Bill > SB464

This bill requires health insurance issuers offering qualified health plans, which are plans meeting federal definitions for health insurance marketplaces, to submit annual cost estimates for severe obesity treatments to the Department of Insurance by August 1, 2026, and each year after. These estimates, prepared by actuaries, must detail all cost components, including expected service volumes and population data. The Department of Insurance will then publish an estimated cost for the state to cover these services by December 1, 2026, and annually thereafter, as mandated by federal law (42 U.S.C. 18031). By July 1, 2027, and annually, the department will also inform issuers of a "funding ratio" (state appropriations divided by estimated costs) and a "minimum coverage standard." Starting January 1, 2028, if the funding ratio is 1.0 or higher, insurers cannot limit the number of covered services for severe obesity treatment. If the funding ratio is less than 1.0, insurers can impose a numerical cap on services, but it must be at least the minimum coverage standard multiplied by the number of member-months from the previous year, rounded up. Any such cap must be clearly stated in plan documents with the actual numerical limit.