| Last Version Text |
<?xml version="1.0" ?>
<ns0:MeasureDoc xmlns:html="http://www.w3.org/1999/xhtml" xmlns:ns0="http://lc.ca.gov/legalservices/schemas/caml.1#" xmlns:ns3="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" version="1.0" xsi:schemaLocation="http://lc.ca.gov/legalservices/schemas/caml.1# xca.1.xsd">
<ns0:Description>
<ns0:Id>20250SB__025795ENR</ns0:Id>
<ns0:VersionNum>95</ns0:VersionNum>
<ns0:History>
<ns0:Action>
<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2025-02-03</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-07-03</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-07-17</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-09-04</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>PASSED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-09-09</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>PASSED_SENATE</ns0:ActionText>
<ns0:ActionDate>2025-09-10</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>ENROLLED</ns0:ActionText>
<ns0:ActionDate>2025-09-12</ns0:ActionDate>
</ns0:Action>
</ns0:History>
<ns0:LegislativeInfo>
<ns0:SessionYear>2025</ns0:SessionYear>
<ns0:SessionNum>0</ns0:SessionNum>
<ns0:MeasureType>SB</ns0:MeasureType>
<ns0:MeasureNum>257</ns0:MeasureNum>
<ns0:MeasureState>ENR</ns0:MeasureState>
</ns0:LegislativeInfo>
<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Senator Wahab</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthors: Senators Ashby, Cabaldon, Cervantes, Laird, Limón, Rubio, and Wiener)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Wahab</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Ashby</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Cabaldon</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Cervantes</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Laird</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Limón</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Rubio</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Wiener</ns0:Name>
</ns0:Legislator>
</ns0:Authors>
<ns0:Title> An act to amend Section 1399.849 of the Health and Safety Code, and to amend Section 10965.3 of the Insurance Code, relating to health care coverage.</ns0:Title>
<ns0:RelatingClause>health care coverage</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>PARENT Act.</ns0:Subject>
</ns0:GeneralSubject>
<ns0:DigestText>
<html:p>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 disability insurers by the Department of Insurance. Existing law requires a health care service plan or disability insurer to allow an individual to enroll in or change their health benefit plan as a result of a specified triggering event.</html:p>
<html:p>This bill, the PARENT Act, would make pregnancy a triggering event for purposes of enrollment or changing a health benefit plan. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program.</html:p>
<html:p>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.</html:p>
<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
</ns0:DigestText>
<ns0:DigestKey>
<ns0:VoteRequired>MAJORITY</ns0:VoteRequired>
<ns0:Appropriation>NO</ns0:Appropriation>
<ns0:FiscalCommittee>YES</ns0:FiscalCommittee>
<ns0:LocalProgram>YES</ns0:LocalProgram>
</ns0:DigestKey>
<ns0:MeasureIndicators>
<ns0:ImmediateEffect>NO</ns0:ImmediateEffect>
<ns0:ImmediateEffectFlags>
<ns0:Urgency>NO</ns0:Urgency>
<ns0:TaxLevy>NO</ns0:TaxLevy>
<ns0:Election>NO</ns0:Election>
<ns0:UsualCurrentExpenses>NO</ns0:UsualCurrentExpenses>
<ns0:BudgetBill>NO</ns0:BudgetBill>
<ns0:Prop25TrailerBill>NO</ns0:Prop25TrailerBill>
</ns0:ImmediateEffectFlags>
</ns0:MeasureIndicators>
</ns0:Description>
<ns0:Bill id="bill">
<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_AF07EC7F-8C77-4CFE-BA20-27D645314253">
<ns0:Num>SECTION 1.</ns0:Num>
<ns0:Content>
<html:p>This act shall be known, and may be cited, as the PARENT Act.</html:p>
</ns0:Content>
</ns0:BillSection>
<ns0:BillSection id="id_1C3A10F4-4F89-4F64-9141-58C506B90663">
<ns0:Num>SEC. 2.</ns0:Num>
<ns0:ActionLine action="IS_AMENDED" ns3:href="urn:caml:codes:HSC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'2.2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'ARTICLE'%20and%20caml%3ANum%3D'11.8.'%5D%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'1399.849.'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 1399.849 of the
<ns0:DocName>Health and Safety Code</ns0:DocName>
is amended to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_EC38F8C9-4089-4475-A9A0-CF67C18FE3DE">
<ns0:Num>1399.849.</ns0:Num>
<ns0:LawSectionVersion id="id_A9DA337A-EB5B-42A1-B72A-06E841796B13">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
On and after October 1, 2013, a plan shall fairly and affirmatively offer, market, and sell all of the plan’s health benefit plans that are sold in the individual market for policy years on or after January 1, 2014, to all individuals and dependents in each service area in which the plan provides or arranges for the provision of health care services. A plan shall limit enrollment in individual health benefit plans to open enrollment periods, annual enrollment periods, and special enrollment periods as provided in subdivisions (c) and (d).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A plan shall allow the subscriber of an individual health benefit plan to add a dependent to the subscriber’s plan at
the
option of the subscriber, consistent with the open enrollment, annual enrollment, and special enrollment period requirements in this section.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
An individual health benefit plan issued, amended, or renewed on or after January 1, 2014, shall not impose any preexisting condition provision upon any individual.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered outside of the Exchange, a plan shall provide an initial open enrollment period from October 1, 2013, to March 31, 2014, inclusive, an annual enrollment period for the policy year beginning on January 1, 2015, from November 15, 2014, to February 15, 2015, inclusive, annual enrollment periods for policy years beginning on or after January 1, 2016, to December 31, 2018, inclusive,
from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment periods for policy years beginning on or after January 1, 2019,
from October 15, of the preceding calendar year, to January 15 of the benefit year, inclusive.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, a plan shall provide an annual enrollment period for the policy years beginning on January 1, 2016, to December 31, 2018, inclusive, from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment periods for policy years beginning on or after January 1, 2019, from November 1 to December 15 of the preceding calendar year, inclusive.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, for policy years beginning on or after January 1, 2019, a plan shall provide a special enrollment period for all individuals
selecting an individual health benefit plan through the Exchange from October 15 to October 31 of the preceding calendar year, inclusive, and from December 16, of the preceding calendar year, to January 15 of the benefit year, inclusive. An application for a health benefit plan submitted during these two special enrollment periods shall be treated the same as an application submitted during the annual open enrollment period. The effective date of coverage for plan selections made between October 15 and October 31, inclusive, shall be January 1 of the benefit year, and for plan selections made from December 16 to January 15, inclusive, shall be no later than February 1 of the benefit year.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Pursuant to Section 147.104(b)(2) of Title 45 of the Code of Federal Regulations, for individuals enrolled in noncalendar year individual health
plan contracts, a plan shall also provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Subject to paragraph (2), commencing January 1, 2014, a plan shall allow an individual to enroll in or change individual health benefit plans as a result of the following triggering events:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The individual or the individual’s dependent loses minimum essential coverage. For purposes of this paragraph, the following definitions shall apply:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
“Minimum essential coverage” has the same meaning as that term is defined in Section 1345.5 or subsection (f) of Section 5000A of the Internal Revenue Code (26 U.S.C. Sec. 5000A).
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
“Loss of minimum essential coverage” includes, but is not limited to, loss of that coverage due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code. “Loss of minimum essential coverage” also includes loss of that coverage for a reason that is not due to the fault of the individual.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
“Loss of minimum essential coverage” does not include loss of that coverage due to the individual’s failure to pay premiums on a timely basis or situations allowing for a rescission, subject to clause (ii) and Sections 1389.7 and 1389.21.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The individual gains a dependent or
becomes a dependent.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
The individual is mandated to be covered as a dependent pursuant to a valid state or federal court order.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
The individual has been released from incarceration.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
The individual’s health coverage issuer substantially violated a material provision of the health coverage contract.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
The individual gains access to new health benefit plans as a result of a permanent move.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
The individual was receiving services from a contracting provider under another health benefit plan, as defined in Section 1399.845 of this code or Section 10965 of the Insurance Code, for one of the
conditions described in subdivision (c) of Section 1373.96 of this code and that provider is no longer participating in the health benefit plan.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
The individual demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the department, with respect to health benefit plans offered outside the Exchange, that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because the individual was misinformed that the individual was covered under minimum essential coverage.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
The individual is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title
32 of the United States Code.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
The individual is pregnant.
</html:p>
<html:p>
(K)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, in addition to the triggering events listed in this paragraph, any other events listed in Section 155.420(d) of Title 45 of the Code of Federal Regulations.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to individual health benefit plans
offered outside the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to apply for coverage from a health care service plan subject to this section. With respect to individual health benefit plans offered through the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to select a plan offered through the Exchange, unless a longer period is provided in Part 155 (commencing with Section 155.10) of Subchapter B of Subtitle A of Title 45 of the Code of Federal Regulations.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, the effective date of coverage required pursuant to this section shall be consistent with the dates specified in Section 155.410 or 155.420 of Title 45 of the Code of Federal Regulations,
as applicable. A dependent who is a registered domestic partner pursuant to Section 297 of the Family Code shall have the same effective date of coverage as a spouse.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered outside the Exchange, the following provisions shall apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
After an individual submits a completed application form for a plan contract, the health care service plan shall, within 30 days, notify the individual of the individual’s actual premium charges for that plan established in accordance with Section 1399.855. The individual shall have 30 days in which to exercise the right to buy coverage at the quoted premium charges.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an
individual applies during the initial open enrollment period described in paragraph (1) of subdivision (c), when the subscriber submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, by December 15, 2013, coverage under the individual health benefit plan shall become effective no later than January 1, 2014. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16, 2013, to December 31, 2013, inclusive, or after the 15th day of any subsequent month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an individual applies during the annual open enrollment period described in paragraph (1) of subdivision (c), when the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs later, by December 15 of the preceding calendar year, coverage shall become effective on January 1 of the benefit year. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16 to December 31, inclusive, or after the 15th day of any subsequent month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an individual applies during a special enrollment period described in subdivision (d), the following provisions shall apply:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
When the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, within the first 15 days of the month, coverage under the plan shall become effective no later than the first day of the following month. When the premium payment is neither delivered nor postmarked until after the 15th day of the month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Notwithstanding subparagraph (A), in the case of a birth, adoption, or placement for adoption, the coverage shall be effective
on the date of birth, adoption, or placement for adoption.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Notwithstanding subparagraph (A), in the case of marriage or becoming a registered domestic partner or in the case where a qualified individual loses minimum essential coverage, the coverage effective date shall be the first day of the month following the date the plan receives the request for special enrollment.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health care service plan shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of an individual health benefit plan based on any of the following factors:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Health status.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Medical condition, including physical and mental illnesses.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Claims experience.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Receipt of health care.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Medical history.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Genetic information.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Evidence of insurability, including conditions arising out of acts of domestic violence.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Disability.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Any other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the federal Public Health Service Act (Public Law 78-410).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding Section 1389.1, a health care service plan shall not require an individual applicant or the applicant’s dependent to fill out a health assessment or medical questionnaire prior to enrollment under an individual health benefit plan. A health care service plan shall not acquire or request information that relates to a health status-related factor from the applicant or the applicant’s dependent or any other source prior to enrollment of the individual.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health care service plan shall consider as a single risk pool for rating purposes in the individual market the claims experience of all insureds and all enrollees in all nongrandfathered individual health benefit plans offered by that health care service plan in this state, whether
offered as health care service plan contracts or individual health insurance policies, including those insureds and enrollees who enroll in individual coverage through the Exchange and insureds and enrollees who enroll in individual coverage outside of the Exchange. Student health insurance coverage, as that coverage is defined in Section 147.145(a) of Title 45 of the Code of Federal Regulations, shall not be included in a health care service plan’s single risk pool for individual coverage.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Each calendar year, a health care service plan shall establish an index rate for the individual market in the state based on the total combined claims costs for providing essential health benefits, as defined pursuant to Section 1302 of PPACA, within the single risk pool required under paragraph (1). The index rate shall be adjusted on a marketwide
basis based on the total expected marketwide payments and charges under the risk adjustment program established for the state pursuant to Section 1343 of PPACA and Exchange user fees, as described in subdivision (d) of Section 156.80 of Title 45 of the Code of Federal Regulations. The premium rate for all of the health benefit plans in the individual market within the single risk pool required under paragraph (1) shall use the applicable marketwide adjusted index rate, subject only to the adjustments permitted under paragraph (3).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
A health care service plan may vary premium rates for a particular health benefit plan from its index rate based only on the following actuarially justified plan-specific factors:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The actuarial value and cost-sharing design of the health benefit
plan.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The health benefit plan’s provider network, delivery system characteristics, and utilization management practices.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
The benefits provided under the health benefit plan that are in addition to the essential health benefits, as defined pursuant to
Section 1302 of PPACA and Section 1367.005. These additional benefits shall be pooled with similar benefits within the single risk pool required under paragraph (1) and the claims experience from those benefits shall be utilized to determine rate variations for plans that offer those benefits in addition to essential health benefits.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
With respect to catastrophic plans, as described in subsection (e) of Section 1302 of PPACA, the expected impact of the specific eligibility categories for those plans.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Administrative costs, excluding user fees required by the Exchange.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
This section shall only apply with respect to individual health benefit plans for policy years on or after January 1, 2014.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
This section shall not apply to a grandfathered health plan.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_D647EA5F-E831-4E75-8E9F-5AEACB7043B8">
<ns0:Num>SEC. 3.</ns0:Num>
<ns0:ActionLine action="IS_AMENDED" ns3:href="urn:caml:codes:INS:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'PART'%20and%20caml%3ANum%3D'2.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'9.9.'%5D%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'10965.3.'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 10965.3 of the
<ns0:DocName>Insurance Code</ns0:DocName>
is amended to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_6D6D9FE9-2D30-436D-BEAF-232BA53CC5F6">
<ns0:Num>10965.3.</ns0:Num>
<ns0:LawSectionVersion id="id_E0E087B6-CF08-4794-BC1F-1A57BB431694">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
On and after October 1, 2013, a health insurer shall fairly and affirmatively offer, market, and sell all of the insurer’s health benefit plans that are sold in the individual market for policy years on or after January 1, 2014, to all individuals and dependents in each service area in which the insurer provides or arranges for the provision of health care services. A health insurer shall limit enrollment in individual health benefit plans to open enrollment periods, annual enrollment periods, and special enrollment periods as provided in subdivisions (c) and (d).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A health insurer shall allow the policyholder of an individual health benefit plan to add a
dependent to the policyholder’s health benefit plan at the option of the policyholder, consistent with the open enrollment, annual enrollment, and special enrollment period requirements in this section.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
An individual health benefit plan issued, amended, or renewed on or after January 1, 2014, shall not impose any preexisting condition provision upon any individual.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered outside of the Exchange, a health insurer shall provide an initial open enrollment period from October 1, 2013, to March 31, 2014, inclusive, an annual enrollment period for the policy year beginning on January 1, 2015, from November 15, 2014, to February 15, 2015, inclusive, annual enrollment periods for policy years beginning
on or after January 1, 2016, to December 31, 2018, inclusive, from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment
periods for policy years beginning on or after January 1, 2019, from October 15 of the preceding calendar year, to January 15 of the benefit year, inclusive.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, a health insurer shall provide an annual enrollment period for the policy years beginning on January 1, 2016, to December 31, 2018, inclusive, from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment periods for policy years beginning on or after January 1, 2019, from November 1 to December 15 of the preceding calendar year, inclusive.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, for policy years beginning on or after January
1, 2019, a health insurer shall provide a special enrollment period for all individuals selecting an individual health benefit
plan through the Exchange from October 15 to October 31 of the preceding calendar year, inclusive, and from December 16, of the preceding calendar year, to January 15 of the benefit year, inclusive. An application for a health benefit plan submitted during these two special enrollment periods shall be treated the same as an application submitted during the annual open enrollment period. The effective date of coverage for plan selections made between October 15 and October 31, inclusive, shall be January 1 of the benefit year, and for plan selections made from December 16 to January 15, inclusive, shall be no later than February 1 of the benefit year.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Pursuant to Section 147.104(b)(2) of Title 45 of the Code of Federal Regulations, for individuals enrolled in noncalendar year individual health plan contracts, a health
insurer shall also provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Subject to paragraph (2), commencing January 1, 2014, a health insurer shall allow an individual to enroll in or change individual health benefit plans as a result of the following triggering events:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The individual or the individual’s dependent loses minimum essential coverage. For purposes of this paragraph, all of the following definitions shall apply:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
“Minimum essential coverage” has the same meaning as that term is defined in Section 1345.5 of the Health and Safety Code or subsection (f) of Section 5000A of the Internal
Revenue Code (26 U.S.C. Sec. 5000A).
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
“Loss of minimum essential coverage” includes, but is not limited to, loss of that coverage due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code. “Loss of minimum essential coverage” also includes loss of that coverage for a reason that is not due to the fault of the individual.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
“Loss of minimum essential coverage” does not include loss of that coverage due to the individual’s failure to pay premiums on a timely basis or situations allowing for a rescission, subject to clause (ii) and Sections 10119.2 and 10384.17.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The individual gains a dependent or becomes a dependent.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
The individual is mandated to be covered as a dependent pursuant to a valid state or federal court order.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
The individual has been released from incarceration.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
The individual’s health coverage issuer substantially violated a material provision of the health coverage contract.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
The individual gains access to new health benefit plans as a result of a permanent move.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
The individual was receiving services from a contracting provider under another health benefit plan, as defined in Section 10965 of this code or Section 1399.845
of the Health and Safety Code, for one of the conditions described in subdivision (a) of Section 10133.56 of this code and that provider is no longer participating in the health benefit plan.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
The individual demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the department, with respect to health benefit plans offered outside the Exchange, that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because the individual was misinformed that the individual was covered under minimum essential coverage.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
The individual is a member of the reserve forces of the United States military returning from active duty or a member of the California National
Guard returning from active duty service under Title 32 of the United States Code.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
The individual is pregnant.
</html:p>
<html:p>
(K)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, in addition to the triggering events listed in this paragraph, any other events listed in Section 155.420(d) of
Title 45 of the Code of Federal Regulations.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered outside the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to apply for coverage from a health care service plan subject to this section. With respect to individual health benefit plans offered through the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to select a plan offered through the Exchange, unless a longer period is provided in Part 155 (commencing with Section 155.10) of Subchapter B of Subtitle A of Title 45 of the Code of Federal Regulations.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
With respect to individual health benefit plans offered through the Exchange, the effective
date of coverage required pursuant to this section shall be consistent with the dates specified in Section 155.410 or 155.420 of Title 45 of the Code of Federal Regulations, as applicable. A dependent who is a registered domestic partner pursuant to Section 297 of the Family Code shall have the same effective date of coverage as a spouse.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan offered outside the Exchange, the following provisions shall apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
After an individual submits a completed application form for a plan, the insurer shall, within 30 days, notify the individual of the individual’s actual premium charges for that plan established in accordance with Section 10965.9. The individual shall have 30 days in which to exercise the right to buy coverage at the quoted premium
charges.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an individual applies during the initial open enrollment period described in paragraph (1) of subdivision (c), when the policyholder submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, by December 15, 2013, coverage under the individual health benefit plan shall become effective no later than January 1, 2014. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16, 2013, to December 31, 2013, inclusive, or after the 15th day of any subsequent month, coverage shall become effective no later than
the first day of the second month following delivery or postmark of the payment.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an individual applies during the annual open enrollment period described in paragraph (1) of subdivision (c), when the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs later, by December 15 of the preceding calendar year, coverage shall become effective on January 1 of the benefit year. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16 to December 31, inclusive, or after the 15th day of any subsequent month, coverage shall
become effective no later than the first day of the second month following delivery or postmark of the payment.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
With respect to an individual health benefit plan for which an individual applies during a special enrollment period described in subdivision (d), the following provisions shall apply:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
When the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, within the first 15 days of the month, coverage under the plan shall become effective no later than the first day of the following month. When the premium payment is neither delivered nor postmarked until after the 15th day of the month, coverage shall become effective no later than the first day of the second month following delivery
or postmark of the payment.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Notwithstanding subparagraph (A), in the case of a birth, adoption, or placement for adoption, the coverage shall be effective on the date of birth, adoption, or placement for adoption.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Notwithstanding subparagraph (A), in the case of marriage or becoming a registered domestic partner or in the case where a qualified individual loses minimum essential coverage, the coverage effective date shall be the first day of the month following the date the insurer receives the request for special enrollment.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health insurer shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of an individual health
benefit plan based on any of the following factors:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Health status.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Medical condition, including physical and mental illnesses.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Claims experience.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Receipt of health care.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Medical history.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Genetic information.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Evidence of insurability, including conditions arising out of acts of domestic violence.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Disability.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Any
other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the federal Public Health Service Act (Public Law 78-410).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding subdivision (c) of Section 10291.5, a health insurer shall not require an individual applicant or the applicant’s dependent to fill out a health assessment or medical questionnaire prior to enrollment under an individual health benefit plan. A health insurer shall not acquire or request information that relates to a health status-related factor from the applicant or the applicant’s dependent or any other source prior to enrollment of the individual.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
A health insurer shall consider as a single risk pool for rating purposes in the individual market the claims
experience of all insureds and enrollees in all nongrandfathered individual health benefit plans offered by that insurer in this state, whether offered
as health care service plan contracts or individual health insurance policies, including those insureds and enrollees who enroll in individual coverage through the Exchange and insureds and enrollees who enroll in individual coverage outside the Exchange. Student health insurance coverage, as such coverage is defined in Section 147.145(a) of Title 45 of the Code of Federal Regulations, shall not be included in a health insurer’s single risk pool for individual coverage.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Each calendar year, a health insurer shall establish an index rate for the individual market in the state based on the total combined claims costs for providing essential health benefits, as defined pursuant to Section 1302 of PPACA, within the single risk pool required under paragraph (1). The index rate shall be adjusted on a marketwide basis based on
the total expected marketwide payments and charges under the risk adjustment program established for the state pursuant to Section 1343 of PPACA and Exchange user fees, as described in subdivision (d) of Section 156.80 of Title 45 of the Code of Federal Regulations. The premium rate for all of the health benefit plans in the individual market within the single risk pool required under paragraph (1) shall use the applicable marketwide adjusted index rate, subject only to the adjustments permitted under paragraph (3).
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
A health insurer may vary premium rates for a particular health benefit plan from its index rate based only on the following actuarially justified plan-specific factors:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The actuarial value and cost-sharing design of the health benefit plan.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
The health benefit plan’s provider network, delivery system characteristics, and utilization management practices.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
The benefits provided under the health benefit plan that are in addition to the essential health benefits, as defined pursuant to Section 1302 of PPACA and Section 10112.27. These additional benefits shall be pooled with similar benefits within the single risk pool required under paragraph (1) and the claims experience from those benefits shall be utilized to determine rate variations for plans that offer those benefits in addition to essential health benefits.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
With respect to catastrophic plans, as described in subsection (e) of Section 1302 of PPACA, the expected impact of the specific eligibility
categories for those plans.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Administrative costs, excluding any user fees required by the Exchange.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
This section shall only apply with respect to individual health benefit plans for policy years on or after January 1, 2014.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
This section shall not apply to a grandfathered health plan.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_D8FF87E4-EE27-49C4-87F0-F48F07A68DD9">
<ns0:Num>SEC. 4.</ns0:Num>
<ns0:Content>
<html:p>
No reimbursement is required by this act pursuant to Section 6 of Article XIII
<html:span class="ThinSpace"/>
B 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 XIII
<html:span class="ThinSpace"/>
B of the California Constitution.
</html:p>
</ns0:Content>
</ns0:BillSection>
</ns0:Bill>
</ns0:MeasureDoc>
|