Changes coming to CA Health Plans in 2025: Issue 65

The CA state legislature passed multiple bills affecting health plans that were signed into law by Gov. Newsome. These laws impact fully insured health plans regulated by California insurance laws, so most commonly health plans for employers with fewer than 500 employees. The laws covered a number of areas but highlights included maternal healthcare, preventative care, and AI protections.

Let's explore them and for more detail, check out this article for more.

Effective Jan 1 2025

Maternal health Programs must include mental health screenings during pregnancy and after birth

Healthcare providers can separately bill for devices or services related to contraception immediately after birth in hospitals or birth centers.

Medically necessary donor human milk from a licensed tissue bank must be included in basic health care services.

Plans cannot charge for preventive care items or services. This includes home test kits for STDs and certain cancer screenings.

Denials, delays, or care modifications bust be made by a doctor or health care provider and not AI. AI tools used in healthcare decisions must be overseen by licensed medical professionals and comply with specific rules. These tools must consider the patient’s medical history and individual needs.

If healthcare providers use AI to communicate health information to patients, they must disclose that AI generated the message and provide contact information for a human healthcare provider

Insurance plans must cover at least one medication in four categories for treating opioid overdoses and substance use disorders without requiring prior authorization or other barriers

Effective July 1 2025

Insurance must cover emergency room care and follow-up treatment for individuals treated after rape or sexual assault without cost-sharing or requiring a police report or charges. ()

Large group health plans (100+ employees) must cover IVF services, with a limit of three cycles and unlimited embryo transfers. Small group plans (1-100 employees) must offer the option to cover IVF services. FYI these small group infertility riders are pretty bad in my opinion. In one case, the premium is over $1,000 a year for the rider, and the lifetime benefit of the rider is just $2,000...

Effective Jan 1 2026

Insurance plans must pay claims or notify claimants of any issues within 30 days. Complaints about payment delays or denials can be filed as grievances with the Department of Managed Health Care.

Since many health plans are governed by state insurance laws, pay attention to these as they are signed and model regulations come out so you better understand the changes to your group health insurance program.

On to the rest of the newsletter!

?? Risk Decision Support with AI

With discussion about AI seemingly everywhere, you can't be surprised to see it cropping up here in a benefits newsletter multiple times! In this instance, we're finding more and more that we can use AI to support risk management decisions.

With many groups, we don't receive much data from their fully-insured carrier on claims and issues and conditions affecting their population. Not knowing the risk in a group can make managing that risk difficult.

In response, multiple solutions have been developed which seek to give us some insight into claims and health risks in a group when we don't have direct claims data nor do we want to complete individual health questionnaires.

So the next time you're trying to make a health plan decision, consult AI and apply it to your risk management strategies!

?? More Employment Law Updates

US Department of Labor Reissues and Expands on Its AI Guidance for Employers

“The U.S. Department of Labor (“DOL”) released an updated Artificial Intelligence (“AI”) resource for employers, as well as developers, to assist them in avoiding potential harms to workers due to the use of AI and other technology. The document details practices and principles that employers may use to avoid concerns that could arise through the use of AI, and ways to avoid discriminatory or unfair treatment of employees.” Full Article

Eight Phrases Employers Should Watch For During Election Season (And How to Handle Them)

“As we head into the final weeks of the 2024 election campaigns, it's likely that American workplaces will be filled with employees discussing, arguing over, and participating in one of the country's hundreds of local, statewide, and national political contests. While all that activity contributes to the inherent, essential messiness of democracy, employers must take care to know what they may be required to do or are prohibited from doing when it comes to their employees' participation in the electoral process.” Full Article

Don't want an EEOC pregnancy lawsuit? Then DON'T do these 4 things

“Stuff's getting real. As many of you know, the U.S. Equal Employment Opportunity Commission is starting to sue employers who it claims are not complying with the reasonable accommodation requirements of the Pregnant Workers Fairness Act.” Full Article

Union Election Petitions Up 27%; Labor Board Activity Highest in a Decade

“The National Labor Relations Board witnessed a significant increase in union election petitions in fiscal year (FY) 2024 (Oct. 1, 2023 – Sept. 30, 2024). The Board received 3,286 union election petitions, a 27 percent rise from 2,593 petitions received in the previous fiscal year.” Full Article

NLRB GC Proposes Significant Penalties for Employers' Use of Non-Compete and Stay-Or-Pay Agreements

“The Office of the General Counsel of the National Labor Relations Board (Board) released Memorandum GC 25-01, which not only reiterates General Counsel Jennifer Abruzzo's recommendation that the Board find certain non-compete provisions unlawful under the National Labor Relations Act (NLRA) (see May 2023 Memorandum GC 23-08), but also lays out her position that "stay-or-pay" provisions and moonlighting prohibitions are unlawful.” Full Article

EEOC Report Reveals Focus on STEM Industries

“Last year, the EEOC revealed its Strategic Enforcement Plan (“SEP”) for Fiscal Years 2024- 2028. In the SEP, the EEOC stated that a subject matter priority was “the continued underrepresentation of women and workers of color in certain industries and sectors.” One such industry focus is on workers in STEM (Science, Technology, Engineering, Mathematics) fields.” Full Article

New York paid prenatal leave to go into effect on January 1, 2025

“An amendment to New York Labor Law section 196-b, the state’s paid sick leave law, will go into effect. The amendment requires New York employers to provide employees with 20 hours of paid prenatal leave during any 52- week period.” Full Article

New and Improved California Leave Provisions for 2025

“Out with the old and in with the new. Governor Newsom recently signed new laws which extend and clarify employees’ available reasons for use of California paid sick leave. There are expanded unpaid leave protections for victims of domestic violence, sexual assault, stalking, or qualifying acts of violence, as well as for employees summoned to jury duty or responding to a subpoena or court order to testify under FEHA. The changes go into effect on January 1, 2025.” Full Article

That's it for this week's Competitive Advantages! Please reach out if anything caught your eye above and have a great rest of the week!