Keenan Briefings

Briefing

AB 2843: Health Coverage Without Cost-Sharing for Sexual Assault Victims

Due to the passage of AB 2843 (Chapter 971, Statutes of 2024), a new coverage mandate will go into effect for fully insured health plans issued, amended, renewed or delivered on or after July 1, 2025. This law will require plans to provide coverage without cost-sharing for emergency room medical care and follow-up health care treatment for an insured who is treated following a rape or sexual assault for the first nine months after the enrollee initiates treatment.

Under the new law, follow-up health care treatment includes medical or surgical services for the diagnosis, prevention, or treatment of medical conditions arising from an instance of rape or sexual assault.

While the law requires the treating provider to submit all requests for claims payments using accurate diagnosis codes specific to rape or sexual assault, the law specifically does not require the insured to file a police report on the rape or sexual assault. The law does not require charges to be brought against an assailant, and it does not require the assailant to be convicted in order for the insured to receive coverage of medical care and follow-up treatment without cost-sharing.

The law does not require carriers to cover follow-up treatment without cost-sharing if the treatment is furnished by a nonparticipating provider, except under two limited circumstances: (1) if follow-up care is unavailable within the carrier’s network within the time required by statutory timely access standards, or (2) if services are for “emergency services and care.” Emergency services and care include the following:

• Medical screening, examination, and evaluation by a doctor (or other licensed provider under the supervision of a doctor) to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition; and
• Additional screening, examination, and evaluation by a doctor (or other licensed provider under the supervision of a doctor) to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition.

The law does not apply to self-funded plans. It also does not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, TRI-CARE supplement insurance, or hospital indemnity, accident-only, or specified disease insurance. Finally, for persons covered under a high deductible health plan (HDHP), the law does not require coverage without cost-sharing until the person has met their deductible.

BACKGROUND AND ANALYSIS

A 2022 New England Journal of Medicine “Correspondence” signed by seven physicians describes the physicians’ findings upon analyzing nationally representative data on emergency department visits. The letter stated, in part:

Our findings indicate that an estimated 17,842 persons who sought emergency department care related to sexual assault were expected to pay the often-substantial costs themselves. Other data indicate that even privately insured sexual assault victims pay, on average, 14% of emergency department costs out-of-pocket. Such costs may particularly burden low-income women and girls who disproportionately are victims of sexual assault

Emergency department charges may discourage the reporting of rape and seeking of medical care for both short-term and long-term sequelae of sexual assault. Incurring such charges may further harm survivors — even those with full insurance coverage — by serving to disclose a potentially stigmatizing event to parents, partners, or employers. Moreover, such bills may further traumatize survivors by suggesting that they are personally responsible for their assault.

Prior to passage, AB 2843 was analyzed by the California Health Benefits Review Program (CHBRP) to analyze the effectiveness and costs of the bill. CHBRP estimated the coverage mandate would result in an increase of $600,000 (0.0004%) total net annual expenditures for fully insured plans statewide.

Keenan is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Clients are advised to consult with their own attorney for a determination of their legal rights, responsibilities, and liabilities, including the interpretation of any statute or regulation, or its application to the clients’ business activities.