Bill Text: CA AB2389 | 2009-2010 | Regular Session | Amended
Bill Title: Health care coverage: health facilities: cost and
Spectrum: Partisan Bill (Republican 1-0)
Status: (Engrossed - Dead) 2010-08-31 - Re-referred to Com. on P.E.,R. & S.S. pursuant to Assembly Rule 77.2. Action rescinded whereby the bill was re-referred to Com. on P.E.,R. & S.S. pursuant to Assembly Rule 77.2. (Page 6934.) To inactive file on motion of Assembly Member Charles Calderon. [AB2389 Detail]
Download: California-2009-AB2389-Amended.html
BILL NUMBER: AB 2389 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 20, 2010
AMENDED IN SENATE AUGUST 2, 2010
AMENDED IN SENATE JUNE 16, 2010
AMENDED IN ASSEMBLY MAY 24, 2010
AMENDED IN ASSEMBLY MAY 20, 2010
AMENDED IN ASSEMBLY APRIL 8, 2010
INTRODUCED BY Assembly Member Gaines
FEBRUARY 19, 2010
An act to add Section 1367.49 to the Health and Safety Code, and
to add Section 10133.64 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2389, as amended, Gaines. Health care coverage: health
facilities: cost and quality information.
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. Existing law also
provides for the regulation of health insurers by the Department of
Insurance. Existing law prohibits a contract between a plan or
insurer and a health care provider from containing certain terms.
This bill would prohibit a contract by or on behalf of a plan or
insurer and a health care facility, as defined, to provide inpatient
hospital services or ambulatory care services to subscribers and
enrollees of the plan or policyholders and insureds of the insurer
from containing a provision that restricts the ability of the plan or
insurer to furnish information to subscribers or enrollees of the
plan or policyholders or insureds of the insurer concerning the cost
range of procedures at the facility or the quality of services
performed by the facility . The bill would require that
, provided that, among other requirements, the
cost information be is limited to
certain elective, uncomplicated procedures, and be displayed
in a specified manner and would prohibit a health care service plan
from disclosing negotiated capitation rates or other prepaid
arrangements to enrollees or subscribers in either the cost or
quality information, except as specified. The bill would require a
plan or insurer that furnishes the cost or quality information to
the plan or insurer also disclose
discloses the location of its facility cost
ranges and quality measurements to subscribers, enrollees,
policyholders, and insureds, and to make and makes
specified disclosures regarding those measurements and the cost
information provided . The bill would require plans and
insurers to provide , and the plan or insurer provides
affected facilities an opportunity to review the information
prior to furnishing it to subscribers, enrollees, policyholders, or
insureds, as specified , and would also, among other things,
require, if the information is data developed and compiled by the
plan or insurer, that the information be based on specified
guidelines and be updated regularly, as specified . The
bill would make a contractual provision inconsistent with the bill's
requirements void and unenforceable.
Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.49 is added to the Health and Safety Code,
to read:
1367.49. (a) A contract issued, amended, renewed, or delivered on
or after January 1, 2011, by or on behalf of a health care service
plan and a health care facility to provide inpatient hospital
services or ambulatory care services to subscribers and enrollees of
the plan shall not contain any provision that restricts the ability
of the health care service plan to furnish information to subscribers
or enrollees of the plan concerning the cost range of procedures at
the facility or the quality of services performed by the
facility. facility, provided that the fo
llowing requirements are satisfied:
(b)
(1) Information on the cost range of procedures
at a health care facility furnished by a plan to enrollees
or subscribers shall be displayed as an episode is
displayed as an episode of care, unless an episode of care is
not applicable, and applicable. This
information may include, but shall not be limited to,
applicable diagnostic tests, prescription drugs, hospital days, and
medical supplies that are associated with a typical procedure or
illness. The information shall be limited to the cost range of
elective, uncomplicated procedures performed on patients without
malignancy or comorbidity, with a length of stay consistent with the
diagnosis-related group assignment.
(c) A health care service plan shall
(2) The plan does not disclose
negotiated capitation rates or other prepaid arrangements in the
information described in subdivision (a) that is furnished to
enrollees or subscribers. However, if the health care service plan
includes in that information allocated capitation payments to a
health care facility for an episode of care, the plan and the
facility shall consult on an appropriate and reasonable methodology
formula.
(d)
(3) If the information proposed to be furnished to
enrollees and subscribers on the quality of services performed by a
health care facility is quality of care data that the plan has
developed and compiled, all of the following requirements
shall be are satisfied:
(1) The information shall be based on nationally recognized
evidence- or consensus-based clinical
(A) The information is based on
consensus-based, or nationally recognized evidence-based, clinical
recommendations or guidelines. When available, a plan shall use
measures endorsed by the National Quality Forum or other entities
nationally recognized for quality or performance review.
(2) The plan shall utilize
(B) The plan utilizes appropriate
risk adjustment factors to account for different characteristics of
the population, such as case mix, severity of patient's condition,
comorbidities, outlier episodes, and other factors to account for
differences in the use of health care resources among health care
facilities.
(3)
(C) The information, and the data used as the basis for
that information, shall be are updated
regularly, and no less than annually.
(4)
(D) If the health care service plan is evaluating
quality measurements for which it is also furnishing the cost range
of procedures to its enrollees or subscribers, it shall link
links the two together for comparison purposes
when appropriate.
(e) A health care service plan shall, prior to furnishing the
information described in subdivision (a) to its enrollees or
subscribers, provide all of the following to the affected health care
facility:
(4) The plan provides all of the following to the affected health
care facility prior to furnishing the information to enrollees or
subscribers:
(1)
(A ) At least 45-days written notice to
review the information.
(2)
(B ) A summary of the criteria and
methodology used in the development and evaluation of cost range and
quality measurements. This summary shall be sufficiently detailed and
reasonably understandable to allow the facility to verify the data
against its own records.
(3)
(C ) An explanation to the facility that it
has the right to correct errors and seek review of the data used to
measure the quality of services provided at the facility and to
provide supplemental information to the plan if the facility finds
discrepancies in the data or cost range criteria used by the plan.
(4)
(D ) A reasonable, prompt, and transparent
appeal process. If the facility makes an appeal prior to the
expiration of the time period provided under paragraph (1)
subparagraph (A) , the health care service plan
shall make no material changes to its current information about the
facility until the appeal is completed.
(5)
(E ) Notice of, and an annual update of, the
information furnished to enrollees or subscribers on the cost range
of procedures at the facility. A plan may satisfy this requirement by
providing an electronic copy to the facility or by providing the
facility with access to the plan's cost information through an
Internet Web site or electronic portal made available by the plan.
(f) A health care service plan that furnishes information
concerning the cost range of procedures at a health care facility or
the quality of services provided by the facility to its subscribers
or enrollees shall also disclose the
(5) The plan also discloses the
following to its subscribers or enrollees:
(1)
(A) Where the plan's facility cost ranges and quality
measurements can be found.
(2)
(B) That facility cost ranges and quality measurements
provided by the plan are only a guide to choosing a facility, that
enrollees or subscribers should confer with their existing facility
before making a decision, and that these ranges and measurements have
a risk of error and should not be the sole basis for selecting a
facility.
(3)
(C) Information explaining the facility quality
measurement process, including the basis upon which quality is
measured and any limitation of the data used.
(4)
(D) Reasonable details on the factors and criteria used
by the facility quality measurement system, including whether
severity cost adjustments have been utilized.
(5)
(E) How an enrollee or subscriber may register a
complaint about, or provide feedback on, the quality measurement
system or the cost range information provided by the plan.
(g) Any contractural
(b) Any contractual provision
inconsistent with this section shall be void and unenforceable.
(h)
(c) For purposes of this section, "health care facility"
means a health facility defined in subdivision (a), (b), or (f) of
Section 1250.
(i)
(d) Section 1390 shall not apply for purposes of this
section.
SEC. 2. Section 10133.64 is added to the Insurance Code, to read:
10133.64. (a) A contract issued, amended, renewed, or delivered
on or after January 1, 2011, by or on behalf of a health insurer and
a health care facility to provide inpatient hospital services or
ambulatory care services to policyholders and insureds of the insurer
shall not contain any provision that restricts the ability of the
health insurer to furnish information to policyholders or insureds
concerning the cost range of procedures at the health care facility
or the quality of services provided by the facility.
facility, provided that the following requirements are
met:
(b)
(1 ) Information on the cost range of
procedures at a health care facility furnished by an insurer
to policyholders or insureds shall be displayed as an
is displayed as an episode of care, unless an episode of care
is not applicable, and applicable. This
information may include, but shall not be limited to,
applicable diagnostic tests, prescription drugs, hospital days, and
medical supplies that are associated with a typical procedure or
illness. The information shall be limited to the cost range of
elective, uncomplicated procedures performed on patients without
malignancy or comorbidity, with a length of stay consistent with the
diagnosis-related group assignment.
(c)
(2) If the information proposed to be furnished to
policyholders or insureds on the quality of services performed by a
health care facility is quality of care data that the insurer has
developed and compiled, all of the following requirements
shall be are satisfied:
(1) The information shall be based on nationally recognized
evidence- or consensus-based clinical
(A) The information is based on
consensus-based, or nationally recognized evidence-based, clinical
recommendations or guidelines. When available, an insurer shall
use measures endorsed by the National Quality Forum or other
entities nationally recognized for quality or performance review.
(2) The insurer shall utilize
(B) The insurer utilizes
appropriate risk adjustment factors to account for different
characteristics of the population, such as case mix, severity of
patient's condition, comorbidities, outlier episodes, and other
factors to account for differences in the use of health care
resources among health care facilities.
(3)
(C) The information, and the data used as the basis for
that information, shall be are updated
regularly, but no less than annually.
(4)
(D) If the health insurer is evaluating quality
measurements for which it is also furnishing the cost range of
procedures to its policyholders or insureds, it shall link
links the two together for comparison purposes
when appropriate.
(d) A health insurer shall, prior to furnishing the information
described in subdivision (a) to its policyholders or insureds,
provide all of the following to the affected health care facility:
(3) The insurer provides all of the following to the affected
health care facility prior to furnishing the information to
policyholders or insureds:
(1)
(A) At least 45-days written notice to review the
information.
(2)
(B) A summary of the criteria and methodology used in
the development and evaluation of cost range and quality
measurements. This summary shall be sufficiently detailed and
reasonably understandable to allow the facility to verify the data
against its own records.
(3)
(C) An explanation to the facility that it has the
right to correct errors and seek review of the data used to measure
the quality of services provided at the facility and to provide
supplemental information to the insurer if the facility finds
discrepancies in the data or cost range criteria used by the insurer.
(4)
(D) A reasonable, prompt, and transparent appeal
process. If the facility makes an appeal prior to the expiration of
the time period provided under paragraph (1)
subparagraph (A) , the health insurer shall make no material
changes to its current information about the facility until the
appeal is completed.
(5)
(E) Notice of, and an annual update of, the information
furnished to policyholders or insureds on the cost range of
procedures at the facility. A health insurer may satisfy this
requirement by providing an electronic copy to the facility or by
providing the facility with access to the insurer's cost information
through an Internet Web site or electronic portal made available by
the insurer.
(e) A health insurer that furnishes information concerning the
cost range of procedures at a health care facility or the quality of
services provided by the facility to its policyholders or insureds
shall also disclose the following to its policyholders or insureds:
(4) The insurer also discloses the following to its policyholders
or insureds:
(1)
(A) Where the insurer's facility cost ranges and
quality measurements can be found.
(2)
(B) That facility cost ranges and quality measurements
provided by the insurer are only a guide to choosing a facility, that
policyholders or insureds should confer with their existing facility
before making a decision, and that these ranges and measurements
have a risk of error and should not be the sole basis for selecting a
facility.
(3)
(C) Information explaining the facility quality
measurement process, including the basis upon which quality is
measured and any limitation of the data used.
(4)
(D) Reasonable details on the factors and criteria used
by the facility quality measurement system, including whether
severity cost adjustments have been utilized.
(5)
(E) How a policyholder or insured may register a
complaint about, or provide feedback on, the quality measurement
system or the cost range information provided by the insurer.
(f) Any contractural
(b) Any contractual provision
inconsistent with this section shall be void and unenforceable.
(g)
(c) For purposes of this section, "health care facility"
means a health facility defined in subdivision (a), (b), or (f) of
Section 1250 of the Health and Safety Code.
