§ 1367.0061
550 words·~3 min read·
/ca/health-and-safety-code/1367-0061A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(a)For a health care service plan contract issued, amended, or renewed on or after July 1, 2022, in the individual or group market, a health care service plan shall monitor an enrollee’s accrual toward their annual deductible, if any, for covered benefits, as set forth in this section and any regulations promulgated by the department.
(1)A health care service plan shall provide an enrollee with their accrual balance toward their annual deductible for every month in which benefits were used and until the accrual balance equals the full deductible amount.
(2)A health care service plan subject to this section shall establish and maintain a system that allows an enrollee to request their most up-to-date accrual balance toward their annual deductible from their health care service plan at any time.
(3)If the health care service plan contract includes more than one annual deductible for an enrollee, then this section applies to each deductible.
(b)For a health care service plan contract issued, amended, or renewed on or after July 1, 2022, in the individual or group market, a health care service plan shall monitor an enrollee’s accrual toward their annual out-of-pocket maximum, if any, for covered benefits, as set forth in this section and any regulations promulgated by the department.
(1)A health care service plan shall provide an enrollee with their accrual balance toward their annual out-of-pocket maximum for every month in which benefits were used and until the accrual balance equals the full out-of-pocket maximum.
(2)A health care service plan subject to this section shall establish and maintain a system that allows an enrollee to request their most up-to-date accrual balance toward their annual out-of-pocket maximum from their health care service plan at any time.
(c)Accrual updates shall be mailed to enrollees unless the enrollee has elected to opt out of mailed notice and elected to receive the accrual update electronically, or unless the enrollee has previously opted out of mailed notices.
(1)Enrollees who have opted out of receiving mailed notice may opt back in at any time.
(2)Accrual updates may be included with evidence of benefit statements.
(d)A health care service plan shall notify enrollees of their rights pursuant to this section, including, but not limited to, how to request information and how to opt out of mailed notices and elect to instead receive their accrual update electronically, in the manner set forth by the department. The department may issue guidance regarding implementation of, and compliance with, this subdivision. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 1340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2027. The department shall consult with stakeholders in developing guidance pursuant to this subdivision.
(e)If a health care service plan delegates claims payment functions to a contracted entity, including, but not limited to, a medical group or independent practice association, then the delegated entity shall comply with the requirements of this section. A health care service plan shall specify by contract the delegated entity’s responsibilities and shall monitor the delegated entity to ensure compliance with this section. Notwithstanding delegation pursuant to this subdivision, the health care service plan shall remain responsible for compliance with this section.