Amended
IN
Senate
June 23, 2025 |
Amended
IN
Assembly
March 17, 2025 |
Introduced by Assembly Member Bonta (Principal coauthor: Assembly Member Rivas) |
February 18, 2025 |
Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and the regulation of health insurers by the Department of Insurance. For these purposes, existing law defines “unreasonable rate increase” to have the same meaning as in the federal Patient Protection and Affordable Care Act, which is that an unreasonable rate increase exists when the federal Centers for Medicare and Medicaid Services makes a determination that a rate increase is excessive, unjustified, or unfairly discriminatory, among other things.
This bill would instead provide that an “unreasonable rate increase” exists if the Director of the Department of Managed Health Care or the Insurance Commissioner, as applicable, makes a
determination that a rate increase is excessive, unjustified, unfairly discriminatory, or otherwise unreasonable.
(2)Expenditures of campaign funds pursuant to this section shall be limited to a lifetime maximum of ten thousand dollars ($10,000) for a person who is a candidate or elected officer. This lifetime maximum shall apply regardless of whether the person is a candidate or an elected officer for multiple offices.
For purposes of this article, the following definitions shall apply:
(a)(1)“Blended” means a rating method that combines community rating and experience rating methods.
(2)“Community rated” means a rating method in the large group market that bases rates on the expected costs to a health care service plan of providing covered benefits to all enrollees, including both low-risk and high-risk enrollees. Premiums may vary according to the factors in this article.
(3)“Experience rated” means a rating method in the large group market under which a health care service plan calculates the premiums for a large group in whole or blended
based on the group’s prior experience.
(b)(1)For individual and small group market products, “geographic region” has the same meaning as in Sections 1357.512 and 1399.855.
(2)For large group market products, “geographic region” means one of the following areas composed of the regions defined in Sections 1357.512 and 1399.855:
(A)An area composed of regions 2, 4, 5, 6, 7, and 8, which consist of the Counties of Alameda, Contra Costa, Marin, Napa, San Mateo, Santa Clara, Solano, and Sonoma and the City and County of San Francisco.
(B)An area composed of regions 1 and 3, which consist of the Counties of Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Placer,
Plumas, Sacramento, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yolo, and Yuba.
(C)An area composed of regions 9 and 12, which consist of the Counties of Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, and Ventura.
(D)An area composed of regions 10, 11, and 14, which consist of the Counties of Fresno, Kern, Kings, Madera, Mariposa, Merced, San Joaquin, Stanislaus, and Tulare.
(E)An area composed of regions 13 and 17, which consist of the Counties of Imperial, Inyo, Mono, Riverside, and San Bernardino.
(F)An area composed of regions 15 and 16, which consist of the County of Los Angeles.
(G)An area composed of regions 18 and 19, which consist of the
Counties of Orange and San Diego.
(c)“Large group health care service plan contract” means a group health care service plan contract other than a contract issued to a small employer, as defined in Section 1357, 1357.500, or 1357.600.
(d)“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, 1357.500, or 1357.600.
(e)“PPACA” means Section 2794 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-94), as amended by the federal Patient Protection and Affordable Care Act (Public Law (111-148)), and any subsequent rules, regulations, or guidance issued under that section.
(f)An “unreasonable rate increase” exists if the director determines that a rate increase is any of the following:
(1)An excessive rate increase.
(2)An unjustified rate increase.
(3)An unfairly discriminatory rate increase.
(4)Otherwise unreasonable.
For purposes of this article, the following definitions shall apply:
(a)(1)“Blended” means a rating method that combines community rating and experience rating methods.
(2)“Community rated” means a rating method in the large group market that bases rates on the expected costs to a health insurer of providing covered benefits to all insureds, including both low-risk and high-risk insureds. Premiums may vary according to the factors in this article.
(3)“Experience rated” means a rating method in the large group market under which a health insurer calculates the premiums for a large group in whole or blended based on the group’s
prior experience.
(b)(1)For individual and small group market products, “geographic region” has the same meaning as in Sections 10753.14 and 10965.9.
(2)For large group market products, “geographic region” means one of the following areas, composed of the regions defined in Sections 10753.14 and 10965.9:
(A)An area composed of regions 2, 4, 5, 6, 7, and 8, which consist of the Counties of Alameda, Contra Costa, Marin, Napa, San Mateo, Santa Clara, Solano, and Sonoma and the City and County of San Francisco.
(B)An area composed of regions 1 and 3, which consist of the Counties of Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Placer, Plumas, Sacramento,
Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yolo, and Yuba.
(C)An area composed of regions 9 and 12, which consist of the Counties of Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, and Ventura.
(D)An area composed of regions 10, 11, and 14, which consist of the Counties of Fresno, Kern, Kings, Madera, Mariposa, Merced, San Joaquin, Stanislaus, and Tulare.
(E)An area composed of regions 13 and 17, which consist of the Counties of Imperial, Inyo, Mono, Riverside, and San Bernardino.
(F)An area composed of regions 15 and 16, which consist of the County of Los Angeles.
(G)An area composed of regions 18 and 19, which consist of the Counties of Orange and
San Diego.
(c)“Large group health insurance policy” means a group health insurance policy other than a policy issued to a small employer, as defined in Section 10700, 10753, or 10755.
(d)“Small group health insurance policy” means a group health insurance policy issued to a small employer, as defined in Section 10700, 10753, or 10755.
(e)“PPACA” means Section 2794 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-94), as amended by the federal Patient Protection and Affordable Care Act (Public Law 111-148), and any subsequent rules, regulations, or guidance issued pursuant to that law.
(f)An “unreasonable rate increase” exists if the commissioner determines that a rate increase is any of the following:
(1)An excessive rate increase.
(2)An unjustified rate increase.
(3)An unfairly discriminatory rate increase.
(4)Otherwise unreasonable.