In connection with the renewal of any grandfathered health benefit plan to small employers:

Each carrier shall make a reasonable disclosure, as part of its solicitation and sales materials, of the following:

Terms Used In California Insurance Code 10755.16

  • Benefit plan design: means a specific health coverage product issued by a carrier to small employers, to trustees of associations that include small employers, or to individuals if the coverage is offered through employment or sponsored by an employer. See California Insurance Code 10755
  • Carrier: means any disability insurance company or any other entity that writes, issues, or administers health benefit plans that cover the employees of small employers, regardless of the situs of the contract or master policyholder. See California Insurance Code 10755
  • Health benefit plan: means a policy or contract written or administered by a carrier that arranges or provides health care benefits for the covered eligible employees of a small employer and their dependents. See California Insurance Code 10755
  • Nongrandfathered health benefit plan: means a health benefit plan that is not a grandfathered health plan. See California Insurance Code 10755
  • PPACA: means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued thereunder. See California Insurance Code 10755
  • Preexisting condition provision: means a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage, as to a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage. See California Insurance Code 10755
  • Small employer: means either of the following:

    California Insurance Code 10755

(a) The extent to which the premium rates for a specified small employer are established or adjusted in part based upon the actual or expected variation in claims costs of the employees and dependents of the small employer.

(b) The provisions concerning the carrier’s ability to change premium rates and the factors other than claim experience which affect changes in premium rates.

(c) Provisions relating to the guaranteed issue of policies and contracts.

(d) Provisions relating to the prohibition of any preexisting condition provision.

(e) Provisions relating to the small employer’s right to apply for any nongrandfathered health benefit plan written, issued, or administered by the carrier, at the time of application for a new health benefit plan, or at the time of renewal of a health benefit plan, consistent with the requirements of PPACA.

(f) The availability, upon request, of a listing of all the carrier’s nongrandfathered health benefit plans, offered inside or outside the California Health Benefit Exchange, including the rates for each benefit plan design.

(Added by Stats. 2012, Ch. 852, Sec. 15. (AB 1083) Effective January 1, 2013.)

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