the calculation of the total amount of the annual rebate based in part on these ratios. Existing law also requires a health care service plan and a health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies for health care coverage in this state to comply with specified minimum medical loss ratios. Existing law specifically exempts a specialized health care service plan contract or specialized health insurance policy from the requirement to provide an annual rebate.This bill would instead express the intent of the Legislature to enact a medical loss ratio standard enact similar provisions that would require, for specialized health care service plans and specialized health insurance policies policies that cover dental services no later than January 1, 2019. The bill would also make technical changes. services, an annual rebate amount that would be calculated based on a specified ratio, and to comply with specified minimum medical loss ratios that would differ from the minimum medical loss ratios applicable to other health care service plans and health insurers. The bill would also revise related annual reporting requirements. The bill would express the intent of the Legislature to enact legislation, by 2024, to incrementally increase these minimum medical loss ratios until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers. The bill would also require a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan or specialized health insurance policy that provides out-of-network dental services as a covered benefit to provide to a billing and treating provider, on behalf of the enrollee or insured, as applicable, specified information regarding the enrollees or insureds benefits.Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.
The federal Patient Protection and Affordable Care Act requires a health insurance issuer issuing health insurance coverage to comply with minimum medical loss ratios and to provide an annual rebate to each insured if the medical loss ratio of the amount of the revenue expended by the issuer on costs to the total amount of premium revenue is less than a certain percentage, as specified.
Existing law requires a health care service plan that issues, sells, renews, or offers a specialized health care service plan, and a health insurer that issues, sells, renews, or offers a specialized health insurance policy, covering dental services, to annually file a report that is organized by market and product type and contains the same information required in a specified federal medical loss ratio annual reporting form. Existing law expresses the intent of the Legislature that the data reported be considered by the Legislature in adopting a medical loss ratio standard for health care service plans and specialized health insurance policies that cover dental services that was to take effect no later than January 1, 2018.
Existing law requires a health care service plan or health insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy.
This bill would require a health care service plan or a health insurer that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services in California, in addition to any other applicable disclosure requirements, to utilize a uniform benefit disclosure form, with specified contents. The bill also would require a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services, and that offers a dental discount product, to fully disclose the type of discount product that the purchaser will receive on the plans Internet Web site and on the unified benefit disclosure form. The bill would require the Department of Managed Health Care and the Department of Insurance to implement the bills provisions relating to disclosure through emergency regulations, as specified.
Existing law requires a health care service plan or health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies, as applicable, for health care coverage in this state, to provide an annual rebate to each enrollee or insured, as applicable, under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan or health insurer on the costs for reimbursement for clinical services provided to enrollees or insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, as specified, is less than 85% with respect to a plan or insurer in the large group market or less than 80% with respect to a plan or insurer in the small group or individual market. Existing law governs the calculation of the total amount of the annual rebate based in part on these ratios. Existing law also requires a health care service plan and a health insurer that issues, sells, renews, or offers health care service plan contracts or health insurance policies for health care coverage in this state to comply with specified minimum medical loss ratios. Existing law specifically exempts a specialized health care service plan contract or specialized health insurance policy from the requirement to provide an annual rebate.
This bill would instead express the intent of the Legislature to enact a medical loss ratio standard enact similar provisions that would require, for specialized health care service plans and specialized health insurance policies policies that cover dental services no later than January 1, 2019. The bill would also make technical changes. services, an annual rebate amount that would be calculated based on a specified ratio, and to comply with specified minimum medical loss ratios that would differ from the minimum medical loss ratios applicable to other health care service plans and health insurers. The bill would also revise related annual reporting requirements. The bill would express the intent of the Legislature to enact legislation, by 2024, to incrementally increase these minimum medical loss ratios until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers. The bill would also require a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan or specialized health insurance policy that provides out-of-network dental services as a covered benefit to provide to a billing and treating provider, on behalf of the enrollee or insured, as applicable, specified information regarding the enrollees or insureds benefits.
Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1363.04 is added to the Health and Safety Code, to read:1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.SEC. 2. Section 1367.003 of the Health and Safety Code is amended to read:1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).SEC. 3. Section 1367.004 of the Health and Safety Code is amended to read:1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.SEC. 4. Section 1367.013 is added to the Health and Safety Code, to read:1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.SEC. 5. Section 10112.25 of the Insurance Code is amended to read:10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).SEC. 6. Section 10112.255 is added to the Insurance Code, to read:10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.SEC. 7. Section 10112.26 of the Insurance Code is amended to read:10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.SEC. 8. Section 10603.04 is added to the Insurance Code, to read:10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.SEC. 9. It is the intent of the Legislature to enact legislation, by 2024, to incrementally increase the minimum medical loss ratios applicable to specialized health care service plans and specialized health insurance policies that cover dental services, as established by the amendments to Section 1367.003 of the Health and Safety Code and Section 10112.25 of the Insurance Code made by this act, until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers.SEC. 10. 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 1367.004 of the Health and Safety Code is amended to read:1367.004.(a)A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c)If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d)The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e)The department shall make available to the public all of the data provided to the department pursuant to this section.(f)This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health care service plans that cover dental services no later than January 1, 2019.SEC. 2.Section 10112.26 of the Insurance Code is amended to read:10112.26.(a)A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c)If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d)The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e)The department shall make available to the public all of the data provided to the department pursuant to this section.(f)This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g)This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health insurance policies that cover dental services no later than January 1, 2019.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1363.04 is added to the Health and Safety Code, to read:1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
SECTION 1. Section 1363.04 is added to the Health and Safety Code, to read:
### SECTION 1.
1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:(1) The annual overall plan deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental plan reimbursement levels, including estimated enrollee cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
1363.04. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health care service plan to provide all of the following information:
(1) The annual overall plan deductible.
(2) The annual benefit limit.
(3) Coverage for the following categories:
(A) Preventive and diagnostic services.
(B) Basic services.
(C) Major services.
(D) Orthodontia services.
(4) Dental plan reimbursement levels, including estimated enrollee cost share.
(5) Estimated annual out-of-pocket expenses.
(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.
(7) Limitations, exceptions, and waiting periods.
(b) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state and that offers a dental discount product, in addition to any other applicable disclosure requirements, shall fully disclose on the plans Internet Web site and on the disclosure form required by subdivision (a), the type of discount product that the purchaser will receive. The department shall consult with stakeholders to determine the specific disclosure language.
(c) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
SEC. 2. Section 1367.003 of the Health and Safety Code is amended to read:1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
SEC. 2. Section 1367.003 of the Health and Safety Code is amended to read:
### SEC. 2.
1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.(e) The following definitions shall apply for purposes of this section:(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.(c)(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.(h)Nothing in this section shall be construed to(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
1367.003. (a) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, but not including specialized health care service plan contracts, shall provide an annual rebate to each enrollee under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:
(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.
(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.
(b) Every A health care service plan that issues, sells, renews, or offers health care service plan contracts for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:
(1) With respect to a health care service plan offering coverage in the large group market, 85 percent.
(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 80 percent.
(c) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including a dental discount plan or dental discount product, shall provide an annual rebate to each enrollee under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health care service plan on the costs for reimbursement for clinical services provided to enrollees under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:
(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.
(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.
(d) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, including a grandfathered health care service plan, but not including dental discount plans or dental discount products, shall comply with the following minimum medical loss ratios:
(1) With respect to a health care service plan offering coverage in the large group market, 75 percent.
(2) With respect to a health care service plan offering coverage in the small group market or in the individual market, 70 percent.
(e) The following definitions shall apply for purposes of this section:
(1) Dental discount plan means a membership-based discount plan for dental maintenance and intervention, licensed by the Department of Managed Health Care, in which the referring company does not assume financial risk and the patient pays the entire cost of a rate negotiated between the dentist and the referring company.
(2) Dental discount product means a discount dental services product offered under a specialized health care service plan contract that covers dental services.
(c)
(f) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:
(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of subdivision (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of subdivision (c), as applicable.
(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.
(2) A health care service plan shall provide any rebate owing to an enrollee no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.
(d)
(g) (1) The director may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.
(2) The director may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.
(e)
(h) The department shall consult with the Department of Insurance in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.
(f)
(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.
(g)Nothing in this section shall be construed to
(j) This section does not apply to provisions of this chapter pertaining to financial statements, assets, liabilities, and other accounting items to which subdivision (s) of Section 1345 applies.
(h)Nothing in this section shall be construed to
(k) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
SEC. 3. Section 1367.004 of the Health and Safety Code is amended to read:1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.
SEC. 3. Section 1367.004 of the Health and Safety Code is amended to read:
### SEC. 3.
1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.
1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.
1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.
1367.004. (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health care service plans on its Internet Web site within 45 days after receiving all MLR annual reports.
(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.
(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.
(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.
(e) The department shall make available to the public all of the data provided to the department pursuant to this section.
(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(g) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.
(h) Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.
SEC. 4. Section 1367.013 is added to the Health and Safety Code, to read:1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
SEC. 4. Section 1367.013 is added to the Health and Safety Code, to read:
### SEC. 4.
1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
1367.013. A health care service plan that issues, sells, renews, or offers a specialized health plan that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the enrollee, all of the following information regarding the enrollees benefits:
(a) The health care service plans criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.
(b) The dental treatment and procedures covered.
(c) The actual percentages or amounts payable as a benefit toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.
(d) This section does not apply to Medi-Cal dental managed care plan contracts.
SEC. 5. Section 10112.25 of the Insurance Code is amended to read:10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
SEC. 5. Section 10112.25 of the Insurance Code is amended to read:
### SEC. 5.
10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 85 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:(1) With respect to a health insurer offering coverage in the large group market, 75 percent.(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.(c)(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.(d)(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.(2)(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(e)(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.(f)(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.(g)Nothing in this section shall be construed to(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
10112.25. (a) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, but not including specialized health insurance policies, shall provide an annual rebate to each insured under such that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under such that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:
(1) With respect to a health insurer offering coverage in the large group market, 85 percent.
(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.
(b) Every A health insurer that issues, sells, renews, or offers health insurance policies for health care coverage in this state, including a grandfathered health plan, shall comply with the following minimum medical loss ratios:
(1) With respect to a health insurer offering coverage in the large group market, 85 percent.
(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 80 percent.
(c) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall provide an annual rebate to each insured under that coverage, on a pro rata basis, if the ratio of the amount of premium revenue expended by the health insurer on the costs for reimbursement for clinical services provided to insureds under that coverage and for activities that improve health care quality to the total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance, is less than the following:
(1) With respect to a health insurer offering coverage in the large group market, 75 percent.
(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.
(d) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services in this state, including a grandfathered health insurance policy, shall comply with the following minimum medical loss ratios:
(1) With respect to a health insurer offering coverage in the large group market, 75 percent.
(2) With respect to a health insurer offering coverage in the small group market or in the individual market, 70 percent.
(c)
(e) (1) The total amount of an annual rebate required under this section shall be calculated in an amount equal to the product of the following:
(A) The amount by which the percentage described in paragraph (1) or (2) of subdivision (a) or paragraph (1) or (2) of (c), as applicable, exceeds the ratio described in paragraph (1) or (2) of subdivision (a). (a) or paragraph (1) or (2) of (c), as applicable.
(B) The total amount of premium revenue, excluding federal and state taxes and licensing or regulatory fees and after accounting for payments or receipts for risk adjustment, risk corridors, and reinsurance.
(2) A health insurer shall provide any rebate owing to an insured no later than August 1 of the calendar year following the year for which the ratio described in subdivision (a) or (c) was calculated.
(d)
(f) (1)The commissioner may adopt regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) that are necessary to implement the medical loss ratio as described under Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), and any federal rules or regulations issued under that section.
(2)
(g) The commissioner may also adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) when it is necessary to implement the applicable provisions of this section and to address specific conflicts between state and federal law that prevent implementation of federal law and guidance pursuant to Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18). The initial adoption of the emergency regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.
(e)
(h) The department shall consult with the Department of Managed Health Care in adopting necessary regulations, and in taking any other action for the purpose of implementing this section.
(f)
(i) This section shall be implemented to the extent required by federal law and shall comply with, and not exceed, the scope of Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91) and the requirements of Section 2718 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and any rules or regulations issued under those sections.
(g)Nothing in this section shall be construed to
(j) This section does not apply to a health care service plan contract or insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695)), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700)), Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5)), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
SEC. 6. Section 10112.255 is added to the Insurance Code, to read:10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
SEC. 6. Section 10112.255 is added to the Insurance Code, to read:
### SEC. 6.
10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.(b) The dental treatment and procedures covered.(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.(d) This section does not apply to Medi-Cal dental managed care plan contracts.
10112.255. A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide to a billing and treating provider, on behalf of the insured, all of the following information regarding the insureds benefits:
(a) The insurers criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.
(b) The dental treatment and procedures covered.
(c) The actual percentages and amounts payable toward dental care or treatment, including an explanation of benefits or other notification of payment issued by the insurer on behalf of the insured for dental treatment rendered by the billing provider.
(d) This section does not apply to Medi-Cal dental managed care plan contracts.
SEC. 7. Section 10112.26 of the Insurance Code is amended to read:10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.
SEC. 7. Section 10112.26 of the Insurance Code is amended to read:
### SEC. 7.
10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.
10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.
10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.(e) The department shall make available to the public all of the data provided to the department pursuant to this section.(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.
10112.26. (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report, with the department that is report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post the information submitted by the health insurers on its Internet Web site within 45 days after receiving all MLR annual reports.
(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.
(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.
(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.
(e) The department shall make available to the public all of the data provided to the department pursuant to this section.
(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), the California Major Risk Medical Insurance Program (Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.
(h) It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.
(i) Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.
SEC. 8. Section 10603.04 is added to the Insurance Code, to read:10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
SEC. 8. Section 10603.04 is added to the Insurance Code, to read:
### SEC. 8.
10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:(1) The annual overall policy deductible.(2) The annual benefit limit.(3) Coverage for the following categories:(A) Preventive and diagnostic services.(B) Basic services.(C) Major services.(D) Orthodontia services.(4) Dental policy reimbursement levels, including estimated insured cost share.(5) Estimated annual out-of-pocket expenses.(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.(7) Limitations, exceptions, and waiting periods.(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
10603.04. (a) A health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefit disclosure form, which shall be developed by the department. At a minimum, the benefit disclosure form shall require the health insurer to provide all of the following information:
(1) The annual overall policy deductible.
(2) The annual benefit limit.
(3) Coverage for the following categories:
(A) Preventive and diagnostic services.
(B) Basic services.
(C) Major services.
(D) Orthodontia services.
(4) Dental policy reimbursement levels, including estimated insured cost share.
(5) Estimated annual out-of-pocket expenses.
(6) When the disclosure form is updated, the applicable medical loss ratio for the prior year.
(7) Limitations, exceptions, and waiting periods.
(b) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
SEC. 9. It is the intent of the Legislature to enact legislation, by 2024, to incrementally increase the minimum medical loss ratios applicable to specialized health care service plans and specialized health insurance policies that cover dental services, as established by the amendments to Section 1367.003 of the Health and Safety Code and Section 10112.25 of the Insurance Code made by this act, until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers.
SEC. 9. It is the intent of the Legislature to enact legislation, by 2024, to incrementally increase the minimum medical loss ratios applicable to specialized health care service plans and specialized health insurance policies that cover dental services, as established by the amendments to Section 1367.003 of the Health and Safety Code and Section 10112.25 of the Insurance Code made by this act, until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers.
SEC. 9. It is the intent of the Legislature to enact legislation, by 2024, to incrementally increase the minimum medical loss ratios applicable to specialized health care service plans and specialized health insurance policies that cover dental services, as established by the amendments to Section 1367.003 of the Health and Safety Code and Section 10112.25 of the Insurance Code made by this act, until these ratios are equal to the minimum medical loss ratios that are applicable to other health care service plans and health insurers.
### SEC. 9.
SEC. 10. 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.
SEC. 10. 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.
SEC. 10. 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.
### SEC. 10.
(a)A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).
(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.
(c)If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plans representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.
(d)The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.
(e)The department shall make available to the public all of the data provided to the department pursuant to this section.
(f)This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(g)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health care service plans that cover dental services no later than January 1, 2019.
(a)A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, no later than September 30, 2015, and each year thereafter, file a report, which shall be known as the MLR annual report, with the department that is organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).
(b)The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.
(c)If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurers representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.
(d)The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.
(e)The department shall make available to the public all of the data provided to the department pursuant to this section.
(f)This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(g)This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.
(h)It is the intent of the Legislature to enact a medical loss ratio standard for specialized health insurance policies that cover dental services no later than January 1, 2019.