Health care coverage reporting.

Assembly Member Ortega's health care coverage legislation mandates comprehensive monthly reporting of claims denial data from California health plans and insurers, establishing new transparency requirements around coverage decisions and their impacts. The bill amends both the Health and Safety Code and Insurance Code to require detailed tracking of denied and partially denied claims, including total costs, demographic breakdowns, and reasons for denials.

Under the new provisions, health plans and insurers must report monthly statistics on processed claims, prior authorization requests, and appeals processes. The required data encompasses the number of claims denied, associated costs, processing timeframes, and demographic information about affected patients. Plans must also detail denials by specific medical procedures, provider types, and reasons such as medical necessity, experimental treatment, or network status.

The Departments of Managed Health Care and Insurance will publish this claims denial data on their websites, with initial reporting for insurers and Multiple Employer Welfare Arrangements beginning February 2027. The bill includes privacy protections, requiring aggregation of small data sets and compliance with state and federal medical information laws. Department directors may reject non-compliant reports and assess penalties for uncorrected deficiencies.

The legislation maintains existing financial reporting requirements while adding these new claims transparency mandates. While the bill creates a state-mandated local program, it specifies that no reimbursement is required for local agencies or school districts since the changes relate to crime definitions and penalties rather than imposing direct costs.