| 1 | | - | Senate Bill No. 280 CHAPTER 636 An act to add Sections 10112.281 and 10112.282 to the Insurance Code, relating to health insurance. [ Approved by Governor October 07, 2021. Filed with Secretary of State October 07, 2021. ] LEGISLATIVE COUNSEL'S DIGESTSB 280, Limn. Health insurance: large group health insurance.(1) Existing law requires the regulation of health insurance policies by the Department of Insurance under the guidance of the Insurance Commissioner. Under existing law, the department regulates individual, small employer, and large employer health insurance policies, as defined. Existing law requires an individual or small group health insurance policy issued to include coverage for essential health benefits, as defined. This bill would require a large group health insurance policy issued, amended, or renewed on or after July 1, 2022, to cover medically necessary basic health care services, as defined. The bill would authorize the commissioner to adopt regulations to implement these provisions. The bill would require these provisions to apply to an individual, group, or blanket disability insurance policy if a specified condition is met.(2) Existing law prohibits a health insurer or agent or broker from, directly or indirectly, from among other things, employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.This bill would, with respect to large group health insurance, prohibit an insurer and its officials, employees, agents, and representatives from directly or indirectly employing marketing practices or benefit designs that have the effect of discouraging the enrollment of individual on the above-described protected classifications. An insurer that violates this provision would be liable for an administrative penalty of not more than $2,500 for the first violation, and not more than $5,000 for the second. The bill would also subject an insurer that violates this provision with a frequency that indicates a general practice or commits a knowing violation to an administrative penalty of not less than $15,000, and not more than $100,000 for each violation.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 10112.281 is added to the Insurance Code, immediately following Section 10112.28, to read:10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits.SEC. 2. Section 10112.282 is added to the Insurance Code, to read:10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 1 | + | Enrolled August 27, 2021 Passed IN Senate June 01, 2021 Passed IN Assembly August 26, 2021 CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION Senate Bill No. 280Introduced by Senator Limn(Coauthor: Senator Laird)February 01, 2021 An act to add Sections 10112.281 and 10112.282 to the Insurance Code, relating to health insurance. LEGISLATIVE COUNSEL'S DIGESTSB 280, Limn. Health insurance: large group health insurance.(1) Existing law requires the regulation of health insurance policies by the Department of Insurance under the guidance of the Insurance Commissioner. Under existing law, the department regulates individual, small employer, and large employer health insurance policies, as defined. Existing law requires an individual or small group health insurance policy issued to include coverage for essential health benefits, as defined. This bill would require a large group health insurance policy issued, amended, or renewed on or after July 1, 2022, to cover medically necessary basic health care services, as defined. The bill would authorize the commissioner to adopt regulations to implement these provisions. The bill would require these provisions to apply to an individual, group, or blanket disability insurance policy if a specified condition is met.(2) Existing law prohibits a health insurer or agent or broker from, directly or indirectly, from among other things, employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.This bill would, with respect to large group health insurance, prohibit an insurer and its officials, employees, agents, and representatives from directly or indirectly employing marketing practices or benefit designs that have the effect of discouraging the enrollment of individual on the above-described protected classifications. An insurer that violates this provision would be liable for an administrative penalty of not more than $2,500 for the first violation, and not more than $5,000 for the second. The bill would also subject an insurer that violates this provision with a frequency that indicates a general practice or commits a knowing violation to an administrative penalty of not less than $15,000, and not more than $100,000 for each violation.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 10112.281 is added to the Insurance Code, immediately following Section 10112.28, to read:10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits.SEC. 2. Section 10112.282 is added to the Insurance Code, to read:10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 14 | 23 | | |
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| 15 | 24 | | LEGISLATIVE COUNSEL'S DIGEST |
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| 16 | 25 | | |
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| 17 | 26 | | ## LEGISLATIVE COUNSEL'S DIGEST |
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| 18 | 27 | | |
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| 19 | 28 | | SB 280, Limn. Health insurance: large group health insurance. |
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| 20 | 29 | | |
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| 21 | 30 | | (1) Existing law requires the regulation of health insurance policies by the Department of Insurance under the guidance of the Insurance Commissioner. Under existing law, the department regulates individual, small employer, and large employer health insurance policies, as defined. Existing law requires an individual or small group health insurance policy issued to include coverage for essential health benefits, as defined. This bill would require a large group health insurance policy issued, amended, or renewed on or after July 1, 2022, to cover medically necessary basic health care services, as defined. The bill would authorize the commissioner to adopt regulations to implement these provisions. The bill would require these provisions to apply to an individual, group, or blanket disability insurance policy if a specified condition is met.(2) Existing law prohibits a health insurer or agent or broker from, directly or indirectly, from among other things, employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.This bill would, with respect to large group health insurance, prohibit an insurer and its officials, employees, agents, and representatives from directly or indirectly employing marketing practices or benefit designs that have the effect of discouraging the enrollment of individual on the above-described protected classifications. An insurer that violates this provision would be liable for an administrative penalty of not more than $2,500 for the first violation, and not more than $5,000 for the second. The bill would also subject an insurer that violates this provision with a frequency that indicates a general practice or commits a knowing violation to an administrative penalty of not less than $15,000, and not more than $100,000 for each violation. |
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| 22 | 31 | | |
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| 23 | 32 | | (1) Existing law requires the regulation of health insurance policies by the Department of Insurance under the guidance of the Insurance Commissioner. Under existing law, the department regulates individual, small employer, and large employer health insurance policies, as defined. Existing law requires an individual or small group health insurance policy issued to include coverage for essential health benefits, as defined. |
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| 24 | 33 | | |
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| 25 | 34 | | This bill would require a large group health insurance policy issued, amended, or renewed on or after July 1, 2022, to cover medically necessary basic health care services, as defined. The bill would authorize the commissioner to adopt regulations to implement these provisions. The bill would require these provisions to apply to an individual, group, or blanket disability insurance policy if a specified condition is met. |
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| 26 | 35 | | |
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| 27 | 36 | | (2) Existing law prohibits a health insurer or agent or broker from, directly or indirectly, from among other things, employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions. |
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| 28 | 37 | | |
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| 29 | 38 | | This bill would, with respect to large group health insurance, prohibit an insurer and its officials, employees, agents, and representatives from directly or indirectly employing marketing practices or benefit designs that have the effect of discouraging the enrollment of individual on the above-described protected classifications. An insurer that violates this provision would be liable for an administrative penalty of not more than $2,500 for the first violation, and not more than $5,000 for the second. The bill would also subject an insurer that violates this provision with a frequency that indicates a general practice or commits a knowing violation to an administrative penalty of not less than $15,000, and not more than $100,000 for each violation. |
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| 30 | 39 | | |
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| 31 | 40 | | ## Digest Key |
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| 32 | 41 | | |
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| 33 | 42 | | ## Bill Text |
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| 34 | 43 | | |
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| 35 | 44 | | The people of the State of California do enact as follows:SECTION 1. Section 10112.281 is added to the Insurance Code, immediately following Section 10112.28, to read:10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits.SEC. 2. Section 10112.282 is added to the Insurance Code, to read:10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 36 | 45 | | |
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| 37 | 46 | | The people of the State of California do enact as follows: |
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| 38 | 47 | | |
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| 39 | 48 | | ## The people of the State of California do enact as follows: |
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| 40 | 49 | | |
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| 41 | 50 | | SECTION 1. Section 10112.281 is added to the Insurance Code, immediately following Section 10112.28, to read:10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits. |
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| 42 | 51 | | |
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| 43 | 52 | | SECTION 1. Section 10112.281 is added to the Insurance Code, immediately following Section 10112.28, to read: |
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| 44 | 53 | | |
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| 45 | 54 | | ### SECTION 1. |
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| 46 | 55 | | |
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| 47 | 56 | | 10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits. |
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| 48 | 57 | | |
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| 49 | 58 | | 10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits. |
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| 50 | 59 | | |
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| 51 | 60 | | 10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services.(b) Basic health care services means all the following:(1) Physician services, including consultation and referral.(2) Hospital inpatient services and ambulatory care services.(3) Diagnostic laboratory and diagnostic and therapeutic radiologic services.(4) Home health services.(5) Preventive health services.(6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system.(7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions.(c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area.(d) This section does not prohibit a large group health insurance policy from covering additional benefits.(e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations.(f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g).(2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.(g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits. |
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| 52 | 61 | | |
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| 53 | 62 | | |
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| 54 | 63 | | |
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| 55 | 64 | | 10112.281. (a) A large group health insurance policy issued, amended, or renewed on or after July 1, 2022, shall cover medically necessary basic health care services. |
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| 56 | 65 | | |
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| 57 | 66 | | (b) Basic health care services means all the following: |
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| 58 | 67 | | |
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| 59 | 68 | | (1) Physician services, including consultation and referral. |
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| 60 | 69 | | |
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| 61 | 70 | | (2) Hospital inpatient services and ambulatory care services. |
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| 62 | 71 | | |
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| 63 | 72 | | (3) Diagnostic laboratory and diagnostic and therapeutic radiologic services. |
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| 64 | 73 | | |
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| 65 | 74 | | (4) Home health services. |
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| 66 | 75 | | |
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| 67 | 76 | | (5) Preventive health services. |
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| 68 | 77 | | |
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| 69 | 78 | | (6) Emergency health care services, including ambulance and ambulance transport services and out-of-area coverage. Basic health care services includes ambulance and ambulance transport services provided through the 911 emergency response system. |
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| 70 | 79 | | |
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| 71 | 80 | | (7) Hospice care that is, at a minimum, equivalent to hospice care provided by the federal Medicare Program pursuant to Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) and implementing regulations adopted for hospice care under Title XVIII of the Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of Federal Regulations, except Subparts A, B, G, and H, and any amendments or successor provisions. |
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| 72 | 81 | | |
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| 73 | 82 | | (c) Out-of-area coverage means coverage while an insured is anywhere outside the service area of the applicable network, and shall also include coverage for urgently needed services to prevent serious deterioration of an insureds health resulting from unforeseen illness or injury for which treatment cannot be delayed until the insured returns to the service area. |
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| 74 | 83 | | |
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| 75 | 84 | | (d) This section does not prohibit a large group health insurance policy from covering additional benefits. |
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| 76 | 85 | | |
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| 77 | 86 | | (e) The commissioner may adopt regulations pursuant 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) to implement this section. Prior to adopting regulations, the commissioner shall consult with the Department of Managed Health Care to ensure consistency, to the extent practical, with Section 1300.67 of Title 28 of the California Code of Regulations. |
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| 78 | 87 | | |
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| 79 | 88 | | (f) (1) If Section 10112.27 is no longer in effect, this section and any regulations implementing this section shall apply to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, except as provided in subdivision (g). |
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| 80 | 89 | | |
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| 81 | 90 | | (2) If the condition described in paragraph (1) occurs, the department shall post notice on its internet website that this section applies to an individual, group, or blanket disability insurance policy that covers hospital, medical, or surgical benefits, and shall provide written notice to the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. |
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| 82 | 91 | | |
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| 83 | 92 | | (g) This section does not apply to a specialized health insurance policy that covers only dental or vision benefits. |
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| 84 | 93 | | |
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| 85 | 94 | | SEC. 2. Section 10112.282 is added to the Insurance Code, to read:10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 86 | 95 | | |
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| 87 | 96 | | SEC. 2. Section 10112.282 is added to the Insurance Code, to read: |
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| 88 | 97 | | |
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| 89 | 98 | | ### SEC. 2. |
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| 90 | 99 | | |
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| 91 | 100 | | 10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 92 | 101 | | |
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| 93 | 102 | | 10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 94 | 103 | | |
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| 95 | 104 | | 10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.(b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation.(c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation.(d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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| 96 | 105 | | |
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| 97 | 106 | | |
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| 98 | 107 | | |
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| 99 | 108 | | 10112.282. (a) With respect to large group health insurance, an insurer and its officials, employees, agents, and representatives shall not, directly or indirectly, employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminating based on an individuals race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions. |
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| 100 | 109 | | |
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| 101 | 110 | | (b) An insurer that violates this section shall be liable for an administrative penalty of not more than two thousand five hundred dollars ($2,500) for the first violation, and not more than five thousand dollars ($5,000) for each subsequent violation. |
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| 102 | 111 | | |
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| 103 | 112 | | (c) An insurer that violates this section with a frequency that indicates a general business practice or commits a knowing violation of this section shall be liable for an administrative penalty of not less than fifteen thousand dollars ($15,000), and not more than one hundred thousand dollars ($100,000) for each violation. |
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| 104 | 113 | | |
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| 105 | 114 | | (d) This section does not apply to a grandfathered large group health insurance policy or a specialized health insurance policy that covers only dental or vision benefits. |
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