AB 2012 Frequently Asked Questions

Can an insurer place an annual cap on the amount of the O&P benefit?

No. Current law prohibits annual caps on basic medical services. AB 2012 mandates that O&P benefits be treated as basic medical services.

Can an insurer place an life time cap on the amount of the O&P benefit?

No. Current law prohibits lifetime caps on basic medical services. AB 2012 mandates that O&P benefits be treated as basic medical services.

May the Plan charge a co-pay for each visit for O&P?

Yes. The collection of office visit co-pays is a decision made by the insurer providing the coverage. It is best to consult with each plan administrator individually for direction on office visit co-pays. AB 2012 does not mandate the exact amount of copayments or coinsurance for O&P, but the insurer may charge a copay/coinsurance for however many office visits are required to evaluate and fit the enrollee with the prostheses.

If a consumer has exceeded his or her annual out-of-pocket expenses, does the patient still have co-insurance or co-pay obligations for the O&P benefit?

No. Out-of-pocket expenses for basic medical services now include payments for O&P benefits. If the annual amount has been reached by the consumer, additional out-of-pocket payments can not be collected for the O&P benefit.

Did AB 2012 make O&P coverage mandatory?

No. O&P coverage in California is an optional benefit which consumers may opt to purchase under the terms and conditions set by the insurer.

If a consumer has a question about his or her policy and the applicability of the new law, who can be called?

If the patient is covered by a managed care plan (all HMOs) he or she can call the Department of Managed Health Care, at 1-888-HMO-2219 (1-888-466-2219). For insurance plans that are not managed care plans, consumers can call the Department of Insurance Consumer Hotline, at 800-927-help (800-927-4357).

If I have a problem with an insurer not following the law, who do I call?

Please notify COPA, at (916) 446-4343. We have been working with both departments on several implementation issues. If new ones arise, please let us know.