Implementing federal health insurance law changes

Under current law, a policy or plan providing individual health insurance may not reduce or deny coverage based on a preexisting disease or condition (preexisting condition exclusion) after 12 months after the date of issue of the policy or plan unless the condition was specifically excluded from coverage. The preexisting condition that is excluded from coverage must have been one for which the individual received or was recommended medical advice, diagnosis, care, or treatment within 12 months before the coverage under the plan became effective. A group health benefit plan, under current law may impose a preexisting condition exclusion on an individual's coverage only if the condition being excluded was one for which the individual was recommended or received medical advice, diagnosis, care, or treatment within six months before the individual's enrollment date under the plan. This bill prohibits an insurer under a group health benefit plan or an individual health insurance policy, except for a grandfathered health plan providing individual health coverage, from imposing a preexisting condition exclusion on a participant or beneficiary under the plan who is under 19 years of age. A grandfathered health plan is a health policy or plan in existence on March 23, 2010. As of January 1, 2014, this bill prohibits an insurer that offers a group health benefit plan or an individual health insurance policy, except for a grandfathered health plan providing individual health coverage, from imposing a preexisting condition exclusion on any participant or beneficiary under the plan, regardless of age.

Under the bill, every group health plan, except for a grandfathered health plan, and every insurer providing a health insurance policy, and every self-insured governmental health plan must provide coverage for all preventive care services as defined in PPACA. The bill prohibits a plan or insurer from subjecting the coverage of a preventive care service to a copayment or coinsurance.

This bill requires an individual or group health plan, except a grandfathered health plan, to provide in plain language to the secretary of the federal department of health and human services (DHHS), the commissioner of insurance, any insurance exchange if the plan is sold through an exchange, and the public certain disclosures including claims payment policies and practices, data on enrollment and disenrollment in the plan, and enrollee and participant rights. A health benefit plan, except a grandfathered health plan, is also required to make available upon request on its Internet Web site, and through another means for those without Internet access, a means to permit individuals to learn the amount of cost sharing required under the plan for a specific item or service.

This bill requires that a group or individual health benefit plan, except for a grandfathered health plan, that requires or provides for an individual or beneficiary to designate a primary care provider must allow each individual or beneficiary to designate any participating primary care provider who is available to accept that individual or beneficiary.

Under current law, a health care plan or a self-insured governmental health plan that provides coverage of any emergency medical services must provide coverage of emergency medical services that are provided in a hospital emergency facility and that are needed to evaluate or stabilize an emergency medical condition.

Current law prohibits the health care plan or self-insured governmental health plan from requiring prior authorization for those emergency medical services. This bill specifies that the services must be covered regardless whether the hospital emergency facility is a participating provider in the health care plan or self-insured governmental health plan. This bill also requires that the health care plan or self-insured governmental health plan, except for a grandfathered health plan, impose the same cost-sharing requirements on coverage for emergency medical services provided by a nonparticipating provider as it imposes for a participating provider.

With some exceptions, this bill prohibits a self-insured governmental health plan or a health care plan, except for a grandfathered health plan, from restricting benefits for a hospital stay for a mother or newborn to less than 48 hours for a vaginal delivery or less than 96 hours for a cesarean section.

Under current law, every health insurance policy and self-insured governmental health plan that provides coverage of mastectomies must provide coverage of breast reconstruction of the affected tissue incident to a mastectomy. The policy or plan may impose cost-sharing provisions on the breast reconstruction coverage that apply generally under the policy or plan. This bill specifies that all stages of breast reconstruction must be covered by a policy or plan. Under the bill, the policy or plan must also cover surgery and reconstruction of the other breast than the one on which the mastectomy was performed to produce a symmetrical appearance and prostheses and physical complications of mastectomy. The bill also specifies that all procedures covered must be provided in a manner determined in consultation with the attending physician and the patient. A policy or plan is required under the bill to provide written notice of the available coverage upon enrollment in the policy and annually thereafter.

Under current law, every health insurance policy and every self-insured governmental health plan that provides coverage for a full-time student dependent of the insured, must continue to provide coverage for that dependent if, due to a medically necessary leave of absence, the dependent is no longer a full-time student.

The policy or plan is not required to continue coverage unless the medical necessity of the leave of absence is documented and certified by the attending physician. The coverage continues until the dependent advises the policy or plan that he or she no longer intends to return to school full time, becomes employed full time, obtains other health care coverage, marries and is eligible for coverage as a spouse, reaches an age where he or she is no longer eligible for dependent coverage, or has not returned to school full time after one year since the continuation began or until the coverage of the insured under which the dependent has coverage is discontinued or not renewed.

This bill specifies that a policy or plan must continue coverage only if the leave commences while the individual is suffering from a serious illness or injury, the leave is medically necessary, and the leave causes the individual to lose student status.

The bill specifies that the physician must also document that the dependent is suffering from a serious illness. The bill requires dependent coverage to continue until the coverage would otherwise end or until one year has elapsed since the continuation began and the dependent has not returned to school full time, and the bill eliminates the other situations under which the continued coverage requirement ends. The bill also requires that every policy and plan provide a description of the continued coverage during a medically necessary leave of absence with any notice regarding a requirement for certification of student status for the dependent's coverage. The dependent whose coverage is being continued during a medically necessary leave of absence is entitled under the bill to the same coverage as a full-time student who is not on leave.

Under current law, an insurer is required to provide consumers policies that are coherent, written in commonly understood language, legible, appropriately divided and captioned, and presented in a meaningful sequence. The commissioner of insurance must make rules establishing standards for the understandability of policies and may exempt types of policies from the specific understandability requirements if the commissioner determines that the type of policy is generally understood by those receiving it or those individuals are adequately protected. This bill additionally requires that, no later than March 23, 2012, each health insurer, health plan, and self-insured governmental health plan comply with the standards that the secretary of the federal DHHS will create regarding compiling and providing a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the plan.

This bill requires that no later than March 23, 2012, every health care plan, except for a grandfathered health care plan, and self-insured governmental health plan must comply with the standards developed by the secretary of the federal DHHS regarding reporting for reimbursement structures to improve health outcomes and other quality measures.

This bill prohibits an insurer or self-insured governmental health plan from imposing a lifetime limit on the dollar value of benefits under the group or individual health care plan or self-insured plan. Before January 1, 2014, an insurer under a group or an individual health care plan, except for a grandfathered health plan providing individual coverage, or a self-insured governmental health plan may impose only a certain annual limit on the dollar value of benefits as defined by the secretary of the federal DHHS. Starting on January 1, 2014, an insurer under a group or individual health care plan, except for a grandfathered health plan providing individual coverage, and a self-insured governmental health plan may not impose an annual limit on the dollar value of benefits.

Under current law, if an insurer provides coverage under a group health benefit plan, the insurer must provide coverage to any eligible employee who becomes an eligible employee after the group coverage commences, and his or her dependents, regardless of health condition or claims experience, with certain exceptions. A self-insured governmental health plan must similarly provide coverage to an eligible employee who waived coverage during an enrollment period, regardless of health condition or claims experience, with certain exceptions. With certain exceptions, under current law, an insurer offering a group health benefit plan must renew coverage at the option of the employer. Current law also requires an insurer that provides an individual health benefit plan to renew the coverage for the insured at the option of the insured, with certain exceptions, but modifications to the individual health benefit plan that comply with the law are allowed. This bill requires any insurer that offers an individual health benefit plan, except for a grandfathered health plan, to offer coverage to any individual, and his or her dependents, that apply for coverage.

Under current law, insurers offering individual or group health insurance policies or plans are not limited in what factors they use to set rates, or premiums, except that they may not discriminate on the basis of race, color, creed, or national origin and they may not under a group health insurance policy or plan charge a higher rate based on a health status-related factor. Rates, under current law, may be modified for individual risks. As of January 1, 2014, health care plans, except for grandfathered health plans, and self-insured governmental health plans, when setting premium rates, may only consider whether the plan covers an individual or a family and the age, tobacco use, and geographic location of any individual covered under the plan. Rates based on age or tobacco use may only vary a certain amount under the bill.