What You'll Lose in California
California has consumer protections that: Comparable Federal Rule for AHPs?

Ensure fair insurance premiums for small groups. There are strict limits on:

  • How much insurers can charge sicker groups
  • Premiums for similar small employers can only vary +/-10% of a standard rate based on health-status or claims experience

  • Limits on other rating factors: Age brackets and family size categories are specified; No more than 9 different geographic areas permitted. Use of gender, industry and group size is prohibited
  • How much insurers can increase an employer's premiums when an employee gets sick
  • 10% annual limit on increases for changes in health status
  • How often rates can increase (every 6 months)

 


No

 

 









No





No


Ensure access to independent review:

  • Consumers can demand independent external review of claims denials

 


No

Ensure appropriate access to care. Insurers must:

  • Cover emergency services that a “prudent layperson” thought necessary

  • Cover transitional care from a provider who leaves a network

  • Cover non-formulary prescription drugs in certain situations

  • Allow direct access to OB-GYNs

  • Cover cancer clinical trials

 

No


No


No

No

No

Ensure marketing protections:

  • Insurers must follow detailed requirements for marketing materials





No

Ensure health plans cover important benefits, such as:

  • Mental health parity that goes beyond federal requirements

  • Mammography screening

  • Minimum mastectomy stays

  • Cervical cancer screening

  • Well-child care

  • Diabetes supplies and education

  • Prompt payment rules


 


No


No

No

No


No

No


No (Self-funded AHPs exempt)

Ensure appropriate oversight of insurers:

  • State handles complaints from consumers & providers

  • State investigates, oversees, enforces rules (including financial penalties)

 

No


No$

Prevent failures and ensure payment of claims:

  • Insurers must maintain financial surpluses that grow with size of insurer

  • State oversees corrective action once insurer nears minimum standards

  • State acts quickly to seize assets to pay claims


 

No ($2M cap)



No



No

Promote access for the uninsured:

  • Mini-COBRA rules for small employers with fewer than 20 employees


 

No