Chapter 9.9. Individual Access To Health Insurance of California Insurance Code >> Division 2. >> Part 2. >> Chapter 9.9.
For purposes of this chapter, the following definitions
shall apply:
(a) "Child" means a child described in Section 22775 of the
Government Code and subdivisions (n) to (p), inclusive, of Section
599.500 of Title 2 of the California Code of Regulations.
(b) "Dependent" means the spouse or registered domestic partner,
or child, of an individual, subject to applicable terms of the health
benefit plan.
(c) "Exchange" means the California Health Benefit Exchange
created by Section 100500 of the Government Code.
(d) "Family" means the policyholder and dependent or dependents.
(e) "Grandfathered health plan" has the same meaning as that term
is defined in Section 1251 of PPACA.
(f) "Health benefit plan" means any individual or group policy of
health insurance, as defined in Section 106. The term does not
include a health insurance policy that provides excepted benefits, as
described in Sections 2722 and 2791 of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg-21; 42 U.S.C. Sec. 300gg-91),
subject to Section 10965.01 a health insurance policy provided in the
Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part
3 of Division 9 of the Welfare and Institutions Code), the Healthy
Families Program (Part 6.2 (commencing with Section 12693) of
Division 2), the Access for Infants and Mothers Program (Part 6.3
(commencing with Section 12695) of Division 2), or the program under
Part 6.4 (commencing with Section 12699.50) of Division 2, or
Medicare supplement coverage, to the extent consistent with PPACA or
a specified disease or hospital indemnity policy, subject to Section
10965.01.
(g) "Policy year" means the period from January 1 to December 31,
inclusive.
(h) "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 pursuant to that law.
(i) "Preexisting condition provision" means a policy provision
that excludes coverage for charges or expenses incurred during a
specified period following the insured's effective date of coverage,
as to a condition for which medical advice, diagnosis, care, or
treatment was recommended or received during a specified period
immediately preceding the effective date of coverage.
(j) "Rating period" means the calendar year for which premium
rates are in effect pursuant to subdivision (d) of Section 10965.9.
(k) "Registered domestic partner" means a person who has
established a domestic partnership as described in Section 297 of the
Family Code.
(a) For purposes of this chapter, "health benefit plan"
does not include policies or certificates of specified disease or
hospital confinement indemnity provided that the carrier offering
those policies or certificates complies with the following:
(1) The carrier files, on or before March 1 of each year, a
certification with the commissioner that contains the statement and
information described in paragraph (2).
(2) The certification required in paragraph (1) shall contain the
following:
(A) A statement from the carrier certifying that policies or
certificates described in this section (i) are being offered and
marketed as supplemental health insurance and not as a substitute for
coverage that provides essential health benefits as defined by the
state pursuant to Section 1302 of PPACA, and (ii) the disclosure
forms as described in Section 10603 contains the following statement
prominently on the first page:
"This is a supplement to health insurance. It is not a substitute
for essential health benefits or minimum essential coverage as
defined in federal law."
(B) A summary description of each policy or certificate described
in this section, including the average annual premium rates, or range
of premium rates in cases where premiums vary by age, gender, or
other factors, charged for the policies and certificates issued or
delivered in this state.
(3) In the case of a policy or certificate that is described in
this section and that is offered in this state on or after January 1,
2014, the carrier files with the commissioner the information and
statement required in paragraph (2) at least 30 days prior to the
date such a policy or certificate is issued or delivered in this
state.
(4) The carrier issuing a policy or certificate of specified
disease or a policy or certificate of hospital confinement indemnity
requires that the person to be insured is covered by an individual or
group policy or contract that arranges or provides medical,
hospital, and surgical coverage not designed to supplement other
private or governmental plans.
(b) As used in this section, "policies or certificates of
specified disease" and "policies or certificates of hospital
confinement indemnity" mean policies or certificates of insurance
sold to an insured to supplement other health insurance coverage as
specified in this section.
Except as provided in Section 10965.15, the provisions of
this chapter shall only apply with respect to nongrandfathered
individual health benefit plans offered by a health insurer, and
shall apply in addition to other provisions of this chapter and the
rules adopted thereunder.
(a) (1) On and after October 1, 2013, a health insurer
shall fairly and affirmatively offer, market, and sell all of the
insurer's health benefit plans that are sold in the individual market
for policy years on or after January 1, 2014, to all individuals and
dependents in each service area in which the insurer provides or
arranges for the provision of health care services. A health insurer
shall limit enrollment in individual health benefit plans to open
enrollment periods, annual enrollment periods, and special enrollment
periods as provided in subdivisions (c) and (d).
(2) A health insurer shall allow the policyholder of an individual
health benefit plan to add a dependent to the policyholder's health
benefit plan at the option of the policyholder, consistent with the
open enrollment, annual enrollment, and special enrollment period
requirements in this section.
(b) An individual health benefit plan issued, amended, or renewed
on or after January 1, 2014, shall not impose any preexisting
condition provision upon any individual.
(c) (1) A health insurer shall provide an initial open enrollment
period from October 1, 2013, to March 31, 2014, inclusive, an annual
enrollment period for the policy year beginning on January 1, 2015,
from November 15, 2014, to February 15, 2015, inclusive, and annual
enrollment periods for policy years beginning on or after January 1,
2016, from November 1, of the preceding calendar year, to January 31
of the benefit year, inclusive.
(2) Pursuant to Section 147.104(b)(2) of Title 45 of the Code of
Federal Regulations, for individuals enrolled in noncalendar year
individual health plan contracts, a health insurer shall also provide
a limited open enrollment period beginning on the date that is 30
calendar days prior to the date the policy year ends in 2014.
(d) (1) Subject to paragraph (2), commencing January 1, 2014, a
health insurer shall allow an individual to enroll in or change
individual health benefit plans as a result of the following
triggering events:
(A) He or she or his or her dependent loses minimum essential
coverage. For purposes of this paragraph, both of the following
definitions shall apply:
(i) "Minimum essential coverage" has the same meaning as that term
is defined in subsection (f) of Section 5000A of the Internal
Revenue Code (26 U.S.C. Sec. 5000A).
(ii) "Loss of minimum essential coverage" includes, but is not
limited to, loss of that coverage due to the circumstances described
in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the
Code of Federal Regulations and the circumstances described in
Section 1163 of Title 29 of the United States Code. "Loss of minimum
essential coverage" also includes loss of that coverage for a reason
that is not due to the fault of the individual.
(iii) "Loss of minimum essential coverage" does not include loss
of that coverage due to the individual's failure to pay premiums on a
timely basis or situations allowing for a rescission, subject to
clause (ii) and Sections 10119.2 and 10384.17.
(B) He or she gains a dependent or becomes a dependent.
(C) He or she is mandated to be covered as a dependent pursuant to
a valid state or federal court order.
(D) He or she has been released from incarceration.
(E) His or her health coverage issuer substantially violated a
material provision of the health coverage contract.
(F) He or she gains access to new health benefit plans as a result
of a permanent move.
(G) He or she was receiving services from a contracting provider
under another health benefit plan, as defined in Section 10965 of
this code or Section 1399.845 of the Health and Safety Code, for one
of the conditions described in subdivision (a) of Section 10133.56 of
this code and that provider is no longer participating in the health
benefit plan.
(H) He or she demonstrates to the Exchange, with respect to health
benefit plans offered through the Exchange, or to the department,
with respect to health benefit plans offered outside the Exchange,
that he or she did not enroll in a health benefit plan during the
immediately preceding enrollment period available to the individual
because he or she was misinformed that he or she was covered under
minimum essential coverage.
(I) He or she is a member of the reserve forces of the United
States military returning from active duty or a member of the
California National Guard returning from active duty service under
Title 32 of the United States Code.
(J) With respect to individual health benefit plans offered
through the Exchange, in addition to the triggering events listed in
this paragraph, any other events listed in Section 155.420(d) of
Title 45 of the Code of Federal Regulations.
(2) With respect to individual health benefit plans offered
outside the Exchange, an individual shall have 60 days from the date
of a triggering event identified in paragraph (1) to apply for
coverage from a health care service plan subject to this section.
With respect to individual health benefit plans offered through the
Exchange, an individual shall have 60 days from the date of a
triggering event identified in paragraph (1) to select a plan offered
through the Exchange, unless a longer period is provided in Part 155
(commencing with Section 155.10) of Subchapter B of Subtitle A of
Title 45 of the Code of Federal Regulations.
(e) With respect to individual health benefit plans offered
through the Exchange, the effective date of coverage required
pursuant to this section shall be consistent with the dates specified
in Section 155.410 or 155.420 of Title 45 of the Code of Federal
Regulations, as applicable. A dependent who is a registered domestic
partner pursuant to Section 297 of the Family Code shall have the
same effective date of coverage as a spouse.
(f) With respect to an individual health benefit plan offered
outside the Exchange, the following provisions shall apply:
(1) After an individual submits a completed application form for a
plan, the insurer shall, within 30 days, notify the individual of
the individual's actual premium charges for that plan established in
accordance with Section 10965.9. The individual shall have 30 days in
which to exercise the right to buy coverage at the quoted premium
charges.
(2) With respect to an individual health benefit plan for which an
individual applies during the initial open enrollment period
described in subdivision (c), when the policyholder submits a premium
payment, based on the quoted premium charges, and that payment is
delivered or postmarked, whichever occurs earlier, by December 15,
2013, coverage under the individual health benefit plan shall become
effective no later than January 1, 2014. When that payment is
delivered or postmarked within the first 15 days of any subsequent
month, coverage shall become effective no later than the first day of
the following month. When that payment is delivered or postmarked
between December 16, 2013, to December 31, 2013, inclusive, or after
the 15th day of any subsequent month, coverage shall become effective
no later than the first day of the second month following delivery
or postmark of the payment.
(3) With respect to an individual health benefit plan for which an
individual applies during the annual open enrollment period
described in subdivision (c), when the individual submits a premium
payment, based on the quoted premium charges, and that payment is
delivered or postmarked, whichever occurs later, by December 15,
coverage shall become effective as of the following January 1. When
that payment is delivered or postmarked within the first 15 days of
any subsequent month, coverage shall become effective no later than
the first day of the following month. When that payment is delivered
or postmarked between December 16 to December 31, inclusive, or after
the 15th day of any subsequent month, coverage shall become
effective no later than the first day of the second month following
delivery or postmark of the payment.
(4) With respect to an individual health benefit plan for which an
individual applies during a special enrollment period described in
subdivision (d), the following provisions shall apply:
(A) When the individual submits a premium payment, based on the
quoted premium charges, and that payment is delivered or postmarked,
whichever occurs earlier, within the first 15 days of the month,
coverage under the plan shall become effective no later than the
first day of the following month. When the premium payment is neither
delivered nor postmarked until after the 15th day of the month,
coverage shall become effective no later than the first day of the
second month following delivery or postmark of the payment.
(B) Notwithstanding subparagraph (A), in the case of a birth,
adoption, or placement for adoption, the coverage shall be effective
on the date of birth, adoption, or placement for adoption.
(C) Notwithstanding subparagraph (A), in the case of marriage or
becoming a registered domestic partner or in the case where a
qualified individual loses minimum essential coverage, the coverage
effective date shall be the first day of the month following the date
the insurer receives the request for special enrollment.
(g) (1) A health insurer shall not establish rules for
eligibility, including continued eligibility, of any individual to
enroll under the terms of an individual health benefit plan based on
any of the following factors:
(A) Health status.
(B) Medical condition, including physical and mental illnesses.
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability, including conditions arising out of
acts of domestic violence.
(H) Disability.
(I) Any other health status-related factor as determined by any
federal regulations, rules, or guidance issued pursuant to Section
2705 of the federal Public Health Service Act (Public Law 78-410).
(2) Notwithstanding subdivision (c) of Section 10291.5, a health
insurer shall not require an individual applicant or his or her
dependent to fill out a health assessment or medical questionnaire
prior to enrollment under an individual health benefit plan. A health
insurer shall not acquire or request information that relates to a
health status-related factor from the applicant or his or her
dependent or any other source prior to enrollment of the individual.
(h) (1) A health insurer shall consider as a single risk pool for
rating purposes in the individual market the claims experience of all
insureds and enrollees in all nongrandfathered individual health
benefit plans offered by that insurer in this state, whether offered
as health care service plan contracts or individual health insurance
policies, including those insureds and enrollees who enroll in
individual coverage through the Exchange and insureds and enrollees
who enroll in individual coverage outside the Exchange. Student
health insurance coverage, as such coverage is defined in Section
147.145(a) of Title 45 of the Code of Federal Regulations, shall not
be included in a health insurer's single risk pool for individual
coverage.
(2) Each calendar year, a health insurer shall establish an index
rate for the individual market in the state based on the total
combined claims costs for providing essential health benefits, as
defined pursuant to Section 1302 of PPACA, within the single risk
pool required under paragraph (1). The index rate shall be adjusted
on a marketwide basis based on the total expected marketwide payments
and charges under the risk adjustment and reinsurance programs
established for the state pursuant to Sections 1343 and 1341 of PPACA
and Exchange user fees, as described in subdivision (d) of Section
156.80 of Title 45 of the Code of Federal Regulations. The premium
rate for all of the health benefit plans in the individual market
within the single risk pool required under paragraph (1) shall use
the applicable marketwide adjusted index rate, subject only to the
adjustments permitted under paragraph (3).
(3) A health insurer may vary premium rates for a particular
health benefit plan from its index rate based only on the following
actuarially justified plan-specific factors:
(A) The actuarial value and cost-sharing design of the health
benefit plan.
(B) The health benefit plan's provider network, delivery system
characteristics, and utilization management practices.
(C) The benefits provided under the health benefit plan that are
in addition to the essential health benefits, as defined pursuant to
Section 1302 of PPACA and Section 10112.27. These additional benefits
shall be pooled with similar benefits within the single risk pool
required under paragraph (1) and the claims experience from those
benefits shall be utilized to determine rate variations for plans
that offer those benefits in addition to essential health benefits.
(D) With respect to catastrophic plans, as described in subsection
(e) of Section 1302 of PPACA, the expected impact of the specific
eligibility categories for those plans.
(E) Administrative costs, excluding any user fees required by the
Exchange.
(i) This section shall only apply with respect to individual
health benefit plans for policy years on or after January 1, 2014.
(j) This section shall not apply to a grandfathered health plan.
(k) 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), subdivisions
(a), (b), and (g) shall become inoperative 12 months after the date
of that repeal or amendment and individual health care benefit plans
shall thereafter be subject to Sections 10901.2, 10951, and 10953.
(a) Commencing on October 1, 2013, a health insurer or
agent or broker shall not, directly or indirectly, engage in the
following activities:
(1) Encourage or direct an individual to refrain from filing an
application for individual coverage with an insurer because of the
health status, claims experience, industry, occupation, or geographic
location, provided that the location is within the insurer's
approved service area, of the individual.
(2) Encourage or direct an individual to seek individual coverage
from another health care service plan or health insurer or the
California Health Benefit Exchange because of the health status,
claims experience, industry, occupation, or geographic location,
provided that the location is within the insurer's approved service
area, of the individual.
(3) Employ marketing practices or benefit designs that will have
the effect of discouraging the enrollment of individuals with
significant health needs or discriminate based on an individual's
race, color, national origin, present or predicted disability, age,
sex, gender identity, sexual orientation, expected length of life,
degree of medical dependency, quality of life, or other health
conditions.
(b) Commencing on October 1, 2013, a health insurer shall not,
directly or indirectly, enter into any contract, agreement, or
arrangement with a broker or agent that provides for or results in
the compensation paid to a broker or agent for the sale of an
individual health benefit plan to be varied because of the health
status, claims experience, industry, occupation, or geographic
location of the individual. This subdivision does not apply to a
compensation arrangement that provides compensation to a broker or
agent on the basis of percentage of premium, provided that the
percentage shall not vary because of the health status, claims
experience, industry, occupation, or geographic area of the
individual.
(c) This section shall only apply with respect to individual
health benefit plans for policy years on or after January 1, 2014.
(d) This section shall be enforced in the same manner as Section
790.03, including through Sections 790.05 and 790.035.
(a) An individual health benefit plan shall be renewable
at the option of the insured except as permitted to be canceled,
rescinded, or not renewed pursuant to Section 155.430(b) of Title 45
of the Code of Federal Regulations.
(b) Any insurer that ceases to offer for sale new individual
health benefit plans pursuant to Section 10273.6 shall continue to be
governed by this chapter with respect to business conducted under
this chapter.
(a) With respect to individual health benefit plans
issued, amended, or renewed on or after January 1, 2014, a health
insurer may use only the following characteristics of an individual,
and any dependent thereof, for purposes of establishing the rate of
the individual health benefit plan covering the individual and the
eligible dependents thereof, along with the health benefit plan
selected by the individual:
(1) Age, pursuant to the age bands established by the United
States Secretary of Health and Human Services and the age rating
curve established by the federal Centers for Medicare and Medicaid
Services pursuant to Section 2701(a)(3) of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg(a)(3)). Rates based on age shall be
determined using the individual's age as of the date of the plan
issuance or renewal, as applicable, and shall not vary by more than
three to one for like individuals of different ages who are 21 years
of age or older as described in federal regulations adopted pursuant
to Section 2701(a)(3) of the federal Public Health Service Act (42
U.S.C. Sec. 300gg(a)(3)).
(2) (A) Geographic region. The geographic regions for purposes of
rating shall be the following:
(i) Region 1 shall consist of the Counties of Alpine, Amador,
Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen,
Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter,
Tehama, Trinity, Tuolumne, and Yuba.
(ii) Region 2 shall consist of the Counties of Marin, Napa,
Solano, and Sonoma.
(iii) Region 3 shall consist of the Counties of El Dorado, Placer,
Sacramento, and Yolo.
(iv) Region 4 shall consist of the City and County of San
Francisco.
(v) Region 5 shall consist of the County of Contra Costa.
(vi) Region 6 shall consist of the County of Alameda.
(vii) Region 7 shall consist of the County of Santa Clara.
(viii) Region 8 shall consist of the County of San Mateo.
(ix) Region 9 shall consist of the Counties of Monterey, San
Benito, and Santa Cruz.
(x) Region 10 shall consist of the Counties of Mariposa, Merced,
San Joaquin, Stanislaus, and Tulare.
(xi) Region 11 shall consist of the Counties of Fresno, Kings, and
Madera.
(xii) Region 12 shall consist of the Counties of San Luis Obispo,
Santa Barbara, and Ventura.
(xiii) Region 13 shall consist of the Counties of Imperial, Inyo,
and Mono.
(xiv) Region 14 shall consist of the County of Kern.
(xv) Region 15 shall consist of the ZIP Codes in the County of Los
Angeles starting with 906 to 912, inclusive, 915, 917, 918, and 935.
(xvi) Region 16 shall consist of the ZIP Codes in the County of
Los Angeles other than those identified in clause (xv).
(xvii) Region 17 shall consist of the Counties of Riverside and
San Bernardino.
(xviii) Region 18 shall consist of the County of Orange.
(xix) Region 19 shall consist of the County of San Diego.
(B) No later than June 1, 2017, the department, in collaboration
with the Exchange and the Department of Managed Heath Care, shall
review the geographic rating regions specified in this paragraph and
the impacts of those regions on the health care coverage market in
California, and make a report to the appropriate policy committees of
the Legislature.
(3) Whether the plan covers an individual or family, as described
in PPACA.
(b) The rate for a health benefit plan subject to this section
shall not vary by any factor not described in this section.
(c) With respect to family coverage under an individual health
benefit plan, the rating variation permitted under paragraph (1) of
subdivision (a) shall be applied based on the portion of the premium
attributable to each family member covered under the plan. The total
premium for family coverage shall be determined by summing the
premiums for each individual family member. In determining the total
premium for family members, premiums for no more than the three
oldest family members who are under 21 years of age shall be taken
into account.
(d) The rating period for rates subject to this section shall be
from January 1 to December 31, inclusive.
(e) This section shall not apply to an individual health benefit
plan that is a grandfathered health plan.
(f) The requirement for submitting a report imposed under
subparagraph (B) of paragraph (2) of subdivision (a) is inoperative
on June 1, 2021, pursuant to Section 10231.5 of the Government Code.
(g) 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-4), this section
shall become inoperative 12 months after the date of that repeal or
the amendment.
(a) A health insurer shall not be required to offer an
individual health benefit plan or accept applications for the plan
pursuant to Section 10965.3 in the case of any of the following:
(1) To an individual who does not live or reside within the
insurer's approved service areas.
(2) (A) Within a specific service area or portion of a service
area, if the insurer reasonably anticipates and demonstrates to the
satisfaction of the commissioner both of the following:
(i) It will not have sufficient health care delivery resources to
ensure that health care services will be available and accessible to
the individual because of its obligations to existing insureds.
(ii) It is applying this subparagraph uniformly to all individuals
without regard to the claims experience of those individuals or any
health status-related factor relating to those individuals.
(B) A health insurer that cannot offer an individual health
benefit plan to individuals because it is lacking in sufficient
health care delivery resources within a service area or a portion of
a service area pursuant to subparagraph (A) shall not offer an
individual health benefit plan in that area until the later of the
following dates:
(i) The 181st day after the date coverage is denied pursuant to
this paragraph.
(ii) The date the insurer notifies the commissioner that it has
the ability to deliver services to individuals, and certifies to the
commissioner that from the date of the notice it will enroll all
individuals requesting coverage in that area from the insurer.
(C) Subparagraph (B) shall not limit the insurer's ability to
renew coverage already in force or relieve the insurer of the
responsibility to renew that coverage as described in Section
10273.6.
(D) Coverage offered within a service area after the period
specified in subparagraph (B) shall be subject to this section.
(b) (1) A health insurer may decline to offer an individual health
benefit plan to an individual if the insurer demonstrates to the
satisfaction of the commissioner both of the following:
(A) It does not have the financial reserves necessary to
underwrite additional coverage. In determining whether this
subparagraph has been satisfied, the commissioner shall consider, but
not be limited to, the insurer's compliance with the requirements of
this part and the rules adopted thereunder.
(B) It is applying this subdivision uniformly to all individuals
without regard to the claims experience of those individuals or any
health status-related factor relating to those individuals.
(2) A health insurer that denies coverage to an individual under
paragraph (1) shall not offer coverage before the later of the
following dates:
(A) The 181st day after the date coverage is denied pursuant to
this subdivision.
(B) The date the insurer demonstrates to the satisfaction of the
commissioner that the insurer has sufficient financial reserves
necessary to underwrite additional coverage.
(3) Paragraph (2) shall not limit the insurer's ability to renew
coverage already in force or relieve the insurer of the
responsibility to renew that coverage as described in Section
10273.6. Coverage offered within a service area after the period
specified in paragraph (2) shall be subject to this section.
(c) This chapter shall not be construed to limit the commissioner'
s authority to develop and implement a plan of rehabilitation for a
health insurer whose financial viability or organizational and
administrative capacity has become impaired, to the extent permitted
by PPACA.
(d) This section shall not apply to an individual health benefit
plan that is a grandfathered plan.
(a) A health insurer that receives an application for an
individual health benefit plan outside the Exchange during the
initial open enrollment period, an annual enrollment period, or a
special enrollment period described in Section 10965.3 shall inform
the applicant that he or she may be eligible for lower cost coverage
through the Exchange and shall inform the applicant of the applicable
enrollment period provided through the Exchange described in Section
10965.3.
(b) On or before October 1, 2013, and annually every October 1
thereafter, a health insurer shall issue a notice to a policyholder
enrolled in an individual health benefit plan offered outside the
Exchange. The notice shall inform the policyholder that he or she may
be eligible for lower cost coverage through the Exchange and shall
inform the policyholder of the applicable open enrollment period
provided through the Exchange described in Section 10965.3.
(c) This section shall not apply where the individual health
benefit plan described in subdivision (a) or (b) is a grandfathered
health plan.
(a) On or before October 1, 2013, and annually every
October 1 thereafter, a health insurer shall issue the following
notice to all policyholders enrolled in an individual health benefit
plan that is a grandfathered health plan:
New improved health insurance options are available in California.
You currently have health insurance that is not required to follow
many of the new laws. For example, your policy may not provide
preventive health services without you having to pay any cost sharing
(copayments or coinsurance). Also your current policy may be allowed
to increase your rates based on your health status while new
policies cannot. You have the option to remain in your current policy
or switch to a new policy. Under the new rules, a health insurance
company cannot deny your application based on any health conditions
you may have. For more information about your options, please contact
Covered California at ____, your policy representative or insurance
agent, or an entity paid by Covered California to assist with health
coverage enrollment, such as a navigator or an assister.
(b) Commencing October 1, 2013, a health insurer shall include the
notice described in subdivision (a) in any renewal material of the
individual grandfathered health plan and in any application for
dependent coverage under the individual grandfathered health plan.
(c) A health insurer shall not advertise or market an individual
health benefit plan that is a grandfathered health plan for purposes
of enrolling a dependent of a policyholder into the plan for policy
years on or after January 1, 2014. Nothing in this subdivision shall
be construed to prohibit an individual enrolled in an individual
grandfathered health plan from adding a dependent to that plan to the
extent permitted by PPACA.
Except as otherwise provided in this chapter, this
chapter shall be implemented to the extent that it meets or exceeds
the requirements set forth in PPACA.
(a) The commissioner may, no later than December 31,
2014, adopt emergency regulations implementing this chapter. The
commissioner may readopt any emergency regulation authorized by this
section that is the same as or substantially equivalent to an
emergency regulation previously adopted under this section.
(b) The initial adoption of emergency regulations implementing
this chapter and the one readoption of emergency regulation
authorized by this section shall be deemed an emergency and necessary
for the immediate preservation of the public peace, health, safety,
or general welfare. Initial emergency regulations and the one
readoption of emergency regulations authorized by this section shall
be exempt from review by the Office of Administrative Law. The
initial emergency regulations and the one readoption of emergency
regulations authorized by this section shall be submitted to the
Office of Administrative Law for filing with the Secretary of State
and each shall remain in effect for no more than one year, by which
time final regulations may be adopted. The commissioner shall consult
with the Director of the Department of Managed Health Care prior to
adopting any regulations pursuant to this subdivision for the
specific purpose of ensuring, to the extent practical, that there is
consistency of regulations applicable to entities regulated by the
commissioner and those regulated by the Department of Managed Health
Care.
(a) For purposes of this chapter, a bridge plan product
shall mean an individual health benefit plan that is offered by a
health insurer licensed under this part that contracts with the
Exchange pursuant to Title 22 (commencing with Section 100500) of the
Government Code.
(b) On and after September 30, 2013, if a health insurance policy
has not been filed with the commissioner, a health insurer that
contracts with the Exchange to offer a qualified bridge plan product
pursuant to Section 100504.5 of the Government Code shall file the
policy form with the commissioner pursuant to Section 10290.
(c) (1) Notwithstanding subdivision (a) of Section 10965.3, a
health insurer selling a bridge plan product shall not be required to
fairly and affirmatively offer, market, and sell the health insurer'
s bridge plan product except to individuals eligible for the bridge
plan product pursuant to the State Department of Health Care Services
and the Medi-Cal managed care plan's contract entered into pursuant
to Section 14005.70 of the Welfare and Institutions Code, provided
the health care service plan meets the requirements of subdivision
(b) of Section 14005.70 of the Welfare and Institutions Code.
(2) Notwithstanding subdivision (c) of Section 10965.3, a health
insurer selling a bridge plan product shall provide an initial open
enrollment period of six months, and an annual enrollment period and
a special enrollment period consistent with the annual enrollment and
special enrollment periods of the Exchange.
(d) A health insurer that contracts with the Exchange to offer a
qualified bridge plan product pursuant to Section 100504.5 of the
Government Code shall maintain a medical loss ratio of 85 percent for
the bridge plan product. A health insurer shall utilize, to the
extent possible, the same methodology for calculating the medical
loss ratio for the bridge plan product that is used for calculating
the health insurer's medical loss ratio pursuant to Section 10112.25
and shall report its medical loss ratio for the bridge plan product
to the department as provided in Section 10112.25.
(e) This section shall become inoperative on the October 1 that is
five years after the date that federal approval of the bridge plan
option occurs, and, as of the second January 1 thereafter, is
repealed, unless a later enacted statute that is enacted before that
date deletes or extends the dates on which it becomes inoperative and
is repealed.