SB 388: Health care coverage: solicitation and enrollment.
- Session Year: 2015-2016
- House: Senate
- Latest Version Date: 2015-10-08
Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a group health plan and a health insurance issuer offering group or individual health insurance coverage to provide a written summary of benefits and coverage (SBC) and requires that the SBC be provided in a culturally and linguistically appropriate manner, as specified.
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.
Existing law requires a plan or insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy. Existing law requires that contracts and policies subject to PPACA satisfy certain of those disclosure requirements by providing the SBC required under PPACA. Existing law requires the departments to adopt regulations establishing standards and requirements to provide enrollees and insureds with access to language assistance, including requirements for the translation of vital documents, as specified.
This bill would, commencing October 1, 2016, provide that the SBC constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. The bill would, commencing July 1, 2016, require the Department of Managed Health Care and the Insurance Commissioner to develop written translations of the template uniform summary of benefits and coverage and to make available those translations in specified languages on their respective Internet Web sites. Because a willful violation of those requirements by a health care service plan 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.
Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a group health plan and a health insurance issuer offering group or individual health insurance coverage to provide a written summary of benefits and coverage (SBC) and requires that the SBC be provided in a culturally and linguistically appropriate manner, as specified.
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.
Existing law requires a plan or insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy. Existing law requires that contracts and policies subject to PPACA satisfy certain of those disclosure requirements by providing the SBC required under PPACA. Existing law requires the departments to adopt regulations establishing standards and requirements to provide enrollees and insureds with access to language assistance, including requirements for the translation of vital documents, as specified.
This bill would, commencing October 1, 2016, provide that the SBC constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. The bill would, commencing July 1, 2016, require the Department of Managed Health Care and the Insurance Commissioner to develop written translations of the template uniform summary of benefits and coverage and to make available those translations in specified languages on their respective Internet Web sites. Because a willful violation of those requirements by a health care service plan 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.
Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a group health plan and a health insurance issuer offering group or individual health insurance coverage to provide a written summary of benefits and coverage (SBC) and requires that the SBC be provided in a culturally and linguistically appropriate manner, as specified.
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.
Existing law requires a plan or insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy. Existing law requires that contracts and policies subject to PPACA satisfy certain of those disclosure requirements by providing the SBC required under PPACA. Existing law requires the departments to adopt regulations establishing standards and requirements to provide enrollees and insureds with access to language assistance, including requirements for the translation of vital documents, as specified.
This bill would, commencing July 1, October 1, 2016, provide that the SBC constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. The bill would, commencing July 1, 2016, require the department Department of Managed Health Care and the Insurance Commissioner to develop written translations of the template uniform summary of benefits and coverage and to make available those translations in specified languages on its their respective Internet Web site. sites. Because a willful violation of those requirements by a health care service plan 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.
Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a group health plan and a health insurance issuer offering group or individual health insurance coverage to provide a written summary of benefits and coverage (SBC) and requires that the SBC be provided in a culturally and linguistically appropriate manner, as specified.
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.
Existing law requires a plan or insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy. Existing law requires that contracts and policies subject to PPACA satisfy certain of those disclosure requirements by providing the SBC required under PPACA. Existing law requires the departments to adopt regulations establishing standards and requirements to provide enrollees and insureds with access to language assistance, including requirements for the translation of vital documents, as specified.
This bill would, commencing July 1, 2016, provide that the SBC constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. The bill would, commencing July 1, 2016, require the department to develop written translations of the template uniform summary of benefits and coverage and to make available those translations in specified languages on its Internet Web site. Because a willful violation of those requirements by a health care service plan 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.
Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a group health plan and a health insurance issuer offering group or individual health insurance coverage to provide a written summary of benefits and coverage (SBC) and requires that the SBC be provided in a culturally and linguistically appropriate manner, as specified.
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.
Existing law requires a plan or insurer to provide certain disclosures of the benefits, services, and terms of a contract or policy. Existing law requires that contracts and policies subject to PPACA satisfy certain of those disclosure requirements by providing the SBC required under PPACA. Existing law requires the departments to adopt regulations establishing standards and requirements to provide enrollees and insureds with access to language assistance, including requirements for the translation of vital documents, as specified.
This bill would provide that the SBC constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. Because a willful violation of those requirements by a health care service plan 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.
(a)The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may require, so as to afford the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan in readily understood language and in a clearly organized manner. The director may require that the materials be presented in a reasonably uniform manner so as to facilitate comparisons between plan contracts of the same or other types of plans. Nothing contained in this chapter shall preclude the director from permitting the disclosure form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following information, in concise and specific terms, relative to the plan, together with additional information as may be required by the director, in connection with the plan or plan contract:
(1)The principal benefits and coverage of the plan, including coverage for acute care and subacute care.
(2)The exceptions, reductions, and limitations that apply to the plan.
(3)The full premium cost of the plan.
(4)Any copayment, coinsurance, or deductible requirements that may be incurred by the member or the members family in obtaining coverage under the plan.
(5)The terms under which the plan may be renewed by the plan member, including any reservation by the plan of any right to change premiums.
(6)A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:
(A)(i)States that the evidence of coverage discloses the terms and conditions of coverage.
(ii)States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.
(B)Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.
(C)Includes the plans telephone number or numbers that may be used by an applicant to receive additional information about the benefits of the plan or a statement where the telephone number or numbers are located in the disclosure form.
(D)For individual contracts, and small group plan contracts as defined in Article 3.1 (commencing with Section 1357), the disclosure form shall state where the health plan benefits and coverage matrix is located.
(E)Is printed in type no smaller than that used for the remainder of the disclosure form and is displayed prominently on the page.
(7)A statement as to when benefits shall cease in the event of nonpayment of the prepaid or periodic charge and the effect of nonpayment upon an enrollee who is hospitalized or undergoing treatment for an ongoing condition.
(8)To the extent that the plan permits a free choice of provider to its subscribers and enrollees, the statement shall disclose the nature and extent of choice permitted and the financial liability that is, or may be, incurred by the subscriber, enrollee, or a third party by reason of the exercise of that choice.
(9)A summary of the provisions required by subdivision (g) of Section 1373, if applicable.
(10)If the plan utilizes arbitration to settle disputes, a statement of that fact.
(11)A summary of, and a notice of the availability of, the process the plan uses to authorize, modify, or deny health care services under the benefits provided by the plan, pursuant to Sections 1363.5 and 1367.01.
(12)A description of any limitations on the patients choice of primary care physician, specialty care physician, or nonphysician health care practitioner, based on service area and limitations on the patients choice of acute care hospital care, subacute or transitional inpatient care, or skilled nursing facility.
(13)General authorization requirements for referral by a primary care physician to a specialty care physician or a nonphysician health care practitioner.
(14)Conditions and procedures for disenrollment.
(15)A description as to how an enrollee may request continuity of care as required by Section 1373.96 and request a second opinion pursuant to Section 1383.15.
(16)Information concerning the right of an enrollee to request an independent review in accordance with Article 5.55 (commencing with Section 1374.30).
(17)A notice as required by Section 1364.5.
(b)(1)As of July 1, 1999, the director shall require each plan offering a contract to an individual or small group to provide with the disclosure form for individual and small group plan contracts a uniform health plan benefits and coverage matrix containing the plans major provisions in order to facilitate comparisons between plan contracts. The uniform matrix shall include the following category descriptions together with the corresponding copayments and limitations in the following sequence:
(A)Deductibles.
(B)Lifetime maximums.
(C)Professional services.
(D)Outpatient services.
(E)Hospitalization services.
(F)Emergency health coverage.
(G)Ambulance services.
(H)Prescription drug coverage.
(I)Durable medical equipment.
(J)Mental health services.
(K)Chemical dependency services.
(L)Home health services.
(M)Other.
(2)The following statement shall be placed at the top of the matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(3)(A)A health care service plan contract subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15), shall satisfy the requirements of this subdivision by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) and any rules or regulations issued thereunder. A health care service plan that issues the uniform summary of benefits referenced in this paragraph shall do both of the following:
(i)Ensure that all applicable benefit disclosure requirements specified in this chapter and in Title 28 of the California Code of Regulations are met in other health plan documents provided to enrollees under the provisions of this chapter.
(ii)Consistent with applicable law, advise applicants and enrollees, in a prominent place in the plan documents referenced in subdivision (a), that enrollees are not financially responsible in payment of emergency care services, in any amount that the health care service plan is obligated to pay, beyond the enrollees copayments, coinsurance, and deductibles as provided in the enrollees health care service plan contract.
(B)Commencing October 1, 2016, the uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than July 1, 2016, the department shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(C)Subdivision (c) shall not apply to a health care service plan contract subject to subparagraph (A).
(c)Nothing in this section shall prevent a plan from using appropriate footnotes or disclaimers to reasonably and fairly describe coverage arrangements in order to clarify any part of the matrix that may be unclear.
(d)All plans, solicitors, and representatives of a plan shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide the individual with a properly completed disclosure form, as prescribed by the director pursuant to this section for each plan so examined or sold.
(e)In the case of group contracts, the completed disclosure form and evidence of coverage shall be presented to the contractholder upon delivery of the completed health care service plan agreement.
(f)Group contractholders shall disseminate copies of the completed disclosure form to all persons eligible to be a subscriber under the group contract at the time those persons are offered the plan. If the individual group members are offered a choice of plans, separate disclosure forms shall be supplied for each plan available. Each group contractholder shall also disseminate or cause to be disseminated copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(g)In the case of conflicts between the group contract and the evidence of coverage, the provisions of the evidence of coverage shall be binding upon the plan notwithstanding any provisions in the group contract that may be less favorable to subscribers or enrollees.
(h)In addition to the other disclosures required by this section, every health care service plan and any agent or employee of the plan shall, when presenting a plan for examination or sale to any individual purchaser or the representative of a group consisting of 25 or fewer individuals, disclose in writing the ratio of premium costs to health services paid for plan contracts with individuals and with groups of the same or similar size for the plans preceding fiscal year. A plan may report that information by geographic area, provided the plan identifies the geographic area and reports information applicable to that geographic area.
(i)Subdivision (b) shall not apply to any coverage provided by a plan for the Medi-Cal program or the Medicare Program pursuant to Title XVIII and Title XIX of the federal Social Security Act.
SEC. 2.Section 10603 of the Insurance Code, as amended by Section 8 of Chapter 1 of the First Extraordinary Session of the Statutes of 2013, is amended to read:10603.(a)(1)On or before April 1, 1975, the commissioner shall promulgate a standard supplemental disclosure form for all disability insurance policies. Upon the appropriate disclosure form as prescribed by the commissioner, each insurer shall provide, in easily understood language and in a uniform, clearly organized manner, as prescribed and required by the commissioner, the summary information about each disability insurance policy offered by the insurer as the commissioner finds is necessary to provide for full and fair disclosure of the provisions of the policy.
(2)On and after January 1, 2014, a disability insurer offering health insurance coverage subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) shall satisfy the requirements of this section and the implementing regulations by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act and any rules or regulations issued thereunder. An insurer that issues the federal uniform summary of benefits referenced in this paragraph shall ensure that all applicable disclosures required in this chapter and its implementing regulations are met in other documents provided to policyholders and insureds. An insurer subject to this paragraph shall provide the uniform summary of benefits and coverage to the commissioner together with the corresponding health insurance policy pursuant to Section 10290.
(3)Commencing October 1, 2016, the uniform summary of benefits and coverage referenced in this subdivision shall constitute a vital document for the purposes of Section 10133.8. Not later than July 1, 2016, the commissioner shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the commissioner shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the commissioner, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(b)Nothing in this section shall preclude the disclosure form from being included with the evidence of coverage or certificate of coverage or policy.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(a)The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may require, so as to afford the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan in readily understood language and in a clearly organized manner. The director may require that the materials be presented in a reasonably uniform manner so as to facilitate comparisons between plan contracts of the same or other types of plans. Nothing contained in this chapter shall preclude the director from permitting the disclosure form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following information, in concise and specific terms, relative to the plan, together with additional information as may be required by the director, in connection with the plan or plan contract:
(1)The principal benefits and coverage of the plan, including coverage for acute care and subacute care.
(2)The exceptions, reductions, and limitations that apply to the plan.
(3)The full premium cost of the plan.
(4)Any copayment, coinsurance, or deductible requirements that may be incurred by the member or the members family in obtaining coverage under the plan.
(5)The terms under which the plan may be renewed by the plan member, including any reservation by the plan of any right to change premiums.
(6)A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:
(A)(i)States that the evidence of coverage discloses the terms and conditions of coverage.
(ii)States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.
(B)Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.
(C)Includes the plans telephone number or numbers that may be used by an applicant to receive additional information about the benefits of the plan or a statement where the telephone number or numbers are located in the disclosure form.
(D)For individual contracts, and small group plan contracts as defined in Article 3.1 (commencing with Section 1357), the disclosure form shall state where the health plan benefits and coverage matrix is located.
(E)Is printed in type no smaller than that used for the remainder of the disclosure form and is displayed prominently on the page.
(7)A statement as to when benefits shall cease in the event of nonpayment of the prepaid or periodic charge and the effect of nonpayment upon an enrollee who is hospitalized or undergoing treatment for an ongoing condition.
(8)To the extent that the plan permits a free choice of provider to its subscribers and enrollees, the statement shall disclose the nature and extent of choice permitted and the financial liability that is, or may be, incurred by the subscriber, enrollee, or a third party by reason of the exercise of that choice.
(9)A summary of the provisions required by subdivision (g) of Section 1373, if applicable.
(10)If the plan utilizes arbitration to settle disputes, a statement of that fact.
(11)A summary of, and a notice of the availability of, the process the plan uses to authorize, modify, or deny health care services under the benefits provided by the plan, pursuant to Sections 1363.5 and 1367.01.
(12)A description of any limitations on the patients choice of primary care physician, specialty care physician, or nonphysician health care practitioner, based on service area and limitations on the patients choice of acute care hospital care, subacute or transitional inpatient care, or skilled nursing facility.
(13)General authorization requirements for referral by a primary care physician to a specialty care physician or a nonphysician health care practitioner.
(14)Conditions and procedures for disenrollment.
(15)A description as to how an enrollee may request continuity of care as required by Section 1373.96 and request a second opinion pursuant to Section 1383.15.
(16)Information concerning the right of an enrollee to request an independent review in accordance with Article 5.55 (commencing with Section 1374.30).
(17)A notice as required by Section 1364.5.
(b)(1)As of July 1, 1999, the director shall require each plan offering a contract to an individual or small group to provide with the disclosure form for individual and small group plan contracts a uniform health plan benefits and coverage matrix containing the plans major provisions in order to facilitate comparisons between plan contracts. The uniform matrix shall include the following category descriptions together with the corresponding copayments and limitations in the following sequence:
(A)Deductibles.
(B)Lifetime maximums.
(C)Professional services.
(D)Outpatient services.
(E)Hospitalization services.
(F)Emergency health coverage.
(G)Ambulance services.
(H)Prescription drug coverage.
(I)Durable medical equipment.
(J)Mental health services.
(K)Chemical dependency services.
(L)Home health services.
(M)Other.
(2)The following statement shall be placed at the top of the matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(3)(A)A health care service plan contract subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15), shall satisfy the requirements of this subdivision by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) and any rules or regulations issued thereunder. A health care service plan that issues the uniform summary of benefits referenced in this paragraph shall do both of the following:
(i)Ensure that all applicable benefit disclosure requirements specified in this chapter and in Title 28 of the California Code of Regulations are met in other health plan documents provided to enrollees under the provisions of this chapter.
(ii)Consistent with applicable law, advise applicants and enrollees, in a prominent place in the plan documents referenced in subdivision (a), that enrollees are not financially responsible in payment of emergency care services, in any amount that the health care service plan is obligated to pay, beyond the enrollees copayments, coinsurance, and deductibles as provided in the enrollees health care service plan contract.
(B)Commencing October 1, 2016, the uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than July 1, 2016, the department shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(C)Subdivision (c) shall not apply to a health care service plan contract subject to subparagraph (A).
(c)Nothing in this section shall prevent a plan from using appropriate footnotes or disclaimers to reasonably and fairly describe coverage arrangements in order to clarify any part of the matrix that may be unclear.
(d)All plans, solicitors, and representatives of a plan shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide the individual with a properly completed disclosure form, as prescribed by the director pursuant to this section for each plan so examined or sold.
(e)In the case of group contracts, the completed disclosure form and evidence of coverage shall be presented to the contractholder upon delivery of the completed health care service plan agreement.
(f)Group contractholders shall disseminate copies of the completed disclosure form to all persons eligible to be a subscriber under the group contract at the time those persons are offered the plan. If the individual group members are offered a choice of plans, separate disclosure forms shall be supplied for each plan available. Each group contractholder shall also disseminate or cause to be disseminated copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(g)In the case of conflicts between the group contract and the evidence of coverage, the provisions of the evidence of coverage shall be binding upon the plan notwithstanding any provisions in the group contract that may be less favorable to subscribers or enrollees.
(h)In addition to the other disclosures required by this section, every health care service plan and any agent or employee of the plan shall, when presenting a plan for examination or sale to any individual purchaser or the representative of a group consisting of 25 or fewer individuals, disclose in writing the ratio of premium costs to health services paid for plan contracts with individuals and with groups of the same or similar size for the plans preceding fiscal year. A plan may report that information by geographic area, provided the plan identifies the geographic area and reports information applicable to that geographic area.
(i)Subdivision (b) shall not apply to any coverage provided by a plan for the Medi-Cal program or the Medicare Program pursuant to Title XVIII and Title XIX of the federal Social Security Act.
SEC. 2.Section 10603 of the Insurance Code, as amended by Section 8 of Chapter 1 of the First Extraordinary Session of the Statutes of 2013, is amended to read:10603.(a)(1)On or before April 1, 1975, the commissioner shall promulgate a standard supplemental disclosure form for all disability insurance policies. Upon the appropriate disclosure form as prescribed by the commissioner, each insurer shall provide, in easily understood language and in a uniform, clearly organized manner, as prescribed and required by the commissioner, the summary information about each disability insurance policy offered by the insurer as the commissioner finds is necessary to provide for full and fair disclosure of the provisions of the policy.
(2)On and after January 1, 2014, a disability insurer offering health insurance coverage subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) shall satisfy the requirements of this section and the implementing regulations by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act and any rules or regulations issued thereunder. An insurer that issues the federal uniform summary of benefits referenced in this paragraph shall ensure that all applicable disclosures required in this chapter and its implementing regulations are met in other documents provided to policyholders and insureds. An insurer subject to this paragraph shall provide the uniform summary of benefits and coverage to the commissioner together with the corresponding health insurance policy pursuant to Section 10290.
(3)Commencing October 1, 2016, the uniform summary of benefits and coverage referenced in this subdivision shall constitute a vital document for the purposes of Section 10133.8. Not later than July 1, 2016, the commissioner shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the commissioner shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the commissioner, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(b)Nothing in this section shall preclude the disclosure form from being included with the evidence of coverage or certificate of coverage or policy.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(a)The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may require, so as to afford the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan in readily understood language and in a clearly organized manner. The director may require that the materials be presented in a reasonably uniform manner so as to facilitate comparisons between plan contracts of the same or other types of plans. Nothing contained in this chapter shall preclude the director from permitting the disclosure form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following information, in concise and specific terms, relative to the plan, together with additional information as may be required by the director, in connection with the plan or plan contract:
(1)The principal benefits and coverage of the plan, including coverage for acute care and subacute care.
(2)The exceptions, reductions, and limitations that apply to the plan.
(3)The full premium cost of the plan.
(4)Any copayment, coinsurance, or deductible requirements that may be incurred by the member or the members family in obtaining coverage under the plan.
(5)The terms under which the plan may be renewed by the plan member, including any reservation by the plan of any right to change premiums.
(6)A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:
(A)(i)States that the evidence of coverage discloses the terms and conditions of coverage.
(ii)States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.
(B)Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.
(C)Includes the plans telephone number or numbers that may be used by an applicant to receive additional information about the benefits of the plan or a statement where the telephone number or numbers are located in the disclosure form.
(D)For individual contracts, and small group plan contracts as defined in Article 3.1 (commencing with Section 1357), the disclosure form shall state where the health plan benefits and coverage matrix is located.
(E)Is printed in type no smaller than that used for the remainder of the disclosure form and is displayed prominently on the page.
(7)A statement as to when benefits shall cease in the event of nonpayment of the prepaid or periodic charge and the effect of nonpayment upon an enrollee who is hospitalized or undergoing treatment for an ongoing condition.
(8)To the extent that the plan permits a free choice of provider to its subscribers and enrollees, the statement shall disclose the nature and extent of choice permitted and the financial liability that is, or may be, incurred by the subscriber, enrollee, or a third party by reason of the exercise of that choice.
(9)A summary of the provisions required by subdivision (g) of Section 1373, if applicable.
(10)If the plan utilizes arbitration to settle disputes, a statement of that fact.
(11)A summary of, and a notice of the availability of, the process the plan uses to authorize, modify, or deny health care services under the benefits provided by the plan, pursuant to Sections 1363.5 and 1367.01.
(12)A description of any limitations on the patients choice of primary care physician, specialty care physician, or nonphysician health care practitioner, based on service area and limitations on the patients choice of acute care hospital care, subacute or transitional inpatient care, or skilled nursing facility.
(13)General authorization requirements for referral by a primary care physician to a specialty care physician or a nonphysician health care practitioner.
(14)Conditions and procedures for disenrollment.
(15)A description as to how an enrollee may request continuity of care as required by Section 1373.96 and request a second opinion pursuant to Section 1383.15.
(16)Information concerning the right of an enrollee to request an independent review in accordance with Article 5.55 (commencing with Section 1374.30).
(17)A notice as required by Section 1364.5.
(b)(1)As of July 1, 1999, the director shall require each plan offering a contract to an individual or small group to provide with the disclosure form for individual and small group plan contracts a uniform health plan benefits and coverage matrix containing the plans major provisions in order to facilitate comparisons between plan contracts. The uniform matrix shall include the following category descriptions together with the corresponding copayments and limitations in the following sequence:
(A)Deductibles.
(B)Lifetime maximums.
(C)Professional services.
(D)Outpatient services.
(E)Hospitalization services.
(F)Emergency health coverage.
(G)Ambulance services.
(H)Prescription drug coverage.
(I)Durable medical equipment.
(J)Mental health services.
(K)Chemical dependency services.
(L)Home health services.
(M)Other.
(2)The following statement shall be placed at the top of the matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(3)(A)A health care service plan contract subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15), shall satisfy the requirements of this subdivision by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) and any rules or regulations issued thereunder. A health care service plan that issues the uniform summary of benefits referenced in this paragraph shall do both of the following:
(i)Ensure that all applicable benefit disclosure requirements specified in this chapter and in Title 28 of the California Code of Regulations are met in other health plan documents provided to enrollees under the provisions of this chapter.
(ii)Consistent with applicable law, advise applicants and enrollees, in a prominent place in the plan documents referenced in subdivision (a), that enrollees are not financially responsible in payment of emergency care services, in any amount that the health care service plan is obligated to pay, beyond the enrollees copayments, coinsurance, and deductibles as provided in the enrollees health care service plan contract.
(B)Commencing July 1, October 1, 2016, the uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than July 1, 2016, the department shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(C)Subdivision (c) shall not apply to a health care service plan contract subject to subparagraph (A).
(c)Nothing in this section shall prevent a plan from using appropriate footnotes or disclaimers to reasonably and fairly describe coverage arrangements in order to clarify any part of the matrix that may be unclear.
(d)All plans, solicitors, and representatives of a plan shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide the individual with a properly completed disclosure form, as prescribed by the director pursuant to this section for each plan so examined or sold.
(e)In the case of group contracts, the completed disclosure form and evidence of coverage shall be presented to the contractholder upon delivery of the completed health care service plan agreement.
(f)Group contractholders shall disseminate copies of the completed disclosure form to all persons eligible to be a subscriber under the group contract at the time those persons are offered the plan. If the individual group members are offered a choice of plans, separate disclosure forms shall be supplied for each plan available. Each group contractholder shall also disseminate or cause to be disseminated copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(g)In the case of conflicts between the group contract and the evidence of coverage, the provisions of the evidence of coverage shall be binding upon the plan notwithstanding any provisions in the group contract that may be less favorable to subscribers or enrollees.
(h)In addition to the other disclosures required by this section, every health care service plan and any agent or employee of the plan shall, when presenting a plan for examination or sale to any individual purchaser or the representative of a group consisting of 25 or fewer individuals, disclose in writing the ratio of premium costs to health services paid for plan contracts with individuals and with groups of the same or similar size for the plans preceding fiscal year. A plan may report that information by geographic area, provided the plan identifies the geographic area and reports information applicable to that geographic area.
(i)Subdivision (b) shall not apply to any coverage provided by a plan for the Medi-Cal program or the Medicare Program pursuant to Title XVIII and Title XIX of the federal Social Security Act.
SEC. 2.Section 10603 of the Insurance Code, as amended by Section 8 of Chapter 1 of the First Extraordinary Session of the Statutes of 2013, is amended to read:10603.(a)(1)On or before April 1, 1975, the commissioner shall promulgate a standard supplemental disclosure form for all disability insurance policies. Upon the appropriate disclosure form as prescribed by the commissioner, each insurer shall provide, in easily understood language and in a uniform, clearly organized manner, as prescribed and required by the commissioner, the summary information about each disability insurance policy offered by the insurer as the commissioner finds is necessary to provide for full and fair disclosure of the provisions of the policy.
(2)On and after January 1, 2014, a disability insurer offering health insurance coverage subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) shall satisfy the requirements of this section and the implementing regulations by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act and any rules or regulations issued thereunder. An insurer that issues the federal uniform summary of benefits referenced in this paragraph shall ensure that all applicable disclosures required in this chapter and its implementing regulations are met in other documents provided to policyholders and insureds. An insurer subject to this paragraph shall provide the uniform summary of benefits and coverage to the commissioner together with the corresponding health insurance policy pursuant to Section 10290.
(3)Commencing July 1, October 1, 2016, the uniform summary of benefits and coverage referenced in this subdivision shall constitute a vital document for the purposes of Section 10133.8. Not later than July 1, 2016, the commissioner shall develop written translations of the template uniform summary of benefits and coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department commissioner shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, commissioner, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(b)Nothing in this section shall preclude the disclosure form from being included with the evidence of coverage or certificate of coverage or policy.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(a)The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may require, so as to afford the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan in readily understood language and in a clearly organized manner. The director may require that the materials be presented in a reasonably uniform manner so as to facilitate comparisons between plan contracts of the same or other types of plans. Nothing contained in this chapter shall preclude the director from permitting the disclosure form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following information, in concise and specific terms, relative to the plan, together with additional information as may be required by the director, in connection with the plan or plan contract:
(1)The principal benefits and coverage of the plan, including coverage for acute care and subacute care.
(2)The exceptions, reductions, and limitations that apply to the plan.
(3)The full premium cost of the plan.
(4)Any copayment, coinsurance, or deductible requirements that may be incurred by the member or the members family in obtaining coverage under the plan.
(5)The terms under which the plan may be renewed by the plan member, including any reservation by the plan of any right to change premiums.
(6)A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:
(A)(i)States that the evidence of coverage discloses the terms and conditions of coverage.
(ii)States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.
(B)Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.
(C)Includes the plans telephone number or numbers that may be used by an applicant to receive additional information about the benefits of the plan or a statement where the telephone number or numbers are located in the disclosure form.
(D)For individual contracts, and small group plan contracts as defined in Article 3.1 (commencing with Section 1357), the disclosure form shall state where the health plan benefits and coverage matrix is located.
(E)Is printed in type no smaller than that used for the remainder of the disclosure form and is displayed prominently on the page.
(7)A statement as to when benefits shall cease in the event of nonpayment of the prepaid or periodic charge and the effect of nonpayment upon an enrollee who is hospitalized or undergoing treatment for an ongoing condition.
(8)To the extent that the plan permits a free choice of provider to its subscribers and enrollees, the statement shall disclose the nature and extent of choice permitted and the financial liability that is, or may be, incurred by the subscriber, enrollee, or a third party by reason of the exercise of that choice.
(9)A summary of the provisions required by subdivision (g) of Section 1373, if applicable.
(10)If the plan utilizes arbitration to settle disputes, a statement of that fact.
(11)A summary of, and a notice of the availability of, the process the plan uses to authorize, modify, or deny health care services under the benefits provided by the plan, pursuant to Sections 1363.5 and 1367.01.
(12)A description of any limitations on the patients choice of primary care physician, specialty care physician, or nonphysician health care practitioner, based on service area and limitations on the patients choice of acute care hospital care, subacute or transitional inpatient care, or skilled nursing facility.
(13)General authorization requirements for referral by a primary care physician to a specialty care physician or a nonphysician health care practitioner.
(14)Conditions and procedures for disenrollment.
(15)A description as to how an enrollee may request continuity of care as required by Section 1373.96 and request a second opinion pursuant to Section 1383.15.
(16)Information concerning the right of an enrollee to request an independent review in accordance with Article 5.55 (commencing with Section 1374.30).
(17)A notice as required by Section 1364.5.
(b)(1)As of July 1, 1999, the director shall require each plan offering a contract to an individual or small group to provide with the disclosure form for individual and small group plan contracts a uniform health plan benefits and coverage matrix containing the plans major provisions in order to facilitate comparisons between plan contracts. The uniform matrix shall include the following category descriptions together with the corresponding copayments and limitations in the following sequence:
(A)Deductibles.
(B)Lifetime maximums.
(C)Professional services.
(D)Outpatient services.
(E)Hospitalization services.
(F)Emergency health coverage.
(G)Ambulance services.
(H)Prescription drug coverage.
(I)Durable medical equipment.
(J)Mental health services.
(K)Chemical dependency services.
(L)Home health services.
(M)Other.
(2)The following statement shall be placed at the top of the matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(3)(A)A health care service plan contract subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15), shall satisfy the requirements of this subdivision by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) and any rules or regulations issued thereunder. A health care service plan that issues the uniform summary of benefits referenced in this paragraph shall do both of the following:
(i)Ensure that all applicable benefit disclosure requirements specified in this chapter and in Title 28 of the California Code of Regulations are met in other health plan documents provided to enrollees under the provisions of this chapter.
(ii)Consistent with applicable law, advise applicants and enrollees, in a prominent place in the plan documents referenced in subdivision (a), that enrollees are not financially responsible in payment of emergency care services, in any amount that the health care service plan is obligated to pay, beyond the enrollees copayments, coinsurance, and deductibles as provided in the enrollees health care service plan contract.
(B)The Commencing July 1, 2016, the uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than January July 1, 2016, the department shall make available on its Internet Web site develop written translations of the template uniform summary of benefits and coverage. In developing the translations, the department shall consider subdivision (c) of Section 1367.04. coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(C)Subdivision (c) shall not apply to a health care service plan contract subject to subparagraph (A).
(c)Nothing in this section shall prevent a plan from using appropriate footnotes or disclaimers to reasonably and fairly describe coverage arrangements in order to clarify any part of the matrix that may be unclear.
(d)All plans, solicitors, and representatives of a plan shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide the individual with a properly completed disclosure form, as prescribed by the director pursuant to this section for each plan so examined or sold.
(e)In the case of group contracts, the completed disclosure form and evidence of coverage shall be presented to the contractholder upon delivery of the completed health care service plan agreement.
(f)Group contractholders shall disseminate copies of the completed disclosure form to all persons eligible to be a subscriber under the group contract at the time those persons are offered the plan. If the individual group members are offered a choice of plans, separate disclosure forms shall be supplied for each plan available. Each group contractholder shall also disseminate or cause to be disseminated copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(g)In the case of conflicts between the group contract and the evidence of coverage, the provisions of the evidence of coverage shall be binding upon the plan notwithstanding any provisions in the group contract that may be less favorable to subscribers or enrollees.
(h)In addition to the other disclosures required by this section, every health care service plan and any agent or employee of the plan shall, when presenting a plan for examination or sale to any individual purchaser or the representative of a group consisting of 25 or fewer individuals, disclose in writing the ratio of premium costs to health services paid for plan contracts with individuals and with groups of the same or similar size for the plans preceding fiscal year. A plan may report that information by geographic area, provided the plan identifies the geographic area and reports information applicable to that geographic area.
(i)Subdivision (b) shall not apply to any coverage provided by a plan for the Medi-Cal program or the Medicare Program pursuant to Title XVIII and Title XIX of the federal Social Security Act.
SEC. 2.Section 10603 of the Insurance Code, as amended by Section 8 of Chapter 1 of the First Extraordinary Session of the Statutes of 2013, is amended to read:10603.(a)(1)On or before April 1, 1975, the commissioner shall promulgate a standard supplemental disclosure form for all disability insurance policies. Upon the appropriate disclosure form as prescribed by the commissioner, each insurer shall provide, in easily understood language and in a uniform, clearly organized manner, as prescribed and required by the commissioner, the summary information about each disability insurance policy offered by the insurer as the commissioner finds is necessary to provide for full and fair disclosure of the provisions of the policy.
(2)On and after January 1, 2014, a disability insurer offering health insurance coverage subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) shall satisfy the requirements of this section and the implementing regulations by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act and any rules or regulations issued thereunder. An insurer that issues the federal uniform summary of benefits referenced in this paragraph shall ensure that all applicable disclosures required in this chapter and its implementing regulations are met in other documents provided to policyholders and insureds. An insurer subject to this paragraph shall provide the uniform summary of benefits and coverage to the commissioner together with the corresponding health insurance policy pursuant to Section 10290.
(3)The Commencing July 1, 2016, theuniform summary of benefits and coverage referenced in this subdivision shall constitute a vital document for the purposes of Section 10133.8. Not later than January July 1, 2016, the commissioner shall make available on its Internet Web site develop written translations of the template uniform summary of benefits and coverage. In developing the translations, the commissioner shall consider subdivision (c) of Section 10133.8. coverage for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services pursuant to Section 14029.91 of the Welfare and Institutions Code, except for any language group for which the United States Department of Labor has already prepared a written translation. Not later than July 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage developed by the department, and written translations prepared by the United States Department of Labor, if available, for any language group to which this subparagraph applies.
(b)Nothing in this section shall preclude the disclosure form from being included with the evidence of coverage or certificate of coverage or policy.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(a)The director shall require the use by each plan of disclosure forms or materials containing information regarding the benefits, services, and terms of the plan contract as the director may require, so as to afford the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan in readily understood language and in a clearly organized manner. The director may require that the materials be presented in a reasonably uniform manner so as to facilitate comparisons between plan contracts of the same or other types of plans. Nothing contained in this chapter shall preclude the director from permitting the disclosure form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following information, in concise and specific terms, relative to the plan, together with additional information as may be required by the director, in connection with the plan or plan contract:
(1)The principal benefits and coverage of the plan, including coverage for acute care and subacute care.
(2)The exceptions, reductions, and limitations that apply to the plan.
(3)The full premium cost of the plan.
(4)Any copayment, coinsurance, or deductible requirements that may be incurred by the member or the members family in obtaining coverage under the plan.
(5)The terms under which the plan may be renewed by the plan member, including any reservation by the plan of any right to change premiums.
(6)A statement that the disclosure form is a summary only, and that the plan contract itself should be consulted to determine governing contractual provisions. The first page of the disclosure form shall contain a notice that conforms with all of the following conditions:
(A)(i)States that the evidence of coverage discloses the terms and conditions of coverage.
(ii)States, with respect to individual plan contracts, small group plan contracts, and any other group plan contracts for which health care services are not negotiated, that the applicant has a right to view the evidence of coverage prior to enrollment, and, if the evidence of coverage is not combined with the disclosure form, the notice shall specify where the evidence of coverage can be obtained prior to enrollment.
(B)Includes a statement that the disclosure and the evidence of coverage should be read completely and carefully and that individuals with special health care needs should read carefully those sections that apply to them.
(C)Includes the plans telephone number or numbers that may be used by an applicant to receive additional information about the benefits of the plan or a statement where the telephone number or numbers are located in the disclosure form.
(D)For individual contracts, and small group plan contracts as defined in Article 3.1 (commencing with Section 1357), the disclosure form shall state where the health plan benefits and coverage matrix is located.
(E)Is printed in type no smaller than that used for the remainder of the disclosure form and is displayed prominently on the page.
(7)A statement as to when benefits shall cease in the event of nonpayment of the prepaid or periodic charge and the effect of nonpayment upon an enrollee who is hospitalized or undergoing treatment for an ongoing condition.
(8)To the extent that the plan permits a free choice of provider to its subscribers and enrollees, the statement shall disclose the nature and extent of choice permitted and the financial liability that is, or may be, incurred by the subscriber, enrollee, or a third party by reason of the exercise of that choice.
(9)A summary of the provisions required by subdivision (g) of Section 1373, if applicable.
(10)If the plan utilizes arbitration to settle disputes, a statement of that fact.
(11)A summary of, and a notice of the availability of, the process the plan uses to authorize, modify, or deny health care services under the benefits provided by the plan, pursuant to Sections 1363.5 and 1367.01.
(12)A description of any limitations on the patients choice of primary care physician, specialty care physician, or nonphysician health care practitioner, based on service area and limitations on the patients choice of acute care hospital care, subacute or transitional inpatient care, or skilled nursing facility.
(13)General authorization requirements for referral by a primary care physician to a specialty care physician or a nonphysician health care practitioner.
(14)Conditions and procedures for disenrollment.
(15)A description as to how an enrollee may request continuity of care as required by Section 1373.96 and request a second opinion pursuant to Section 1383.15.
(16)Information concerning the right of an enrollee to request an independent review in accordance with Article 5.55 (commencing with Section 1374.30).
(17)A notice as required by Section 1364.5.
(b)(1)As of July 1, 1999, the director shall require each plan offering a contract to an individual or small group to provide with the disclosure form for individual and small group plan contracts a uniform health plan benefits and coverage matrix containing the plans major provisions in order to facilitate comparisons between plan contracts. The uniform matrix shall include the following category descriptions together with the corresponding copayments and limitations in the following sequence:
(A)Deductibles.
(B)Lifetime maximums.
(C)Professional services.
(D)Outpatient services.
(E)Hospitalization services.
(F)Emergency health coverage.
(G)Ambulance services.
(H)Prescription drug coverage.
(I)Durable medical equipment.
(J)Mental health services.
(K)Chemical dependency services.
(L)Home health services.
(M)Other.
(2)The following statement shall be placed at the top of the matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(3)(A)A health care service plan contract subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15), shall satisfy the requirements of this subdivision by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) and any rules or regulations issued thereunder. A health care service plan that issues the uniform summary of benefits referenced in this paragraph shall do both of the following:
(i)Ensure that all applicable benefit disclosure requirements specified in this chapter and in Title 28 of the California Code of Regulations are met in other health plan documents provided to enrollees under the provisions of this chapter.
(ii)Consistent with applicable law, advise applicants and enrollees, in a prominent place in the plan documents referenced in subdivision (a), that enrollees are not financially responsible in payment of emergency care services, in any amount that the health care service plan is obligated to pay, beyond the enrollees copayments, coinsurance, and deductibles as provided in the enrollees health care service plan contract.
(B)The uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than January 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage. In developing the translations, the department shall consider subdivision (c) of Section 1367.04.
(B)
(C)Subdivision (c) shall not apply to a health care service plan contract subject to subparagraph (A).
(c)Nothing in this section shall prevent a plan from using appropriate footnotes or disclaimers to reasonably and fairly describe coverage arrangements in order to clarify any part of the matrix that may be unclear.
(d)All plans, solicitors, and representatives of a plan shall, when presenting any plan contract for examination or sale to an individual prospective plan member, provide the individual with a properly completed disclosure form, as prescribed by the director pursuant to this section for each plan so examined or sold.
(e)In the case of group contracts, the completed disclosure form and evidence of coverage shall be presented to the contractholder upon delivery of the completed health care service plan agreement.
(f)Group contractholders shall disseminate copies of the completed disclosure form to all persons eligible to be a subscriber under the group contract at the time those persons are offered the plan. If the individual group members are offered a choice of plans, separate disclosure forms shall be supplied for each plan available. Each group contractholder shall also disseminate or cause to be disseminated copies of the evidence of coverage to all applicants, upon request, prior to enrollment and to all subscribers enrolled under the group contract.
(g)In the case of conflicts between the group contract and the evidence of coverage, the provisions of the evidence of coverage shall be binding upon the plan notwithstanding any provisions in the group contract that may be less favorable to subscribers or enrollees.
(h)In addition to the other disclosures required by this section, every health care service plan and any agent or employee of the plan shall, when presenting a plan for examination or sale to any individual purchaser or the representative of a group consisting of 25 or fewer individuals, disclose in writing the ratio of premium costs to health services paid for plan contracts with individuals and with groups of the same or similar size for the plans preceding fiscal year. A plan may report that information by geographic area, provided the plan identifies the geographic area and reports information applicable to that geographic area.
(i)Subdivision (b) shall not apply to any coverage provided by a plan for the Medi-Cal program or the Medicare program pursuant to Title XVIII and Title XIX of the Social Security Act.
SEC. 2.Section 10603 of the Insurance Code, as amended by Section 8 of Chapter 1 of the 1st Extraordinary Session of the Statutes of 2013, is amended to read:10603.(a)(1)On or before April 1, 1975, the commissioner shall promulgate a standard supplemental disclosure form for all disability insurance policies. Upon the appropriate disclosure form as prescribed by the commissioner, each insurer shall provide, in easily understood language and in a uniform, clearly organized manner, as prescribed and required by the commissioner, the summary information about each disability insurance policy offered by the insurer as the commissioner finds is necessary to provide for full and fair disclosure of the provisions of the policy.
(2)On and after January 1, 2014, a disability insurer offering health insurance coverage subject to Section 2715 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-15) shall satisfy the requirements of this section and the implementing regulations by providing the uniform summary of benefits and coverage required under Section 2715 of the federal Public Health Service Act and any rules or regulations issued thereunder. An insurer that issues the federal uniform summary of benefits referenced in this paragraph shall ensure that all applicable disclosures required in this chapter and its implementing regulations are met in other documents provided to policyholders and insureds. An insurer subject to this paragraph shall provide the uniform summary of benefits and coverage to the commissioner together with the corresponding health insurance policy pursuant to Section 10290.
(3)The uniform summary of benefits and coverage referenced in this subdivision shall constitute a vital document for the purposes of Section 10133.8. Not later than January 1, 2016, the commissioner shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage. In developing the translations, the commissioner shall consider subdivision (c) of Section 10133.8.
(b)Nothing in this section shall preclude the disclosure form from being included with the evidence of coverage or certificate of coverage or policy.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
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Date
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Status
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| Jun 2, 2015 | In Assembly. Read first time. Held at Desk. |
| Oct 8, 2015 | Chaptered by Secretary of State. Chapter 655, Statutes of 2015. |
| Oct 8, 2015 | Approved by the Governor. |
| Sep 10, 2015 | Enrolled and presented to the Governor at 3:30 p.m. |
| Sep 4, 2015 | Assembly amendments concurred in. (Ayes 40. Noes 0.) Ordered to engrossing and enrolling. |
| Sep 4, 2015 | Assembly amendments concurred in. (Ayes 40. Noes 0. Page 388.) Ordered to engrossing and enrolling. |
| Sep 3, 2015 | Read third time. Passed. (Ayes 79. Noes 0. Page 2848.) Ordered to the Senate. |
| Sep 3, 2015 | Read third time. Passed. Ordered to the Senate. |
| Sep 3, 2015 | In Senate. Concurrence in Assembly amendments pending. |
| Aug 28, 2015 | Read second time. Ordered to third reading. |
| Aug 28, 2015 | From committee: Do pass. (Ayes 17. Noes 0.) (August 27). |
| Jul 15, 2015 | July 15 set for first hearing. Placed on APPR. suspense file. |
| Jul 6, 2015 | Read second time and amended. Re-referred to Com. on APPR. |
| Jul 2, 2015 | From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 18. Noes 0.) (June 30). |
| Jun 23, 2015 | From committee with author's amendments. Read second time and amended. Re-referred to Com. on HEALTH. |
| Jun 18, 2015 | Referred to Com. on HEALTH. |
| Feb 25, 2015 | Introduced. Read first time. To Com. on RLS. for assignment. To print. |
| Jun 1, 2015 | Read third time. Passed. (Ayes 40. Noes 0.) Ordered to the Assembly. |
| Jun 1, 2015 | Read third time. Passed. (Ayes 40. Noes 0. Page 1201.) Ordered to the Assembly. |
| May 28, 2015 | Read second time. Ordered to third reading. |
| May 28, 2015 | From committee: Do pass. (Ayes 7. Noes 0.) (May 28). |
| May 28, 2015 | From committee: Do pass. (Ayes 7. Noes 0. Page 1153.) (May 28). |
| May 23, 2015 | Set for hearing May 28. |
| May 4, 2015 | May 4 hearing: Placed on APPR. suspense file. |
| Apr 24, 2015 | Set for hearing May 4. |
| Apr 23, 2015 | From committee: Do pass and re-refer to Com. on APPR. (Ayes 8. Noes 0. Page 758.) (April 22). Re-referred to Com. on APPR. |
| Apr 7, 2015 | Set for hearing April 22. |
| Apr 6, 2015 | April 15 set for first hearing canceled at the request of author. |
| Mar 27, 2015 | Set for hearing April 15. |
| Mar 5, 2015 | Referred to Com. on HEALTH. |
| Feb 26, 2015 | From printer. May be acted upon on or after March 28. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Sep 4, 2015 | Unfinished Business SB388 Mitchell Concurrence | Senate Floor |
Passed |
|
| Sep 3, 2015 | SB 388 Mitchell Senate Third Reading By KIM | Assembly Floor |
Passed |
|
| Aug 27, 2015 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
|
| Jun 30, 2015 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
|
| Jun 1, 2015 | Senate 3rd Reading SB388 Mitchell | Senate Floor |
Passed |
|
| May 28, 2015 | Do pass | Senate Standing Committee on Appropriations |
Passed |
|
| May 4, 2015 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Apr 22, 2015 | Do pass, but first be re-referred to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| American Cancer Society-Cancer Action Network | ** Support | Sep 3, 2015 |
| American Federation Of State, County And Municipal Employees, Afl-Cio | ** Support | Sep 3, 2015 |
| Asian Law Alliance | ** Support | Sep 3, 2015 |
| Asian Resources Inc. | * Indeterminate | Apr 22, 2015 |
| California Council of the Service Employees International Union | ** Support | Sep 3, 2015 |
| California Immigrant Policy Center | ** Support | Sep 3, 2015 |
| California Pan-Ethnic Health Network | ** Support | Sep 3, 2015 |
| California Primary Care Association | * Indeterminate | Apr 22, 2015 |
| Community Health Councils | ** Support | Sep 3, 2015 |
| Consumers Union | ** Support | Sep 3, 2015 |
| Guam Communications Network | ** Support | Sep 3, 2015 |
| Having Our Say Coalition | ** Support | Sep 3, 2015 |
| Health Access California | * Support | May 4, 2015 |
| Latino Coalition for a Healthy California | ** Support | Sep 3, 2015 |
| National Health Law Program | ** Support | Sep 3, 2015 |
| National Immigration Law Center | * Support | May 4, 2015 |
| Planned Parenthood | ** Support | Sep 3, 2015 |
| SEIU-California | ** Support | Sep 3, 2015 |
| Southeast Asia Action Resource Center | ** Support | Sep 3, 2015 |
| Southeast Asia Resource Action Center | ** Support | Sep 3, 2015 |
| Western Center On Law And Poverty Inc. | ** Support | Sep 3, 2015 |
SB 388
Page 8
|
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 |
UNFINISHED BUSINESS
Bill No: SB 388
Amended: 7/6/15
SENATE HEALTH COMMITTEE: 8-0, 4/22/15
AYES: Hernandez, Nguyen, Mitchell, Monning, Nielsen, Pan, Roth, Wolk
NO VOTE RECORDED: Hall
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SENATE FLOOR: 40-0, 6/1/15
AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk
ASSEMBLY FLOOR: 79-0, 9/3/15 - See last page for vote
SUBJECT: Health care coverage: solicitation and enrollment
SOURCE: California Pan-Ethnic Health Network
DIGEST: This bill makes uniform summary of benefits and coverage (SBC) information which must be provided to consumers by health plans and insurers under the federal Affordable Care Act (ACA) and California law, a vital document, subject to specified translation requirements commencing October 1, 2016. This bill requires, not later than July 1, 2016, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI), to make available on their Internet Web sites written translations of the template of uniform SBC, and specifies the language groups which require translation.
Assembly
Amendments (1) delay implementation of the requirement that the
uniform SBC constitute a vital document to October 1, 2016; (2) delay
the date the departments must make available on their Internet Web
sites written translations of the template uniform SBC, as specified,
to not later than July 1, 2016; and (3) require the written
translations for all language groups identified by the State
Department of Health Care Services in all plan letters as of August
27, 2014, for translation services, as specified, except for any
language group for which the United States Department of Labor has
already prepared a written translation.
Existing law:
Requires the DMHC and CDI to develop and adopt regulations establishing standards and requirements to provide health plan enrollees and insureds with appropriate access to language assistance in obtaining health care services.
Requires DMHC and CDI to require every health plan, specialized health plan, health insurer and specialized health insurer to assess the linguistic needs of the enrollee or insured population, excluding Medi-Cal enrollees, and to provide for translation and interpretation for medical services, including translating vital documents in threshold languages based on the size of enrollment and the needs assessment, as specified.
Includes as vital documents to be translated:
Applications.
Consent forms.
Letters containing important information regarding eligibility and participation criteria.
Notices pertaining to the denial, reduction, modification, or termination of services and benefits, and the right to file a grievance or appeal.
Notices advising limited-English-proficient (LEP) persons of the availability of free language assistance and other outreach materials that are provided to enrollees.
Excludes as vital documents, explanation of benefits or similar claims processing information that are sent to enrollees or insureds, unless the documents require a response by the enrollee or insured.
Requires the translation of specified documents, including the uniform SBC, if a health plan or health insurer advertises or markets products in a non-English language that is not a threshold language or allows any other person or business to market or advertise on its behalf. This applies to health plan and health insurance products advertised or marketed in the individual and small group market.
Establishes multiple consumer disclosure requirements on health plans, including a requirement related to individual and small group products, for a uniform health plan benefits and coverage matrix containing the plan’s major provisions in order to facilitate comparisons between plan contracts. Establishes consumer disclosures on disability insurers offering health insurance coverage.
Requires under the ACA, health insurance issuers to provide uniform SBC information.
Permits, under state law, a health plan subject to the ACA uniform SBC to satisfy state requirements for a uniform health plan benefits and coverage matrix if all applicable benefit disclosure requirements are met in other health plan documents, and if applicants and enrollees are advised that enrollees are not financially responsible in the payment of emergency services, in any amount that the health plan is obligated to pay, beyond the enrollee’s copayments, coinsurance, and deductibles as provided in the enrollee’s health plan contract.
Requires on and after January 1, 2014, a disability insurer offering health insurance coverage subject to the ACA uniform SBC to ensure that all applicable disclosures are met in other documents provided to policyholders and insureds. Requires the uniform SBC to be provided to the Insurance Commissioner together with the corresponding health insurance policy information, as specified.
This
bill:
Makes, commencing October 1, 2016, the uniform SBC information required under the ACA and state law, a vital document, as specified.
Requires, not later than July 1, 2016, DMHC and CDI, to make available on their Internet Web sites written translations of the template of uniform SBC, for all language groups identified by the State Department of Health Care Services in all plan letters as of August 27, 2014, for translation services, as specified, except for any language group for which the United States Department of Labor has already prepared a written translation.
Requires not later than July 1, 2016, the departments to make available on its Internet Website written translations of the template uniform SBC developed by the departments, and written translations prepared by the United States Department of Labor, if available, for any language group, as specified.
Comments
Author’s statement. According to the author, the ACA requires health plans and insurers to provide consumers with an easy-to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. The ACA requires this information to be provided in a “culturally and linguistically appropriate manner.” Unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The federal rule states that the document should be translated into languages spoken by 10% or more of the population residing in a consumer’s county. By contrast, California law requires a “vital” document to be translated when a LEP population is a certain percent of the plan’s enrollment. SB 388 makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that Californians are informed about their health coverage options and have equal access to critical information about their healthcare.
California language access. California health plans are required to provide language assistance services, including translation and interpretation services, to LEP enrollees. The regulation became effective on January 1, 2009. The DMHC Division of Plan Surveys monitors compliance with the regulation in its routine medical survey process, which takes place at least every three years for each health plan. In addition, the DMHC tracks complaints filed with its Help Center to identify trends in compliance with the regulation. According to a report to the Legislature issued by DMHC for the January 2011-December 2012 period, DMHC completed 38 routine medical surveys during the reporting period. While deficiencies were cited, those deficiencies were corrected and to date there have been no serious concerns identified through medical surveys. Likewise, there have been few complaints to the DMHC Help Center. One action by the DMHC Office of Enforcement resulted in a $2,500 fine for failing to translate a vital document. Overall, the DMHC has not noted any trend toward non-compliance with the regulation. DMHC also makes available on its Web site threshold languages by health plan. For example Molina Health Care of California has the following threshold languages identified: English, Spanish, Vietnamese, Chinese, Russian, and Hmong.
Medi-Cal defines threshold language as a language that has been identified as the primary language of 3,000 beneficiaries or 5% of the beneficiary population, whichever is lower, in an identified geographic area. 13 distinct languages qualify as threshold languages, according to a May 2014 Medi-Cal statistical brief. Those languages are: Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian, and other Chinese. Spanish is the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49). Los Angeles has the greatest number of threshold languages (12) of any county.
ACA SBC. Amendments to the Public Health Service Act, made by the ACA direct the federal Departments of Labor, Health and Human Services, and the Treasury to develop standards for use by a group health plan (which includes both insured and self-insured plans) and a health insurance issuer offering group or individual health insurance coverage in compiling and providing a SBC that ‘‘accurately describes the benefits and coverage under the applicable plan or coverage,’’ and also calls for the ‘‘development of standards for the definitions of terms used in health insurance coverage.’’ The ACA requires group health plans and health insurance issuers offering group and individual coverage to provide the SBC and uniform glossary in a culturally and linguistically appropriate manner.
The regulations indicate a group health plan and a health insurance issuer offering group or individual health insurance coverage are considered to provide relevant notices in a culturally and linguistically appropriate manner if the plan or issuer provides oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language. Additionally, the plan or issuer must provide, upon request, a notice in any applicable non-English language; and the plan or issuer must include in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the plan or issuer. The regulations require these plans and issuers to make certain accommodations for notices sent to an address in a county meeting a threshold percentage of people who are literate only in the same non-English language. This threshold percentage is set at 10% or more of the population residing in the claimant’s county, as determined based on American Community Survey data published by the United States Census Bureau. 25 California counties meet the 10% threshold requirement to translate SBCs in Spanish. Those counties are: Colusa, Fresno, Glenn, Imperial, Kern, Kings, Los Angeles, Madera, Merced, Monterey, Napa, Orange, Riverside, San Benito, San Bernardino, San Diego, San Joaquin, San Mateo, Santa Barbara, Santa Cruz, Stanislaus, Sutter, Tulare, Ventura and Yolo. One county (San Francisco) meets the 10% threshold requirement to translate SBCs in Chinese.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Assembly Appropriations Committee:
Estimated one-time costs of $350,000 (Managed Care Fund) to DMHC for translation, policy development, and technical assistance to plans regarding issues related to using the templates.
Similar one-time costs for similar activities at CDI, as well as $60,000 ongoing to ensure compliance (Insurance Fund).
California Pan-Ethnic Health Network (source)
American Cancer Society-Cancer Action Network
American Federation of State, County and Municipal Employees, AFL-CIO
Asian Law Alliance
California Council of the Service Employees International Union
California Immigrant Policy Center
California State Council of the Service Employees International Union
Community Health Councils
Consumers Union
Guam Communications Network
Having Our Say Coalition
Latino Coalition for a Healthy California
National Health Law Program
Planned Parenthood
SEIU California
Southeast Asia Action Resource Center
Western Center on Law & Poverty
None received
ARGUMENTS IN SUPPORT: California Pan-Ethnic Health Network (CPEHN), this bill’s sponsor, writes this bill is necessary because California residents speak over 100 different languages and more than 40% speak a language other than English at home. Although federal law requires the SBC to be provided in a culturally and linguistically appropriate manner, the federal definition differs from California’s long-standing language access requirements. The federal standard for California counties requires translation into two languages, Spanish and Chinese (only in San Francisco). CPEHN writes, in California there are 10 languages that meet language access thresholds under California law, with Spanish, Chinese, and Vietnamese being the most commonly required language for translations. CPEHN informally surveyed Covered California Qualified Health Plans (QHPs) and found only seven QHPs are providing SBCs in Spanish upon request. Only six QHPs are providing SBCs in Chinese upon request even though seven are required to and only three are providing SBCs in Vietnamese upon request even though five are required to and none are providing SBCs in Korean even though one is required. CPEHN also states that most QHPs are using the federal SBC template which only includes taglines for where to access language assistance services in the four federally required non-English languages: Spanish, Chinese, Navajo, and Tagalog. This list is not representative of California’s demographics.
ASSEMBLY FLOOR: 79-0, 9/3/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Beth Gaines
Prepared by: Teri Boughton / HEALTH /
9/3/15 18:23:02
**** END ****
SB 388
Page 2
SENATE THIRD READING
SB 388
(Mitchell)
As Amended July 6, 2015
Majority vote
SENATE VOTE: 40-0
Committee |
Votes |
Ayes |
Noes |
Health |
18-0 |
Bonta, Maienschein, Bonilla, Burke, Chiu, Gomez, Gonzalez, Roger Hernández, Lackey, McCarty, Nazarian, Patterson, Ridley-Thomas, Rodriguez, Steinorth, Thurmond, Waldron, Wood |
|
Appropriations |
17-0 |
Gomez, Bigelow, Bloom, Bonta, Calderon, Chang, Nazarian, Eggman, Gallagher, Eduardo Garcia, Holden, Jones, Quirk, Rendon, Wagner, Weber, Wood |
|
SUMMARY: Makes the uniform summary of benefits and coverage (SBC) document, provided by health care service plans (plans) and health insurers (insurers) to consumers, a vital document subject to specified language translation requirements. Specifically, this bill:
Makes, commencing October 1, 2016, the uniform SBC a vital document for the purposes of language translation requirements for plans and insurers.
Requires, not later than July 1, 2016, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to develop written translations of SBC templates in all language groups identified by the Department of Health Care Services as Medi-Cal threshold languages, except for any language group for which the United States Department of Labor (DOL) has already prepared a written translation.
Requires DMHC and CDI, not later than July 1, 2016, to make the written translations of the template uniform SBC available on their websites, as well as any written translations prepared by the DOL, if available.
FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill would result in:
Estimated one-time costs of $350,000 (Managed Care Fund) to DMHC for translation, policy development, and technical assistance to plans regarding issues related to using the templates.
Similar one-time costs for similar activities at CDI, as well as $60,000 ongoing to ensure compliance (Insurance Fund).
COMMENTS: According to the author, the Patient Protection and Affordable Care Act (ACA) requires plans and insurers to provide consumers with an easy to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. The author states that the ACA requires this information to be provided in a culturally and linguistically appropriate manner, but, unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The author states that this bill makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that more Californians are informed about their health coverage options and have equal access to critical information about their health care.
The ACA sets forth specified disclosure requirements to help consumers better understand their health coverage, as well as to gain a better understanding of other coverage options and an ability to compare plans. One such disclosure requirement is for plans and insurers to provide SBCs, and a uniform glossary of common terms used in health coverage and medical care, to consumers so that they may obtain summarized information about plan benefits and coverage, and evaluate and compare their health coverage options.
Under federal language access rules, plans and insurers must translate the SBC and uniform glossary if 10% or more of the population in a county is literate in the same non-English language. Based on these rules, two languages in California would meet the thresholds for written translations: Spanish and Chinese.
California law requires vital documents to be translated when a limited English proficiency (LEP) enrollee represents a certain percentage of the plan's enrollment. Specifically, plans and insurers must assess the linguistic needs of the enrollee or insured population, and translate vital documents in threshold languages based on the sizes of enrollment and the needs assessment. According to DMHC, 10 languages qualify as meeting language access thresholds under California's translation requirements for vital documents. Those languages are Spanish, Vietnamese, Chinese, Korean, Tagalog, Russian, Armenian, Khmer, Arabic, and Hmong.
This bill requires DMHC and CDI to develop and post templates of the SBC translated into Medi-Cal threshold languages which in addition to English include Arabic, Armenian, Cambodian, Chinese, Farsi, Hmong, Korean, Russian, Spanish, Tagalog, and Vietnamese.
The California Pan-Ethnic Health Network, the sponsor of this bill, and other supporters state that this bill will ensure LEP consumers can access vital information included in the SBCs by expanding the languages into which it will be translated; ensure health plans are meeting their language access obligations; improve access to language assistance services; and help ensure Californians can access a standardized glossary of insurance terms. Supporters state that the SBC forms are important tools for consumers, and help them make sense of health care coverage, and that consumers' new right to the SBC under the ACA means they finally have a uniform document that can be used to reliably compare plans and policies, and obtain important coverage information.
There is no known opposition to this bill.
Analysis Prepared by: Kelly Green / HEALTH / (916) 319-2097 FN: 0001664
Date of Hearing: July 15, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
SB 388
(Mitchell) – As Amended July 6, 2015
Policy Committee: |
Health |
Vote: |
18 - 0 |
|
|
|
|
|
|
|
|
Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill designates the uniform summary of benefits and coverage (SBC) information that must be provided to consumers by health plans and health insurers as a vital document, thereby requiring it to be provided in certain languages other than English.
FISCAL EFFECT:
Estimated one-time costs of $350,000 (Managed Care Fund) to the Department of Managed Health Care for translation, policy development, and technical assistance to plans regarding issues related to using the templates.
Similar one-time costs for similar activities at the Department of Insurance, as well as $60,000 ongoing to ensure compliance (Insurance Fund).
COMMENTS:
Purpose. According to the author, the Patient Protection and Affordable Care Act (ACA) requires plans and insurers to provide consumers with an easy to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage, such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. Unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The author states that this bill makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that more Californians are informed about their health coverage options and have equal access to critical information about their health care.
Background. A range of federal and state laws and regulations apply to language access for consumer documents produced by a health plan or insurer documents. Federal law requires carriers to provide enrollees with a uniform SBC, which provides information about covered services, cost sharing, and other key information about the enrollee’s health care coverage. Federal law requires the uniform SBC to be translated into non-English languages when 10 percent or more of the population of the enrollees' county speaks that language. Under federal law, only Spanish and Chinese meet the thresholds requiring translation. State law requires vital documents to be translated into ten languages (Spanish, Vietnamese, Chinese, Korean, Tagalog, Russian, Armenian, Khmer, Arabic, and Hmong).
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
SB 388
Page 5
Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB 388
(Mitchell) – As Amended June 23, 2015
SENATE VOTE: 40-0
SUBJECT: Health care coverage: solicitation and enrollment.
SUMMARY: Makes the uniform summary of benefits and coverage (SBC) document, provided by health care service plans (plans) and health insurers (insurers) to consumers, a vital document subject to specified language translation requirements. Specifically, this bill:
Makes, commencing July 1, 2016, the uniform SBC a vital document for the purposes of language translation requirements for plans and insurers.
Requires, not later than July 1, 2016, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to develop written translations of SBC templates in all language groups identified by the Department of Health Care Services (DHCS) in all plan letters as of August 27, 2014 (commonly referred to as Medi-Cal threshold languages), except for any language group for which the United States Department of Labor (DOL) has already prepared a written translation.
Requires DMHC and CDI, not later than July 1, 2016, to make the written translations of the template uniform SBC available on their websites, as well as any written translations prepared by the DOL, if available.
EXISTING LAW:
Requires, under the Patient Protection and Affordable Care Act (ACA), federal agencies, as specified, to develop standards for an SBC that accurately describes the benefits and coverage under an applicable plan or coverage. Requires health plans and insurers to provide the uniform SBC to enrollees.
Requires DMHC and CDI to develop and adopt regulations establishing standards and requirements to provide enrollees and insureds with appropriate access to language assistance in obtaining health care services.
Requires DMHC and CDI to require plans, and insurers to assess the linguistic needs of the enrollee or insured population, excluding Medi-Cal enrollees, and to provide for translation and interpretation for medical services, as indicated, including translating vital documents in threshold languages based on the sizes of enrollment and the needs assessment, as specified.
Specifies the type of vital documents produced by the plan that are required to be translated, including:
Applications;
Consent forms;
Letters containing important information regarding eligibility and participation criteria;
Notices pertaining to the denial, reduction, modification, or termination of benefits, and the right to file a grievance or appeal; and,
Notices advising limited-English-proficient persons (LEP) of the availability of free language assistance and other outreach materials that are provided to enrollees.
Specifies that vital documents shall not include an explanation of benefits or similar claim processing information sent to the enrollee or insured, unless the document requires a response by the enrollee or insured.
Establishes various consumer disclosure requirements on health plans, including a requirement for plans to provide a uniform health plan benefits and coverage matrix (matrix) containing the plan’s major provisions in order to facilitate comparisons between individual and small group market plans.
Requires insurers to provide to insureds summary information about each disability insurance policy offered by the insurer for full and fair disclosure of the provisions of the policy.
Permits plans and insurers subject to ACA uniform SBC requirements to satisfy requirements to provide the matrix referenced in 5) above and the summary information referenced in 6) above by providing the uniform SBC, as specified.
FISCAL EFFECT: According to the Senate Appropriations Committee, this bill, as introduced, will result in:
One-time administrative costs likely between $150,000 and $300,000 to develop policies and translate template documents by CDI (Insurance Fund).
One-time administrative costs of about $200,000 to develop policies and translate template documents by the DMHC (Managed Care Fund).
COMMENTS:
PURPOSE OF THIS BILL. According to the author, the ACA requires plans and insurers to provide consumers with an easy to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. The author states that the ACA requires this information to be provided in a culturally and linguistically appropriate manner, but, unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The author states that this bill makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that more Californians are informed about their health coverage options and have equal access to critical information about their health care.
BACKGROUND.
SBC. The ACA sets forth specified disclosure requirements to help consumers better understand their health coverage, as well as to gain a better understanding of other coverage options and an ability to compare plans. One such disclosure requirement is for plans and insurers to provide SBCs, and a uniform glossary of common terms used in health coverage and medical care, to consumers so that they may obtain summarized information about plan benefits and coverage, and evaluate and compare their health coverage options.
The SBC provides basic information regarding benefits and coverage including specific cost-sharing information; coverage limitations and exclusions; and, information regarding continuity of coverage and grievances and appeals. Under the ACA, consumers have the right to obtain an SBC and uniform glossary when shopping for or enrolling in coverage, and plans and insurers must provide the SBC and uniform glossary in a culturally and linguistically appropriate manner.
The ACA requires the federal Health and Human Services, the Treasury, and the DOL (collectively referred to as the Departments) to develop SBC and uniform glossary standards for use by plans and insurers offering group and individual coverage. The Departments published proposed regulations in December 2011 to implement the SBC standards, along with a proposed SBC template to be used by plans and insurers. After consideration of comments from the public, the Departments published joint final regulations implementing specified disclosures, accompanied by an SBC template, instructions, and related material.
On December 30, 2014, the Departments issued a new set of proposed regulations, as well as a revised SBC template. The Departments released final SBC regulations on June 12, 2015. However, the new SBC template will not be finalized until January 2016 in order to allow for consumer testing and more public comment. Once finalized, the new SBC template will apply to coverage that would renew or commence for plan years on or after January 1, 2017.
FEDERAL AND STATE LANGUAGE ACCESS. Under federal language access rules, plans and insurers must translate the SBC and uniform glossary if 10% or more of the population in a county is literate in the same non-English language. According to the Centers for Medicare and Medicaid Services, based on these rules, two languages in California would meet the thresholds for written translations: Spanish and Chinese. Twenty-five California counties meet the 10%t threshold requirement to translate SBCs in Spanish. Those counties are: Colusa, Fresno, Glenn, Imperial, Kern, Kings, Los Angeles, Madera, Merced, Monterey, Napa, Orange, Riverside, San Benito, San Bernardino, San Diego, San Joaquin, San Mateo, Santa Barbara, Santa Cruz, Stanislaus, Sutter, Tulare, Ventura, and Yolo. One county, San Francisco, meets the 10% threshold requirement to translate SBCs in Chinese.
California law requires vital documents to be translated when an LEP enrollee represents a certain percentage of the plan’s enrollment. Specifically, plans and insurers must assess the linguistic needs of the enrollee or insured population, and translate vital documents in threshold languages based on the sizes of enrollment and the needs assessment. For example, a plan with enrollment of 1 million or more is required to translate vital documents into the top two languages other than English as determined by the needs assessment, and any additional languages when 0.75% or 15,000 enrollees, whichever is less, indicates a preference for written materials in their language.
According to DMHC, 10 languages qualify as meeting language access thresholds under California’s translation requirements for vital documents. Those languages are Spanish, Vietnamese, Chinese, Korean, Tagalog, Russian, Armenian, Khmer, Arabic, and Hmong.
This bill requires DMHC and CDI to develop and post templates of the SBC translated into Medi-Cal threshold languages, except for those already translated by the DOL (Chinese, Spanish, Navajo, and Tagalog). DHCS is responsible for promulgating standards that Medi-Cal managed care health plans must apply to determine which languages, at a minimum, they must use to provide translated materials to enrollees. Specifically, DHCS qualifies a language as a threshold language for the purposes of translation when 3,000, or 5% of the beneficiary population in a service area indicate a primary language other than English; or when 1,000 beneficiaries in a single zip code, or 1,500 in two contiguous zip codes speak a primary language other than English.
On April 27, 2014, DHCS released an All-Plan Letter, which, in addition to English, lists the following languages as the current set of Medi-Cal threshold languages: Arabic, Armenian, Cambodian, Chinese, Farsi, Hmong, Korean, Russian, Spanish, Tagalog, and Vietnamese.
SUPPORT. The California Pan-Ethnic Health Network (CPEHN) is the sponsor of this bill. CPEHN states that although the ACA expanded coverage for millions of Californians, consumers are still confused about health insurance terminology and do not fully understand key details of their plans and policies. CPEHN argues that this bill will ensure LEP consumers can access vital information included in the SBCs by expanding the languages into which it will be translated; ensure health plans are meeting their language access obligations; improve access to language assistance services; and help ensure Californians can access a standardized glossary of insurance terms. Other supporters state that California is extremely diverse, with over 100 languages spoken and 40% of the population comprised by LEP individuals. Supporters state that the SBC forms are important tools for consumers, and help them make sense of health care coverage, and that consumers’ new right to the SBC under the ACA means they finally have a uniform document that can be used to reliably compare plans and policies, and obtain important coverage information. Supporters argue that this bill ensures that the SBC is available to all Californians, not just those who speak English, and moves California steps forward by ensuring one of the most basic and informative documents is translated and of use to millions of LEP Californians who rely on insurance for their health.
PREVIOUS LEGISLATION.
SB 353 (Lieu), Chapter 447, Statutes of 2013, requires the translation of specified documents by trained and qualified translators when a health plan, insurer, or any other person or business markets or advertises health insurance products in the individual or small group markets in a non-English language that is not a threshold language under existing law.
SB 853 (Escutia), Chapter 713, Statutes of 2003, required DMHC to adopt, not later than January 1, 2006, regulations establishing standards and requirements to provide health plan enrollees with access to language assistance in obtaining health care services.
POLICY COMMENTS.
Timeframes. This bill would require DMHC and CDI to develop and post translated templates of the SBC no later than July 1, 2016. According to the author, these requirements are designed to provide assistance to plans and insurers by providing access to translated templates for them to use for their SBCs. However, by making the SBC a vital document on July 1, 2016, thus requiring the SBC to be translated by that same date, the bill does not appear to allow time for the plans to use the templates unless both DMHC and CDI develop and post the templates in advance of their own deadline. The author may wish to amend the bill to provide plans and insurers additional time to access and utilize the templates by delaying the date by which the SBC becomes a vital document. Open enrollment for the 2017 plan year commences on November 1, 2016. Consumers should be able to obtain access to the translated SBCs in advance of the commencement of open enrollment. Thus, the author may wish to amend the bill to make the SBC document a vital document by October 1, 2016.
Technical amendment. The author has asked for the following technical amendments on Page 8, lines 24 to 27 as follows:
“…has already prepared a written translation. Not later than
July 1, 2016, the department commissioner
shall make available on its Internet Web site written
translations of the template uniform summary of benefits and coverage
developed by the department commissioner,
and written…”
REGISTERED SUPPORT / OPPOSITION:
Support
California Pan-Ethnic Health Network (sponsor)
American Cancer Society-Cancer Action Network
American Federation of State, County and Municipal Employees, AFL-CIO
Asian Law Alliance
California Council of the Service Employees International Union
California Immigrant Policy Center
Community Health Councils
Consumers Union
National Health Law Program
SEIU-California
Southeast Asia Resource Action Center
Western Center on Law and Poverty
Opposition
None on file.
Analysis Prepared by: Kelly Green / HEALTH / (916) 319-2097
SB 388
Page 7
|
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 |
THIRD READING
Bill No: SB 388
Introduced: 2/25/15
SENATE HEALTH COMMITTEE: 8-0, 4/22/15
AYES: Hernandez, Nguyen, Mitchell, Monning, Nielsen, Pan, Roth, Wolk
NO VOTE RECORDED: Hall
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SUBJECT: Solicitation and enrollment
SOURCE: California Pan-Ethnic Health Network
DIGEST: This bill makes uniform summary of benefits and
coverage information which must be provided to consumers by health
plans and insurers under the federal Affordable Care Act and
California law, a vital document, subject to specified translation
requirements. This bill requires, not later than January 1, 2016,
the Department of Managed Health Care and the California Department
of Insurance, to make available on their Internet Web sites written
translations of the template of uniform summary of benefits and
coverage, and requires the departments to consider existing law in
developing the translations.
Existing law:
Requires the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to develop and adopt regulations establishing standards and requirements to provide health plan enrollees and insureds with appropriate access to language assistance in obtaining health care services.
Requires DMHC and CDI to require every health plan, specialized health plan, health insurer and specialized health insurer to assess the linguistic needs of the enrollee or insured population, excluding Medi-Cal enrollees, and to provide for translation and interpretation for medical services, including translating vital documents in threshold languages based on the size of enrollment and the needs assessment, as specified.
Includes as vital documents to be translated:
Applications.
Consent forms.
Letters containing important information regarding eligibility and participation criteria.
Notices pertaining to the denial, reduction, modification, or termination of services and benefits, and the right to file a grievance or appeal.
Notices advising limited-English-proficient persons of the availability of free language assistance and other outreach materials that are provided to enrollees.
Excludes as vital documents, explanation of benefits or similar claims processing information that are sent to enrollees or insureds, unless the documents require a response by the enrollee or insured.
Requires the translation of specified documents, including the uniform summary of benefits and coverage (SBC), if a health plan or health insurer advertises or markets products in a non-English language that is not a threshold language or allows any other person or business to market or advertise on its behalf. This applies to health plan and health insurance products advertised or marketed in the individual and small group market.
Establishes multiple consumer disclosure requirements on health plans, including a requirement related to individual and small group products, for a uniform health plan benefits and coverage matrix containing the plan’s major provisions in order to facilitate comparisons between plan contracts. Establishes consumer disclosures on disability insurers offering health insurance coverage.
Requires under the federal Affordable Care Act (ACA), health insurance issuers to provide uniform SBC information.
Permits, under state law, a health plan subject to the ACA uniform SBC to satisfy state requirements for a uniform health plan benefits and coverage matrix if all applicable benefit disclosure requirements are met in other health plan documents, and if applicants and enrollees are advised that enrollees are not financially responsible in the payment of emergency services, in any amount that the health plan is obligated to pay, beyond the enrollee’s copayments, coinsurance, and deductibles as provided in the enrollee’s health plan contract.
Requires on and after January 1, 2014, a disability insurer offering health insurance coverage subject to the ACA uniform SBC to ensure that all applicable disclosures are met in other documents provided to policyholders and insureds. Requires the uniform SBC to be provided to the Insurance Commissioner together with the corresponding health insurance policy information, as specified.
This
bill:
Makes the uniform SBC information required under the ACA and state law, a vital document, as specified.
Requires, not later than January 1, 2016, DMHC and CDI, to make available on their Internet Web sites written translations of the template of uniform SBC, and requires the departments to consider existing law in developing the translations.
Comments
Author’s statement. According to the author, the ACA requires health plans and insurers to provide consumers with an easy-to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. The ACA requires this information to be provided in a “culturally and linguistically appropriate manner.” Unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The federal rule states that the document should be translated into languages spoken by 10% or more of the population residing in a consumer’s county. By contrast, California law requires a “vital” document to be translated when a limited English proficient (LEP) population is a certain percent of the plan’s enrollment. SB 388 makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that Californians are informed about their health coverage options and have equal access to critical information about their healthcare.
California language access. California health plans are required to provide language assistance services, including translation and interpretation services, to LEP enrollees. The regulation became effective on January 1, 2009. The DMHC Division of Plan Surveys monitors compliance with the regulation in its routine medical survey process, which takes place at least every three years for each health plan. In addition, the DMHC tracks complaints filed with its Help Center to identify trends in compliance with the regulation. According to a report to the Legislature issued by DMHC for the January 2011-December 2012 period, DMHC completed 38 routine medical surveys during the reporting period. While deficiencies were cited, those deficiencies were corrected and to date there have been no serious concerns identified through medical surveys. Likewise, there have been few complaints to the DMHC Help Center. One action by the DMHC Office of Enforcement resulted in a $2,500 fine for failing to translate a vital document. Overall, the DMHC has not noted any trend toward non-compliance with the regulation. DMHC also makes available on its Web site threshold languages by health plan. For example Molina Health Care of California has the following threshold languages identified: English, Spanish, Vietnamese, Chinese, Russian, and Hmong.
Medi-Cal defines threshold language as a language that has been identified as the primary language of 3,000 beneficiaries or 5% of the beneficiary population, whichever is lower, in an identified geographic area. 13 distinct languages qualify as threshold languages, according to a May 2014 Medi-Cal statistical brief. Those languages are: Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian, and other Chinese. Spanish is the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49). Los Angeles has the greatest number of threshold languages (12) of any county.
ACA SBC. Amendments to the Public Health Service Act, made by the ACA direct the federal Departments of Labor, Health and Human Services, and the Treasury to develop standards for use by a group health plan (which includes both insured and self-insured plans) and a health insurance issuer offering group or individual health insurance coverage in compiling and providing a SBC that ‘‘accurately describes the benefits and coverage under the applicable plan or coverage,’’ and also calls for the ‘‘development of standards for the definitions of terms used in health insurance coverage.’’ The ACA requires group health plans and health insurance issuers offering group and individual coverage to provide the SBC and uniform glossary in a culturally and linguistically appropriate manner.
The
regulations indicate a group health plan and a health insurance
issuer offering group or individual health insurance coverage are
considered to provide relevant notices in a culturally and
linguistically appropriate manner if the plan or issuer provides oral
language services (such as a telephone customer assistance hotline)
that include answering questions in any applicable non-English
language and providing assistance with filing claims and appeals
(including external review) in any applicable non-English language.
Additionally, the plan or issuer must provide, upon request, a notice
in any applicable non-English language; and the plan or issuer must
include in the English versions of all notices, a statement
prominently displayed in any applicable non-English language clearly
indicating how to access the language services provided by the plan
or issuer. The regulations require these plans and issuers to
make certain accommodations for notices sent to an address in a
county meeting a threshold percentage of people who are literate only
in the same non-English language. This threshold percentage is set at
10% or more of the population residing in the claimant’s county, as
determined based on American Community Survey data published by the
United States Census Bureau. 25 California
counties meet the 10% threshold requirement to translate SBCs in
Spanish. Those counties are: Colusa, Fresno, Glenn, Imperial, Kern,
Kings, Los Angeles, Madera, Merced, Monterey, Napa, Orange,
Riverside, San Benito, San Bernardino, San Diego, San Joaquin, San
Mateo, Santa Barbara, Santa Cruz, Stanislaus, Sutter, Tulare, Ventura
and Yolo. One county (San Francisco) meets the 10% threshold
requirement to translate SBCs in Chinese.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Senate Appropriations Committee:
One-time administrative costs likely between $150,000 and $300,000 to develop policies and translate template documents by CDI (Insurance Fund).
One-time administrative costs of about $200,000 to develop policies and translate template documents by DMHC (Managed Care Fund).
California Pan-Ethnic Health Network (source)
Asian Law Alliance
California State Council of the Service Employees International Union
Consumers Union
Guam Communications Network
Having Our Say Coalition
Latino Coalition for a Healthy California
National Health Law Program
Planned Parenthood Affiliates of California
SEIU California
Southeast Asia Resource Action Center
Western Center on Law and Poverty
OPPOSITION: (Verified 5/28/15)
None received
ARGUMENTS IN SUPPORT: California Pan-Ethnic Health Network (CPEHN), this bill’s sponsor, writes this bill is necessary because California residents speak over 100 different languages and more than 40% speak a language other than English at home. Although federal law requires the SBC to be provided in a culturally and linguistically appropriate manner, the federal definition differs from California’s long-standing language access requirements. The federal standard for California counties requires translation into two languages, Spanish and Chinese (only in San Francisco). CPEHN writes, in California there are ten languages that meet language access thresholds under California law, with Spanish, Chinese, and Vietnamese being the most commonly required language for translations. CPEHN informally surveyed Covered California Qualified Health Plans (QHPs) and found only seven QHPs are providing SBCs in Spanish upon request. Only six QHPs are providing SBCs in Chinese upon request even though seven are required to and only three are providing SBCs in Vietnamese upon request even though five are required to and none are providing SBCs in Korean even though one is required. CPEHN also states that most QHPs are using the federal SBC template which only includes taglines for where to access language assistance services in the four federally required non-English languages: Spanish, Chinese, Navajo, and Tagalog. This list is not representative of California’s demographics.
Prepared by: Teri Boughton / HEALTH /
5/31/15 13:11:42
**** END ****
SB 388 (Mitchell) Page 2 of 2
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
SB 388 (Mitchell) - Solicitation and enrollment
|
|
Version: February 25, 2015 |
Policy Vote: HEALTH 8 - 0 |
Urgency: No |
Mandate: Yes |
Hearing Date: May 4, 2015 |
Consultant: Brendan McCarthy |
This bill meets the criteria for referral to the Suspense File.
Bill Summary:
SB 388 would designate the uniform summary of benefits and coverage information, which must be provided to consumers by health plans and health insurers, a vital document. That would require health plans and health insurers to provide the document in certain languages other than English.
Fiscal Impact:
One-time administrative costs likely between $150,000 and $300,000 to develop policies and translate template documents by the Department of Insurance (Insurance Fund).
One-time administrative costs of about $200,000 to develop policies and translate template documents by the Department of Managed Health Care (Managed Care Fund).
Background:
Under current law, health insurers and health plans (collectively referred to as “carriers”) are required to provide consumers with certain vital documents, such as application forms, consent forms, and certain notices, in “threshold languages”. The threshold depends on the size of the plan’s enrollment and the number of limited-English proficient enrollees. Currently there are ten threshold languages in the state (Spanish, Vietnamese, Chinese, Korean, Tagalog, Russian, Armenian, Khmer, Arabic, and Hmong).
In addition, state law requires carriers to translate certain documents, including the uniform summary of benefits and coverage, into non-English languages if the carrier markets coverage in that non-English language. This requirement applies to languages which are not threshold languages.
Federal law requires carriers to provide enrollees with a uniform summary of benefits and coverage, which provides information about covered services, cost sharing, and other key information about the enrollee’s health care coverage. Federal law requires the uniform summary of benefits and coverage to be translated into non-English languages when 10 percent or more of the population of the enrollees county speaks that language.
The federal standard is less stringent than state law for translation of vital documents. Under federal law, only Spanish and Chinese meet the thresholds requiring translation of the uniform summary of benefits and coverage into those languages. Whereas, current state law requires vital documents to be translated into ten languages.
Proposed Law:
SB 388 would designate the uniform summary of benefits and coverage information, which must be provided to consumers by health plans and health insurers, a vital document. That would require health plans and health insurers to provide the document in certain threshold languages other than English.
The bill would require the Department of Insurance and the Department of Managed Health Care to post written translations of the template uniform summary of benefits and coverage in the threshold languages by January 1, 2016.
Related Legislation:
SB 353 (Lieu, Statutes of 2013) requires the translation of specified documents into a non-English languages when a carrier markets or advertises health care coverage in that language.
Staff Comments:
The only costs that may be incurred by a local agency relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state.
-- END --
SB 388 (Mitchell) Page 5 of 5
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 388
AUTHOR: |
Mitchell |
||
VERSION: |
February 25, 2015 |
||
HEARING DATE: |
April 22, 2015 |
|
|
CONSULTANT: |
Teri Boughton |
||
SUBJECT: Solicitation and enrollment
SUMMARY:
Makes uniform summary of benefits and coverage information, which must be provided to consumers by health plans and insurers under the federal Affordable Care Act and state law, a vital document and therefore subject to translation requirements. Requires, not later than January 1, 2016, the Department of Managed Health Care and the California Department of Insurance, to make available on their Internet Websites written translations of the template of uniform summary of benefits and coverage, and requires the departments to consider existing law in developing the translations.
Existing law:
Requires the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to develop and adopt regulations establishing standards and requirements to provide health plan enrollees and insureds with appropriate access to language assistance in obtaining health care services.
Requires DMHC and CDI to require every health plan, specialized health plan, health insurer and specialized health insurer to assess the linguistic needs of the enrollee or insured population, excluding Medi-Cal enrollees, and to provide for translation and interpretation for medical services, including translating vital documents in threshold languages based on the size of enrollment and the needs assessment, as required.
Includes as vital documents to be translated:
Applications;
Consent forms;
Letters containing important information regarding eligibility and participation criteria;
Notices pertaining to the denial, reduction, modification, or termination of services and benefits, and the right to file a grievance or appeal; and,
Notices advising limited-English-proficient persons of the availability of free language assistance and other outreach materials that are provided to enrollees.
Excludes as vital documents, explanation of benefits or similar claims processing information that is sent to enrollees or insureds, unless the document requires a response by the enrollee or insured.
Requires a health plan or health insurer that advertises or markets products in the individual or small group markets, or allows any other person or business to market or advertise on its behalf in the individual or small group markets, in a non-English language that does not meet specified requirements related to vital documents to translate specified documents in the same non-English language, including, the uniform summary of benefits and coverage (SBC), as specified.
Establishes multiple consumer disclosure requirements on health plans, including a requirement related to individual and small group products, for a uniform health plan benefits and coverage matrix containing the plan’s major provisions in order to facilitate comparisons between plan contracts. Establishes consumer disclosures on disability insurers offering health insurance coverage.
Requires, under the federal Affordable Care Act (ACA), health insurance issuers to provide uniform SBC information.
Permits a health plan subject to the ACA uniform SBC requirement to satisfy state requirements for a uniform health plan benefits and coverage matrix if all applicable benefit disclosure requirements are met in other health plan documents, and, if applicants and enrollees are advised that enrollees are not financially responsible in the payment of emergency services, in any amount that the health plan is obligated to pay, beyond the enrollee’s cost sharing requirements.
Requires on and after January 1, 2014, a disability insurer offering health insurance coverage subject to the ACA uniform SBC to ensure that all applicable disclosures are met in other documents provided to policyholders and insureds. Requires the uniform SBC to be provided to the Insurance Commissioner together with the corresponding health insurance policy information, as specified.
This
bill:
Makes the uniform SBC information required under the ACA and state law, a vital document, as specified.
Requires, not later than January 1, 2016, DMHC and CDI, to make available on their Internet Websites written translations of the template of uniform SBC, and requires the departments to consider existing law in developing the translations.
FISCAL EFFECT:
This bill has not been analyzed by a fiscal committee.
COMMENTS:
Author’s statement. According to the author, the ACA requires health plans and insurers to provide consumers with an easy-to understand SBC to help them evaluate and compare their health insurance options. The SBC includes key features of coverage such as covered benefits, cost-sharing provisions, and coverage limitations as well as a standard glossary of terms. The ACA requires this information to be provided in a “culturally and linguistically appropriate manner.” Unfortunately, federal standards on translating the SBC are inconsistent with California’s translation requirements. The federal rule states that the document should be translated into languages spoken by 10 percent or more of the population residing in a consumer’s county. By contrast, California law requires a “vital” document to be translated when a limited English proficient (LEP) population is a certain percent of the plan’s enrollment. SB 388 makes clear that translation of the SBC must be consistent with California’s current language access laws, helping to ensure that Californians are informed about their health coverage options and have equal access to critical information about their healthcare.
California Language Access. California health plans are required to provide language assistance services, including translation and interpretation services, to LEP enrollees. The regulation became effective on January 1, 2009. The DMHC Division of Plan Surveys monitors compliance with the regulation in its routine medical survey process, which takes place at least every three years for each health plan. In addition, the DMHC tracks complaints filed with its Help Center to identify trends in compliance with the regulation. According to a report to the Legislature issued by DMHC for the January 2011-December 2012 period, DMHC completed 38 routine medical surveys during the reporting period. While deficiencies were cited, those deficiencies were corrected, and to date there have been no serious concerns identified through medical surveys. Likewise, there have been few complaints to the DMHC Help Center. One action by the DMHC Office of Enforcement resulted in a $2,500 fine for failing to translate a vital document. Overall, DMHC has not noted any trend toward non-compliance with the regulation. An update to this report is forthcoming. DMHC also makes available on its website threshold languages by health plan. For example Molina Health Care of California has the following threshold languages identified: English, Spanish, Vietnamese, Chinese, Russian, and Hmong.
Medi-Cal defines threshold language as a language that has been identified as the primary language of 3,000 beneficiaries or five percent of the beneficiary population, whichever is lower, in an identified geographic area. Thirteen distinct languages qualify as threshold languages, according to a May 2014 Medi-Cal statistical brief. Those languages are: Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian, and other Chinese. Spanish is the most frequently occurring, threshold language (34.5 percent) and was represented in the greatest number of counties (49). Los Angeles has the greatest number of threshold languages (12) of any county.
ACA SBC. The ACA directs the federal Departments of Labor, Health and Human Services (HHS), and Treasury to develop standards for use by a group health plan (which includes both insured and self-insured plans) and a health insurance issuer offering group or individual health insurance coverage in compiling and providing a SBC that ‘‘accurately describes the benefits and coverage under the applicable plan or coverage,’’ and also calls for the ‘‘development of standards for the definitions of terms used in health insurance coverage.’’ The ACA requires group health plans and health insurance issuers offering group and individual coverage to provide the SBC and uniform glossary in a culturally and linguistically appropriate manner.
The
regulations indicate a group health plan and a health insurance
issuer offering group or individual health insurance coverage are
considered to provide relevant notices in a culturally and
linguistically appropriate manner if the plan or issuer provides oral
language services (such as a telephone customer assistance hotline)
that include answering questions in any applicable non-English
language and providing assistance with filing claims and appeals
(including external review) in any applicable non-English language.
Additionally, the plan or issuer must provide, upon request, a notice
in any applicable non-English language; and, the plan or issuer must
include in the English versions of all notices, a statement
prominently displayed in any applicable non-English language clearly
indicating how to access the language services provided by the plan
or issuer. The
regulations require these plans and issuers to make certain
accommodations for notices sent to an address in a county meeting a
threshold percentage of people who are literate only in the same
non-English language. This threshold percentage is set at 10 percent
or more of the population residing in the claimant’s county, as
determined based on American Community Survey data published by the
United States Census Bureau. Twenty-five
California counties meet the 10 percent threshold requirement to
translate SBCs in Spanish. Those counties are: Colusa, Fresno,
Glenn, Imperial, Kern, Kings, Los Angeles, Madera, Merced, Monterey,
Napa, Orange, Riverside, San Benito, San Bernardino, San Diego, San
Joaquin, San Mateo, Santa Barbara, Santa Cruz, Stanislaus, Sutter,
Tulare, Ventura and Yolo. One county (San Francisco) meets the 10
percent threshold requirement to translate SBCs in Chinese.
Prior legislation.
SB 353 (Lieu), Chapter 447, Statutes of 2013, requires the translation of specified documents by trained and qualified translators when a health plan, insurer, or any other person or business markets or advertises health insurance products in the individual or small group markets in a non-English language that is not a threshold language under existing law.
SB 853 (Escutia), Chapter 713, Statutes of 2003, required DMHC to adopt, not later than January 1, 2006, regulations establishing standards and requirements to provide health plan enrollees with access to language assistance in obtaining health care services.
Support. This bill is sponsored by the California Pan-Ethnic Health Network (CPEHN) because in California residents speak over 100 different languages and more than 40 percent speak a language other than English at home. Although federal law requires the SBC to be provided in a culturally and linguistically appropriate manner, the federal definition differs from California’s long-standing language access requirements. The federal standard for California counties requires translation into two languages, Spanish and Chinese (only in San Francisco). CPEHN writes, in California there are ten languages that meet language access thresholds under California law: Spanish, Vietnamese, Chinese, Korean, Tagalog, Russian, Armenian, Khmer, Arabic and Hmong, with Spanish, Chinese, and Vietnamese being the most commonly required language for translations. CPEHN informally surveyed Covered California Qualified Health Plans (QHPs) and found only seven QHPs are providing SBCs in Spanish upon request even though nine are required by law. Only six QHPs are providing SBCs in Chinese upon request even though seven are required by law, only three are providing SBCs in Vietnamese upon request even though five are required by law, and none are providing SBCs in Korean even though one is required to by law. CPEHN also states that most QHPs are using the federal SBC template, which only includes taglines for where to access language assistance services in the four federally required non-English languages: Spanish, Chinese, Navajo, and Tagalog. This list is not representative of California’s demographics. Additionally, this bill would require DMHC and CDI to post online a standard translated glossary of terms. Currently different glossaries are being used and the federal glossary is only available in the four federally required non-English languages.
Requested Amendments. The California Association of Health Plans (CAHP) believes this bill is duplicative of information currently translated in the matrix and that clarification is needed to ensure that plans are only required to translate one document summarizing coverage. They also ask that this bill be implemented six months after the revised federal SBC template is published.
Amendments. The author requests the committee adopt the following amendment on page 6, line 2 and page 7, line 38 (revised to apply to CDI regulated health insurance).
(B) The uniform summary of benefits and coverage referenced in this paragraph shall constitute a vital document for the purposes of Section 1367.04. Not later than January 1, 2016, the department shall make available on its Internet Web site written translations of the template uniform summary of benefits and coverage. In developing the translations, the department shall consider subdivision (c) of Section 1367.04. This requirement is in addition to the requirements of Section 1367.041.
SUPPORT AND OPPOSITION:
Support: California Pan-Ethnic Health Network (sponsor)
Asian Law Alliance
California State Council of the Service Employees International Union
Consumers Union
Guam Communications Network
Having Our Say Coalition
National Health Law Program
Planned Parenthood Affiliates of California
Southeast Asia Resource Action Center
Western Center on Law and Poverty
Oppose: None received
-- END --
Bill Author
Bill Co-Author(s):