Health care coverage reporting.

With Assembly Member Ortega and principal coauthor Kalra guiding the measure, the bill would require health care service plans and health insurers to publish detailed, annual data on prior authorization and claims processing, making the information publicly accessible on the regulating departments’ websites. The two departments would oversee the reporting, and data would be disaggregated by each plan or insurer. The measure specifies that plans and insurers must design and submit these reports under rules the departments may adopt.

For prior authorization, health care service plans would publicly report, on a calendar-year basis, the items and services that require prior authorization, the share of standard requests approved or denied (including approvals after appeal), extensions granted and the reasons, and the distribution of expedited determinations. Plans would also report the average and median processing times for standard and expedited prior authorization requests. Entities contracted by the plan for prior authorization would be required to relay the same information to the plan, and the director could set the form and content of the reports and require verification. The bill treats willful violations by a plan as a crime. For health insurers, a parallel set of prior authorization reporting requirements mirrors the plan obligations, with the same emphasis on public posting and regulatory rulemaking, and similar criminalization for willful insurer noncompliance.

In addition to prior authorization data, the bill adds comprehensive, monthly disclosures of claims payment and dispute activity for both plans and insurers. Each month, the plan or insurer would report counts of claims processed or adjudicated, denials or adjustments, and total costs of denied, adjusted, or contested claims, including breakdowns for in-network and out-of-network activity and for claims from enrollees. Disaggregated failure reasons would cover categories such as out-of-network status, lack of prior authorization, medical necessity, lack of efficacy, clerical errors, and other specified grounds, with a designated list of reasons the reporting entity must include if other is chosen. Starting in 2029, reports would also disaggregate contested claims by demographic categories (age, gender identity, sex, ethnicity, disability, sexual orientation) and by specific procedures and diagnoses. Monthly data would be filed with the applicable department by February 1 of each year, with public posting by April 15, and data would be deidentified in accordance with privacy laws and department rules. If the number of disaggregated claims is fewer than 11 for any category, the department would aggregate those claims as “other.” The commissioner or director would be empowered to reject a filing for deficiencies and require correction within 30 days, with penalties for noncompliance; the insurer provisions include similar correction and penalty authority.

The measure maintains alignment with existing regulatory structures by extending reporting obligations to the departments that oversee health plans and health insurers, while preserving privacy protections and providing a mechanism for regulatory oversight and enforcement. It signals a broader transparency agenda around utilization management and claims processing, situating the new reporting within the broader framework that governs the regulation of health plans and insurers in California. The act specifies that costs borne by local agencies or districts do not trigger reimbursement requirements, and it designates these new reporting duties as a state-mandated local program only insofar as they interact with existing crime or penalty provisions, thereby clarifying fiscal responsibilities under the constitution.