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(1) Existing law provides for the regulation of health insurers by the Insurance Commissioner. Existing law prohibits group health insurance policies and individual health insurance policies from canceling or refusing to renew plans and policies, except under specified circumstances, including, but not limited to, nonpayment of the required premiums if the appropriate party has been notified and given at least a 30-day grace period or other period of time as required by the federal Public Health Service Act. The health insurer is required to continue to provide coverage during the grace period.
This bill would require that individuals receiving coverage through the California Health Benefit Exchange and who are receiving a tax credit pursuant to the federal Patient Protection and Affordable Care Act (PPACA) would be subject to the required grace period and provisions of coverage during the grace period, if any, as provided by PPACA.
(2) Existing law authorizes group health insurance policies to provide, among other things, that the benefits payable are subject to reduction if the insured has any other coverage, other than individual policies or contracts, providing hospital, surgical, or medical benefits, resulting in the insured being eligible for more than 100% of the covered expenses. Except as permitted and except in the case of group practice prepayment plan contracts that do not provide for coordination of benefits, to the extent they provide for a reduction of benefits on account of other coverage with respect to emergency services that are not obtained from providers that contract with the plan, a group or individual health insurance policy or service contract issued by nonprofit hospital service plans, operating as provided, is not allowed to limit payment of benefits by reason of the existence of other insurance or service coverage.
This bill would delete the provisions prohibiting a group or individual health insurance policy or service contract issued by nonprofit hospital service plans, operating as provided, from limiting payment of benefits by reason of the existence of other insurance or service coverage. The bill would add individual health insurance policies to those policies authorized to reduce benefits where the insured has other coverage providing hospital, surgical, or medical benefits, resulting in the insured being eligible for more than 100% of the covered expenses. The bill would also make conforming changes.
(3) Existing law, the California Continuation Benefits Replacement Act (Cal-COBRA) , provides for a continuation of health care coverage without evidence of insurability for up to 36 months after the date a qualified beneficiary's benefits would end due to a qualifying event, including the exhaustion of benefits under federal COBRA. Existing law also provides for certain underwriting practices regarding health care service plans and health insurance policies, including, but not limited to, an agent, broker, solicitor, solicitor firm, or representative who assists an applicant in submitting an application to a health care service plan or health insurer being required to attest in writing to the completeness and accuracy of the application to the best of his or her knowledge and that he or she explained to the applicant and was understood regarding the risk of providing inaccurate information.
This bill would make Cal-COBRA and certain underwriting requirements inoperative on January 1, 2014, and, if certain provisions of the federal Patient Protection and Affordable Care Act are repealed or amended, those provisions would become operative as of the date of the repeal or amendment.
(4) The federal Patient Protection and Affordable Care Act (PPACA) enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA authorizes the federal Secretary of Health and Human Services to award states with demonstration grants to develop and test alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers and organizations. States interested in receiving a grant are required to develop an alternative to current tort litigation and submit an application to the secretary.
This bill would require the Secretary of California Health and Human Services to submit an application on behalf of the state to the federal Department of Health and Human Services to receive a grant for state demonstration programs to evaluate alternatives to current medical tort litigation, as authorized by PPACA. The bill would require the secretary to write the application to design a program to create health courts based upon a no-fault process to improve the injury resolution of liability. The bill would specify what items a patient would need to prove under the health court demonstration program.