Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of disability insurers by the Department of Insurance. Existing law requires a health care service plan or disability insurer to allow an individual to enroll in or change their health benefit plan as a result of a specified triggering event. This bill would make pregnancy a triggering event for purposes of enrollment or changing a health benefit plan. Because a willful violation of this provision 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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally prohibits a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs that are medically necessary for the prevention of HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy. Under existing law, a health care service plan or health insurer is not required to cover all of the therapeutically equivalent versions of those drugs without prior authorization or step therapy if at least one is covered without prior authorization or step therapy. This bill would instead prohibit a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs, drug devices, or drug products that are medically necessary for the prevention of HIV/AIDS to prior authorization or step therapy. The bill would require, for a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, a non-self-administered antiretroviral drug, drug device, or drug product that is approved by the United States Food and Drug Administration for the prevention of HIV/AIDS to be covered under both the plan or policy's medical benefit and prescription drug benefit, and if obtained under the plan or policy's drug benefit, would require the drug, device, or product to be dispensed and administered by a health care provider acting within the scope of their license. Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth requirements for a contract between a plan or insurer and a dentist and requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. This bill would require a dental plan or dental insurer to establish a dental portal accessible to a treating dental provider to provide information regarding an enrollee's contract or insured's policy, including the actual payment or reimbursement amounts for covered services. The bill would require the portal to provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format, provide specified information about a corresponding payment, accept attachments in an electronic format, and be made available at no cost to contracted and noncontracted dental providers, among other requirements. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law provides that reproductive health care services, gender-affirming health care services, and gender-affirming mental health care services are rights secured by the Constitution and laws of California, and interference with these rights, whether or not under the color of law, is against the public policy of California. Existing law defines "gender-affirming health care services" to mean medically necessary health care that respects the gender identity of the patient, as experienced and defined by the patient, as specified. Existing law provides for various protective measures for persons engaging in legally protected health care activity, including prohibiting a provider of health care, health care service plan, health insurer, or contractor from releasing medical information related to, among other things, an individual seeking or obtaining gender-affirming health care or gender-affirming mental health care, and prohibiting a state or local public agency, or any employee thereof acting in their official capacity, from cooperating with or providing information to an individual or agency from another state or a federal law enforcement agency, as specified, regarding a legally protected health care activity that is lawful in this state and performed in this state. Existing law defines "legally protected health care activity" for those purposes to include, among other things, the exercise and enjoyment, or attempted exercise and enjoyment, by a person of rights to the health care services described above and the provision of those health care services by a person duly licensed under the laws of California. This bill would require a person or entity that is located, headquartered, incorporated, or otherwise conducting business in California and receives, is served with, or is subject to a subpoena, discovery request, or other request for information that is part of a legal process related to a civil, criminal, regulatory, or legislative investigation regarding abortion, as defined, or gender-affirming health care services that are legally protected health care activities secured by the Constitution or laws of California to provide specified notice to the Attorney General at least 7 business days prior to producing records in response to the request unless a shorter response time is required by federal law or other federal obligation, as specified. If a shorter response time is required by federal law or other federal obligation, the bill would require the responding person or entity to provide notice to the Attorney General no later than contemporaneously with producing the responsive records. The bill would exempt a person or entity from the notice requirement if the subpoena, discovery request, or other request for information meets certain requirements, including that it is accompanied by an attestation verifying that the use or disclosure of the requested information meets certain requirements, including that the requested information is related to an investigation or proceeding regarding activity that is unlawful under California civil or criminal law, and it identifies the California law under which the activity is unlawful. The bill would prohibit a person or entity receiving, served with, or subject to a subpoena, discovery request, or other request for information described above who is not subject to the above-described exemption from producing the responsive records until at least 7 business days after providing notice to the Attorney General unless a shorter response time is required by federal law or other federal obligation, as specified. If a shorter response time is required by federal law or other federal obligation, the bill would require the responding person or entity to make best efforts to deliver the responsive records on the date on which the person or entity is required to respond to the subpoena, discovery request, or other request for information. The bill would authorize the Attorney General to make reasonable attempts to notify the individual who provided, sought, received, facilitated, or otherwise engaged in the abortion or gender-affirming health care service pertaining to the subpoena, discovery request, or other request for information. The bill would entitle a person or entity subject to these provisions to rely on the representations made in an attestation described above. The bill would authorize the Attorney General to intervene in any civil action instituted by a person or entity to protect against compliance with or providing information in response to the subpoena, discovery request, or other request for information. The bill would authorize the Attorney General to commence certain actions, including a civil action against any person or entity that attaches a false attestation described above, and would make the attachment of a false attestation by a person or entity punishable by a civil penalty of $15,000, as specified. The bill would require any action brought by the Attorney General to be commenced within 6 years of the date on which the Attorney General received the notice of the subpoena, discovery request, or other request for information at issue, and would require the court to award court costs and attorney's fees to the Attorney General in any civil action in which the court imposes any penalty authorized by the bill's provisions.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Existing law requires this treatment to be provided under a prescribed treatment plan that is reviewed no less than every 6 months by the qualified autism service provider. This bill would prohibit a health care service plan or health insurer from imposing restrictions on the utilization of authorized treatment hours within the treatment plan's 6-month authorization period. The bill would require authorized hours to remain available for use throughout the authorization period if the use of the hours is consistent with the treatment plan and clinical guidelines, and is documented in the treatment plan and progress reports. Because a willful violation of these provisions 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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to reimburse a complete claim or a portion thereof within 30 calendar days after receipt of the claim, or, if a claim or portion thereof does not meet the criteria for completeness, to notify the claimant no later than 30 calendar days after receipt that the claim or portion thereof is contested or denied. This bill would grant a claimant no less than 90 calendar days to submit a corrected claim after a health care service plan or health insurer denies a claim or portion thereof or sends a notice of overpayment for a claim based on a defect that may be remedied by submitting a corrected claim. The bill would prohibit a plan or insurer from denying a corrected claim on the grounds that the claim was not submitted within another applicable claim filing deadline. Under the bill, a dispute related to a corrected claim would be required to be eligible for submission to the plan's or insurer's fast, fair, and cost-effective dispute resolution mechanism. Because a willful violation of these provisions 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.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies to meet certain criteria for its formularies and the placement of drugs on formularies. This bill would prohibit a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies from making changes to a formulary during a plan or policy year, except in specified circumstances. If a plan or insurer implements a formulary change requiring an enrollee or insured to change to a different drug in the same drug class during the plan year, the bill would authorize the individual to remain on the previously covered drug for the rest of the plan year if the drug was previously approved for coverage for the individual's medical condition, is appropriately prescribed, and is considered safe and effective for treating that condition, and would require the plan or insurer to notify the individual and their provider no less than 90 days before the change is implemented. The bill would require a plan or insurer, or its pharmacy benefit manager, to report to the appropriate department any changes made to a formulary during a plan or policy year within 30 days of the change being made. The bill would authorize the departments to investigate and take enforcement action against a plan or insurer for noncompliance with the above-described requirements and to impose, after notice and the opportunity for a hearing, administrative penalties, as specified, for a violation of these provisions. The bill would authorize the departments to conduct audits related to these provisions. Because a willful violation of the bill's provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law requires a health care service plan that provides prescription drug benefits to maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary nonformulary prescription drug. This bill would define "expeditious process" for the above-described purpose to require a plan to approve authorization within 72 hours for nonurgent requests, or within 24 hours if exigent circumstances exist, of a request for approval of a drug prescription. If the plan fails to meet those requirements, the bill would authorize an enrollee to request, and would require the plan to provide, 90 days of transitional coverage to the enrollee for the previously covered drug. The bill would require the Department of Managed Health Care to utilize existing data and its existing authority to collect data from plans and annually publish on its internet website and submit to the Legislature an aggregated report on information related to requests for approval of a nonformulary drug as described above. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a violation of the act by a health care service plan a misdemeanor. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law defines "unreasonable rate increase," for these purposes, to have the same meaning as in the federal Patient Protection and Affordable Care Act, which is that an unreasonable rate increase exists when the federal Centers for Medicare and Medicaid Services makes a determination that a rate increase is excessive, unjustified, or unfairly discriminatory, among other things. This bill would instead define "unreasonable rate increase," for the above-described purposes, to mean a rate increase that the Director of the Department of Managed Health Care or the Insurance Commissioner, as applicable, determines is excessive, unjustified, unfairly discriminatory, or otherwise unreasonable. Existing law requires a health care service plan or health insurer to submit rates to their regulating entity for review and to demonstrate the impact of any changes in the rate of growth of health care costs resulting from health care cost targets. This bill would instead require a health care service plan or health insurer to demonstrate the impact of health care cost targets and to demonstrate whether a health care service plan's or health insurer's annual rate growth exceeds or will exceed the cost target for the rating period. The bill would require, if a health care service plan's or health insurer's rate growth is expected to exceed the cost target for a rating period, the health care service plan or health insurer to include specified information in its rate filing, including, among other things, a detailed list of any proactive steps it is taking, or plans to take, for annual rate growth to meet the cost targets. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law requires the director or the commissioner, as applicable, in determining if a rate is unreasonable or not justified for purposes of the above-described review, to consider the impact on changes in health care costs as a result of the health care cost targets described above. This bill would delete those provisions and instead require the Department of Managed Health Care and the Department of Insurance to report on if rates, by plan or policy and in aggregate, meet the affordability standard, as defined, for an individual, a couple, and a family of four. The bill would require the report to include the annual change in premiums and cost sharing for the prior 5 years. The bill would, as part of the existing rate submission process, require a health care service plan or health insurer to provide information on premiums, deductibles, cost sharing, and any other factors specified by the department as necessary to complete the reports. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law authorizes health care service plans and health insurers that cover prescription drugs to utilize reasonable medical management practices, including prior authorization and step therapy, consistent with applicable law. This bill would prohibit a health care service plan contract or a health insurance policy that is issued, amended, or renewed on or after January 1, 2027, from imposing step therapy as a prerequisite to authorizing coverage of any prescription drug used for the treatment of a serious mental illness or substance use disorder, as those terms are defined, except as specified. The bill would specify that the prohibition on step therapy does not apply when the United States Food and Drug Administration-labeled indications and usage of a drug indicate that some prior medication must be taken. Because a willful violation of this provision 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.
(1) Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2002, to provide coverage for an annual cervical cancer screening test upon the referral of the patient's health care provider. This bill would require a health care service plan contract or health insurance policy, except for a vision-only, dental-only, or Medicare supplement contract or policy, issued, amended, or renewed on or after January 1, 2027, to provide coverage without cost sharing for cervical cancer screening, including the United States Food and Drug Administration (FDA) -authorized or cleared self-collected cervical screening kits, when ordered or provided by an in-network provider and consistent with specified recommendations published by the State Department of Public Health. For health savings account-eligible plans or policies, the bill would require the above-described coverage only to the extent the plan is a high deductible health plan under specified federal law. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program. (2) Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to low-income individuals pursuant to a schedule of benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. An annual cervical cancer test for screening or diagnostic purposes, upon the referral of a patient's physician, is a covered benefit under the Medi-Cal program to the extent required or permitted by federal law. This bill would instead include cervical cancer tests for screening that are ordered by a patient's health care provider and consistent with specified recommendations published by the State Department of Public Health as a covered benefit under the Medi-Cal program on or after January 1, 2027. The bill would additionally include FDA-authorized or cleared cervical cancer home test kits for screening that are ordered by a patient's health care provider and consistent with specified recommendations published by the State Department of Public Health and Medi-Cal policies as a covered benefit under the Medi-Cal program on or after January 1, 2027, without cost sharing, to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained. (3) 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.
