SB 780, as amended, Jackson. Health care coverage.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime.
Existing law requires a health care service plan to submit a filing to the department at least 75 days prior to the termination date of its contract with a provider group or a general acute care hospital that includes the written notice the plan proposes to send to its affected enrollees. The filing is required to be reviewed and approved by the department prior to the notice being sent the enrollees. Existing law also requires the plan to provide written notice to affected enrollees, as provided, prior to the termination date of a contract between the plan and a provider group or a general acute care hospital. A plan operating as a preferred provider organization is only required to send the written notice to all enrollees who reside within a 15-mile radius of a terminated hospital if it is a general acute care hospital.
This bill would delete the requirements with regard to preferred provider organizations.begin insert The bill would change the timing of the 75-day filing to 45 days prior to the termination date for a contract between a health care service plan that is not a health maintenance organization and a provider group or general acute care hospital, and would not prohibit the plan from sending the notice to the enrollees prior to the filing being reviewed and approved by the department.end insert The bill would distinguish between enrollees of an assigned group provider and enrollees of an unassigned group provider for purposes of whetherbegin delete the 75-dayend deletebegin insert
theend insert
filing is required to be submitted to the department. The bill would also require that the plan send a department approved written notice to the enrollees, whether or not a filing was required, when a provider group contract or a general acute care hospital contract is terminated. The bill would distinguish between the enrollees of an assigned or an unassigned provider group or general acute care hospital with regard to the timing of the consumer notice and method of delivery, and would impose specified continued access to servicesbegin delete andend deletebegin insert requirements,end insert billing requirementsbegin insert, and requirements to obtain informationend insert on plans and providers for the enrollees of an unassigned provider group or an unassigned general
acute care hospital. Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program.
Existing law provides for the regulation of health insurers by the Department of Insurance. Under existing law, a health insurer may contract with providers for alternative rates of payment. Existing law requires those insurers to file a policy with the department describing how the insurer facilitates the continuity of care for new insureds under group policies receiving services for an acute condition from a noncontracting provider. Existing law also requires those health insurers to, at the request of an insured, arrange for the completion of covered services by a terminated provider if the insured is undergoing treatment for certain conditions, as specified.
This bill would require, among other things, a health insurer to submit a filing
to the department, at leastbegin delete 75end deletebegin insert 45end insert days prior to the termination date of its contract with a provider group or a general acute care hospital to provide services at alternative rates of payment, that includes the written notice the insurer proposes to send to its insureds. The bill would require the filing to be reviewed and approved by the department prior to the notice being sent to the insureds. The bill would set a threshold for the number of insureds receiving health care services from a group provider within the preceding 12 months for purposes of whether the filing is required to be submitted to the department. The bill would also require that the health insurer send a department approved written notice to specified insureds, whether or not a filing was required, when a provider group contract or a general acute
care hospital contract is terminated, and would impose specified continued access to servicesbegin delete andend deletebegin insert requirements,end insert billing requirementsbegin insert, and requirements to obtain informationend insert on insurers and providers for insureds receiving health care services from a terminated provider group or general acute care hospital.
Existing law requires disability insurance policies to include a disclosure form that contains specified information, including the principal benefits and coverage of the policy, the exceptions, reductions, and limitations that apply to the policy, and a statement, with respect to health insurance policies, describing how participation in the policy may affect the choice of physician, hospital, or health care providers, and describing the extent of financial liability that may be incurred if care is furnished by a nonparticipating provider.
With respect to health insurance policies, this bill would require the disclosure form to include additional information, including conditions and procedures for cancellation, rescission, or nonrenewal, a description of the limitations on the insured’s choice of provider, and, with respect to insurers that contract for alternate rates of payment, a statement describing the basic method of reimbursement made to its participating providers, as specified. The bill would also require the first page of the disclosure form for health insurance policies to include other specified information. The bill would require a health insurer, medical group, or participating provider that uses or receives financial bonuses or other incentives to provide a written summary of specified information to any requesting person.
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.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
Section 1373.65 of the Health and Safety Code
2 is amended to read:
(a) For the purposes of this section, the following
4terms have the following meanings:
5(1) “Assigned general acute care hospital” means a general acute
6care hospital to which the healthbegin insert care serviceend insert plan, either directly
7or through its contracts with its delegated entities, directs enrollees
8to receive nonemergency services.
9(2) “Assigned provider group” means a provider group to which
10a healthbegin insert care serviceend insert
plan directs its enrollees to receive specialty
11physician services or a provider group that includes primary care
12physicians to which a healthbegin insert care serviceend insert plan assigns its members.
13(3) “Provider group” means a medical group, independent
14practice association, or any other similar organization.
15(4) “Unassigned general acute care hospital” is a general acute
16care hospital that is not an assigned general acute care hospital.
17(5) “Unassigned provider group” means a provider group that
18is not an assigned provider group.
19(b) (1) begin deleteAt end deletebegin insertExcept
as provided in paragraph (2), at end insertleast 75 days
20prior to the termination date of its contract with a provider group
21or a general acute care hospital, the health care service plan shall
22submit a filing to the department that includes the written notice
23the plan proposes to send to enrollees. The plan shall not send this
24notice to enrollees until the department has reviewed and approved
25the filing. If the department does not respond within seven days
26of the date ofbegin insert its receipt ofend insert the filing, the filing shall be deemed
27approved.
28(2) At least 45 days prior to the termination date of a contract
29between a health care service plan that is not a health maintenance
30organization and a provider group or a general acute care
31hospital, the health
care service plan shall submit a filing to the
32department that includes the written notice the plan proposes to
33send to enrollees.
34(2)
end delete
35begin insert(3)end insert For the purposes of a termination with an assigned provider
36groupbegin insert or assigned general acute care hospitalend insert, the health care
37service plan shall submit a filing to the department, as required by
38paragraph (1), if 2,000 or more enrollees will be transferred or
P5 1redirected by the plan from the assigned provider group as a result
2of the termination of the provider contract.
3(3)
end delete
4begin insert(4)end insert For purposes of a termination with an unassigned provider
5group, the health care service plan shall submit a filing to the
6department, as required by paragraph (1)begin insert or (2)end insert, if 1,700 or more
7enrollees were treated by the unassigned provider group within
8the 12 months preceding the filing date specified in paragraph (1)
9begin insert or (2)end insert.
10(4)
end delete
11begin insert(5)end insert The director may adopt by regulation a different filing
12threshold from the threshold stated inbegin delete paragraph
(2)end delete
13(3) and (4)end insert, and in consultation with the Department of Insurance,
14may adopt by regulation a different filing threshold from the
15threshold stated inbegin delete paragraph (3).end deletebegin insert paragraphs (3) and (4).end insert
16(c) (1) In the event of a contract termination between a health
17care service plan and an assigned provider group or an assigned
18general acute care hospital, the plan shall do all of the following:
19(A) Send the written notice described in subdivision (b) by
20United States mail at least 60 days prior to the termination date to
21enrollees who are assigned to the
terminated provider group or
22general acute care hospital.
23(B) A plan that is unable to comply with the timeframe in
24subparagraph (A) because of exigent circumstances shall apply to
25the department for a waiver. The planbegin delete isend deletebegin insert shall beend insert excused from
26complying with the 60-day notice requirement only if its waiver
27application is granted by the department or the department does
28not respond within seven days of the date of its receipt of the
29waiver application.
30(2) In the event of a contract termination between a health care
31service plan and an unassigned provider group or an unassigned
32general acute care hospital, the plan shall do all of the following:
33(A) Send the written notice described in subdivision (b), within
34begin delete one business dayend deletebegin insert five business daysend insert of the contract termination
35with an unassigned provider group, to all of the following persons:
36(i) Any unassigned enrollee who has received health care
37services from the terminatedbegin delete unassignedend delete provider group within the
3812 months preceding the date of termination.
39(ii) Any unassigned enrollee who has any health care services
40begin delete scheduled with the terminated unassigned provider groupend delete
P6 1begin insert
authorized, but not yet scheduled as of the date of termination, or
2scheduled forend insert after the date of terminationbegin insert end insertbegin insertwith the terminated
3provider groupend insert.
4(B) Send the written notice described in subdivision (b), within
5begin delete one business dayend deletebegin insert
five business daysend insert of the contract termination
6with an unassigned general acute care hospital, to all of the
7following persons:
8(i) Any enrollee who has received health care services from the
9terminatedbegin delete unassignedend delete
general acute care hospital within the 12
10months preceding the date of termination.
11(ii) Any enrollee who is assigned to a provider group with any
12physicians who have exclusive admitting privileges to the
13terminatedbegin delete unassignedend delete general acute care hospital.
14(iii) Any enrollee who hasbegin delete authorizedend delete health care services
15begin delete scheduled at a terminating unassigned general acute care hospitalend delete
16begin insert authorized, but not yet scheduled as of the date of termination, or
17scheduled for end insertafter the date of terminationbegin insert
at the terminated general
18acute care hospitalend insert.
19(C) Allow enrollees to continue to access services that were
20authorized or scheduled at the terminated unassigned provider
21group or unassigned general acute care hospital prior to the date
22ofbegin insert end insertbegin inserteither the notice required by subdivisions (c) and (d), or theend insert
23 terminationbegin insert, whichever is later, regardless of whether the enrollee
24has requested completion of covered servicesend insert. Those services shall
25be providedbegin insert from the date of the contract terminationend insert until
26
completion of the authorized or scheduled services for at least 60
27days from the date ofbegin insert eitherend insert the noticebegin delete unless a longer period of begin insert or the termination,
28time is required pursuant to Section 1373.96.end delete
29whichever is later.end insert The amount of, and the requirement for payment
30of, copayments, deductibles, coinsurance, and other cost-sharing
31components by an enrollee during the period of completion of
32authorized or scheduled services with a terminatedbegin delete unassignedend delete
33 provider group orbegin delete unassignedend delete general acute care hospital pursuant
34to this subparagraph shall be the same that would be paid by the
35enrollee when receiving care from a provider currently contracting
36with or employed by the plan.
37(D) Provide reimbursement for services provided under
38subparagraph (C) either at a rate agreed upon by the health care
39service plan and the terminated provider group or general acute
40care hospital or the rate for those services as provided in the
P7 1terminating contract. In no event shall the provider bill the patient
2for the cost of services beyond the copayment, deductible, or other
3cost-sharing components of what the enrollee would have been
4responsible for if the provider group or general acute care hospital
5was currently contracted with the health care service plan.
6(E) Obtain information from the terminated provider group or
7general acute care hospital regarding enrollees who have health
8care services scheduled for after the date of termination with the
9terminated provider group or general acute care hospital,
10including the names of those enrollees and the dates on which
11their services were scheduled. Unless otherwise prohibited by law,
12a terminated provider group or general acute care hospital shall
13comply with a health care service plan’s request for that
14information.
15(d) Even if a filing is not required to be submitted by subdivision
16(b), a health care service plan shall send enrollee notices as required
17by subdivision (c). A health care service plan may only send
18enrollee notices for which a template has been filed and approved
19by the department pursuant to Section 1373.95.
20(e) If an individual provider terminates his or her contract or
21employment with a provider group that contracts with a health
22care service plan, the plan may require that the provider group
23send the notices required by subdivisions (c) and (d).
24(f) If, after sending the notices required by subdivisions (c) and
25(d), a health care service plan reaches an agreement with any
26terminated provider group or general acute care hospital to renew
27or enter into a new contract or to not terminate their contract, the
28plan shall send a subsequent written notice to all enrollees that
29were sent the notices required by subdivisions (c) and (d) informing
30them of the status. The plan shall offer each affected enrollee the
31option to return to that providerbegin insert group or general acute care
32hospitalend insert. If an
assigned enrollee does not exercise this option, the
33plan shall reassign the enrollee to another provider group or general
34acute care hospital.
35(g) A health care service plan and a providerbegin insert group or general
36acute care hospitalend insert shall include in all written, printed, or electronic
37communications sent to an enrollee that concern the contract
38termination or block transfer, the following statement in not less
39thanbegin delete 8-pointend deletebegin insert 12-pointend insert type:
40
P8 1“If you have been receiving care from a health care provider,
2you may have a right to keep your provider for a
designated time
3period. Please contact your HMO’s customer service department,
4and if you have further questions, you are encouraged to contact
5the Department of Managed Health Care, which protects HMO
6consumers, by telephone at its toll-free number, 1-888-HMO-2219,
7or at a TDD number for the hearing impaired at 1-877-688-9891,
8or online at www.hmohelp.ca.gov.”
9
begin insert
10(h) Nothing in this section shall be construed to limit the rights
11or protections of enrollees under Section 1373.96.
Section 10123.12 of the Insurance Code is amended
13to read:
(a) Every health insurer, including those insurers
15that contract for alternative rates of payment pursuant to Section
1610133, and every self-insured employee welfare benefit plan that
17will affect the choice of physician, hospital, or other health care
18providers, shall include within its disclosure form and within its
19evidence or certificate of coverage a statement clearly describing
20how participation in the policy or plan may affect the choice of
21physician, hospital, or other health care providers, and describing
22the nature and extent of the financial liability that is, or that may
23be, incurred by the insured, enrollee, or covered dependents if care
24is furnished by a provider that does not have a contract with the
25insurer or plan to provide service at alternative rates of payment
26
pursuant to Section 10133. The form shall clearly inform
27prospective insureds or plan enrollees that participation in the
28policy or plan will affect the person’s choice in this regard by
29placing the following statement in a conspicuous place on all
30material required to be given to prospective insureds or plan
31enrollees including promotional and descriptive material, disclosure
32forms, and certificates and evidences of coverage:
38It is not the intent of this section to require that the names of
39individual health care providers be enumerated to prospective
40insureds or enrollees.
P9 1If a health insurer providing coverage for hospital, medical, or
2surgical expenses provides a list of facilities to patients or
3
contracting providers, the insurer shall include within the listing
4a notification that insureds or enrollees may contact the insurer in
5order to obtain a list of the facilities with which the health insurer
6is contracting for subacute care and/or transitional inpatient care.
7(b) Every health insurer that contracts for alternative rates of
8payment pursuant to Section 10133 shall include within its
9disclosure form a statement clearly describing the basic method
10of reimbursement, including the scope and general methods of
11payment, made to its contracting providers of health care services,
12and whether financial bonuses or any other incentives are used.
13The disclosure form shall indicate that, if an insured wishes to
14know more about these issues, the insured may request additional
15information from the insurer, the insured’s provider, or the
16provider’s medical group regarding the information required
17pursuant to subdivision (c).
18(c) If a health insurer, medical group, or participating health
19care provider uses or receives financial bonuses or any other
20incentives, the insurer, medical group, or health care provider shall
21provide a written summary to any person who requests it that
22includes both of the following:
23(1) A general description of the bonus and any other incentive
24arrangements used in its compensation agreements. Nothing in
25this paragraph shall be construed to require disclosure of trade
26secrets or commercial or financial information that is privileged
27or confidential, such as payment rates, as determined by the
28commissioner, pursuant to state law.
29(2) A description regarding whether, and in what manner, the
30bonuses and any other incentives are related to a provider’s use of
31referral services.
32(d) The statements and written information provided pursuant
33to subdivisions (b) and (c) shall be communicated in clear and
34simple language that enables consumers to evaluate and compare
35health insurance policies.
Section 10133.57 is added to the Insurance Code, to
37read:
(a) For purposes of this section, “provider group”
39means a medical group, independent practice association, or any
40other similar organization.
P10 1(b) (1) At leastbegin delete 75end deletebegin insert 45end insert days prior to the termination date of its
2contract with a provider group or a general acute care hospital to
3provide services at alternative rates of payment pursuant to Section
410133, the health insurer shall submit a filing to the department
5that includes the written notice the insurer proposes to send to the
6insureds. The insurer shall not send this notice to the
insureds until
7the department has reviewed and approved the filing. If the
8department does not respond to thebegin delete insuredend deletebegin insert insurerend insert
within seven
9days of the datebegin insert of its receiptend insert of the filing, the filing shall be
10deemed approved.
11(2) For purposes of a termination with a provider group, the
12health insurer shall submit a filing to the department, as required
13by paragraph (1), if 1,700 or more insureds were treated by the
14provider group within the 12 months preceding the filing date
15specified in paragraph (1).
16(3) The department, in consultation with the Department of
17Managed Health Care, may adopt by regulation a different filing
18threshold from the threshold stated in paragraph (2).
19(c) In the event of a contract termination between a health
20insurer and a provider group or general acute care hospital, the
21insurer shall do all of
the following:
22(1) Send the written notice described in subdivision (b), within
23begin delete one business dayend deletebegin insert five business daysend insert of the contract termination
24with a provider group, to all of the following persons:
25(A) Any insured who has received health care services from the
26terminated provider group within the 12 months preceding the date
27of termination.
28(B) Any insured who has any health care servicesbegin insert
authorized,
29but not yet scheduled as of the date of termination, orend insert scheduled
30begin delete with the terminated provider groupend deletebegin insert forend insert after the date of termination
31begin insert with the terminated provider groupend insert.
32(2) Send the written notice described in subdivision (b), within
33begin delete one business dayend deletebegin insert five business daysend insert of the contract termination
34with a general acute care hospital, to all of the following persons:
35(A) Any insured who has received health care services from the
36terminated general acute care hospital within the 12 months
37preceding the date of termination.
38(B) Any insured who hasbegin delete authorizedend delete health care services
39begin insert authorized, but not yet scheduled as of the date of termination, or end insert
40 scheduledbegin delete at a terminating general acute care hospitalend deletebegin insert forend insert after
P11 1the date of terminationbegin insert
at the terminated general acute care
2hospitalend insert.
3(3) Allow insureds to continue to access services that were
4authorized or scheduled at the terminated provider group or general
5acute care hospital prior to the date ofbegin insert end insertbegin inserteither the notice required
6by subdivisions (c) and (d), or theend insert terminationbegin insert, end insertbegin insertwhichever is later,
7regardless of whether the insured has requested completion of
8covered servicesend insert. Those services shall be providedbegin insert
from the date
9of the contract terminationend insert until completion of the authorized or
10scheduled services for at least 60 days from the date ofbegin insert eitherend insert the
11noticebegin delete unless a longer period of time is required pursuant to Section begin insert or the termination, whichever is later.end insert The amount of,
1210133.56.end delete
13and the requirement for payment of, copayments, deductibles,
14coinsurance, and other cost-sharing components by an insured
15during the period of completion of authorized or scheduled services
16with a terminated provider group or general acute care hospital
17pursuant to this paragraph shall be the same that would be paid by
18the insured when receiving care from a provider currently
19contracting with the
insurer.
20(4) Provide reimbursement for services provided under
21paragraph (3) either at a rate agreed upon by the insurer and the
22terminated provider group or general acute care hospital or the
23rate for those services as provided in the terminating contract. In
24no event shall the provider bill the patient for the cost of services
25beyond the copayment, deductible, or other cost-sharing
26components of what the insured would have been responsible for
27if the provider group or general acute care hospital was currently
28contracted with the insurer.
29(5) Obtain information from the terminated provider group or
30general acute care hospital regarding insureds who have health
31care services scheduled for after the date of termination with the
32terminated provider group or general acute care hospital,
33including the
names of those insureds and the dates on which their
34services were scheduled. Unless otherwise prohibited by law, a
35terminated provider group or general acute care hospital shall
36comply with a health insurer’s request for that information.
37(d) Even if a filing is not required to be submitted by subdivision
38(b), a health insurer shall send insured notices as required by
39subdivision (c). A health insurer may only send insured notices
P12 1that have been filed and approved by the department pursuant to
2this section.
3(e) If an individual provider terminates his or her contract or
4employment with a provider group that contracts with a health
5insurer, the insurer may require that the provider group send the
6notices required by subdivisions (c) and (d).
7(f) If, after sending the notices required by
subdivisions (c) and
8(d), a health insurer reaches an agreement with a terminated
9provider group or general acute care hospital to renew or enter
10into a new contract or to not terminate its contract, the insurer shall
11send a subsequent written notice to all insureds that were sent the
12notices required by subdivisions (c) and (d) informing those
13insureds that the provider group or hospital remains in their
14provider network.
15(g) A health insurer or a provider group shall include in all
16written, printed, or electronic communications sent to an insured
17that concern the contract termination, the following statement in
18not less thanbegin delete 8-pointend deletebegin insert 12-pointend insert type:
19
20“If you have been receiving care from a health care provider,
21you may have a right to keep your provider for a designated time
22period. Please contact your insurer’s customer service department,
23and if you have further questions, you are encouraged to contact
24the Department of Insurance, which protects insurance consumers,
25by telephone at its toll-free number, 800-927-HELP (4357), or at
26a TDD number for the hearing impaired at 800-482-4833, or online
27at www.insurance.ca.gov.”
28
29(h) The commissioner may adopt regulations in accordance with
30the Administrative Procedure Act (Chapter 3.5 (commencing with
31Section 11340) of Part 1 of Division 3 of Title 2 of the Government
32Code) that are necessary to implement the provisions of this
33section.
34(i) Nothing in this section shall be construed to limit the rights
35or protections of insureds under Section 10133.56.
Section 10601 of the Insurance Code is amended to
37read:
As used in this chapter:
39(a) “Benefits and coverage” means the accident, sickness, or
40disability indemnity available under a policy of disability insurance.
P13 1(b) “Exception” means any provision in a policy whereby
2coverage for a specified hazard or condition is entirely eliminated.
3(c) “Reduction” means any provision in a policy that reduces
4the amount of a policy benefit to some amount or period less than
5would be otherwise payable for medically authorized expenses or
6services had the reduction not been used.
7(d) “Limitation” means any provision other than
an exception
8or a reduction that restricts coverage under the policy.
9(e) “Presenting for examination or sale” means either (1)
10publication and dissemination of any brochure, mailer,
11advertisement, or form that constitutes a presentation of the
12provisions of the policy and that provides a policy enrollment or
13application form, or (2) consultations or discussions between
14prospective beneficiaries or their contract agents and employees
15or agents of disability insurers, when those consultations or
16discussions include presentation of formal, organized information
17about the policy that is intended to influence or inform the
18prospective insured or beneficiary, such as brochures, summaries,
19charts, slides, or other modes of information in lieu of or in addition
20to the policy itself.
21(f) “Disability insurance” means every policy of disability
22insurance and self-insured employee welfare
benefit plan issued,
23delivered, or entered into pursuant to or described in Chapter 1
24(commencing with Section 10110) or Chapter 4 (commencing with
25Section 10270) of this part.
26(g) “Insurer” means every insurer transacting disability insurance
27and every self-insured employee welfare plan specified in
28subdivision (f).
29(h) “Disclosure form” means the standard supplemental
30disclosure form required pursuant to Section 10603.
31(i) “Small group health insurance policy” means a group health
32insurance policy issued to a small employer, as defined in Section
3310700, 10753, or 10755.
Section 10604 of the Insurance Code is amended to
35read:
The disclosure form shall include at least the following
37information, in concise and specific terms, relative to the disability
38insurance policy, together with additional information as the
39commissioner may require in connection with the policy:
P14 1(a) The applicable category or categories of coverage provided
2by the policy, from among the following:
3(1) Basic hospital expense coverage.
4(2) Basic medical-surgical expense coverage.
5(3) Hospital confinement indemnity coverage.
6(4) Major medical expense coverage.
7(5) Disability income protection coverage.
8(6) Accident only coverage.
9(7) Specified disease or specified accident coverage.
10(8) Other categories as the commissioner may prescribe.
11(b) The principal benefits and coverage of the disability
12insurance policy, including coverage for acute care and subacute
13care if the policy is a health insurance policy, as defined in Section
14106.
15(c) The exceptions, reductions, and limitations that apply to the
16policy.
17(d) A summary, including a citation of the relevant contractual
18provisions, of the process used
to authorize, modify, delay, or deny
19payments for services under the coverage provided by the policy
20including coverage for subacute care, transitional inpatient care,
21or care provided in skilled nursing facilities. This subdivision shall
22only apply to policies of health insurance as defined in Section
23106.
24(e) The full premium cost of the policy.
25(f) Any copayment, coinsurance, or deductible requirements
26that may be incurred by the insured or his or her family in obtaining
27coverage under the policy.
28(g) The terms under which the policy may be renewed by the
29insured, including any reservation by the insurer of any right to
30change premiums.
31(h) A statement that the disclosure form is a summary only, and
32that the policy itself should be consulted to
determine governing
33contractual provisions.
34(i) For a health insurance policy, as defined in Section 106, all
35of the following:
36(1) A notice on the first page of the disclosure form that
37conforms with all of the following conditions:
38(A) (i) States that the form discloses the terms and conditions
39of coverage.
P15 1(ii) States, with respect to individual health insurance policies,
2small group health insurance policies, and any group health
3insurance policies, that the applicant has a right to view the
4disclosure form and policy prior to beginning coverage under the
5policy, and, if the policy does not accompany the disclosure form,
6the notice shall specify where the policy can be obtained prior to
7beginning coverage.
8(B) Includes a statement that the disclosure and the policy should
9be read completely and carefully and that individuals with special
10health care needs should read carefully those sections that apply
11to them.
12(C) Includes the insurer’s telephone number or numbers that
13may be used by an applicant to receive additional information
14about the benefits of the policy, or states where those telephone
15number or numbers are located in the disclosure form.
16(D) For individual health insurance policies and small group
17health insurance policies, states where a health policy benefits and
18coverage matrix is located.
19(E) Is printed in type no smaller than that used for the remainder
20of the disclosure form and is displayed prominently on the page.
21(2) A statement as to when benefits shall cease in the event of
22nonpayment of premium and the effect of nonpayment upon an
23insured who is hospitalized or undergoing treatment for an ongoing
24condition.
25(3) To the extent that the policy or insurer permits a free choice
26of provider to its insureds, the statement shall disclose, consistent
27with Section 10123.12, the nature and extent of choice permitted
28and the financial liability that is, or may be, incurred by the insured,
29covered dependents, or a third party by reason of the exercise of
30that choice.
31(4) For group health insurance policies, including small group
32health insurance policies, a summary of the terms and conditions
33under which insureds may remain in the policy in the event the
34group ceases to exist, the group policy is terminated, an individual
35insured leaves
the group, or the insureds’ eligibility status changes.
36(5) If the policy utilizes arbitration to settle disputes, a statement
37of that fact. If the policy requires binding arbitration, a disclosure
38pursuant to Section 10123.19.
39(6) A description of any limitations on the insured’s choice of
40primary care physician, specialty care physician, or nonphysician
P16 1health care practitioner, based on service area and limitations on
2the insured’s choice of acute care hospital care, subacute or
3transitional inpatient care, or skilled nursing facility.
4(7) Conditions and procedures for cancellation, rescission, or
5nonrenewal.
6(8) A description as to how an insured may request continuity
7of care as required by Sections 10133.55 and 10133.56, and request
8a second
opinion pursuant to Section 10123.68.
9(9) Information concerning the right of an insured to request an
10independent medical review in accordance with Article 3.5
11(commencing with Section 10169) of Chapter 1.
12(10) A notice as required by Section 791.04.
No reimbursement is required by this act pursuant to
14Section 6 of Article XIII B of the California Constitution because
15the only costs that may be incurred by a local agency or school
16district will be incurred because this act creates a new crime or
17infraction, eliminates a crime or infraction, or changes the penalty
18for a crime or infraction, within the meaning of Section 17556 of
19the Government Code, or changes the definition of a crime within
20the meaning of Section 6 of Article XIII B of the California
21 Constitution.
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