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SB-1008 Health insurance: dental services: reporting and disclosures.(2017-2018)

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Date Published: 08/06/2018 02:00 PM
SB1008:v94#DOCUMENT

Amended  IN  Assembly  August 06, 2018
Amended  IN  Assembly  July 03, 2018
Amended  IN  Senate  May 25, 2018
Amended  IN  Senate  May 01, 2018
Amended  IN  Senate  April 10, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 1008


Introduced by Senator Skinner

February 06, 2018


An act to amend Section 1367.004 of, and to add Sections 1363.04 and 1367.013 to, the Health and Safety Code, and to amend Section 10112.26 of, and to add Sections 10112.255 and 10603.04 to, the Insurance Code, relating to dental services.


LEGISLATIVE COUNSEL'S DIGEST


SB 1008, as amended, Skinner. Health insurance: dental services: reporting and disclosures.
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 provides for the regulation of health insurers by the Department of Insurance.
The federal Patient Protection and Affordable Care Act requires a health insurance issuer issuing health insurance coverage to comply with minimum medical loss ratios and to provide an annual rebate to each insured if the medical loss ratio of the amount of the revenue expended by the issuer on costs to the total amount of premium revenue is less than a certain percentage, as specified.
Existing law requires a health care service plan or health insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy.
This bill would require a health care service plan or a health insurer that issues, sells, renews, or offers a specialized health care service plan contract or insurance policy that covers dental services in California, in addition to any other applicable disclosure requirements, to utilize a uniform benefits and coverage disclosure matrix, with specified contents. The bill would require the Department of Managed Health Care and the Department of Insurance to develop the uniform benefits and disclosure matrix in consultation with stakeholders. The bill would require the Department of Managed Health Care and the Department of Insurance to implement the bill’s provisions relating to the benefits and coverage disclosure matrix through emergency regulations, as specified. The benefits and coverage disclosure matrix requirements would take effect for plan or policy years on and after January 1, 2021, or 12 months after adoption of the emergency regulations, whichever occurs later.
This bill would also require a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan or specialized health insurance policy that provides out-of-network dental services as a covered benefit, for plan years on and after July 1, 2020, to provide make available to a billing and treating provider, on behalf of the enrollee or insured, as applicable, specified information regarding the enrollee’s or insured’s benefits.
Existing law requires a health care service plan or health insurer that issues, sells, renews, or offers a specialized health care service plan contract or health insurance policy covering dental services, no later than September 30, 2015, and each year thereafter, to file a report known as the Medical Loss Ratio (MLR) annual report, with the Department of Managed Health Care or the Department of Insurance, respectively, that is organized by market and product type.
This bill would require the MLR annual report to be filed with the Department of Managed Health Care or the Department of Insurance by July 1 of each year. The bill would require the respective department to post a health care service plan’s or health insurer’s MLR annual report on its Internet Web site within 45 days after receiving the report.
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.
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   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1363.04 is added to the Health and Safety Code, to read:

1363.04.
 (a) For plan years on and after January 1, 2021, or 12 months after regulations are adopted under subdivision (f), whichever occurs later, a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services in this state, in addition to any other applicable disclosure requirements, shall utilize a uniform benefits and coverage disclosure matrix, which shall be developed by the department, in conjunction with the Department of Insurance, and in consultation with stakeholders. At a minimum, the benefits and coverage disclosure matrix shall require the health care service plan to make available all of the following information, together with the corresponding copayments and limitations:
(1) The annual overall plan deductible.
(2) The annual benefit limit.
(3) Coverage for the following categories:
(A) Preventive and diagnostic services.
(B) Basic services.
(C) Major services.
(D) Orthodontia services.
(4) Dental plan reimbursement levels, including estimated enrollee cost share.
(5) Waiting periods.
(b) All plans, solicitors, and representatives of a plan that issue, sell, renew, or offer a specialized health care plan contract that covers dental services shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide make available to the individual with a properly completed benefits and coverage disclosure matrix, as prescribed by the director pursuant to this section for each dental plan examined or sold.
(c) In the case of group contracts for dental services, the completed benefits and coverage disclosure matrix and evidence of coverage shall be presented made available to the contractholder upon delivery of the completed health care service plan agreement.
(d) Group contractholders shall disseminate copies of make available the completed benefits and coverage disclosure matrix to all persons eligible to be a subscriber under the group contract at the time those persons are offered the dental plan. If the individual group members are offered a choice of dental plans, separate matrices shall be supplied made available for each dental plan available. offered. Each group contractholder shall also disseminate or cause to be disseminated make available copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(e) The specialized health care service plan offering a dental product in the individual, small, or large group market, for insured accounts and self-insured insured group dental plans, shall provide make available the benefits and coverage disclosure matrix to all individuals newly enrolling for coverage, experiencing a special enrollment event, and renewing coverage, and shall provide make available the benefits and coverage disclosure matrix to all other enrollees upon request.
(f) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Insurance in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
(g) This section shall not apply to a plan qualified under the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001 et seq.).

SEC. 2.

 Section 1367.004 of the Health and Safety Code is amended to read:

1367.004.
 (a) A health care service plan that issues, sells, renews, or offers a specialized health care service plan contract covering dental services shall file a report with the department by July 1 of each year, which shall be known as the MLR annual report. The MLR annual report shall be organized by market and product type and shall contain the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post a health care service plan’s MLR annual report on its Internet Web site within 45 days after receiving the report.
(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations, and Section 1367.003.
(c) If the director decides to conduct a financial examination, as described in Section 1382, because the director finds it necessary to verify the health care service plan’s representations in the MLR annual report, the department shall provide the health care service plan with a notification 30 days before the commencement of the financial examination.
(d) The health care service plan shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 1381. The director may extend the time for a health care service plan to comply with this subdivision upon a finding of good cause.
(e) The department shall make available to the public all of the data provided to the department pursuant to this section.
(f) This section does not apply to a health care service plan contract issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) 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 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).

(g)It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for health care service plans that cover dental services that would take effect no later than January 1, 2018.

(h)Until January 1, 2018, the director may issue guidance to health care service plans subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Any guidance issued pursuant to this subdivision shall be effective only until the director adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance in issuing guidance pursuant to this subdivision.

SEC. 3.

 Section 1367.013 is added to the Health and Safety Code, to read:

1367.013.
 (a) For plan years on and after July 1, 2020, a health care service plan that issues, sells, renews, or offers a specialized health care service plan contract that covers dental services and provides out-of-network dental services as a covered benefit shall make available to a billing and treating provider, on behalf of a specific enrollee, via the health care service plan’s Internet Web site, or in real time upon request, all of the following information regarding the enrollee’s benefits:
(1) The health care service plan’s criteria and procedures for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.
(2) The dental treatment and procedures covered.
(3) The actual percentages or amounts payable as a benefit toward dental care or treatment. In the case of a percentage, the plan shall disclose whether the reimbursable percentage is based upon the provider’s submitted fee, regional fees, a maximum plan allowance, or another specified amount or calculation.
(b) A health care service plan that issues, sells, or renews, or offers a specialized health care service plan contract that covers dental services and provides out-of-network dental services as a covered benefit shall provide make available an explanation of benefits or explanation of payments to the billing provider for any amounts issued by the plan on behalf of the enrollee for dental treatment rendered by the billing provider.
(c) This section does not apply to Medi-Cal dental managed care plan contracts. contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.

SEC. 4.

 Section 10112.255 is added to the Insurance Code, to read:

10112.255.
 (a) For plan years on and after July 1, 2020, a health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall make available to a billing and treating provider, on behalf of a specific insured, via the health insurer’s Internet Web site, or in real time upon request, all of the following information regarding the insured’s benefits:
(1) The insurer’s criteria and procedure for deciding whether to provide or deny payment for or coverage of dental procedures or treatment.
(2) The dental treatment and procedures covered.
(3) The actual percentages and or amounts payable as a benefit toward dental care or treatment. In the case of a percentage, the insurer shall disclose whether the reimbursable percentage is based upon the provider’s submitted fee, regional fees, a maximum policy plan allowance, or another specified amount or calculation.
(b) A health insurer that issues, sells, renews, or offers a specialized health insurance policy that covers dental services and provides out-of-network dental services as a covered benefit shall provide an explanation of benefits or explanation of payments to the billing provider for any amounts issued by the policy on behalf of the insured for dental treatment rendered by the billing provider.
(c) This section does not apply to Medi-Cal dental managed care plan contracts. contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.

SEC. 5.

 Section 10112.26 of the Insurance Code is amended to read:

10112.26.
 (a) A health insurer that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall file a report with the department, by July 1 of each year, which shall be known as the MLR annual report. The MLR annual report shall be organized by market and product type and contains the same information required in the 2013 federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418). The department shall post a health insurer’s MLR annual report on its Internet Web site within 45 days after receiving the report.
(b) The MLR reporting year shall be for the calendar year during which dental coverage is provided by the plan. All terms used in the MLR annual report shall have the same meaning as used in the federal Public Health Service Act (42 U.S.C. Sec. 300gg-18) and Part 158 (commencing with Section 158.101) of Title 45 of the Code of Federal Regulations.
(c) If the commissioner decides to conduct an examination, as described in Section 730, because the commissioner finds it necessary to verify the health insurer’s representations in the MLR annual report, the department shall provide the health insurer with a notification 30 days before the commencement of the examination.
(d) The health insurer shall have 30 days from the date of notification to electronically submit to the department all requested records, books, and papers specified in subdivision (a) of Section 733. The commissioner may extend the time for a health insurer to comply with this subdivision upon a finding of good cause.
(e) The department shall make available to the public all of the data provided to the department pursuant to this section.
(f) This section does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) 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 of the Insurance Code), the Medi-Cal Access Program (Chapter 2 (commencing with Section 15810) of Part 3.3 of Division 9 of the Welfare and Institutions Code), the California Major Risk Medical Insurance Program (Chapter 4 (commencing with Section 15870) of Part 3.3 of Division 9 of the Welfare and Institutions Code), or the Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with Section 12739.5) of Division 2 of the Insurance Code), to the extent consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(g) This section does not apply to disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment only basis.

(h)It is the intent of the Legislature that the data reported pursuant to this section be considered by the Legislature in adopting a medical loss ratio standard for specialized health insurance policies that cover dental services that would take effect no later than January 1, 2018.

(i)Until January 1, 2018, the department may issue guidance to health insurers of specialized health insurance policies subject to this section regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Guidance issued pursuant to this subdivision is effective only until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care in issuing guidance pursuant to this subdivision.

SEC. 6.

 Section 10603.04 is added to the Insurance Code, to read:

10603.04.
 (a) For policy years on and after January 1, 2021, or 12 months after regulations are adopted under subdivision (f), whichever occurs later, a health insurer that issues, sells, renews, or offers a policy that covers dental services in this state, in addition to any other applicable disclosure requirements, shall use a uniform benefits and coverage disclosure matrix, which shall be developed by the department, in conjunction with the Department of Managed Health Care, and in consultation with stakeholders. At a minimum, the benefits and coverage disclosure matrix shall require the health insurer to make available all of the following information, together with the corresponding copayments and limitations:
(1) The annual overall policy deductible.
(2) The annual benefit limit.
(3) Coverage for the following categories:
(A) Preventive and diagnostic services.
(B) Basic services.
(C) Major services.
(D) Orthodontia services.
(4) Dental policy reimbursement levels, including estimated insured cost share.
(5) Waiting periods.
(b) All health insurers, solicitors, and representatives of a health insurer that issue, sell, renew, or offer a policy that covers dental services shall, when presenting any policy for examination or sale to an individual prospective insured, provide make available to the individual with a properly completed benefits and coverage disclosure matrix, as prescribed by the commissioner pursuant to this section for each dental policy examined or sold.
(c) In the case of group policies for dental services, the completed disclosures and coverage matrix and evidence of coverage shall be presented made available to the policyholder upon delivery of the completed policy for dental insurance.
(d) Group policyholders shall disseminate copies of make available the completed benefits and coverage disclosure matrix to all persons eligible to be a policyholder under the group policy at the time those persons are offered the dental insurance. If the individual group members are offered a choice of dental policies, separate benefits and coverage disclosure matrices shall be supplied made available for each dental policy available. offered. Each group policyholder shall also disseminate or cause to be disseminated make available copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all policyholders insured under the group policy.
(e) The health insurer offering a policy that covers dental services in the individual, small, or large group market, for insured accounts and self-insured insured group dental policies, shall provide make available the benefits and coverage disclosure matrix to all individuals newly enrolling for coverage, experiencing a special enrollment event, and renewing coverage, and shall provide make available the benefits and coverage disclosure matrix to all other insureds upon request.
(f) (1) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The department shall consult with the Department of Managed Health Care in adopting the emergency regulations, as appropriate. The adoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted pursuant to this section shall not be subject to the review and approval of the Office of Administrative Law. The regulations shall become effective immediately upon filing with the Secretary of State. The regulations shall not remain in effect more than 120 days unless the adopting agency complies with all of the provisions of Chapter 3.5 (commencing with Section 11340) as required by subdivision (c) of Section 11346.1 of the Government Code.
(g) This section shall not apply to a policy qualified under the Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001 et seq.).

SEC. 7.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.