Bill Text: CA SB1100 | 2013-2014 | Regular Session | Amended
Bill Title: Continuity of care.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2014-06-24 - Set, first hearing. Hearing canceled at the request of author. [SB1100 Detail]
Download: California-2013-SB1100-Amended.html
BILL NUMBER: SB 1100 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 3, 2014
INTRODUCED BY Senator Hernandez
FEBRUARY 19, 2014
An act to amend Section 1373.96 of the Health and Safety Code, and
to amend Section 10133.56 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1100, as amended, Hernandez. Continuity of care.
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 also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan or a health insurer
to provide for the completion of covered services by a terminated
provider for enrollees or insureds who were receiving services from
the provider for a specified condition at the time of the provider
termination. Existing law also requires a health care service plan
or a health insurer, at the request of a newly covered enrollee
or insured, to provide for the completion of covered services
by a nonparticipating provider to a newly covered enrollee
who, if, at the time his or her coverage became
effective, the newly covered enrollee or insured was
receiving services from that provider for a specified condition
and if his or her prior coverage was terminated as provided .
Existing law requires a health care service plan to provide a
disclosure form regarding the benefits, services, and terms of a plan
contract and requires the disclosure form to include a description
of how an enrollee can request continuity of care under the
provisions described above.
This bill would also require a health care service plan to include
notice of the process to obtain continuity of care in every evidence
of coverage issued after January 1, 2015. The bill would also
require a plan to provide a written copy of this information to its
contracting providers and provider groups, as well as a copy to its
enrollees upon request. The bill would delete the conditions
that needed to be fulfilled in order for a health care service plan
or health insurer, upon request of a newly covered enrollee or
insured, to be required to provide for the completion of covered
services for a specified condition by a nonparticipating provider.
The bill would make other technical changes to the provisions
governing health insurers and continuity of care. Because a willful
violation of the bill's requirements by a health care service plan
would be a crime, the bill would impose a state-mandated local
program.
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.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1373.96 of the
Health and Safety Code is amended to read:
1373.96. (a) A health care service plan shall, at the request of
an enrollee, provide the completion of covered services as set forth
in this section by a terminated provider or by a nonparticipating
provider.
(b) (1) The completion of covered services shall be provided by a
terminated provider to an enrollee who, at the time of the contract's
termination, was receiving services from that provider for one of
the conditions described in subdivision (c).
(2) The completion of covered services shall be provided by a
nonparticipating provider to a newly covered enrollee who, at the
time his or her coverage became effective, was receiving services
from that provider for one of the conditions described in subdivision
(c).
(c) The health care service plan shall provide for the completion
of covered services for the following conditions:
(1) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
(2) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health care service plan in consultation with the enrollee and the
terminated provider or nonparticipating provider and consistent with
good professional practice. Completion of covered services under this
paragraph shall not exceed 12 months from the contract termination
date or 12 months from the effective date of coverage for a newly
covered enrollee.
(3) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
(4) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date or 12 months from the
effective date of coverage for a new enrollee.
(5) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date or 12 months from the
effective date of coverage for a newly covered enrollee.
(6) Performance of a surgery or other procedure that is authorized
by the plan as part of a documented course of treatment and has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date or within 180 days of the
effective date of coverage for a newly covered enrollee.
(d) (1) The plan may require the terminated provider whose
services are continued beyond the contract termination date pursuant
to this section to agree in writing to be subject to the same
contractual terms and conditions that were imposed upon the provider
prior to termination, including, but not limited to, credentialing,
hospital privileging, utilization review, peer review, and quality
assurance requirements. If the terminated provider does not agree to
comply or does not comply with these contractual terms and
conditions, the plan is not required to continue the provider's
services beyond the contract termination date.
(2) Unless otherwise agreed by the terminated provider and the
plan or by the individual provider and the provider group, the
services rendered pursuant to this section shall be compensated at
rates and methods of payment similar to those used by the plan or the
provider group for currently contracting providers providing similar
services who are not capitated and who are practicing in the same or
a similar geographic area as the terminated provider. Neither the
plan nor the provider group is required to continue the services of a
terminated provider if the provider does not accept the payment
rates provided for in this paragraph.
(e) (1) The plan may require a nonparticipating provider whose
services are continued pursuant to this section for a newly covered
enrollee to agree in writing to be subject to the same contractual
terms and conditions that are imposed upon currently contracting
providers providing similar services who are not capitated and who
are practicing in the same or a similar geographic area as the
nonparticipating provider, including, but not limited to,
credentialing, hospital privileging, utilization review, peer review,
and quality assurance requirements. If the nonparticipating provider
does not agree to comply or does not comply with these contractual
terms and conditions, the plan is not required to continue the
provider's services.
(2) Unless otherwise agreed upon by the nonparticipating provider
and the plan or by the nonparticipating provider and the provider
group, the services rendered pursuant to this section shall be
compensated at rates and methods of payment similar to those used by
the plan or the provider group for currently contracting providers
providing similar services who are not capitated and who are
practicing in the same or a similar geographic area as the
nonparticipating provider. Neither the plan nor the provider group is
required to continue the services of a nonparticipating provider if
the provider does not accept the payment rates provided for in this
paragraph.
(f) The amount of, and the requirement for payment of, copayments,
deductibles, or other cost sharing components during the period of
completion of covered services with a terminated provider or a
nonparticipating provider are the same as would be paid by the
enrollee if receiving care from a provider currently contracting with
or employed by the plan.
(g) If a plan delegates the responsibility of complying with this
section to a provider group, the plan shall ensure that the
requirements of this section are met.
(h) This section shall not require a plan to provide for
completion of covered services by a provider whose contract with the
plan or provider group has been terminated or not renewed for reasons
relating to a medical disciplinary cause or reason, as defined in
paragraph (6) of subdivision (a) of Section 805 of the Business and
Profession Code, or fraud or other criminal activity.
(i) This section shall not require a plan to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the plan contract. Except as provided in
subdivision (l), this section shall not apply to a newly covered
enrollee covered under an individual subscriber agreement who is
undergoing a course of treatment on the effective date of his or her
coverage for a condition described in subdivision (c).
(j) Except as provided in subdivision (l), this section shall not
apply to a newly covered enrollee who is offered an out-of-network
option or to a newly covered enrollee who had the option to continue
with his or her previous health plan or provider and instead
voluntarily chose to change health plans.
(k) The provisions contained in this section are in addition to
any other responsibilities of a health care service plan to provide
continuity of care pursuant to this chapter. Nothing in this section
shall preclude a plan from providing continuity of care beyond the
requirements of this section.
(l) (1) A health care
service plan shall, at the request of a newly covered enrollee under
an individual health care service plan contract, arrange for the
completion of covered services as set forth in this section by a
nonparticipating provider for one of the conditions described in
subdivision (c) if the newly covered enrollee meets both of
the following: subdivision (c).
(A) The newly covered enrollee's prior coverage was terminated
under paragraph (5) or (6) of subdivision (a) of Section 1365 or
subdivision (d) or (e) of Section 10273.6 of the Insurance Code
between December 1, 2013, and March 31, 2014, inclusive.
(B) At the time his or her coverage became effective, the newly
covered enrollee was receiving services from that provider for one of
the conditions described in subdivision (c).
(2) The completion of covered services required to be provided
under this subdivision apply to services rendered to the newly
covered enrollee on and after the effective date of his or her new
coverage.
(3) A violation of this subdivision does not constitute a crime
under Section 1390.
(m) The following definitions apply for the purposes of this
section:
(1) "Individual provider" means a person who is a licentiate, as
defined in Section 805 of the Business and Professions Code, or a
person licensed under Chapter 2 (commencing with Section 1000) of
Division 2 of the Business and Professions Code.
(2) "Nonparticipating provider" means a provider who is not
contracted with the enrollee's health care service plan to provide
services under the enrollee's plan contract.
(3) "Provider" shall have the same meaning as set forth in
subdivision (i) of Section 1345.
(4) "Provider group" means a medical group, independent practice
association, or any other similar organization.
(n) Notice as to the process by which an enrollee may request
completion of covered services pursuant to this section shall be
provided in every disclosure form as required under Section 1363 and
in any evidence of coverage issued after January 1, 2015. A plan
shall provide a written copy of this information to its contracting
providers and provider groups. A plan shall also provide a copy to
its enrollees upon request.
SEC. 2. Section 10133.56 of the
Insurance Code is amended to read:
10133.56. (a) (1) A health insurer that enters into a contract
with a professional or institutional provider to provide services at
alternative rates of payment pursuant to Section 10133 shall, at the
request of an insured, arrange for the completion of covered services
by a terminated provider, if the insured is undergoing a course of
treatment for any of the following conditions:
(A) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
(B) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health insurer in consultation with the insured and the terminated
provider and consistent with good professional practice. Completion
of covered services under this paragraph shall not exceed 12 months
from the contract termination date or 12 months from the effective
date of coverage for a newly covered insured.
(C) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
(D) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date or 12 months from the
effective date of coverage for a new insured.
(E) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date or 12 months from the
effective date of coverage for a newly covered insured.
(F) Performance of a surgery or other procedure that has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date or within 180 days of the
effective date of coverage for a newly covered insured.
(2) The insurer may require the terminated provider whose services
are continued beyond the contract termination date pursuant to this
subdivision, to agree in writing to be subject to the same
contractual terms and conditions that were imposed upon the provider
prior to termination, including, but not limited to, credentialing,
hospital privileging, utilization review, peer review, and quality
assurance requirements. If the terminated provider does not agree to
comply or does not comply with these contractual terms and
conditions, the insurer is not required to continue the provider's
services beyond the contract termination date.
(3) Unless otherwise agreed upon between the terminated provider
and the insurer or between the terminated provider and the provider
group, the agreement shall be construed to require a rate and method
of payment to the terminated provider, for the services rendered
pursuant to this subdivision, that are the same as the rate and
method of payment for the same services while under contract with the
insurer and at the time of termination. The provider shall accept
the reimbursement as payment in full and shall not bill the insured
for any amount in excess of the reimbursement rate, with the
exception of copayments and deductibles pursuant to subdivision (c).
(b) Notice as to the process by which an insured may request
completion of covered services pursuant to this section shall be
provided in any insurer evidence of coverage and disclosure form
issued after March 31, 2004. An insurer shall provide a written copy
of this information to its contracting providers and provider groups.
An insurer shall also provide a copy to its insureds upon request.
(c) The payment of copayments, deductibles, or other cost-sharing
components by the insured during the period of completion of covered
services with a terminated provider pursuant to subdivision (a) or a
nonparticipating provider pursuant to subdivision (i) shall be the
same copayments, deductibles, or other cost-sharing components that
would be paid by the insured when receiving care from a provider
currently contracting with the insurer.
(d) If an insurer delegates the responsibility of complying with
this section to its contracting entities, the insurer shall ensure
that the requirements of this section are met.
(e) For the purposes of this section, the following terms
have the following meanings: definitions apply:
(1) "Provider" means a person who is a licentiate as defined in
Section 805 of the Business and Professions Code or a person licensed
under Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code.
(2) "Provider group" includes a medical group, independent
practice association, or any other similar organization.
(3) "Nonparticipating provider" means a provider who is not
contracted with the insured's health insurer to provide services
under the insured's policy. A nonparticipating provider does not
include a terminated provider.
(4) "Terminated provider" means a provider whose contract to
provide services to insureds is terminated or not renewed by the
insurer or one of the insurer's contracting provider groups. A
terminated provider is not a provider who voluntarily leaves the
insurer or contracting provider group.
(f) This section shall not require an insurer or provider group to
provide for the completion of covered services by a provider whose
contract with the insurer or provider group has been terminated or
not renewed for reasons relating to medical disciplinary cause or
reason, as defined in paragraph (6) of subdivision (a) of Section 805
of the Business and Professions Code, or fraud or other criminal
activity.
(g) This section shall not require an insurer to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the insurer contract.
(h) The provisions contained in this section are in addition to
any other responsibilities of insurers to provide continuity of care
pursuant to this chapter. Nothing in this section shall preclude an
insurer from providing continuity of care beyond the requirements of
this section.
(i) (1) A health insurer shall, at the request of a newly covered
insured under an individual insurance policy, arrange for the
completion of covered services as set forth in this section by a
nonparticipating provider for one of the conditions described in
subdivision (a) if the newly covered insured meets both of
the following: subdivision (a).
(A) The newly covered insured's prior coverage was terminated
under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or
(6) of subdivision (a) of Section 1365 of the Health and Safety Code
between December 1, 2013, and March 31, 2014, inclusive.
(B) At the time his or her coverage became effective, the newly
covered insured was receiving services from that provider for one of
the conditions described in subdivision (a).
(2) The completion of covered services required to be provided
under this subdivision shall apply to services rendered to the newly
covered insured on and after the effective date of his or her new
coverage.
(3)
(2) (A) The insurer may require a nonparticipating
provider whose services are continued pursuant to this subdivision
for a newly covered insured to agree in writing to be subject to the
same contractual terms and conditions that are imposed upon currently
participating providers providing similar services who are
practicing in the same or a similar geographic area as the
nonparticipating provider, including, but not limited to,
credentialing, hospital privileging, utilization review, peer review,
and quality assurance requirements. If the nonparticipating provider
does not agree to comply or does not comply with these contractual
terms and conditions, the insurer is not required to continue the
provider's services.
(B) Unless otherwise agreed upon by the nonparticipating provider
and the insurer, the services rendered pursuant to this subdivision
shall be compensated at rates and methods of payment similar to those
used by the insurer for currently participating providers providing
similar services who are practicing in the same or a similar
geographic area as the nonparticipating provider. Neither the insurer
nor the provider group is required to continue the services of a
nonparticipating provider if the provider does not accept the payment
rates provided for in this paragraph. The provider who agrees to
provide services pursuant to this subdivision shall accept the
reimbursement as payment in full and shall not bill the insured for
any amount in excess of the reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (c).
(C) A provider's agreement to contractual terms and conditions and
acceptance of payment rates to provide the completion of covered
services to an insured pursuant to this subdivision shall not be
construed as an agreement to contractual terms and conditions or
acceptance of payment rates for any other insureds or for any
services other than covered services pursuant to this subdivision,
nor shall it be construed as agreement to any other contract.
SEC. 3. No reimbursement is required by this act
pursuant to Section 6 of Article XIII B of the California
Constitution because the only costs that may be incurred by a local
agency or school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction, or
changes the penalty for a crime or infraction, within the meaning of
Section 17556 of the Government Code, or changes the definition of a
crime within the meaning of Section 6 of Article XIII B of the
California Constitution. All matter omitted in this version of
the bill appears in the bill as introduced in the Senate, February
19, 2014. (JR11)
