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<ns0:Id>20250SB__006295CHP</ns0:Id>
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<ns0:ActionText>FILED</ns0:ActionText>
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<ns0:LegislativeInfo>
<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Senator Menjivar</ns0:AuthorText>
<ns0:AuthorText authorType="PRINCIPAL_COAUTHOR_OPPOSITE">(Principal coauthor: Assembly Member Bonta)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Menjivar</ns0:Name>
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<ns0:Legislator>
<ns0:Contribution>PRINCIPAL_COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Bonta</ns0:Name>
</ns0:Legislator>
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<ns0:Title> An act to amend Section 1367.005 of the Health and Safety Code, relating to health care coverage. </ns0:Title>
<ns0:RelatingClause>health care coverage</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Health care coverage: essential health benefits.</ns0:Subject>
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<ns0:DigestText>
<html:p>Existing law, the Knox-Keene Health Care Service Plan Act of 1975, requires the Department of Managed Health Care to license and regulate health care service plans and makes a willful violation of the act a crime. Existing law requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act. Existing law requires a health care service plan contract
to cover the same health benefits that the benchmark plan, the Kaiser Foundation Health Plan Small Group HMO 30 plan, offered during the first quarter of 2014, as specified.</html:p>
<html:p>This bill would express the intent of the Legislature to review California’s essential health benefits benchmark plan and establish a new benchmark plan for the 2027 plan year for health care service plans. The bill would require, commencing January 1, 2027, if the United States Department of Health and Human Services approves a new essential health benefits benchmark plan for the state, as specified, the benchmark plan for health care service plans to include certain additional
benefits, including coverage for specified fertility services and specified durable medical equipment. Because a violation of the bill 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>
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<ns0:VoteRequired>MAJORITY</ns0:VoteRequired>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_5EEDA83E-30A4-4342-B865-AD9E2C16AE6C">
<ns0:Num>SECTION 1.</ns0:Num>
<ns0:Content>
<html:p>It is the intent of the Legislature to review California’s essential health benefits benchmark plan and establish a new benchmark plan for the 2027 plan year for health care service plans.</html:p>
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<ns0:BillSection id="id_48732909-5B59-4965-808D-D3C4293C31F8">
<ns0:Num>SEC. 2.</ns0:Num>
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Section 1367.005 of the
<ns0:DocName>Health and Safety Code</ns0:DocName>
is amended to read:
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<ns0:Num>1367.005.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
An individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, shall include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act (PPACA) and as outlined in this section. For purposes of this section, “essential health benefits” means all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Health benefits within the categories identified in Section 1302(b) of PPACA: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and
habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
The health benefits covered by the Kaiser Foundation Health Plan Small Group HMO 30 plan (federal health product identification number 40513CA035) as this plan was offered during the first quarter of 2014, as follows, regardless of whether the benefits are specifically referenced in the evidence of coverage or plan contract for that plan:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Medically necessary basic health care services, as defined in subdivision (b) of Section 1345 and Section 1300.67 of Title 28 of the California Code of Regulations.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
The health benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in the following sections: Sections 1367.002, 1367.06, and 1367.35 (preventive services for children); Section 1367.25 (prescription drug coverage for contraceptives); Section 1367.45 (AIDS vaccine); Section 1367.46 (HIV testing); Section 1367.51 (diabetes); Section 1367.54 (alpha-fetoprotein testing); Section 1367.6 (breast cancer screening); Section 1367.61 (prosthetics for laryngectomy); Section 1367.62 (maternity hospital stay); Section 1367.63 (reconstructive surgery); Section 1367.635 (mastectomies); Section 1367.64 (prostate cancer); Section 1367.65 (mammography); Section 1367.66 (cervical cancer); Section 1367.665 (cancer screening tests); Section 1367.67 (osteoporosis); Section 1367.68 (surgical procedures for jaw bones); Section 1367.71 (anesthesia
for dental); Section 1367.9 (conditions attributable to diethylstilbestrol); Section 1368.2 (hospice care); Section 1370.6 (cancer clinical trials); Section 1371.5 (emergency response ambulance or ambulance transport services); subdivision (b) of Section 1373 (sterilization operations or procedures); Section 1373.4 (inpatient hospital and ambulatory maternity); Section 1374.56 (phenylketonuria); Section 1374.17 (organ transplants for HIV); Section 1374.72 (mental health parity); and Section 1374.73 (autism/behavioral health treatment).
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Any other benefits mandated to be covered by the plan pursuant to statutes enacted before December 31, 2011, as described in those statutes.
</html:p>
<html:p>
(iv)
<html:span class="EnSpace"/>
The health benefits covered by the plan that are not otherwise required to be covered under
this chapter, to the extent required pursuant to Sections 1367.18, 1367.21, 1367.215, 1367.22, 1367.24, and 1367.25, and Section 1300.67.24 of Title 28 of the
California Code of Regulations.
</html:p>
<html:p>
(v)
<html:span class="EnSpace"/>
Any other health benefits covered by the plan that are not otherwise required to be covered under this chapter.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
If there are any conflicts or omissions in the plan identified in subparagraph (A) as compared with the requirements for health benefits under this chapter that were enacted prior to December 31, 2011, the requirements of this chapter shall be controlling, except as otherwise specified in this section.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Notwithstanding subparagraph (B) or any other provision of this section, the home health services benefits covered under the plan identified in subparagraph (A) shall be deemed to not be in conflict with this chapter.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
For purposes of this section, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343) shall apply to a contract subject to this section. Coverage of mental health and substance use disorder services pursuant to this paragraph, along with any scope and duration limits imposed on the benefits, shall be in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343), and all rules, regulations, or guidance issued pursuant to Section 2726 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-26).
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Commencing January 1, 2027, if the United States Department of Health and Human Services approves a new essential health benefits benchmark plan for the State of California pursuant to submissions to the
department made on behalf of the state in 2025 for this purpose, the benchmark plan described in subparagraph (A) shall additionally include all of the following benefits:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Services to evaluate, diagnose, and treat infertility that include all of the following:
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Artificial insemination.
</html:p>
<html:p>
(II)
<html:span class="EnSpace"/>
Three attempts to retrieve gametes.
</html:p>
<html:p>
(III)
<html:span class="EnSpace"/>
Three attempts to create embryos.
</html:p>
<html:p>
(IV)
<html:span class="EnSpace"/>
Three rounds of pretransfer testing.
</html:p>
<html:p>
(V)
<html:span class="EnSpace"/>
Cryopreservation of gametes and embryos.
</html:p>
<html:p>
(VI)
<html:span class="EnSpace"/>
Two years of
storage for cryopreserved embryos.
</html:p>
<html:p>
(VII)
<html:span class="EnSpace"/>
Unlimited storage for cryopreserved gametes.
</html:p>
<html:p>
(VIII)
<html:span class="EnSpace"/>
Unlimited embryo transfers.
</html:p>
<html:p>
(IX)
<html:span class="EnSpace"/>
Two vials of donor sperm.
</html:p>
<html:p>
(X)
<html:span class="EnSpace"/>
Ten donor eggs.
</html:p>
<html:p>
(XI)
<html:span class="EnSpace"/>
Surrogacy coverage for the services described above.
</html:p>
<html:p>
(XII)
<html:span class="EnSpace"/>
Health testing of the surrogate for each attempted round of covered services.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
All of the following durable medical equipment:
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Mobility devices, including, but not limited to, walkers
and manual and power wheelchairs and scooters.
</html:p>
<html:p>
(II)
<html:span class="EnSpace"/>
Augmented communications devices, including, but not limited to, speech generating devices, communications boards, and computer applications.
</html:p>
<html:p>
(III)
<html:span class="EnSpace"/>
Continuous positive airway pressure machines.
</html:p>
<html:p>
(IV)
<html:span class="EnSpace"/>
Portable oxygen.
</html:p>
<html:p>
(V)
<html:span class="EnSpace"/>
Hospital beds.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
(I)
<html:span class="EnSpace"/>
An annual hearing exam.
</html:p>
<html:p>
(II)
<html:span class="EnSpace"/>
One hearing aid per ear every three years.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
With respect to habilitative services, in addition to any habilitative services and
devices identified in paragraph (2), coverage shall also be provided as required by federal rules, regulations, and guidance issued pursuant to Section 1302(b) of PPACA. Habilitative services and devices shall be covered under the same terms and conditions applied to rehabilitative services and devices under the plan contract. Limits on habilitative and rehabilitative services and devices shall not be combined.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
With respect to pediatric vision care, the same health benefits for pediatric vision care covered under the Federal Employees Dental and Vision Insurance Program vision plan with the largest national enrollment as of the first quarter of 2014. The pediatric vision care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any vision services covered under the plan identified in paragraph
(2).
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
With respect to pediatric oral care, the same health benefits for pediatric oral care covered under the dental benefit received by children under the Medi-Cal program as of 2014, including the provision of medically necessary orthodontic care provided pursuant to the federal Children’s Health Insurance Program Reauthorization Act of 2009. The pediatric oral care benefits covered pursuant to this paragraph shall be in addition to, and shall not replace, any dental or orthodontic services covered under the plan identified in paragraph (2).
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
Treatment limitations imposed on health benefits described in this section shall be no greater than the treatment limitations imposed by the corresponding plans identified in subdivision (a), subject to the requirements set
forth in paragraph (2) of subdivision (a).
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
Except as provided in subdivision (d), this section does not permit a health care service plan to make substitutions for the benefits required to be covered under this section, regardless of whether those substitutions are actuarially equivalent.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
To the extent permitted under Section 1302 of PPACA and any rules, regulations, or guidance issued pursuant to that section, and to the extent that substitution would not create an obligation for the state to defray costs for any individual, a plan may substitute its prescription drug formulary for the formulary provided under the plan identified in subdivision (a) if the coverage for prescription drugs complies with the sections referenced in clauses (ii) and (iv) of subparagraph (A) of
paragraph (2) of subdivision (a) that apply to prescription drugs.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
A health care service plan, or its agent, solicitor, or representative, shall not issue, deliver, renew, offer, market, represent, or sell any product, contract, or discount arrangement as compliant with the essential health benefits requirement in federal law, unless it meets all of the requirements of this section.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
This section applies regardless of whether the plan contract is offered inside or outside the California Health Benefit Exchange created by Section 100500 of the Government Code.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
This section does not exempt a plan or a plan contract from meeting other applicable requirements of law.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
This section does not prohibit a plan contract from covering additional benefits, including, but not limited to, spiritual care services that are tax deductible under Section 213 of the Internal Revenue Code.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Subdivision (a) does not apply to any of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
A specialized health care service plan contract.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A Medicare supplement plan.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
A plan contract that qualifies as a grandfathered health plan under Section 1251 of PPACA or any rules, regulations, or guidance issued pursuant to that section.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
This section shall not be implemented in a manner that conflicts with
a requirement of PPACA.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
An essential health benefit is required to be provided under this section only to the extent that federal law does not require the state to defray the costs of the benefit.
</html:p>
<html:p>
(l)
<html:span class="EnSpace"/>
This section does not obligate the state to incur costs for the coverage of benefits that are not essential health benefits as defined in this section.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
A plan is not required to cover, under this section, changes to health benefits that are the result of statutes enacted on or after December 31, 2011.
</html:p>
<html:p>
(n)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
On or before January 1, 2027, the department may issue guidance to health care service plans regarding compliance with this section. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The department may promulgate regulations subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) to implement this section. This subdivision shall not be construed to impair or restrict the department’s rulemaking authority pursuant to another provision of this code or the Administrative Procedure
Act.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The department shall consult with the Department of Insurance in issuing guidance and in adopting regulations pursuant to paragraphs (1) and (2) for the purpose of implementing this section.
</html:p>
<html:p>
(o)
<html:span class="EnSpace"/>
For purposes of this section, the following definitions apply:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Habilitative services” means health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings, or both. Habilitative services shall be
covered under the same terms and conditions applied to rehabilitative services under the plan contract.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
“Health benefits,” unless otherwise required to be defined pursuant to federal rules, regulations, or guidance issued pursuant to Section 1302(b) of PPACA, means health care items or services for the diagnosis, cure, mitigation, treatment, or prevention of illness, injury, disease, or a health condition, including a behavioral health condition.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
“Health benefits” does not mean any cost-sharing requirements such as copayments, coinsurance, or deductibles.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
“PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued thereunder.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
“Small group health care service plan contract” means a group health care service plan contract issued to a small employer, as defined in Section 1357.500.
</html:p>
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<ns0:Num>SEC. 3.</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.
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