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Legal Resources | Health and Safety Code |  HS  1367.0065  

Health Care Coverage   

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(a) This section shall apply to nongrandfathered individual and group health care service plan contracts that provide coverage for essential health benefits defined in Section 1367.005 and that are issued, amended, or renewed for the 2014 plan year.

(b) (1) For nongrandfathered health care service plan contracts in the individual market, and to the extent allowed by federal law, regulations, and guidance, a health care service plan contract, except a specialized health care service plan contract, shall provide for a limit on annual out-of-pocket expenses for all covered benefits that meet the definition of essential health benefits as defined in Section 1367.005, including out-of-network emergency care consistent with Section 1371.4. The total out-of-pocket maximum shall not exceed six thousand three hundred fifty dollars ($6,350) for individual coverage and twelve thousand seven hundred dollars ($12,700) for family coverage.

(2) For nongrandfathered specialized health care service plan contracts in the individual market that provide the pediatric oral care benefit meeting the definition in Section 1302(b)(1)(j) of PPACA, the out-of-pocket maximum for the pediatric oral care benefit shall not exceed one thousand dollars ($1,000) for one child and two thousand dollars ($2,000) for more than one child.

(3) A health care service plan shall not apply a separate out-of-pocket maximum to mental health or substance use disorder benefits.

(c) For nongrandfathered health care service plan contracts in the small group markets, and to the extent allowed by federal law, regulations, and guidance, a health care service plan contract, except a specialized health care service plan contract, shall provide for a limit on annual out-of-pocket expenses for all covered benefits that meet the definition of essential health benefits, as defined in Section 1367.005, including out-of-network emergency care consistent with Section 1371.4, as follows:

(1) With respect to all essential health benefits, except for the pediatric oral care benefit, the total out-of-pocket maximum shall not exceed six thousand three hundred fifty dollars ($6,350) for individual coverage and twelve thousand seven hundred dollars ($12,700) for family coverage. For small group health plan contracts the total out-of-pocket maximum limit in this paragraph may be split between prescription drug services and all other essential health benefits.

(2) The separate out-of-pocket maximum for pediatric oral care benefits meeting the definition in Section 1302(b)(1)(j) of PPACA shall not exceed one thousand dollars ($1,000) for one child or two thousand dollars ($2,000) for more than one child.

(3) A health care service plan shall not apply a separate out-of-pocket maximum to mental health or substance use disorder benefits.

(d) For nongrandfathered health care service plan contracts in the large group market, a health care service plan contract, except a specialized health care service plan contract, shall provide for a limit on annual out-of-pocket expenses for covered benefits, including out-of-network emergency care consistent with Section 1371.4. This limit shall apply only to essential health benefits, as defined in Section 1367.005, that are covered under the plan contract. This limit shall be as follows:

(1) The total out-of-pocket maximum shall not exceed six thousand three hundred fifty dollars ($6,350) for individual coverage or twelve thousand seven hundred dollars ($12,700) for family coverage with respect to basic health care services as defined in subdivision (b) of Section 1345, and services, except for prescription drugs, required under Sections 1374.72 and 1374.73.

(2) To the extent the plan contract includes an out-of-pocket maximum on coverage other than the coverage defined in paragraph (1), that out-of-pocket maximum shall not exceed six thousand three hundred fifty dollars ($6,350) for individual coverage or twelve thousand seven hundred dollars ($12,700) for family coverage.

(3) An enrollee in a large group plan contract shall not be subject to more than two limits on annual out-of-pocket expenses for covered benefits that meet the definition of essential health benefits.

(4) A health care service plan shall not apply a separate out-of-pocket maximum to mental health or substance use disorder benefits.

(5) This subdivision shall apply only to the extent that it does not conflict with federal law or guidance on out-of-pocket maximums for nongrandfathered health plan contracts in the large group market.

(e) Nothing in this section shall be construed to affect the reduction in cost sharing for eligible enrollees described in Section 1402 of PPACA, and any subsequent rules, regulations, or guidance issued under that section.

(f) The limits described in this section shall apply to any copayment, coinsurance, deductible, and any other form of cost sharing for all covered services that meet the definition of essential health benefits.

(g) For nongrandfathered health plan contracts in the group market, ?plan year? has the meaning set forth in Section 144.103 of Title 45 of the Code of Federal Regulations. For nongrandfathered health plan contracts sold in the individual market, ?plan year? means the calendar year.

(h) ?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.

(i) This section shall remain in effect only until January 1, 2016, and as of that date is repealed, unless a later enacted statute, that is enacted before January 1, 2016, deletes or extends that date.

(Added by Stats. 2013, Ch. 316, Sec. 4.)