Bill Text: CA AB2080 | 2021-2022 | Regular Session | Amended
Bill Title: Health Care Consolidation and Contracting Fairness Act of 2022.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2022-06-22 - In committee: Hearing postponed by committee. [AB2080 Detail]
Download: California-2021-AB2080-Amended.html
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Amended
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Assembly
May 19, 2022 |
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Amended
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May 02, 2022 |
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Amended
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April 06, 2022 |
CALIFORNIA LEGISLATURE—
2021–2022 REGULAR SESSION
Assembly Bill
No. 2080
| Introduced by Assembly Member Wood |
February 14, 2022 |
An act to add Section 685 to the Business and Professions Code, to add Sections 5931, 5932, and 5933 to the Corporations Code, to amend Section 1399.65 of, to amend the heading of Article 10.2 (commencing with Section 1399.65) of Chapter 2.2 of Division 2 of, and to add Sections 1255.4 and 1371.26 to, the Health and Safety Code, and to add Section 10123.149 to the Insurance Code, relating to health care.
LEGISLATIVE COUNSEL'S DIGEST
AB 2080, as amended, Wood.
Health Care Consolidation and Contracting Fairness Act of 2022.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law regulates contracts between health care service plans or health insurers and health care providers or health facilities, including requirements for reimbursement and the cost-sharing amount collected from an enrollee or insured.
This bill, the Health Care Consolidation and Contracting Fairness Act of 2022, would prohibit a contract issued, amended, or renewed on or after January 1, 2023, between a health care service plan or health insurer and a health care provider or health facility from containing terms that,
among other things, restrict the plan or insurer from steering an enrollee or insured to another provider or facility or require the plan or insurer to contract with other affiliated providers or facilities. The bill would authorize the appropriate regulating department to refer a plan’s or insurer’s contract to the Attorney General, and would authorize the Attorney General or state entity charged with reviewing health care market competition to review a health care practitioner’s or health facility’s entrance into a contract that contains specified terms. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.
Existing law requires a health care service plan that intends to merge with, consolidate with, or enter into an agreement resulting in its purchase,
acquisition, or control by, an entity to give notice to, and secure prior approval from, the Director of the Department of Managed Health Care. Existing law authorizes the director to disapprove the transaction or agreement if the director finds it would substantially lessen competition in health care service plan products or create a monopoly in this state.
This bill would additionally require a health care service plan that intends to acquire or obtain control of an entity, as specified, to give notice to, and secure prior approval from, the director. Because a willful violation of this provision would be a crime, the bill would impose a state-mandated local program. The bill would also authorize the director to disapprove a transaction or agreement if it would substantially lessen competition in the health system or among a particular category of health care providers, and would require the director to provide information related to competition to the Attorney
General.
Existing law requires a nonprofit corporation that operates or controls a health facility to obtain the written permission of the Attorney General before entering an agreement to dispose of its assets or transfer control of a material amount of its assets. Existing law requires the Attorney General to notify the corporation within 90 days of receiving notice the request of the Attorney General’s decision to consent to, give conditional consent to, or not consent to the agreement, and authorizes that period to be extended by 45 days if specified conditions are met.
This bill would require a medical group, hospital or hospital system, specified health facility, health care service plan, health insurer, or pharmacy benefit manager to provide written notice to the Attorney General
at the same time as another state or federal agency is notified or otherwise at least 90 days before entering an agreement or transaction to make a specified material change with a value of $5,000,000 $15,000,000 or more. The bill would authorize the Attorney General to consent to, give conditional consent to, or not consent to that agreement, and would require the Attorney General to notify the entity of the decision within 90 days, which may be extended by one 45-day period if specified conditions are met. The bill would authorize a medical group, hospital or hospital system, specified health
facility,
health care service plan, health insurer, or pharmacy benefit manager, within 30 calendar days of that notification, to request an adjudicative proceeding, as specified. The bill would require the Attorney General to conduct one or more public meetings before issuing a written decision on a major transaction, and would authorize the Attorney General to contract for assistance in reviewing a proposed material change and for monitoring ongoing compliance with the terms of a material change. The bill would prohibit an entity from entering into an agreement without the Attorney General’s written consent.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
SECTION 1.
This act shall be known and may be cited as the Health Care Consolidation and Contracting Fairness Act of 2022.SEC. 2.
Section 685 is added to the Business and Professions Code, to read:685.
(a) Notwithstanding any other law, a health care practitioner licensed under this division shall not enter into, amend, enforce, or renew a contractual provision on or after January 1, 2023, with a health care service plan or health insurer that directly or indirectly does or implements any of the following:(1) Restricts the health care service plan or health insurer from doing or implementing either of the following:
(A) Directing or steering enrollees or insureds to other health care practitioners.
(B) Offering incentives to encourage enrollees or
insureds to utilize or avoid health care practitioners.
(2) Requires the health care service plan or health insurer to enter into an additional contract with any or all affiliates or individual facilities of any health care practitioner as a condition of entering into a contract.
(3) Requires the health care service plan or health insurer to agree to payment rates or terms for an individual facility or affiliate of any health care practitioner as a condition of entering into a contract.
(4) Requires the health care service plan or health insurer to agree to payment rates or other terms for an affiliate or individual facility that is not party to the contract.
(5) Restricts other health care service plans or health insurers that are not party to the contract from paying a lower rate for items or services than the rate the contracting plan pays for those items or services.
(6) Prevents a health care service plan or health insurer, directly or indirectly, from providing provider-specific cost or quality of care information, through a consumer engagement tool or any other means, to referring providers, the plan or insurer sponsor, enrollees, insureds, or eligible enrollees or insureds of the plan or insurer.
(b) A health care practitioner’s entrance into a contract that does or implements any of the conduct described in subdivision (a) may be reviewed by the Attorney General and any other state entity charged with reviewing
health care market competition for compliance with this section.
(c) Notwithstanding any other law, the Attorney General and any other state entity charged with reviewing health care market competition under this section shall be entitled to specific performance, injunctive relief, and other equitable remedies a court deems appropriate for enforcement of this section and shall be entitled to recover attorney’s fees and costs incurred in remedying each violation.
(d) The Attorney General and any other state agency charged with reviewing health care market competition under this section may adopt regulations to implement this section.
(e) The authority of the Attorney General to maintain competitive markets and
prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this section.
SEC. 3.
Section 5931 is added to the Corporations Code, to read:5931.
(a) (1) A medical group, hospital or hospital system, health facility described in subdivision (a), (b), or (c) of Section 1250 of the Health and Safety Code, health care service plan, health insurer, or pharmacy benefit manager, except for a nonprofit corporation subject to Sections 5914 and 5920, shall provide written notice to, and obtain the written consent of, the Attorney General before entering into an agreement or transaction to do either of the following:(A) Sell, transfer, lease, exchange, option, encumber, convey, or otherwise dispose of a material amount of its
assets.
(B) Transfer control, responsibility, or governance of a material amount of its assets or operations.
(2) The substitution of a new corporate member or members that transfers the control of, responsibility for, or governance of the corporation shall be deemed a transfer for purposes of this section. The substitution of one or more members of the governing body, or an arrangement, written or oral, that would transfer voting control of the members of the governing body, shall also be deemed a transfer for purposes of this section.
(3) This section applies to a material change with a value of five million dollars ($5,000,000)
fifteen million dollars ($15,000,000) or more.
(b) (1) Subdivision (a) does not apply to a nonphysician provider. For purposes of this section, “nonphysician provider” means an individual or group of individuals licensed under Division 2 (commencing with Section 500) of the Business and Professions Code who does not provide health-related physician, surgery, or laboratory services to consumers.
(2) Subdivision (a) does not apply to an ambulatory surgical center that is not affiliated with or owned by a general acute care facility, as defined in subdivision (a) of Section 1250 of the Health and Safety Code, and is any of the following:
(A) A surgical clinic licensed
by the State Department of Public Health.
(B) An ambulatory surgical center certified by the federal Centers for Medicare and Medicaid Services to participate in the Medicare Program.
(C) An outpatient setting that is accredited by an accreditation agency approved by the Medical Board of California.
(3) Subdivision (a) does not apply if a county is purchasing, acquiring, or taking over control, responsibility, or governance of an entity to ensure continued health care access in that county.
(c) The notice to the Attorney General pursuant to subdivision (a) shall be
submitted at the same time that any other state or federal agency is notified pursuant to state or federal law, and otherwise shall be provided at least 90 days before the changes, and shall include and contain the information the Attorney General deems is required. The notice, including any other information that is provided to the Attorney General pursuant to this section and that is in the public file, shall be made available by the Attorney General to the public in written form, as soon as is practicable after it is received by the Attorney General. The notice shall include a list of the threshold languages for Medi-Cal beneficiaries, as determined by the State Department of Health Care Services. The Attorney General may require the medical group, hospital or hospital system,
health facility described in subdivision (a), (b), or (c) of Section 1250 of the Health and Safety Code, health care service plan, health insurer, or pharmacy benefit manager to provide certain components of the notice in any of these languages.
(d) The Attorney General shall have discretion to consent to, give conditional consent to, or not consent to an agreement or transaction described in subdivision (a). In making the determination, the Attorney General may consider any factors that the Attorney General deems relevant, including all of the following:
(1) Whether or not the proposed material change may have a significant impact on market competition or costs for payers, purchasers, or consumers.
(2) Whether or not the proposed material change may have a significant impact on the quality of care, including the ability to offer culturally competent and appropriate care.
(3) Whether or not the proposed material change may have a significant impact on the access to or availability of health care for payers, purchasers, or consumers.
(4) Whether or not the proposed material change is in the public interest.
(5) Whether or not the proposed material change is likely to maintain access to care in a rural
community, low-income community, or disadvantaged community. If the Attorney General finds that access to care in a rural community, low-income community, or disadvantaged community will become more limited with the proposed material change, the Attorney General may approve the proposed material change, and may place conditions on the proposed material change.
(e) Within 90 days of the receipt of the written notice required by subdivision (a), the Attorney General shall notify the medical group, hospital or hospital system, health care service plan, health insurer, or pharmacy benefit manager of the decision to consent to, give conditional consent to, or not consent to the agreement or transaction. The Attorney
General may extend this period for one additional 45-day period if any of the following conditions apply:
(1) The extension is necessary to obtain additional information.
(2) The proposed agreement or transaction is substantially modified after the original notice was provided to the Attorney General.
(3) The proposed agreement or transaction involves a multifacility health system serving multiple communities, rather than a single facility or entity.
(f) (1) If the Attorney General does not approve an agreement or transaction, the medical group, hospital or hospital system,
health facility described in subdivision (a), (b), or (c) of Section 1250 of the Health and Safety Code, health care service plan, health insurer, or pharmacy benefit manager may, within 30 calendar days of notification pursuant to subdivision (e), request an adjudicative proceeding. The adjudicative proceeding shall be conducted pursuant to the administrative adjudication provisions of Chapter 4.5 (commencing with Section 11400) and Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
(2) Any alternative procedure specified by the Department of Justice in accordance with Section 11400.20 of the Government Code shall conform to the purpose of the Government Code provision it replaces insofar as it is possible to do so consistent with the specific procedural
requirement applicable to the type of
hearing.
(g) This section applies to a foreign corporation entity, that operates or controls a medical group, hospital or hospital system, health facility described in subdivision (a), (b), or (c) of Section 1250 of the Health and Safety Code, health care service plan, health insurer, or pharmacy benefit manager, if that foreign entity operates, manages, or controls any domestic entities that provide similar health care or coverage, or if that foreign entity provides similar health care or
coverage to a domestic corporation, entity regardless of whether it is currently operating or has a suspended license. license in California.
(h) The Attorney General may adopt regulations to implement this section.
(i) The authority of the Attorney General to maintain competitive markets and prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this
section.
SEC. 4.
Section 5932 is added to the Corporations Code, to read:5932.
(a) Before issuing a written decision pursuant to Section 5931, the Attorney General shall conduct one or more public meetings on a major transaction. The Attorney General may also conduct one or more public meetings on other transactions.(b) If the transaction involves a medical group or a hospital or hospital system, one of the public meetings shall be in the county in which the medical group or hospital acquired entity is located, to hear comments from interested parties.
(c) At least 14 days before conducting the public meeting, the Attorney General shall provide written notice of the time and place of the meeting through publication in one or more newspapers of general circulation in the affected community and to the boards of supervisors of the county or counties in which the medical group or the hospital or hospital system is located. This notice shall be provided in English and in the primary languages spoken at the facility, if any, and the threshold languages for Medi-Cal beneficiaries, as determined by the State Department of Health Care Services.
(d) If a substantive change in the proposed agreement or transaction is submitted to the Attorney General after the initial public meeting, the Attorney General may conduct an additional public
meeting to hear comments from interested parties with respect to that change.
(e) (1) With respect to a health care service plan, health insurer, or pharmacy benefit manager, “major transaction” has the same meaning as in Section 1399.65 of the Health and Safety Code.
(2) With respect to a hospital or hospital system, “major transaction” means a transaction that would have been subject to Section 5914 if it involved a nonprofit corporation.
(3) With respect to a medical group, the Attorney General shall define “major transaction” by regulation.
(f) The Attorney General may adopt regulations to implement this section.
SEC. 5.
Section 5933 is added to the Corporations Code, to read:5933.
(a) (1) Within the time periods designated in Section 5931 and relating to the factors specified in Section 5931, the Attorney General may do both of the following:(A) Contract with, consult, and receive advice from a state agency on the terms and conditions that the Attorney General deems appropriate.
(B) In the Attorney General’s sole discretion, contract with experts or consultants to assist in reviewing the proposed material change in control.
(2) Contract costs shall not exceed an amount that is reasonable and
necessary to conduct the review and evaluation. A contract entered into under this section shall be on a noncompetitive bid basis and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. Upon request, the Attorney General shall be paid promptly by the entities seeking consent for all contract costs.
(3) The Attorney General shall be entitled to reimbursement from the entities seeking consent for all actual, reasonable, direct costs incurred in reviewing, evaluating, and making the determination referred to in this section, including administrative costs. The entities seeking consent shall promptly pay the Attorney General, upon request, for all of those costs.
(b) (1) To monitor effectively ongoing
compliance with the terms and conditions of a material change of control subject to Section 5931, the Attorney General may, in their sole discretion, contract with experts and consultants to assist in this regard.
(2) Contract costs shall not exceed an amount that is reasonable and necessary to conduct the review and evaluation. A contract entered into under this section shall be on a noncompetitive bid basis and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. The entities seeking consent shall pay the Attorney General promptly for all contract costs.
(3) The Attorney General shall be entitled to reimbursement from either the selling or the acquiring entity, depending upon which one the burden of compliance
falls, for all actual, reasonable, and direct costs incurred in monitoring ongoing compliance with the terms and conditions of the sale or transfer of assets, including contract and administrative costs. The Attorney General may bill either the selling or the acquiring entity and the entity billed by the Attorney General shall promptly pay for all of those costs.
(c) The Attorney General may adopt regulations to implement this section.
SEC. 6.
Section 1255.4 is added to the Health and Safety Code, to read:1255.4.
(a) Notwithstanding any other law, a health facility shall not enter into, amend, enforce, or renew a contractual provision on or after January 1, 2023, with a health care service plan or health insurer that directly or indirectly does or implements any of the following:(1) Restricts the health care service plan or health insurer from doing or implementing either of the following:
(A) Directing or steering enrollees or insureds to other health facilities.
(B) Offering incentives to encourage enrollees or insureds to utilize or avoid health
facilities.
(2) Requires the health care service plan or health insurer to enter into an additional contract with any or all affiliates of the health facility, or individual facilities, as a condition of entering into a contract with a health facility.
(3) Requires the health care service plan or health insurer to agree to payment rates or terms for an individual facility or affiliate of the health facility as a condition of entering into a contract with
a health facility, other individual facility, or affiliate.
(4) Requires the health care service plan or health insurer to agree to payment rates or other terms for an affiliate or individual facility that is not party to the contract.
(5) Restricts other health care service plans or health insurers that are not party to the contract from paying a lower rate for items or services than the rate the contracting plan or insurer pays for those items or services.
(6) Prevents a health care service plan or health insurer, directly or indirectly, from providing provider-specific cost or quality of care information, through a consumer engagement tool or any other means, to referring providers, the plan or insurer
sponsor, enrollees, insureds, or eligible enrollees or insureds of the plan or insurer.
(b)The department may refer contracts subject to this section to the Attorney General or any other state entity charged with reviewing health care market competition to review the contract for compliance with this section. The
(b) A health facility’s entrance into a contract that does or implements any of the conduct described in subdivision (a) may be reviewed by the Attorney General and any other state entity charged with
reviewing health care market competition for compliance with this section.
(c) Notwithstanding any other law, the Attorney General and any other state entity charged with reviewing health care market competition under this section shall be entitled to specific performance, injunctive relief, and other equitable remedies a court deems appropriate for enforcement of this section and shall be entitled to recover attorney’s fees and costs incurred in remedying each violation.
(d) The Attorney General and any other state agency charged with reviewing health care market competition under this section may adopt regulations to implement this section.
(e) The authority of the Attorney General
to maintain competitive markets and prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this section.
SEC. 7.
Section 1371.26 is added to the Health and Safety Code, to read:1371.26.
(a) A contract issued, amended, or renewed on or after January 1, 2023, between a health care service plan offering coverage in the group market or individual market and a health care provider, network or association of health care providers, or other service provider offering access to a network of service providers shall not contain a contract term that directly or indirectly does or implements any of the following:(1) Restricts the health care service plan from doing or implementing either of the following:
(A) Directing or steering enrollees to other health care providers.
(B) Offering incentives to encourage enrollees to utilize or avoid specific health care providers.
(2) Requires the health care service plan to enter into an additional contract with any or all affiliates or individual facilities of any provider as a condition of entering into a contract.
(3) Requires the health care service plan to agree to payment rates or terms for an individual facility or affiliate of any provider as a condition of entering into a contract with another provider, other individual facility, or affiliate.
(4) Requires the health care service plan to agree to payment rates or other terms for an affiliate or individual facility that is not party
to the contract.
(5) Restricts other health care service plans or health insurers that are not party to the contract from paying a lower rate for items or services than the rate the contracting plan pays for those items or services.
(6) Prevents a health care service plan, directly or indirectly, from providing provider-specific cost or quality of care information, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, enrollees, or eligible enrollees of the plan.
(b) The director may refer contracts subject to this section to the Attorney General or any other state entity charged with reviewing health care market competition to review the contract for compliance with this
section. The authority of the Attorney General to maintain competitive markets and prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this section.
SEC. 8.
The heading of Article 10.2 (commencing with Section 1399.65) of Chapter 2.2 of Division 2 of the Health and Safety Code is amended to read:Article 10.2. Mergers and Acquisitions of and by Health Care Service Plans
SEC. 9.
Section 1399.65 of the Health and Safety Code is amended to read:1399.65.
(a) (1) A health care service plan that intends to merge or consolidate with, or enter into an agreement resulting in its purchase, acquisition, or control by, any entity, including another health care service plan or a health insurer licensed under the Insurance Code, shall give notice to, and secure prior approval from, the director. A health care service plan that intends to acquire or obtain control of an entity through a change of governance or control of a material amount of assets of that entity shall give notice to, and secure prior approval from, the director.(2) The transactions or agreements described in paragraph (1) may not be completed until the
director approves the transaction or agreement.
(3) A health care service plan described in paragraph (1) shall meet all of the requirements of this chapter. The health care service plan shall file all the information necessary for the director to make the determination to approve, conditionally approve, or disapprove the transaction or agreement described in paragraph (1), including, but not limited to, a complete description of the proposed transaction or agreement, any modified exhibits for plan licensure pursuant to Section 1351, any approvals by federal or other state agencies required for the transaction or agreement, and any supporting documentation required by the director.
(4) The director may conditionally approve the transaction or agreement, contingent upon the
health care service plan’s agreement to fulfill one or more conditions to benefit subscribers and enrollees of the health care service plan, provide for a stable health care delivery system, control costs to subscribers and enrollees, and impose other conditions specific to the transaction or agreement in furtherance of this chapter. The director shall engage stakeholders in determining the measures for improvement. For a major transaction or agreement, the director shall obtain an independent analysis of the impact of the transaction or agreement on subscribers and enrollees, the stability of the health care delivery system, and other relevant provisions of this chapter. For any other transaction or agreement, the director may obtain an independent analysis consistent with this paragraph.
(5) If an entity involved in the transaction or
agreement is a nonprofit corporation described in Section 5046 of the Corporations Code, the health care service plan shall file all the information required by Article 11 (commencing with Section 1399.70).
(b) (1) In addition to any grounds for disapproval as a result of information provided by a health care service plan pursuant to paragraph (3) of subdivision (a), the director may disapprove the transaction or agreement if the director finds the transaction or agreement would substantially lessen competition in health care service plan products or create a monopoly in this state, including, but not limited to, health coverage products for a specific line of business.
(2) In addition to any grounds for disapproval as a result of information provided by a
health care service plan pursuant to paragraph (3) of subdivision (a) or paragraph (1) of this subdivision, the director may disapprove the transaction or agreement if the director finds the transaction or agreement would substantially lessen competition in the health system or among a particular category of health care providers. In so doing, the director shall provide to the Attorney General information related to competition. The authority of the Attorney General to maintain competitive markets and prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this section.
(3) In making a finding pursuant to paragraph (1) or (2), the director may obtain an opinion from a consultant or consultants with the expertise to assess the competitive impact of the transaction
or agreement.
(c) Prior to approving, conditionally approving, or disapproving a major transaction or agreement, the department shall hold a public meeting on the proposed transaction or agreement. For any other transaction or agreement, the department may hold a public meeting on the proposed transaction or agreement. The public meeting shall be conducted pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of the Government Code). The meeting shall permit the parties to the proposed transaction and members of the public to provide written and verbal comments regarding the proposed transaction. If a substantive change in the proposed transaction or agreement is submitted to the director after the initial public meeting, the director may conduct an additional
public meeting to hear comments from interested parties with respect to that change. The director shall consider the testimony and comments received at the public meeting in making the determination to approve, conditionally approve, or disapprove the transaction or agreement.
(d) If the director determines a material amount of assets of a health care service plan is subject to purchase, acquisition, or control, the director shall prepare a statement describing the proposed transaction or agreement subject to subdivision (a) and make it available to the public. The statement shall be made available before the public meeting.
(e) This section does not limit the authority of the director to enforce any other provision of this chapter.
(f) For purposes of this section:
(1) “Acquiring” an entity includes the sale, transfer, lease, exchange, option, conveyance, or other disposition of an entity’s assets by a health care service plan if a material amount of the assets of the entity are involved in the agreement or transaction.
(2) “Entity” means a health care service plan, an individual, a corporation, a limited liability company, a partnership, an association, a joint stock company, a business trust, an unincorporated organization, any similar entity, or any combination thereof acting in concert.
(3) (A) “Major transaction or agreement” means a transaction or agreement that meets any of the following criteria:
(i) Affects a significant number of enrollees.
(ii) Involves a material amount of assets.
(iii) Adversely affects either the subscribers or enrollees or the stability of the health care delivery system because of the entity’s market position, including, but not limited to, the entity’s market exit from a market segment or the entity’s dominance of a market segment.
(B) The director shall, upon request, make available to the public the director’s determination of whether a transaction or agreement meets the criteria set forth in this paragraph.
(4) “Obtaining control” of an entity occurs if the entity
transfers control, responsibility, or governance of a material amount of its assets or operations to a health care service plan.
(5) “Transfer” includes the substitution of one or more new corporate members that would transfer the control of, responsibility for, or governance of the entity. “Transfer” also includes the substitution of one or more members of the entity’s governing body, or an arrangement, written or oral, that would transfer voting control of the members of the governing body.
SEC. 10.
Section 10123.149 is added to the Insurance Code, to read:10123.149.
(a) A contract issued, amended, or renewed on or after January 1, 2023, between a health insurer offering coverage in the group market or individual market and a health care provider, network or association of health care providers, or other service provider offering access to a network of service providers shall not contain a contract term that directly or indirectly does or implements any of the following:(1) Restricts the health insurer from doing or implementing either of the following:
(A) Directing or steering insureds to other health care providers.
(B) Offering incentives to encourage insureds to utilize or avoid health care providers.
(2) Requires the health insurer to enter into an additional contract with any or all affiliates or individual facilities of a provider as a condition of entering into a contract.
(3) Requires the health insurer to agree to payment rates or terms for an individual facility or affiliate of any providers as a condition of entering into a contract with another provider, other individual facility, or affiliate.
(4) Requires the health insurer to agree to payment rates or other terms for an affiliate or individual facility that is not party to the contract.
(5) Restricts other health insurers or health care service plans that are not party to the contract from paying a lower rate for items or services than the rate the contracting plan pays for those items or services.
(6) Prevents a health insurer, directly or indirectly, from providing provider-specific cost or quality of care information, through a consumer engagement tool or any other means, to referring providers, the insurer sponsor, insureds, or eligible insureds of the insurer.
(b) The commissioner may refer contracts subject to this section to the Attorney General or any other state entity charged with reviewing health care market competition to review the contract for compliance with this section. The authority of the Attorney General to maintain competitive
markets and prosecute state and federal antitrust and unfair competition violations shall not be narrowed, abrogated, or otherwise altered by this section.
