Cal. HSC § 1385.043 — California Code / Code hsc / Division 2 / Chapter 2.2 / Article 6.2 / Section 1385.043
Section 1385.043
Status: in_force

(a) A health care service plan, not including a specialized health care service plan, shall annually report to the department the information described in subdivision (c) for all grandfathered and nongrandfathered products that the plan offers and sells in the individual market, including both on-exchange and off-exchange enrollment, for rates effective during the 12-month period ending January 1 of the following year.

(b) A health care service plan, not including a specialized health care service plan, shall annually report to the department the information described in subdivision (c) for all grandfathered and nongrandfathered products that the plan offers and sells in the small group market, including both on-exchange and off-exchange enrollment, for products with rates effective during that 12-month period ending January 1 of the following year.

(c) (1) Information on premiums, including share of premium, if applicable, average premium weighted by enrollment, and weighted average rate change.

(2) Cost sharing, including deductibles, maximum out-of-pocket limit, copayments, coinsurance, and any other cost sharing for covered benefits as well as high deductible health plans.

(3) (A) For nongrandfathered plans, benefits, including essential health benefits or basic health care services.

(B) For grandfathered plans, basic health care services and mandates.

(4) Standard and nonstandard benefit designs, including on-exchange and off-exchange nonstandard benefit designs.

(5) Enrollment by actuarial value tier, product, benefit design and premiums, including both of the following:

(A) Enrollment in products with zero deductibles, high deductibles as defined in this section, and deductibles between zero and high.

(B) (i) Enrollment by premium.

(ii)  For small group products, enrollment by share of premium.

(6) Trend factors as reported in individual and small group rate filings for the health care service plan, including both price and utilization, as required in Section 1385.03.

(d) By October 1, 2021, and annually thereafter, a health care service plan shall submit the annual report, as described under subdivision (a), to the department in a form and manner determined by the department.

(e) Beginning in 2022, the department shall annually present the information reported under this section in the meeting specified in Section 1385.045, a meeting of the Financial Solvency Standards Board, or at any other public meeting the department deems appropriate. The department also shall post the information reported under this section on its internet website no later than December 15 of each year.

(f) The following definitions apply for purposes of this section:

(1) “Average premium weighted by enrollment” means the following:

(A) For the individual market, the average premium shall be weighted by the number of individual enrollees in the plan’s individual market during the 12-month period.

(B) For the small group market, the average premium shall be weighted by the number of enrollees in each small group benefit design in the plan’s small group market during the 12-month period.

(2) “Benefit design” means the cost sharing for covered benefits.

(3) “High deductible” has the same meaning as defined in Section 223(c)(2)(A) of Title 26 of the United States Code.

(4) “Nonstandard benefit design” means a benefit design other than the standard benefit design.

(5) “Share of premium” means the share of premium paid by the enrollee on behalf of the enrollee and any dependents, not the subscriber.

(6) “Standard benefit design” means the standardized products approved by the executive board of the California Health Benefit Exchange pursuant to subdivision (c) of Section 100504 of the Government Code.

(g) Until January 1, 2023, a health care service plan shall not be required to report either of the following information:

(1) Share of premium paid by enrollee.

(2) Enrollment by benefit design, deductible, or share of premium.

(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-plan letters, forms, or similar instructions, without taking regulatory action until January 1, 2024.