1367.006
. (a) This section shall apply to nongrandfathered
individual and group health care service plan contracts that provide
coverage for essential health benefits, as defined in Section
1367.005, and that are issued, amended, or renewed on or after
January 1, 2015.
(b) (1) For nongrandfathered health care service plan contracts in
the individual or small group markets, a health care service plan
contract, except a specialized health care service plan contract,
that is issued, amended, or renewed on or after January 1, 2015,
shall provide for a limit on annual out-of-pocket expenses for all
covered benefits that meet the definition of essential health
benefits in Section 1367.005, including out-of-network emergency care
consistent with Section 1371.4.
(2) For nongrandfathered health care service plan contracts in the
large group market, a health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, or renewed on or after January 1, 2015, shall provide for a
limit on annual out-of-pocket expenses for covered benefits,
including out-of-network emergency care consistent with Section
1371.4. This limit shall only apply to essential health benefits, as
defined in Section 1367.005, that are covered under the plan to the
extent that this provision does not conflict with federal law or
guidance on out-of-pocket maximums for nongrandfathered health care
service plan contracts in the large group market.
(c) (1) The limit described in subdivision (b) shall not exceed
the limit described in Section 1302(c) of PPACA, and any subsequent
rules, regulations, or guidance issued under that section.
(2) The limit described in subdivision (b) shall result in a total
maximum out-of-pocket limit for all covered essential health
benefits equal to the dollar amounts in effect under Section 223(c)
(2)(A)(ii) of the Internal Revenue Code of 1986 with the dollar
amounts adjusted as specified in Section 1302(c)(1)(B) of PPACA.
(3) For family coverage, an individual within a family shall not
have a maximum out-of-pocket limit that is greater than the maximum
out-of-pocket limit for individual coverage for that product.
(d) Nothing in this section shall be construed to affect the
reduction in cost sharing for eligible enrollees described in Section
1402 of PPACA, and any subsequent rules, regulations, or guidance
issued under that section.
(e) If an essential health benefit is offered or provided by a
specialized health care service plan, the total annual out-of-pocket
maximum for all covered essential benefits shall not exceed the limit
in subdivision (b). This section shall not apply to a specialized
health care service plan that does not offer an essential health
benefit as defined in Section 1367.005.
(f) The maximum out-of-pocket limit shall apply to any copayment,
coinsurance, deductible, and any other form of cost sharing for all
covered benefits that meet the definition of essential health
benefits in Section 1367.005.
(g) (1) (A) Except as provided in paragraph (2), if a health care
service plan contract for family coverage includes a deductible, an
individual within a family shall not have a deductible that is
greater than the deductible limit for individual coverage for that
product.
(B) Except as provided in paragraph (2), if a large group market
health care service plan contract for family coverage that is issued,
amended, or renewed on or after January 1, 2017, includes a
deductible, an individual within a family shall not have a deductible
that is more than the deductible limit for individual coverage for
that product.
(2) (A) If a health care service plan contract for family coverage
includes a deductible and is a high deductible health plan under the
definition set forth in Section 223(c)(2) of Title 26 of the United
States Code, the plan contract shall include a deductible for each
individual covered by the plan that is equal to either the amount set
forth in Section 223(c)(2)(A)(i)(II) of Title 26 of the United
States Code or the deductible for individual coverage under the plan
contract, whichever is greater.
(B) If a large group market health care service plan contract for
family coverage that is issued, amended, or renewed on or after
January 1, 2017, includes a deductible and is a high deductible
health plan under the definition set forth in Section 223(c)(2) of
Title 26 of the United States Code, the plan contract shall include a
deductible for each individual covered by the plan that is equal to
either the amount set forth in Section 223(c)(2)(A)(i)(II) of Title
26 of the United States Code or the deductible for individual
coverage under the plan contract, whichever is greater.
(h) For nongrandfathered health plan contracts in the group
market, "plan year" has the meaning set forth in Section 144.103 of
Title 45 of the Code of Federal Regulations. For nongrandfathered
health plan contracts sold in the individual market, "plan year"
means the calendar year.
(i) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.