1399.811
. (a) (1) Premiums for contracts offered, delivered,
amended, or renewed by plans on or after January 1, 2001, shall be
subject to the following requirements:
(A) The premium for new business for a federally eligible defined
individual shall not exceed the following amounts:
(i) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that offer services through a
preferred provider arrangement, the average premium paid by a
subscriber of the Major Risk Medical Insurance Program who is of the
same age and resides in the same geographic area as the federally
eligible defined individual. However, for federally eligible defined
individuals who are between the ages of 60 to 64 years, inclusive,
the premium shall not exceed the average premium paid by a subscriber
of the Major Risk Medical Insurance Program who is 59 years of age
and resides in the same geographic area as the federally eligible
defined individual.
(ii) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that do not offer services through
a preferred provider arrangement, 170 percent of the standard
premium charged to an individual who is of the same age and resides
in the same geographic area as the federally eligible defined
individual. However, for federally eligible defined individuals who
are between the ages of 60 to 64 years, inclusive, the premium shall
not exceed 170 percent of the standard premium charged to an
individual who is 59 years of age and resides in the same geographic
area as the federally eligible defined individual.
(B) The premium for in force business for a federally eligible
defined individual shall not exceed the following amounts:
(i) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that offer services through a
preferred provider arrangement, the average premium paid by a
subscriber of the Major Risk Medical Insurance Program who is of the
same age and resides in the same geographic area as the federally
eligible defined individual. However, for federally eligible defined
individuals who are between the ages of 60 and 64 years, inclusive,
the premium shall not exceed the average premium paid by a subscriber
of the Major Risk Medical Insurance Program who is 59 years of age
and resides in the same geographic area as the federally eligible
defined individual.
(ii) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that do not offer services through
a preferred provider arrangement, 170 percent of the standard
premium charged to an individual who is of the same age and resides
in the same geographic area as the federally eligible defined
individual. However, for federally eligible defined individuals who
are between the ages of 60 and 64 years, inclusive, the premium shall
not exceed 170 percent of the standard premium charged to an
individual who is 59 years of age and resides in the same geographic
area as the federally eligible defined individual. The premium
effective on January 1, 2001, shall apply to in force business at the
earlier of either the time of renewal or July 1, 2001.
(2) This subdivision shall become inoperative on January 1, 2014.
This subdivision shall become operative on January 1, 2020.
(b) (1) Premiums for contracts offered, delivered, amended, or
renewed by plans on or after January 1, 2014, shall be subject to the
following requirements:
(A) With respect to the rate charged for coverage provided in
2014, the rate charged in 2013 for that coverage multiplied by 1.09.
(B) With respect to the rate charged for coverage provided in 2015
and each subsequent year, the rate charged in the prior year
multiplied by a factor of one plus the percentage change in the
statewide average premium for the second lowest cost silver plan
offered on the Exchange. The Exchange shall determine the percentage
change in the statewide average premium for the second lowest cost
silver plan by subtracting clause (i) from clause (ii) and dividing
the result by clause (i).
(i) The average of the premiums charged in the year prior to the
applicable year for the second lowest cost silver plan in all 19
rating regions, with the premium for each region weighted based on
the region's relative share of the Exchange's total individual
enrollment according to the latest data available to the Exchange.
(ii) The average of the premiums to be charged in the applicable
year for the second lowest cost silver plan in all 19 rating regions,
with the premium for each region weighted based on the region's
relative share of the Exchange's total individual enrollment
according to the latest data available to the Exchange.
(C) The Exchange shall determine the percentage change in the
statewide average premium no later than 30 days after the Exchange's
rates for individual coverage for the applicable year have been
finalized.
(2) For purposes of this subdivision, "Exchange" means the
California Health Benefit Exchange established pursuant to Section
100500 of the Government Code.
(3) This subdivision shall become operative on January 1, 2014.
This subdivision shall become inoperative on January 1, 2020.
(c) The premium applied to a federally eligible defined individual
may not increase by more than the following amounts:
(1) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that offer services through a
preferred provider arrangement, the average increase in the premiums
charged to a subscriber of the Major Risk Medical Insurance Program
who is of the same age and resides in the same geographic area as the
federally eligible defined individual.
(2) For health care service plan contracts identified in
subdivision (d) of Section 1366.35 that do not offer services through
a preferred provider arrangement, the increase in premiums charged
to a nonfederally eligible defined individual who is of the same age
and resides in the same geographic area as the federally eligible
defined individual. The premium for an eligible individual may not be
modified more frequently than every 12 months.
(3) For a contract that a plan has discontinued offering, the
premium applied to the first rating period of the new contract that
the federally eligible defined individual elects to purchase shall be
no greater than the premium applied in the prior rating period to
the discontinued contract.
(d) (1) On and after January 1, 2014, and except as provided in
paragraph (2), this section shall apply only to individual
grandfathered health plan contracts previously issued pursuant to
this section to federally eligible defined individuals.
(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. Section 300gg-91), paragraph (1)
shall become inoperative on the date of that repeal or amendment and
this section shall apply to health care service plan contracts
issued, amended, or renewed on or after that date.
(3) For purposes of this subdivision, the following definitions
apply:
(A) "Grandfathered health plan" has the same meaning as that term
is defined in Section 1251 of PPACA.
(B) "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.