Protect Health Coverage Locally

Section 1. The insurance law is amended by adding a new section 3217-i to read as follows:

§ 3217-i. Essential health benefits package. (a) Coverage required. No insurer subject to this article shall decline to provide an essential health benefits package as required by this section.

(b) Definition. The term "essential health benefits package" means, with respect to any health plan, coverage that provides for the essential health benefits as defined by the superintendent under subsection (c) of this section; limits cost-sharing for such coverage in accordance with subsection (d) of this section; and subject to subsection (d) of this section, provides either bronze, silver, gold or platinum level of coverage as described in subsection (e) of this section.

(c) Superintendent's powers and duties with respect to essential health benefits. (1) Subject to paragraph two of this subsection, the superintendent shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within such categories: (i) ambulatory patient services, (ii) emergency services, (iii) hospitalization, (iv) maternity and newborn care, (v) mental health and substance use disorder services, including behavioral health treatment, (vi) prescription drugs, (vii) rehabilitative and habilitative services and devices, (viii) laboratory services, (ix) preventive and wellness services and chronic disease management, and (x) pediatric services, including oral and vision care.

EXPLANATION--Matter in italics (underscored) is new; matter in brackets

[ ] is old law to be omitted.

LBD00844-01-9

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(2) The superintendent shall ensure that the scope of the essential health benefits under paragraph one of this subsection is equal to the scope of benefits provided under a typical employer plan, as determined by the superintendent. In defining the essential health benefits under paragraph one of this subsection, the superintendent shall:

(A) ensure that such essential health benefits reflect an appropriate balance among the categories described in paragraph one of this subsection so that benefits are not unduly weighted toward any category;

(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

(C) take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

(D) ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;

(E) provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits described in paragraph one of this subsection unless the plan provides that:

(i) coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

(ii) if such services are provided out-of-network, the cost-sharing requirement, expressed as a copayment amount or coinsurance rate, is the same requirement that would apply if such services were provided in-network;

(F) provide that if a stand-alone dental benefits plan is offered through an exchange, another health plan offered through such exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the standalone plan that are otherwise required under subparagraph (G) of this paragraph; and

(G) periodically update the essential health benefits under paragraph one of this subsection to address any gaps in access to coverage.

(d) Cost-sharing requirements. (1) There shall be an annual limitation on cost-sharing. (A) The cost-sharing incurred under a health plan with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in two thousand fourteen shall not exceed the dollar amounts in effect for self-only and family coverage, respectively, for taxable years beginning in two thousand fourteen.

(B) In the case of any plan year beginning in a calendar year after two thousand fourteen, the limitation under this paragraph shall:

(i) in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) of this paragraph for self-only coverage for plan years beginning in two thousand fourteen, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph three of this subsection for the calendar year; and

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(ii) in the case of other coverage, twice the amount in effect under clause (i) of this subparagraph. If the amount of any increase under clause (i) of this subparagraph is not a multiple of fifty dollars, such increase shall be rounded to the next lowest multiple of fifty dollars.

(2) (A) The term "cost-sharing" shall include:

(i) deductibles, coinsurance, copayments, or similar charges; and

(ii) any other expenditure required of an insured individual which is a qualified medical expense with respect to essential health benefits covered under the plan.

(B) Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services.

(3) For purposes of clause (i) of subparagraph (B) of paragraph one of this subsection, the premium adjustment percentage for any calendar year is the percentage, if any, by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year exceeds such average per capita premium for the year two thousand thirteen.

(e) Levels of coverage. (1) Levels of coverage described in this subsection are as follows:

(A) Bronze level. A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to sixty percent of the full actuarial value of the benefits provided under the plan.

(B) Silver level. A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to seventy percent of the full actuarial value of the benefits provided under the plan.

(C) Gold level. A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to eighty percent of the full actuarial value of the benefits provided under the plan.

(D) Platinum level. A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to ninety percent of the full actuarial value of the benefits provided under the plan.

(2) (A) Actuarial value. Under regulations issued by the superintendent, the level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection (c) of this section shall be provided to a standard population and without regard to the population the plan may actually provide benefits to.

(B) Employer contributions. The superintendent shall issue regulations under which employer contributions to a health savings account may be taken into account.

§ 2. The insurance law is amended by adding a new section 4306-h to read as follows:

§ 4306-h. Essential health benefits package. (a) Coverage required. No corporation subject to this article shall decline to provide an essential health benefits package as required by this section.

(b) Definition. The term "essential health benefits package" means, with respect to any health plan, coverage that provides for the essential health benefits as defined by the superintendent under subsection (c) of this section; limits cost-sharing for such coverage in accordance with subsection (d) of this section; and subject to subsection (d) of this section, provides either bronze, silver, gold or platinum level of coverage as described in subsection (e) of this section.

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(c) Superintendent's powers and duties with respect to essential health benefits. (1) Subject to paragraph two of this subsection, the superintendent shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within such categories: (i) ambulatory patient services, (ii) emergency services, (iii) hospitalization, (iv) maternity and newborn care, (v) mental health and substance use disorder services, including behavioral health treatment, (vi) prescription drugs, (vii) rehabilitative and habilitative services and devices, (viii) laboratory services, (ix) preventive and wellness services and chronic disease management, and (x) pediatric services, including oral and vision care.

(2) The superintendent shall ensure that the scope of the essential health benefits under paragraph one of this subsection is equal to the scope of benefits provided under a typical employer plan, as determined by the superintendent. In defining the essential health benefits under paragraph one of this subsection, the superintendent shall:

(A) ensure that such essential health benefits reflect an appropriate balance among the categories described in paragraph one of this subsection so that benefits are not unduly weighted toward any category;

(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

(C) take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

(D) ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;

(E) provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits described in paragraph one of this subsection unless the plan provides that:

(i) coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

(ii) if such services are provided out-of-network, the cost-sharing requirement, expressed as a copayment amount or coinsurance rate, is the same requirement that would apply if such services were provided in-network;

(F) provide that if a stand-alone dental benefits plan is offered through an exchange, another health plan offered through such exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the standalone plan that are otherwise required under subparagraph (G) of this paragraph; and

(G) periodically update the essential health benefits under paragraph one of this subsection to address any gaps in access to coverage.

(d) Cost-sharing requirements. (1) There shall be an annual limitation on cost-sharing. (A) The cost-sharing incurred under a health plan with

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respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in two thousand fourteen shall not exceed the dollar amounts in effect for self-only and family coverage, respectively, for taxable years beginning in two thousand fourteen.

(B) In the case of any plan year beginning in a calendar year after two thousand fourteen, the limitation under this paragraph shall:

(i) in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) of this paragraph for self-only coverage for plan years beginning in two thousand fourteen, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph three of this subsection for the calendar year; and

(ii) in the case of other coverage, twice the amount in effect under clause (i) of this subparagraph. If the amount of any increase under clause (i) of this subparagraph is not a multiple of fifty dollars, such increase shall be rounded to the next lowest multiple of fifty dollars.

(2) (A) The term "cost-sharing" shall include:

(i) deductibles, coinsurance, copayments, or similar charges; and