California insurance law and regulation
News that affects your health insurance and planning
June 13, 2022 – Anthem Blue Cross will pay a $1.1 million fine over two member benefits violations. The insurer inappropriately applied certain fully covered office visits to the deductible for more than 6,500 members. It also failed to send out explanation of benefits documents to more than 300,000 Californians.
May 24, 2019 – Status of alternative non-ACA health plans: California does not require individuals to maintain ACA-compliant health coverage. The state provides no premium or cost-sharing subsidies for individual market coverage. California does not permit insurers to sell non-compliant transitional policies in the individual market. California sets stricter limits on the sale of short-term coverage than the federal government, prohibits underwritten short-term coverage and limits the initial contract duration of underwritten short-term coverage to a six month policy. (Source: Commonwealth Fund).
March 19, 2019 – Covered California released a report, “Covered California’s Efforts to Lower Costs While Ensuring Consumers Get the Right Care at the Right Time” designed to explain its strategic plan for consumers.
The history of health care planning in California (Information is outdated and links may be expired)
4/29/2015 Covered California are their fristrations on social media. Over 200 Yelp users gave the state insurance exchange a poor rating and some posted photos illustrating the source of their frustration.
12/7/2014 Covered California acknowledges a systematic probkem in procesing requests to cancel coverage. We recommend that requests to cancel or change coverage be made in writing or online and not by telephone. Contact information is available atwww.CoveredCA.com/contact/.
9/27/2014 Two of California’s five largest health insurance companies Cigna and Blue Shield of California are being sued by consumer advocate groups for misleading consumers during this year’s open enrollment season about the number of doctors and hospitals participating in their networks. Freedom Benefits adviser tony Novak predicted and wrote about this problem as a design fault in Obamacare policies and the exchange system prior to the offering of 2014 coverage. Freedom Benefits clarifies that this limitation on network coverage does not apply to short term medical insurance or any of the Supplemental Accident Insurance plans listed on its web site or offered through Members Insurance Exchange. Kaiserhealthnews.org that reported the story also discloses that Blue Shield of California helps support its service in the state.
2/11/2014 Professional support for any health care reform issue is available free of charge through an arrangement with OnlineNavigator. All online inquiries are handled personally by Tony Novak, CPA. Online support is available through a number of popular social media channels including Facebook and Google+ as well as e-mail. Telephone support for insurance enrollment is available through Members Insurance Exchange at (800) 609-0683.
10/7/2013 Cover California insurance exchange now has more than 500 trained call center workers, 13,000 agents/broker insurance producers, thousands of enrollment advisor applicants and 20,000 county eligibility workers to assist more than 7 million consumers without health insurance. It appears that California’s insurance exchange system is off to a better start than most other states. Some insurance brokers reported significant difficulties in the first week of the online enrollment system.
7/26/2013 Affordable Smart Term Life Insurance is now available to most California residents from age 20 through 60 directly online with no physical exam, agent appointment or telephone verification. Most policies are issued on the same day with coverage amounts of $25,000 up to $350,000. The level premium life insurance is available for terms of 10, 15, 20 and 30 years. Sample rates for $150,000 coverage for a preferred risk male age 30, non-tobacco $30.85 per month; tobacco user $49.55 per month. A preferred risk female age 30 non-tobacco user would be $26.49 per month and a tobacco user would be $40.96 per month. Rates are higher for older applicants and lower health risks as described online. Pricing is based on input you provide about your medical history but, unlike most other life insurers, does not consider family medical history. Coverage is issued by innovative National Life Group, rated “A” by A.M. Best Company for 2013.
5/24/2013 The California Pre-existing Condition Insurance Plan (PCIP) will be discontinued on June 30, 2013. Current enrollees will be notified by mail may they switch to the federal PCIP plan as long as they pay their July premium in advance in accordance to the instructions in the conversion letter. If a subscriber is in the course of treatment or has received prior-authorization for services, he or she will be mailed guidance about transition of care. It is critical that he or she follow required pre-authorization of benefits procedures for hospitalization, durable medical equipment or supplies, transplants, skilled nursing, long-term acute care or rehabilitation facility admission, spinal fusion surgery or cancer treatment plans anticipated to occur on or after July 1. This is necessary even if the subscriber was already authorized with the California PCIP. Those who are not currently enrolled or those who miss the deadline can convert to a limited benefit medical insurance through Freedom Benefits or another commercial insurance exchange until the beginning of 2014 when all major medical insurance is available in the same manner as the current PCIP. More information about the federal PCIP, is available at www.pcip.gov or 866-717-5826 Monday-Friday 5:00 am to 8:00 pm pacific time (TTY: 1-866-561-1604).
5/23/2013 Officials for the Covered California insurance exchange confirmed that large national insurance companies including Aetna, Cigna and UnitedHealth care declined to participate on the new exchange for 2014. The exchange also announced that it expects to sell primarily to working class applicants in the “less than 400% of poverty” income threshold for premium assistance under current federal law.
3/3/2013 California suspended enrollment in its Pre-existing Condition Insurance Plan. Applications received after March 2, 2013 for the PCIP program will no longer be enrolled unless they meet the limited exception criterion. Instead, the PCIP/MRMIP Applications will be processed for the California’s high risk pool, Major Risk Medical Insurance Plan (MRMIP) eligibility. The MRMIP is still open for new enrollment and available for individuals with a pre-existing condition, if eligible. The PCIP/MRMIP Application is currently used for both PCIP and MRMIP.
2/22/2013 This page was updated to include a link to the insurance plan that will be used to determine specific “essential health benefits” for insurance that qualified for 2014 federal tax purposes. Also, a link to additional covered benefits required by state law. Non-qualified insurance is likely to continue to be available at a lower cost that does not include these benefits nor qualify for federal tax purposes.
8/2/2012 The state is planning a massive advertising campaign for the California Health Benefit Exchange next year that will be ready to launch in January 2014 when Californians will be required to have health insurance or pay a penalty tax. The exchange is supposed to work as an online superstore with purchasing power like Amazon.com. Some express concern over the state’s influence in the commercial insurance market or why taxpayer money should be spend advertising commercial products sold by the state. John Graham , director of health care studies for the Pacific Research Institute, is quotes in Wall Street Journal saying “I don’t know of a government agency that works like Amazon.com.” Until now, all insurance had to be offered under the same terms and prices regardless of where it was purchased. It is not clear whether Californian lawmakers intend to change this part of the law in order to have the state gain a legal advantage in health insurance sales.
2/1/2012 The Center for Consumer Information and Insurance Oversight, a division of the Center for Medicare and Medicaid Services (CMS)reported that as of June 30, 2011 Kaiser Foundation Health Plan, Inc., Anthem BC Life and Health, and Blue Cross of California are the state’s largest health insurance providers and as such, earn the right to set the benchmark for the development of the state’s essential benefit plans to debut in 2014 under health reform law.
6/22/2011 A group of 122,000 former Anthem policyholders won a settlement in a class action lawsuit against Blue Shield of California over rates hikes and lack of notification that forced many to drop coverage. These members are now guaranteed eligibility in other lower cost health plans even though the law would not normally require this until 2014.
5/26/2011 California’s largest non-profit health insurer is facing criticism after government-required disclosure of executive compensation showed that Blue Shield of California’s chief executive compensation is more than twice the amount of the largest for-profit insurance company. The highest amount of compensation was $4.6 million and ten executives had pay of more than $749,000.
3/30/2011 California considers 15 new health coverage mandates that will likely make major medical insurance less attractive to individuals who purchase coverage.
2/12/2011 With dozens of health plans choices available online offering a wide range of pricing and benefits, how do you find the best combination of price and benefits? Celtic Insurance realizes that the choices can be overwhelming; the company offers more than 40 possible health plan designs in many parts of the United States. A new feature called “Help Me Choose” lets users easily and quickly select the benefits they value most and narrows the list down to a few of the best choices. No personal information is required other than zip code and date of birth.
2/3/2011 California is named as one of the states most likely to cut back on Medicaid spending and coverage. The Universal Health Insurance blog discusses the impact on the state’s commercial insurance consumers.
2/1/2011 Rates and applications for broker-assisted California Pre-existing Condition Insurance Plan are now available for 2011. Applications can be submitted with or without a broker; there is no difference in the premium cost or the coverage. We may act as the submitting broker upon request; just send an e-mail to Tony Novak at email@example.com. The plan information, application forms and rate table are available only through electronic (e-mail) delivery. Application status confirmations and policyholder notices will also be handled electronically.
1/30/2011 Patients with health insurance and a credit card now have access to VIP treatment when care is needed at a hospital emergency room. Tenet Healthcare hospitals joined the growing list of hospitals in southern California that allows patients to use InQuickER, a reservation system that books appointments and reduces waiting time in the emergency room. The reservation system makes check-in easier by recording your insurance and payment information in advance. The service costs $15 to $25. Of course the nature unpredictable medical emergencies mean that the service cannot absolutely guarantee that you’ll be seen immediately at your appointment time, but you get a full refund if not treated within 15 minutes after arrival. The InQuickER service works in conjunction with any of the private health insurance plans listed here at FreedomBenefits.net but is not available to uninsured patients.
Participating hospitals include Loma Linda University Medical Center in Loma Linda, Loma Linda University Medical Center (Children) in Loma Linda, San Antonio Community Hospital in Upland, John F. Kennedy Memorial Hospital in Indio, Fountain Valley Regional Hospital in Fountain Valley, Placentia-Linda Hospital in Placentia, Los Alamitos Medical Center in Los Alamitos, and Lakewood Regional Medical Center in Lakewood.
1/19/2011 Child-only health insurance for children with significant medical problems will be available through an open enrollment period mandated by federal state law during the months of January and February and during the child’s birth month. All children, regardless of medical condition, continue to be eligible for insurance when applying as a dependent on a parent’s policy and healthy children are eligible for child-only insurance at any time. When applying for child-only insurance for more than one child, make a separate application for each child.
1/11/2011 Consumers will apparently not be immediately affected by new emergency orders by Insurance Commissioner David Jones that threatened to disrupt the availability of insurance. We had feared that companies would stop offering coverage in the wake of the unprecedented regulations by the new regulator but that withdrawal did not happen. Aetna expressed an opinion that the state may not have the authority to override federal health reform rules on minimum loss ratio but the company will not stop offering new insurance policies. A new article “Effect of Minimum Loss Ratio Regulation” provides more information on this topic.
1/7/2011 California Blue Shield announced rate increases averaging 30%, with some as high as 59%. Our blog “A Closer look at California Blue Shield rate increases” breaks down the issue and offers suggestions on what policyholders can do about it.
12/16/2010 California Health and Human Services Agency officials met representatives of 44 other states and numerous employees of the federal Health and Human Services Department in Washington DC this week for a two-day working meeting to discuss the next steps in establish a government-run health insurance exchange under the American Health Benefit Exchange Model Act. Their attendance at this meeting was paid for by a $1 million federal grant awarded by HHS in September to the state for research how to set up an insurance exchange. Two states (Alaska and Minnesota) declined to participate, saying that it was a waste of taxpayer money. Four other states (not identified in press reports) that received federal grants did not send representatives to the meeting. Attendees included representatives of 16 states that are suing the federal government in an attempt to overturn the federal health reform law; specifically the requirement that forces individuals to buy health insurance on the insurance exchange or pay a hefty tax fine.
In its initial federal grant request for the insurance exchange project, California said that it would: 1) Establish an Exchange Board and recruit key staff, 2) Analyze the current public and private insurance markets, 3) Convene stakeholders and the general public to gather input, 4) Develop a multi-year plan for Exchange planning tasks, and 5) Collect data on the demographics of the current and projected population, profiles of insurance markets offering coverage in California and estimates of how the Affordable Care Act will change the number of uninsured Californians.
The meeting reportedly did not address the role of the commercial health insurance exchanges on the implementation of new competing government systems. The model act does not address inter-state insurance exchange proposals nor insurance sales across state lines. Federal officials admitted that they may not be able to provide further guidance until 2012. Meanwhile, most states are motivated to continue to meet requirements to obtain additional funding promised by the federal government for the establishment of insurance exchange by 2014. Freedom Benefits has previously voiced the opinion that the huge amount of money being spent to set up alternate insurance sales system technologies could be better used providing health benefits to the public. We proposed on the Universal Health Insurance blog that adequate commercial insurance sales systems are already in place that could be modified in a public/private partnership to make health insurance more affordable.
11/12/2010 One in ten Californians is now covered by a consumer-directed health plan with high deductible insurance, according to a new report issued by UCLA Health Policy Research. These plans keep health care dollars in the hands of consumers rather than in health insurance premiums and tend to appeal to healthy affluent individuals. Health reform laws could increase the mandated coverage and premium costs but legislative modifications are likely to eventually make high deductible policies the dominant preferred type of insurance coverage in the United States. California currently leads the nation with health plans at the opposite end of the coverage spectrum with almost half of Californians now enrolled in HMOs that the major health care decisions on their behalf. Nationwide, HMOs are far less popular, attracting only about 21% of Americans nationwide. Freedom Benefits Insurance Exchange is committed to offering a full range of high deductible consumer-driven health plans to replace HMOs.
11/9/2010 Medi-Cal Expansion – California’s Medicaid plan now covers about 7.5 million mostly non-working state residents and will add an additional 500,000 residents by expanding program eligibility to residents with annual incomes up to 133% of the federal poverty level. In some counties the income levels are 200% of the federal poverty level. The program expansion is likely to increase complaints that the state’s lower economic class receives better access to health care than the working class especially if federal funding for premium subsidies is withdrawn as expected.
9/21/2010 Rate increases for October 2010 – The California Department of Insurance approved rate increases ranging from 14% to 29% for policies from the state’s four largest insurance companies that cover a large majority of those who but their own health insurance in the state. The rate increases become effective October 1, 2010 so we anticipate a larger than usual number of healthy members will attempt to move to one of the state’s smaller health insurance plans.
8/24/2010 New restrictions for CA insurance shoppers: The California Department of Insurance issued regulations effective August 23, 2010 requiring health insurance companies to thoroughly investigate the histories of those seeking insurance coverage before accepting any premiums. About 1.1 million Californians covered by individual health policies are immediately affected by the department. The rules affect those applying for coverage through the state health insurance exchange as well as those applying though traditional channels. Changing insurance plans could change from a one day process to a 90 day process. Previously insurance companies were allowed to rely on the written statements made by an applicant to determine whether the applicant was eligible for coverage. The new law requires companies to independently verify the eligibility criteria including health history, age, citizenship, residency, eligibility for an employer-sponsored health plan, and sometimes other factors.
The most difficult verification is an applicant’s medical history. Federal law known as HIPAA makes it difficult, tedious and sometimes expensive to obtain medical records. Doctors and hospitals typically require pre-payment of a medical records fee ranging from $35 to $75. An applicant with multiple medical service providers could incur significant fees and delays in the record transmittal. Insurance companies are allowed to charge the insurance applicant for the cost of obtaining medical records but none of the CA insurance companies we spoke with had announced plans to raise application fees as of this date. Insurance companies have acknowledged that it will take significantly longer to underwrite a policy in California under the new rules.
Freedom Benefits is working with the Association of California Life and Health Insurance Companies to stop the new rules and bring the health insurance application process into line with that in all other states. We see no reason that California should adapt a consumer protection policy that is so different from the industry practices followed in every other state in the nation.
Meanwhile, OnlineAdviser offers these five suggestions to Californians who are shopping for health insurance:
Do not cancel previous coverage or allow the previous coverage to expire until after the new policy has been approved, received and reviewed by you or your insurance adviser. While we understand that many consumers cannot afford to make an additional payment on their former insurance plan – especially when premiums jump sharply – it is important to be aware of the expiration date and the reinstatement deadline (usually 30 days after the expiration date) in order to ensure that the prior coverage is available as a fall-back strategy.
Use short term medical insurance for immediate issue coverage while waiting for a new policy to be approved. Short term major medical policies are issued immediately online without the need to check medical history because these polices are exempt from the coverage provisions of pre-existing medical policies. As a result, buyers understand the limitations of this simple form of coverage and fewer disputes over claims. See the listing of short term medical insurance plans available in California on the FB exchange home page.
Collect all of your important documents and copies of all of your personal medical records and keep a digital copy available on your home computer. While the insurer will collect its own information,
Use limited benefit insurance like Core Health Insurance and Supplemental Accident Insurance like Value Emergency Room and Value 24 Hour Accident Insurance that is exempt from the new regulations. This insurance is meant to provide benefits in addition to coverage provided by major medical plans but are sometimes used by Californians in a pinch to provide some limited coverage when other insurance is not available.
Plan ahead for health insurance as if it is the most important part of your personal financial planning. Too many Californians have learned the hard way that lack of adequate health insurance planning can be ruinous. The new health insurance reform laws will amplify that message.
The new law was designed to prevent insurance companies from making illegal rescissions, but . Insurance companies are still allowed to cancel policies if an applicant makes an intentionally false statement on an application but also places a new burden of checking the facts in advance. So little is gained in terms of consumer protection and industry officials estimate that the new law could add up to $200 in costs to the price of an insurance policy. California insurance buyers typically change insurance companies every 2nd or 3rd year, according to Freedom Benefits data collected since 1986. A typical health insurance policy, including short term and limited benefit policies, is in force for about 13 months.
8/23/2010 State funding planned for insurance exchange: The California state legislator is considering legislation to set up a state-sponsored health insurance exchange that would provide $1 to $2 million per year to help consumers find health insurance online. Presumably a state-sponsored exchange would be able to support a wider range of health plans than the current private insurance exchanges. If approved by the state legislature, part of the cost will be subsidized by the federal government until 2014. Some consumer advocates express concerning taxpayer funds to promote the sale of health insurance yet it is possible that a state-sponsored exchange combined marketing program. The price and terms of insurance is not affected by an exchange and insurance purchased on a state exchange. Federal law allows a state to charge insurance companies for participation in an exchange while there are generally no fees to participate in the current insurance exchange system. OnlineAdviser will continue to provide support for all health insurance listed on any exchange.
5/12/2010 Diabetes Coverage: A new resource to help with health insurance for diabetics in California is available