SB 466

Under current law, a city, village, town, county, or school district may offer a

self-insured health plan (self-insured governmental health plan) to its employees.

The Office of the Commissioner of Insurance (OCI) may enforce laws that specify

some of the coverage a self-insured governmental health plan must offer. Current

law requires that a self-insured governmental health plan must offer coverage to all

eligible employees and their dependents and dictates other requirements for plan

participation. Current law also mandates coverage that a self-insured

governmental health plan must offer, such as drugs for treatment of human

immunodeficiency virus (HIV), lead poisoning screening, treatment for the

correction of temporomandibular disorders, anesthetic and surgery center charges

in conjunction with dental care, breast reconstruction if the plan also covers

mastectomy, certain immunizations, and health care for students on medical leave.

Current law requires that if a self-insured governmental health plan covers

dependent children, the plan must also cover adopted children. Among other

requirements, self-insured governmental health plans must develop procedures for

physicians to request an exception for a plan participant for drugs or devices that are

routinely not covered under the plan, must specify any limits on coverage of

experimental treatment, may not require preauthorization for emergency services

if the plan covers emergency services, and may not exclude coverage for treatment

of a condition by a dentist if the treatment is covered when performed by another

health care provider.

This bill expands the authority of OCI to regulate a self-insured health plan of

a city, village, town, county, or school district (governmental body), similar to the way

OCI currently regulates insurers offering a health insurance policy or group health

benefit plan. The bill allows OCI to require a governmental body that provides a

self-insured health plan to provide reports pertaining to the self-insured health

plan and to reply to requests for information made to a person with authority over

the self-insured health plan. OCI may examine the affairs of the governmental body

as they relate to the self-insured health plan. The bill allows OCI to seek an

injunction or temporary restraining order for a violation of the statutes pertaining

to a self-insured governmental health plan and allows forfeitures and criminal

penalties to be imposed for those violations. OCI must promulgate rules regarding

the level of reserves and surpluses that the governmental body must maintain with

respect to its self-insured health plan. The governmental body may reinsure the

self-insured health plan under this bill but must report the name of the reinsurer

to OCI. The bill applies laws pertaining to rehabilitation and liquidation of insurers

and the insurance security fund to governmental bodies, with respect to a

self-insured health plan.

The bill imposes coverage requirements on self-insured governmental health

plans similar to requirements imposed on health insurance policies and group health