Health care coverage: essential health benefits.

Senator Menjivar, with Assembly Member Bonta serving as principal coauthor, advances a plan to recalibrate California’s essential health benefits by directing a formal review of the state’s current benchmark and establishing a new benchmark plan for the 2027 plan year. The measure would commence January 1, 2027, and, contingent on federal approval of a revised state benchmark, require the benchmark for health care service plans to incorporate additional benefits, including specified fertility services and selected durable medical equipment, while also making noncompliance a crime and creating a state-mandated local program.

Under current law, individual or small-group health care service plan contracts issued, amended, or renewed on or after January 1, 2017 must include essential health benefits as defined by the federal act and aligned with the Kaiser Small Group HMO 30 plan as it existed in early 2014. The bill expresses the Legislature’s intent to review the 2027 benchmark and, if a federal new benchmark is approved, to require the revised California benchmark to cover expanded fertility services and durable medical equipment, among other enhancements. The fertility-related package encompasses evaluation and treatment components such as artificial insemination, multiple attempts to retrieve gametes and create embryos, pretransfer testing, cryopreservation of gametes and embryos, donor materials, surrogacy, and associated health testing. The durable medical equipment category includes mobility devices, augmentative communication devices, continuous positive airway pressure machines, portable oxygen, and hospital beds. Additional provisions address habilitative services, pediatric vision and pediatric oral care, and related benefits, all subject to the relevant PPACA frameworks and California regulations.

The bill sets forth mechanisms to implement these changes, including treatment limitations no greater than those of the benchmarks identified and restrictions on substitutions for mandated benefits, with limited exceptions to align with federal law. Implementation tools include the department issuing guidance before 2027 and, if needed, regulations under the Administrative Procedure Act, with consultation to be conducted with the Department of Insurance. The measure applies to plans offered inside or outside the California Health Benefit Exchange and preserves alignment with existing federal and state requirements, while clarifying that the state does not obligate reimbursement for costs not required by federal law.

In a broader policy context, the authors frame the measure as an effort to align evolving federal essential health benefits with California’s regulatory framework, potentially expanding coverage for infertility services, extensive fertility-related protections, and additional durable medical equipment. The bill also maintains the existing structure that ties essential health benefits to federal definitions and state benchmark plans, while preserving the authority to impose enforcement through a crime provision for noncompliance. The legislative trajectory, including prior amendments and enactment steps, reflects ongoing state consideration of how California’s benchmark plan should respond to changes in federal guidance and to the evolving needs of residents in areas such as fertility treatment, pediatric vision and dental care, and durable medical equipment.