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Insurance Code - INS

DIVISION 2. CLASSES OF INSURANCE [1880 - 12880.5]

  ( Division 2 enacted by Stats. 1935, Ch. 145. )

PART 2. LIFE AND DISABILITY INSURANCE [10110 - 11549]

  ( Part 2 enacted by Stats. 1935, Ch. 145. )

CHAPTER 1.5. Health Coverage Contract Notification [10199 - 10199.9]

  ( Chapter 1.5 added by Stats. 1990, Ch. 949, Sec. 2. )

ARTICLE 2. General Provisions [10199.1 - 10199.49]
  ( Article 2 added by Stats. 1990, Ch. 949, Sec. 2. )

10199.1.
  

(a) (1) An insurer or nonprofit hospital service plan or administrator acting on its behalf shall not terminate a group master policy or contract providing hospital, medical, or surgical benefits, increase premiums or charges therefor, reduce or eliminate benefits thereunder, or restrict eligibility for coverage thereunder without providing prior notice of that action. The action shall not become effective unless written notice of the action was delivered by mail to the last known address of the appropriate insurance producer and the appropriate administrator, if any, at least 45 days prior to the effective date of the action and to the last known address of the group policyholder or group contractholder at least 60 days prior to the effective date of the action. If nonemployee certificate holders or employees of more than one employer are covered under the policy or contract, written notice shall also be delivered by mail to the last known address of each nonemployee certificate holder or affected employer or, if the action does not affect all employees and dependents of one or more employers, to the last known address of each affected employee certificate holder, at least 60 days prior to the effective date of the action.

(2) The notice delivered pursuant to paragraph (1) for large group health insurance policies shall also include the following information:

(A) Whether the rate proposed to be in effect is greater than the average rate increase for individual market products negotiated by the California Health Benefit Exchange for the most recent calendar year for which the rates are final.

(B) Whether the rate proposed to be in effect is greater than the average rate increase negotiated by the Board of Administration of the Public Employees’ Retirement System for the most recent calendar year for which the rates are final.

(C) Whether the rate change includes any portion of the excise tax paid by the health insurer.

(b) A holder of a master group policy or a master group nonprofit hospital service plan contract or administrator acting on its behalf shall not terminate the coverage of, increase premiums or charges for, or reduce or eliminate benefits available to, or restrict eligibility for coverage of a covered person, employer unit, or class of certificate holders covered under the policy or contract for hospital, medical, or surgical benefits without first providing prior notice of the action. The action shall not become effective unless written notice was delivered by mail to the last known address of each affected nonemployee certificate holder or employer, or if the action does not affect all employees and dependents of one or more employers, to the last known address of each affected employee certificate holder, at least 60 days prior to the effective date of the action.

(c) A health insurer that declines to offer coverage to or denies enrollment for a large group applying for coverage shall, at the time of the denial of coverage, provide the applicant with the specific reason or reasons for the decision in writing, in clear, easily understandable language.

(d) (1) For small group health insurance policies, if the department determines that a rate is unreasonable or not justified consistent with Article 4.5 (commencing with Section 10181), the insurer shall notify the policyholder of this determination. This notification may be included in the notice required in subdivision (a) or (b).

(2) The notification to the policyholder shall be developed by the department and shall include the following statements in 14-point type:

(A) The Department of Insurance has determined that the rate for this product is unreasonable or not justified after reviewing information submitted to it by the insurer.

(B) The policyholder has the option to obtain other coverage from this insurer or another insurer, or to keep this coverage.

(C) Small business purchasers may want to contact Covered California at www.coveredca.com for help in understanding available options.

(3) The development of the notification required under this subdivision 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).

(4) The insurer may include in the notification to the policyholder the Internet Web site address at which the insurer’s final justification for implementing an increase that has been determined to be unreasonable by the commissioner may be found pursuant to Section 154.230 of Title 45 of the Code of Federal Regulations.

(5) The notice shall also be provided to the agent of record for the policyholder, if any, so that the agent may assist the purchaser in finding other coverage.

(6) In developing the notification, the department shall take into consideration that this notice is required to be provided to a small group applicant pursuant to subdivision (g) of Section 10181.3.

(Amended by Stats. 2016, Ch. 498, Sec. 10. (SB 908) Effective January 1, 2017.)

10199.2.
  

(a)  The written notice described in subdivisions (a) and (b) of Section 10199.1 shall state in italics and in 12-point type the actual dollar amount and the specific percentage of the premium rate increase. Further, the notice shall describe in plain understandable English and highlighted in italics any changes in the plan design or change in benefits with reduction in benefits, waivers, exclusions, or conditions.

(b) The written notice shall specify in a minimum of 10-point bold typeface the reason or reasons for premium rate changes, plan design, or plan benefit changes.

(Amended by Stats. 2010, Ch. 661, Sec. 9. (SB 1163) Effective January 1, 2011.)

10199.3.
  

There shall be no liability on the part of, and no cause of action of any nature shall arise against, any entity required to provide the notice or its authorized representatives, or agents, for any statement made, unless shown to have been made with malice in fact, by any of them in (a) any written notice or in any other oral or written communication specifying the reasons for the notice, (b) any communication providing information pertaining to such notice, or (c) evidence submitted at any court proceeding or informal inquiry in which such notice is at issue.

(Added by Stats. 1990, Ch. 949, Sec. 2.)

10199.4.
  

Proof of mailing a notice and the reason therefor to the appropriate entity or individual at the last known mailing address shall be sufficient proof of the notice required by this chapter.

(Added by Stats. 1990, Ch. 949, Sec. 2.)

10199.44.
  

(a) On or after January 1, 1994, every insurer issuing, amending, or renewing group disability insurance which covers hospital, medical, or surgical expenses shall notify the group policyholders in writing of the cancellation of the group policy and shall include in their contract with group policyholders, regardless of the situs of that contract, a provision requiring the group policyholder to mail promptly to each person covered under the group policy a legible, true copy of any notice of cancellation of the policy which may be received from the insurer and to provide promptly to the insurer proof of that mailing and the date thereof.

(b) The notice of cancellation required by subdivision (a) shall include information regarding the conversion rights of persons covered under the group policy upon termination of the group policy. This information shall be in clear and easily understandable language.

(Added by Stats. 1993, Ch. 1154, Sec. 2. Effective January 1, 1994.)

10199.46.
  

(a) On or after January 1, 1994, every nonprofit hospital service plan issued, amended, or renewed that covers hospital, medical, or surgical expenses on a group basis shall notify the group contractholders in writing of the cancellation of the plan contract and shall include in their contract with group contractholders a provision requiring the group contractholder to mail promptly to each subscriber a legible, true copy of any notice of cancellation of the plan contract which may be received from the plan and to provide promptly to the plan proof of that mailing and the date thereof.

(b) The notice of cancellation required by subdivision (a) shall include information regarding the conversion rights of persons covered under the plan contract upon termination of the plan contract. This information shall be in clear and easily understandable language.

(Added by Stats. 1993, Ch. 1154, Sec. 3. Effective January 1, 1994.)

10199.48.
  

(a) No health insurer shall, with regard to a group contract, change the premium rates or applicable copayments or coinsurances or deductibles for the length of the contract, except as specified in subdivision (b), during any of the following time periods:

(1) After the group policyholder or group contractholder has delivered written notice of acceptance of the contract or policy.

(2) After the start of the employer’s annual open enrollment period.

(3) After the receipt of payment of the premium for the first month of coverage in accordance with the contract or policy effective date.

(b) Changes to the premium rates or applicable copayments or coinsurances or deductibles of a contract or policy shall, subject to the insurer meeting the requirements of this chapter, be allowed in any of the following circumstances:

(1) When authorized or required in the group contract or policy.

(2) When the contract or policy was agreed to under a preliminary agreement that states that it is subject to execution of a definitive agreement.

(3) When the insurer and the policyholder or contractholder mutually agree in writing.

(Added by Stats. 2002, Ch. 336, Sec. 5. Effective January 1, 2003.)

10199.49.
  

(a) This section shall apply to grandfathered health insurance policies and nongrandfathered health insurance policies in the individual or small group markets that are issued, amended, or renewed on or after January 1, 2017.

(b) Notwithstanding paragraph (1) of subdivision (b) of Section 10199.48, a health insurance policy shall not change the cost-sharing design during the policy year, except when required by state or federal law.

(c) For purposes of this section, the following definitions shall apply:

(1) “Cost sharing” includes any copayment, coinsurance, deductible, or any other form of cost sharing by the insured other than the premium or share of premium.

(2) “Policy year” has the meaning set forth in Section 144.103 of Title 45 of the Code of Federal Regulations. For nongrandfathered health insurance policies in the individual market, “policy year” means the calendar year.

(3) “Cost-sharing design” means the amount or proportion of cost sharing applied to a covered benefit.

(Added by Stats. 2016, Ch. 192, Sec. 2. (SB 923) Effective January 1, 2017.)

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