AB 197

Under the federal Patient Protection and Affordable Care Act (ACA), which was

enacted on March 23, 2010, each state must establish an American health benefit

exchange (exchange) through which individuals and certain businesses may

purchase health insurance. The federal government will establish and operate an

exchange in a state that does not establish its own. Health insurance offered through

the exchange must meet certain federal requirements, including offering the

essential health benefits package that is established by the federal Department of

Health and Human Services. Such a health benefit plan is called a qualified health

plan (plan) under the ACA.

This bill requires a insurer that offers plans through an exchange that is

operating in this state to provide access on the insurer's Internet site to information,

in a clear and understandable form, that will enable consumers shopping for health

insurance on the exchange to determine all of the following about the insurer's plans

offered through the exchange: exclusions from coverage and restrictions on use or

quantity of covered services or items; any service or item with a cost-sharing

requirement that depends on the cost of the service or item; whether a specific

prescription drug is covered and any clinical prerequisites or authorization

requirements for coverage of a prescription drug; whether specific types of specialists

are included, and whether a specific named specialist is included, in the plan's

network; the process for appealing a denial of coverage of a service or item; and how

the out-of-pocket costs of medications will or will not be applied towards the

deductible under the plan.