Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Pursuant to section
10290 of the
Insurance Code, a health insurer shall submit all of the following to the
Commissioner together with a specialized health insurance policy form that covers
the pediatric oral essential health benefit:
(1)
Either of the following:
(A) A statement of
variables specifying the cost sharing values for all pediatric oral essential health
benefits subject to cost sharing for each plan submitted.
(B) A schedule of benefits or similar document
specifying the cost sharing values for all pediatric oral essential health benefits
subject to cost sharing for each plan submitted.
(2) An actuarial certification of the methodology
used to determine the actuarial value of the pediatric oral essential health benefit
for the levels of coverage specified in subsection (b) of section 156.150 of Title
45 of the Code of Federal Regulations.
(b) The statement of variables shall include all
of the following:
(1) Unless a schedule of
benefits is submitted for each plan, specified values for all pediatric oral
essential health benefits subject to cost sharing for each plan submitted.
(2) An index to the locations of the variable text
in the policy form.
(3) Explanation of
the purpose for all variable text in the policy form.
(c) The actuarial certification shall include all
of the following:
(1) A statement of the
qualifications of the actuary who prepared the certification. The certifying actuary
shall be a member of the American Academy of Actuaries and shall meet the
qualification standards stated in Qualification Standards for Actuaries
Issuing Statements of Actuarial Opinion in the United States (American
Academy of Actuaries, Jan. 1, 2008 (incorporated by reference)).
(2) A description of the methodology used to
determine the actuarial value of the pediatric oral essential health benefit for the
levels of coverage specified in subsection (b) of section 156.150 of Title 45 of the
Code of Federal Regulations. The description shall be sufficiently clear and
detailed that another qualified health actuary can make an objective appraisal of
the reasonableness of the data, assumptions, factors, models, methods, formulas, and
calculations used to determine the actuarial value. The description shall include
all of the following:
(A) The data, assumptions,
factors, models, methods, formulas, and calculations used to determine the actuarial
value for each plan submitted.
(B) The
actuarial value of the pediatric oral essential health benefit for each plan
submitted.
(C) A discussion of the
standard population used to determine actuarial value for each plan
submitted.
(D) Confirmation that only
in-network cost sharing, including multitier networks, was included in the
calculation of actuarial value for each plan submitted.
(3) A statement of opinion attesting that the
actuarial values reported are based on generally accepted actuarial principles and
methodologies.
(d) When the
actuarial value of a plan associated with a previously submitted specialized health
insurance policy form is no longer within the allowable range for a level of
coverage, a specialized health insurer shall submit either of the following to the
Commissioner:
(1) A new or revised policy form
together with the documents required under subdivision (a) of this section
demonstrating compliance with a level of coverage.
(2) If a change to the text of the policy form is
unnecessary, only the documents required under subdivision (a) of this section
demonstrating compliance with a level of coverage.
1. New section
filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A
Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency
language will be repealed by operation of law on the following day.
2.
New section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013,
No. 50). Pursuant to Insurance Code section
10112.27(o)(2)
a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency
language will be repealed by operation of law on the following day.
3.
Certificate of Compliance as to 12-9-2013 order, including renumbering of former
section 2594.7 to section
2594.6 and new section 2594.7,
transmitted to OAL 1-15-2014 and filed 2-24-2014; new section 2594.7 effective
2-24-2014 pursuant to Government Code section
11343.4(b)(3)
(Register 2014, No. 9).
Note: Authority cited: Sections
10112.27,
10112.295,
10112.297,
12921 and
12926, Insurance
Code. Reference: Sections
10112.27,
10112.295,
10112.297 and
10290, Insurance
Code.
