Section 1363.06 Of Article 4. Solicitation And Enrollment From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 4.
1363.06
. (a) The Department of Managed Health Care and the
Department of Insurance shall compile information as required by this
section and Section 10127.14 of the Insurance Code into two
comparative benefit matrices. The first matrix shall compare benefit
packages offered pursuant to Section 1373.62 and Section 10127.15 of
the Insurance Code. The second matrix shall compare benefit packages
offered pursuant to Sections 1366.35, 1373.6, and 1399.804 and
Sections 10785, 10901.2, and 12682.1 of the Insurance Code.
(b) The comparative benefit matrix shall include:
(1) Benefit information submitted by health care service plans
pursuant to subdivision (d) and by health insurers pursuant to
Section 10127.14 of the Insurance Code.
(2) The following statements in at least 12-point type at the top
of the matrix:
(A) "This benefit summary is intended to help you compare coverage
and benefits and is a summary only. For a more detailed description
of coverage, benefits, and limitations, please contact the health
care service plan or health insurer."
(B) "The comparative benefit summary is updated annually, or more
often if necessary to be accurate."
(C) "The most current version of this comparative benefit summary
is available on (address of the plan's or insurer's Internet Web
site)."
This subparagraph applies only to those plans or insurers that
maintain an Internet Web site.
(3) The telephone number or numbers that may be used by an
applicant to contact either the department or the Department of
Insurance, as appropriate, for further assistance.
(c) The Department of Managed Health Care and the Department of
Insurance shall jointly prepare two standardized templates for use by
health care service plans and health insurers in submitting the
information required pursuant to subdivision (d) and subdivision (d)
of Section 10127.14 of the Insurance Code. The templates shall be
exempt from the provisions of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(d) Health care service plans, except specialized health care
service plans, shall submit the following to the department by
January 31, 2003, and annually thereafter:
(1) A summary explanation of the following for each product
described in subdivision (a).
(A) Eligibility requirements.
(B) The full premium cost of each benefit package in the service
area in which the individual and eligible dependents work or reside.
(C) When and under what circumstances benefits cease.
(D) The terms under which coverage may be renewed.
(E) Other coverage that may be available if benefits under the
described benefit package cease.
(F) The circumstances under which choice in the selection of
physicians and providers is permitted.
(G) Lifetime and annual maximums.
(H) Deductibles.
(2) A summary explanation of coverage for the following, together
with the corresponding copayments and limitations, for each product
described in subdivision (a):
(A) Professional services.
(B) Outpatient services.
(C) Hospitalization services.
(D) Emergency health coverage.
(E) Ambulance services.
(F) Prescription drug coverage.
(G) Durable medical equipment.
(H) Mental health services.
(I) Residential treatment.
(J) Chemical dependency services.
(K) Home health services.
(L) Custodial care and skilled nursing facilities.
(3) The telephone number or numbers that may be used by an
applicant to access a health care service plan customer service
representative and to request additional information about the plan
contract.
(4) Any other information specified by the department in the
template.
(e) Each health care service plan shall provide the department
with updates to the information required by subdivision (d) at least
annually, or more often if necessary to maintain the accuracy of the
information.
(f) The department and the Department of Insurance shall make the
comparative benefit matrices available on their respective Internet
Web sites and to the health care service plans and health insurers
for dissemination as required by Section 1373.6 and Section 12682.1
of the Insurance Code, after confirming the accuracy of the
description of the matrices with the health care service plans and
health insurers.
(g) As used in this section and Section 1363.07, "benefit matrix"
shall have the same meaning as benefit summary.
(h) (1) This section shall be inoperative on January 1, 2014.
(2) If Section 5000A of the Internal Revenue Code, as added by
Section 1501 of PPACA, is repealed or amended to no longer apply to
the individual market, as defined in Section 2791 of the federal
Public Health Service Act (42 U.S.C. Sec. 300gg-91), this section
shall become operative on the date of that repeal or amendment.
(3) For purposes of this subdivision, "PPACA" means the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care Education and Reconciliation Act
of 2010 (Public Law 111-152), and any rules, regulations, or guidance
issued pursuant to that law.