| 1 | | - | Assembly Bill No. 1048 CHAPTER 557An act to amend Section 1385.02 of, and to add Sections 1374.194 and 1385.14 to, the Health and Safety Code, and to amend Section 10181.2 of, and to add Sections 10120.41 and 10181.14 to, the Insurance Code, relating to health care coverage. [ Approved by Governor October 08, 2023. Filed with Secretary of State October 08, 2023. ] LEGISLATIVE COUNSEL'S DIGESTAB 1048, Wicks. Dental benefits and rate review.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 acts requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services.This bill, on and after January 1, 2025, would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.Existing law establishes a process for the Department of Managed Health Care and the Department of Insurance to review proposed rate increases by health care service plans and health insurers in the individual or group market in California. Existing law excludes specialized health care service plan contracts and specialized health insurance policies, among others, from those provisions.This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program.This bill would require, on or after January 1, 2025, and at least annually thereafter, health care service plans and specialized health care service plans covering dental services or specialized health insurance policies covering dental services to file with the Department of Managed Health Care or Department of Insurance specified information, including, among other things, the type of plan or health insurer involved, such as for profit or not for profit. The bill would require the plan or health insurer to file with the respective departments the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. The bill would require the departments to issue a determination, for all plans or health insurers covering dental services, that the plans or health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to makes its determination. The bill would authorize the Director of the Department of Managed Health Care or the Insurance Commissioner, on or before July 1, 2024, to issue guidance to plans and health insurers regarding compliance with these provisions. Because a violation of these requirements by a health care service plan 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: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1374.194 is added to the Health and Safety Code, to read:1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 2. Section 1385.02 of the Health and Safety Code is amended to read:1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code.SEC. 3. Section 1385.14 is added to the Health and Safety Code, to read:1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 4. Section 10120.41 is added to the Insurance Code, to read:10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 5. Section 10181.2 of the Insurance Code is amended to read:10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code.SEC. 6. Section 10181.14 is added to the Insurance Code, to read:10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 7. 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. |
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| 1 | + | Enrolled September 18, 2023 Passed IN Senate September 13, 2023 Passed IN Assembly September 14, 2023 Amended IN Senate September 08, 2023 Amended IN Senate July 03, 2023 Amended IN Assembly May 02, 2023 Amended IN Assembly March 27, 2023 CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 1048Introduced by Assembly Member WicksFebruary 15, 2023An act to amend Section 1385.02 of, and to add Sections 1374.194 and 1385.14 to, the Health and Safety Code, and to amend Section 10181.2 of, and to add Sections 10120.41 and 10181.14 to, the Insurance Code, relating to health care coverage.LEGISLATIVE COUNSEL'S DIGESTAB 1048, Wicks. Dental benefits and rate review.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 acts requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services.This bill, on and after January 1, 2025, would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.Existing law establishes a process for the Department of Managed Health Care and the Department of Insurance to review proposed rate increases by health care service plans and health insurers in the individual or group market in California. Existing law excludes specialized health care service plan contracts and specialized health insurance policies, among others, from those provisions.This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program.This bill would require, on or after January 1, 2025, and at least annually thereafter, health care service plans and specialized health care service plans covering dental services or specialized health insurance policies covering dental services to file with the Department of Managed Health Care or Department of Insurance specified information, including, among other things, the type of plan or health insurer involved, such as for profit or not for profit. The bill would require the plan or health insurer to file with the respective departments the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. The bill would require the departments to issue a determination, for all plans or health insurers covering dental services, that the plans or health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to makes its determination. The bill would authorize the Director of the Department of Managed Health Care or the Insurance Commissioner, on or before July 1, 2024, to issue guidance to plans and health insurers regarding compliance with these provisions. Because a violation of these requirements by a health care service plan 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: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1374.194 is added to the Health and Safety Code, to read:1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 2. Section 1385.02 of the Health and Safety Code is amended to read:1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code.SEC. 3. Section 1385.14 is added to the Health and Safety Code, to read:1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 4. Section 10120.41 is added to the Insurance Code, to read:10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 5. Section 10181.2 of the Insurance Code is amended to read:10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code.SEC. 6. Section 10181.14 is added to the Insurance Code, to read:10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 7. 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. |
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| 14 | 27 | | |
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| 15 | 28 | | LEGISLATIVE COUNSEL'S DIGEST |
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| 16 | 29 | | |
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| 17 | 30 | | ## LEGISLATIVE COUNSEL'S DIGEST |
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| 18 | 31 | | |
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| 19 | 32 | | AB 1048, Wicks. Dental benefits and rate review. |
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| 20 | 33 | | |
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| 21 | 34 | | 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 acts requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services.This bill, on and after January 1, 2025, would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.Existing law establishes a process for the Department of Managed Health Care and the Department of Insurance to review proposed rate increases by health care service plans and health insurers in the individual or group market in California. Existing law excludes specialized health care service plan contracts and specialized health insurance policies, among others, from those provisions.This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program.This bill would require, on or after January 1, 2025, and at least annually thereafter, health care service plans and specialized health care service plans covering dental services or specialized health insurance policies covering dental services to file with the Department of Managed Health Care or Department of Insurance specified information, including, among other things, the type of plan or health insurer involved, such as for profit or not for profit. The bill would require the plan or health insurer to file with the respective departments the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. The bill would require the departments to issue a determination, for all plans or health insurers covering dental services, that the plans or health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to makes its determination. The bill would authorize the Director of the Department of Managed Health Care or the Insurance Commissioner, on or before July 1, 2024, to issue guidance to plans and health insurers regarding compliance with these provisions. Because a violation of these requirements by a health care service plan 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. |
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| 22 | 35 | | |
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| 23 | 36 | | 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 acts requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services. |
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| 24 | 37 | | |
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| 25 | 38 | | This bill, on and after January 1, 2025, would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. |
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| 26 | 39 | | |
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| 27 | 40 | | Existing law establishes a process for the Department of Managed Health Care and the Department of Insurance to review proposed rate increases by health care service plans and health insurers in the individual or group market in California. Existing law excludes specialized health care service plan contracts and specialized health insurance policies, among others, from those provisions. |
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| 28 | 41 | | |
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| 29 | 42 | | This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program. |
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| 30 | 43 | | |
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| 31 | 44 | | This bill would require, on or after January 1, 2025, and at least annually thereafter, health care service plans and specialized health care service plans covering dental services or specialized health insurance policies covering dental services to file with the Department of Managed Health Care or Department of Insurance specified information, including, among other things, the type of plan or health insurer involved, such as for profit or not for profit. The bill would require the plan or health insurer to file with the respective departments the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. The bill would require the departments to issue a determination, for all plans or health insurers covering dental services, that the plans or health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to makes its determination. The bill would authorize the Director of the Department of Managed Health Care or the Insurance Commissioner, on or before July 1, 2024, to issue guidance to plans and health insurers regarding compliance with these provisions. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. |
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| 32 | 45 | | |
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| 33 | 46 | | 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. |
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| 34 | 47 | | |
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| 35 | 48 | | This bill would provide that no reimbursement is required by this act for a specified reason. |
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| 36 | 49 | | |
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| 37 | 50 | | ## Digest Key |
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| 38 | 51 | | |
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| 39 | 52 | | ## Bill Text |
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| 40 | 53 | | |
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| 41 | 54 | | The people of the State of California do enact as follows:SECTION 1. Section 1374.194 is added to the Health and Safety Code, to read:1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 2. Section 1385.02 of the Health and Safety Code is amended to read:1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code.SEC. 3. Section 1385.14 is added to the Health and Safety Code, to read:1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 4. Section 10120.41 is added to the Insurance Code, to read:10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 5. Section 10181.2 of the Insurance Code is amended to read:10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code.SEC. 6. Section 10181.14 is added to the Insurance Code, to read:10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision.SEC. 7. 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. |
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| 42 | 55 | | |
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| 43 | 56 | | The people of the State of California do enact as follows: |
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| 44 | 57 | | |
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| 45 | 58 | | ## The people of the State of California do enact as follows: |
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| 46 | 59 | | |
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| 47 | 60 | | SECTION 1. Section 1374.194 is added to the Health and Safety Code, to read:1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 48 | 61 | | |
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| 49 | 62 | | SECTION 1. Section 1374.194 is added to the Health and Safety Code, to read: |
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| 50 | 63 | | |
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| 51 | 64 | | ### SECTION 1. |
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| 52 | 65 | | |
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| 53 | 66 | | 1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 54 | 67 | | |
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| 55 | 68 | | 1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 56 | 69 | | |
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| 57 | 70 | | 1374.194. (a) The following definitions shall apply for purposes of this section:(1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage.(2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services.(3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 58 | 71 | | |
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| 59 | 72 | | |
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| 60 | 73 | | |
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| 61 | 74 | | 1374.194. (a) The following definitions shall apply for purposes of this section: |
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| 62 | 75 | | |
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| 63 | 76 | | (1) Dental waiting period provision means a plan contract provision that limits coverage for a specified period of time following an enrollees effective date of coverage. |
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| 64 | 77 | | |
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| 65 | 78 | | (2) Plan means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan covering dental services. |
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| 66 | 79 | | |
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| 67 | 80 | | (3) Preexisting condition provision means a contract provision that excludes or limits coverage for services, charges, or expenses incurred following an enrollees effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage. |
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| 68 | 81 | | |
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| 69 | 82 | | (b) On and after January 1, 2025, a plan shall not issue, amend, renew, or offer a plan contract that imposes a dental waiting period provision in a large group plan or preexisting condition provision for any plan. |
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| 70 | 83 | | |
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| 71 | 84 | | (c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 72 | 85 | | |
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| 73 | 86 | | SEC. 2. Section 1385.02 of the Health and Safety Code is amended to read:1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code. |
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| 74 | 87 | | |
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| 75 | 88 | | SEC. 2. Section 1385.02 of the Health and Safety Code is amended to read: |
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| 76 | 89 | | |
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| 77 | 90 | | ### SEC. 2. |
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| 78 | 91 | | |
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| 79 | 92 | | 1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code. |
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| 80 | 93 | | |
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| 81 | 94 | | 1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code. |
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| 82 | 95 | | |
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| 83 | 96 | | 1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code. |
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| 84 | 97 | | |
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| 85 | 98 | | |
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| 86 | 99 | | |
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| 87 | 100 | | 1385.02. This article shall apply to a health care service plan contract offered in the individual or group market in California, including a health care service plan contract covering dental services and a specialized health care service plan contract covering dental services. However, this article shall not apply to a nondental specialized health care service plan contract, a Medicare supplement contract subject to Article 3.5 (commencing with Section 1358.1), a health care service plan contract offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health care service plan contract offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health care service plan conversion contract offered pursuant to Section 1373.6, a health care service plan contract offered to a federally eligible defined individual under Article 4.6 (commencing with Section 1366.35) or Article 10.5 (commencing with Section 1399.801), or a Mexican prepaid health plan subject to Section 1351.2. This article does not limit, impair, or interfere with the authority of the California Public Employees Retirement System, as set forth in Section 22794 of the Government Code and Article 6 (commencing with Section 22850) of Part 5 of Division 5 of Title 2 of the Government Code. |
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| 88 | 101 | | |
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| 89 | 102 | | SEC. 3. Section 1385.14 is added to the Health and Safety Code, to read:1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 90 | 103 | | |
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| 91 | 104 | | SEC. 3. Section 1385.14 is added to the Health and Safety Code, to read: |
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| 92 | 105 | | |
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| 93 | 106 | | ### SEC. 3. |
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| 94 | 107 | | |
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| 95 | 108 | | 1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 96 | 109 | | |
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| 97 | 110 | | 1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 98 | 111 | | |
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| 99 | 112 | | 1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194.(b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of plan involved, such as for profit or not for profit.(2) Product type, such as a preferred provider organization or health maintenance organization.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each plan contract form.(6) Total incurred claims in each plan contract form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of subscribers or enrollees affected by each plan contract form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the plan serves more than one geographic region.(16) The loss ratio for the plan contract as described in Section 1367.004.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department.(3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified.(4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c).(f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the director may issue guidance to plans 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).(3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 100 | 113 | | |
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| 101 | 114 | | |
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| 102 | 115 | | |
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| 103 | 116 | | 1385.14. (a) This section shall apply only to a health care service plan covering dental services and a specialized health care service plan covering dental services, as defined in Section 1374.194. |
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| 104 | 117 | | |
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| 105 | 118 | | (b) On or after January 1, 2025, and at least annually thereafter, a plan shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following: |
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| 106 | 119 | | |
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| 107 | 120 | | (1) Type of plan involved, such as for profit or not for profit. |
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| 108 | 121 | | |
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| 109 | 122 | | (2) Product type, such as a preferred provider organization or health maintenance organization. |
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| 110 | 123 | | |
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| 111 | 124 | | (3) Whether the products are opened or closed. |
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| 112 | 125 | | |
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| 113 | 126 | | (4) Annual rate. |
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| 114 | 127 | | |
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| 115 | 128 | | (5) Total earned premiums in each plan contract form. |
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| 116 | 129 | | |
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| 117 | 130 | | (6) Total incurred claims in each plan contract form. |
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| 118 | 131 | | |
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| 119 | 132 | | (7) Review category: initial filing for new product, filing for existing product, or resubmission. |
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| 120 | 133 | | |
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| 121 | 134 | | (8) Average rate of increase. |
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| 122 | 135 | | |
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| 123 | 136 | | (9) Effective date of rate increase. |
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| 124 | 137 | | |
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| 125 | 138 | | (10) Number of subscribers or enrollees affected by each plan contract form. |
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| 126 | 139 | | |
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| 127 | 140 | | (11) A comparison of claims cost and rate changes over time. |
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| 128 | 141 | | |
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| 129 | 142 | | (12) Any changes in enrollee cost sharing over the prior year associated with the submitted rate filing. |
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| 130 | 143 | | |
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| 131 | 144 | | (13) Any changes in enrollee benefits over the prior year associated with the submitted rate filing. |
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| 132 | 145 | | |
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| 133 | 146 | | (14) Any changes in administrative costs. |
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| 134 | 147 | | |
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| 135 | 148 | | (15) Variation in trend, by geographic region, if the plan serves more than one geographic region. |
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| 136 | 149 | | |
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| 137 | 150 | | (16) The loss ratio for the plan contract as described in Section 1367.004. |
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| 138 | 151 | | |
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| 139 | 152 | | (17) Proposed and effective rates for all products. |
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| 140 | 153 | | |
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| 141 | 154 | | (18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined. |
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| 142 | 155 | | |
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| 143 | 156 | | (19) The base rate or rates and the factors used to determine the base rate or rates. |
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| 144 | 157 | | |
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| 145 | 158 | | (20) Trend, including overall average, and by-product, if different. |
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| 146 | 159 | | |
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| 147 | 160 | | (21) Any other factors affecting dental premium rates. |
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| 148 | 161 | | |
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| 149 | 162 | | (22) An actuarial certification signed by a qualified actuary. |
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| 150 | 163 | | |
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| 151 | 164 | | (23) Any other information required for the department to make its determination. |
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| 152 | 165 | | |
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| 153 | 166 | | (c) (1) The plan shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. |
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| 154 | 167 | | |
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| 155 | 168 | | (2) A plan shall respond to the departments request for any additional information necessary for the department to complete its review of the plans rate filing for individual and group plan contracts within five business days of the departments request or as otherwise required by the department. |
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| 156 | 169 | | |
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| 157 | 170 | | (3) If a plan fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a plans rate change is unreasonable or not justified. |
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| 158 | 171 | | |
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| 159 | 172 | | (4) If the department determines that a plans rate change for individual or group plan contracts is unreasonable or not justified consistent with this article, the plan shall provide notice of that determination to an individual or group applicant or subscriber. |
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| 160 | 173 | | |
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| 161 | 174 | | (5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code). |
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| 162 | 175 | | |
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| 163 | 176 | | (d) For all plans covering dental services, the department shall issue a determination that the plans rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates. |
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| 164 | 177 | | |
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| 165 | 178 | | (e) The department may review the rate filings to ensure compliance with the law, as described in Section 1385.11, excluding subdivision (c). |
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| 166 | 179 | | |
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| 167 | 180 | | (f) The department may require all health care service plans to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section. |
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| 168 | 181 | | |
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| 169 | 182 | | (g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. |
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| 170 | 183 | | |
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| 171 | 184 | | (2) On or before July 1, 2024, the director may issue guidance to plans 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). |
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| 172 | 185 | | |
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| 173 | 186 | | (3) The department shall consult with the Department of Insurance when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 174 | 187 | | |
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| 175 | 188 | | SEC. 4. Section 10120.41 is added to the Insurance Code, to read:10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 176 | 189 | | |
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| 177 | 190 | | SEC. 4. Section 10120.41 is added to the Insurance Code, to read: |
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| 178 | 191 | | |
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| 179 | 192 | | ### SEC. 4. |
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| 180 | 193 | | |
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| 181 | 194 | | 10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 182 | 195 | | |
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| 183 | 196 | | 10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 184 | 197 | | |
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| 185 | 198 | | 10120.41. (a) For purposes of this section, the following definitions shall apply:(1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage.(2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106.(3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage.(b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy.(c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 186 | 199 | | |
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| 187 | 200 | | |
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| 188 | 201 | | |
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| 189 | 202 | | 10120.41. (a) For purposes of this section, the following definitions shall apply: |
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| 190 | 203 | | |
|---|
| 191 | 204 | | (1) Dental waiting period provision means a health insurance policy provision that limits coverage for a specified period of time following an insureds effective date of coverage. |
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| 192 | 205 | | |
|---|
| 193 | 206 | | (2) Health insurer means an insurer that issues, sells, renews, or offers a policy of health insurance, as defined in subdivision (b) of Section 106, covering dental services, including a specialized health insurance policy covering dental services, as defined in subdivision (c) of Section 106. |
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| 194 | 207 | | |
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| 195 | 208 | | (3) Preexisting condition provision means a policy provision that excludes or limits coverage for services, charges, or expenses incurred following an insureds effective date of coverage for a condition for which dental services, diagnosis, care, or treatment was recommended or received preceding the effective date of coverage. |
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| 196 | 209 | | |
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| 197 | 210 | | (b) On and after January 1, 2025, a health insurer shall not issue, sell, renew, or offer a policy that imposes a dental waiting period provision in a large group dental insurance policy or preexisting condition provision upon an insured for any dental insurance policy. |
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| 198 | 211 | | |
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| 199 | 212 | | (c) This section does not apply to Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 200 | 213 | | |
|---|
| 201 | 214 | | SEC. 5. Section 10181.2 of the Insurance Code is amended to read:10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code. |
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| 202 | 215 | | |
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| 203 | 216 | | SEC. 5. Section 10181.2 of the Insurance Code is amended to read: |
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| 204 | 217 | | |
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| 205 | 218 | | ### SEC. 5. |
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| 206 | 219 | | |
|---|
| 207 | 220 | | 10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code. |
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| 208 | 221 | | |
|---|
| 209 | 222 | | 10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code. |
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| 210 | 223 | | |
|---|
| 211 | 224 | | 10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code. |
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| 212 | 225 | | |
|---|
| 213 | 226 | | |
|---|
| 214 | 227 | | |
|---|
| 215 | 228 | | 10181.2. This article shall apply to a health insurance policy offered in the individual or group market in California, including a health insurance policy covering dental services and a specialized health insurance policy covering dental services. However, this article shall not apply to a nondental specialized health insurance policy, a Medicare supplement policy subject to Article 6 (commencing with Section 10192.1), a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), a health insurance policy offered in the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), a health insurance conversion policy offered pursuant to Section 12682.1, a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900), or a Mexican prepaid health plan subject to Section 1351.2 of the Health and Safety Code. |
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| 216 | 229 | | |
|---|
| 217 | 230 | | SEC. 6. Section 10181.14 is added to the Insurance Code, to read:10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 218 | 231 | | |
|---|
| 219 | 232 | | SEC. 6. Section 10181.14 is added to the Insurance Code, to read: |
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| 220 | 233 | | |
|---|
| 221 | 234 | | ### SEC. 6. |
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| 222 | 235 | | |
|---|
| 223 | 236 | | 10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 224 | 237 | | |
|---|
| 225 | 238 | | 10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 226 | 239 | | |
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| 227 | 240 | | 10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41.(b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following:(1) Type of insurer involved, such as for profit or not for profit.(2) Product type.(3) Whether the products are opened or closed.(4) Annual rate.(5) Total earned premiums in each policy form.(6) Total incurred claims in each policy form.(7) Review category: initial filing for new product, filing for existing product, or resubmission.(8) Average rate of increase.(9) Effective date of rate increase.(10) Number of policyholders or insureds affected by each policy form.(11) A comparison of claims cost and rate changes over time.(12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing.(13) Any changes in insured benefits over the prior year associated with the submitted rate filing.(14) Any changes in administrative costs.(15) Variation in trend, by geographic region, if the insurer serves more than one geographic region.(16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293.(17) Proposed and effective rates for all products.(18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined.(19) The base rate or rates and the factors used to determine the base rate or rates.(20) Trend, including overall average, and by-product, if different.(21) Any other factors affecting dental premium rates.(22) An actuarial certification signed by a qualified actuary.(23) Any other information required for the department to make its determination.(c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates.(2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department.(3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified.(4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder.(5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code).(d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates.(e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c).(f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.(g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare.(2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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).(3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 228 | 241 | | |
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| 229 | 242 | | |
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| 230 | 243 | | |
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| 231 | 244 | | 10181.14. (a) This section shall apply only to a specialized health insurance policy covering dental services, as defined in Section 10120.41. |
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| 232 | 245 | | |
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| 233 | 246 | | (b) On or after January 1, 2025, and at least annually thereafter, a health insurer shall file with the department the information required by this article, as applicable, including, but not limited to, all of the following: |
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| 234 | 247 | | |
|---|
| 235 | 248 | | (1) Type of insurer involved, such as for profit or not for profit. |
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| 236 | 249 | | |
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| 237 | 250 | | (2) Product type. |
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| 238 | 251 | | |
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| 239 | 252 | | (3) Whether the products are opened or closed. |
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| 240 | 253 | | |
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| 241 | 254 | | (4) Annual rate. |
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| 242 | 255 | | |
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| 243 | 256 | | (5) Total earned premiums in each policy form. |
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| 244 | 257 | | |
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| 245 | 258 | | (6) Total incurred claims in each policy form. |
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| 246 | 259 | | |
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| 247 | 260 | | (7) Review category: initial filing for new product, filing for existing product, or resubmission. |
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| 248 | 261 | | |
|---|
| 249 | 262 | | (8) Average rate of increase. |
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| 250 | 263 | | |
|---|
| 251 | 264 | | (9) Effective date of rate increase. |
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| 252 | 265 | | |
|---|
| 253 | 266 | | (10) Number of policyholders or insureds affected by each policy form. |
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| 254 | 267 | | |
|---|
| 255 | 268 | | (11) A comparison of claims cost and rate changes over time. |
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| 256 | 269 | | |
|---|
| 257 | 270 | | (12) Any changes in insured cost sharing over the prior year associated with the submitted rate filing. |
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| 258 | 271 | | |
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| 259 | 272 | | (13) Any changes in insured benefits over the prior year associated with the submitted rate filing. |
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| 260 | 273 | | |
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| 261 | 274 | | (14) Any changes in administrative costs. |
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| 262 | 275 | | |
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| 263 | 276 | | (15) Variation in trend, by geographic region, if the insurer serves more than one geographic region. |
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| 264 | 277 | | |
|---|
| 265 | 278 | | (16) The loss ratio for the policy as described in Section 10112.26 and the lifetime loss ratio as described in the regulations adopted pursuant to Section 10293. |
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| 266 | 279 | | |
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| 267 | 280 | | (17) Proposed and effective rates for all products. |
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| 268 | 281 | | |
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| 269 | 282 | | (18) A rating manual that outlines the methodology used in the development of the premium rates, along with a description of how rates were determined. |
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| 270 | 283 | | |
|---|
| 271 | 284 | | (19) The base rate or rates and the factors used to determine the base rate or rates. |
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| 272 | 285 | | |
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| 273 | 286 | | (20) Trend, including overall average, and by-product, if different. |
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| 274 | 287 | | |
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| 275 | 288 | | (21) Any other factors affecting dental premium rates. |
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| 276 | 289 | | |
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| 277 | 290 | | (22) An actuarial certification signed by a qualified actuary. |
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| 278 | 291 | | |
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| 279 | 292 | | (23) Any other information required for the department to make its determination. |
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| 280 | 293 | | |
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| 281 | 294 | | (c) (1) The health insurer shall file with the department the required information at least 120 days before any change in the methodology, factors, or assumptions that would affect rates. |
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| 282 | 295 | | |
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| 283 | 296 | | (2) A health insurer shall respond to the departments request for any additional information necessary for the department to complete its review of the health insurers rate filing for individual and group health insurance policies within five business days of the departments request or as otherwise required by the department. |
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| 284 | 297 | | |
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| 285 | 298 | | (3) If a health insurer fails to provide all the information the department requires in order for the department to make its determination, the department may determine that a health insurers rate change is unreasonable or not justified. |
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| 286 | 299 | | |
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| 287 | 300 | | (4) If the department determines that a health insurers rate change for individual or group health insurance policies is unreasonable or not justified consistent with this article, the health insurer shall provide notice of that determination to an individual or group applicant or policyholder. |
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| 288 | 301 | | |
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| 289 | 302 | | (5) The department may contract with a consultant or consultants with expertise to assist the department in its review. Contracts entered into pursuant to the authority in this article shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, and the State Contract Act (Chapter 1 (commencing with Section 10100) of Part 2 of Division 2 of the Public Contract Code). |
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| 290 | 303 | | |
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| 291 | 304 | | (d) For all health insurers covering dental services, the department shall issue a determination that the health insurers rate change is unreasonable or not justified no later than 60 days following receipt of all the information the department requires to make its determination. The determination by the department shall also apply to the methodology, factors, and assumptions used to determine rates. |
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| 292 | 305 | | |
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| 293 | 306 | | (e) The department may review the rate filings to ensure compliance with the law, as described in Section 10181.11, excluding subdivision (c). |
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| 294 | 307 | | |
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| 295 | 308 | | (f) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section. |
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| 296 | 309 | | |
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| 297 | 310 | | (g) (1) The department may adopt emergency regulations implementing this section. The initial adoption of emergency regulations implementing this section and the readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. |
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| 298 | 311 | | |
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| 299 | 312 | | (2) On or before July 1, 2024, the commissioner may issue guidance to health insurers 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). |
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| 300 | 313 | | |
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| 301 | 314 | | (3) The department shall consult with the Department of Managed Health Care when issuing guidance on adopting necessary regulations pursuant to this subdivision. |
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| 302 | 315 | | |
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| 303 | 316 | | SEC. 7. 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. |
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| 304 | 317 | | |
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| 305 | 318 | | SEC. 7. 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. |
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| 306 | 319 | | |
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| 307 | 320 | | SEC. 7. 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. |
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| 308 | 321 | | |
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| 309 | 322 | | ### SEC. 7. |
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