Health care coverage: deductibles and out-of-pocket expenses.
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. A willful violation of the act is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets limits on the amount of the deductible and out-of-pocket expenses that may be included in specified health care service plan contracts and health insurance policies.
This bill, for a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2022, in the individual or group market, would require the health care service plan or health insurer to monitor an enrollee’s or insured’s accrual balance toward their annual deductible and out-of-pocket maximum, if any. The bill would require a health care service plan or health insurer to provide an enrollee or insured with their accrual balance toward their annual deductible and out-of-pocket maximum for every month in which benefits were used, as specified. The bill would require a health care service plan or health insurer to establish and maintain a system that allows an enrollee or insured to request their most up-to-date accrual balances from their health care service plan or health insurer at any time. The bill would require accrual updates to be mailed to enrollees unless the enrollee has elected to opt out of mailed notice and elected to receive the accrual update electronically, as specified. The bill would require a health care service plan or health insurer to notify enrollees and insureds of their rights under the bill, as specified. The bill would require a contracted entity to which a health care service plan or health insurer has delegated claims payment functions to comply with the requirements of the bill, as specified. Because a willful violation of the bill’s provisions 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.