Bill Text: CA SB1285 | 2011-2012 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Hospital billing: emergency services and care.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Engrossed - Dead) 2012-08-16 - Set, first hearing. Referred to APPR. suspense file. Set, first hearing. Held in committee and under submission. [SB1285 Detail]

Download: California-2011-SB1285-Introduced.html

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BILL NUMBER: SB 1285	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Hernandez

                        FEBRUARY 23, 2012

   An act to amend Section 1371.4 of the Health and Safety Code,
relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1285, as introduced, Hernandez. Health care service plans:
emergency services.
   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 requires
a health care service plan to obtain timely authorization for
medically necessary care when the enrollee has received emergency
care services but, in the opinion of the treating provider, cannot
yet be discharged safely. Existing law provides that in case of a
disagreement between the health care service plan and the provider
regarding the need for necessary medical care, the plan shall assume
responsibility for the care of the patient, as specified.
   This bill would make a technical, nonsubstantive change to these
provisions.
   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 1371.4 of the Health and Safety Code is amended
to read:
   1371.4.  (a) A health care service plan that covers hospital,
medical, or surgical expenses, or its contracting medical providers,
shall provide 24-hour access for enrollees and providers, including,
but not limited to, noncontracting hospitals, to obtain timely
authorization for medically necessary care, for circumstances where
the enrollee has received emergency services and care is stabilized,
but the treating provider believes that the enrollee may not be
discharged safely. A physician and surgeon shall be available for
consultation and for resolving disputed requests for authorizations.
A health care service plan that does not require prior authorization
as a prerequisite for payment for necessary medical care following
stabilization of an emergency medical condition or active labor need
not satisfy the requirements of this subdivision.
   (b) A health care service plan, or its contracting medical
providers, shall reimburse providers for emergency services and care
provided to its enrollees, until the care results in stabilization of
the enrollee, except as provided in subdivision (c). As long as
federal or state law requires that emergency services and care be
provided without first questioning the patient's ability to pay, a
health care service plan shall not require a provider to obtain
authorization prior to the provision of emergency services and care
necessary to stabilize the enrollee's emergency medical condition.
   (c) Payment for emergency services and care may be denied only if
the health care service plan, or its contracting medical providers,
reasonably determines that the emergency services and care were never
performed; provided that a health care service plan, or its
contracting medical providers, may deny reimbursement to a provider
for a medical screening examination in cases when the plan enrollee
did not require emergency services and care and the enrollee
reasonably should have known that an emergency did not exist. A
health care service plan may require prior authorization as a
prerequisite for payment for necessary medical care following
stabilization of an emergency medical condition.
   (d) If there is a disagreement between the health care service
plan and the provider regarding the need for necessary medical care,
following stabilization of the enrollee, the plan shall assume
responsibility for the care of the patient either by having medical
personnel contracting with the plan personally take over the care of
the patient within a reasonable amount of time after the
disagreement, or by having another general acute care hospital under
contract with the plan agree to accept the transfer of the patient as
provided in Section 1317.2, Section 1317.2a, or other 
pertinent   applicable  statute. However, this
requirement shall not apply to necessary medical care provided in
hospitals outside the service area of the health care service plan.
If the health care service plan fails to satisfy the requirements of
this subdivision, further necessary care shall be deemed to have been
authorized by the plan. Payment for this care may not be denied.
   (e) A health care service plan may delegate the responsibilities
enumerated in this section to the plan's contracting medical
providers.
   (f) Subdivisions (b), (c), (d), (g), and (h) shall not apply with
respect to a nonprofit health care service plan that has 3,500,000
enrollees and maintains a prior authorization system that includes
the availability by telephone within 30 minutes of a practicing
emergency department physician.
   (g) The Department of Managed Health Care shall adopt by July 1,
1995, on an emergency basis, regulations governing instances when an
enrollee requires medical care following stabilization of an
emergency medical condition, including appropriate timeframes for a
health care service plan to respond to requests for treatment
authorization.
   (h) The Department of Managed Health Care shall adopt, by July 1,
1999, on an emergency basis, regulations governing instances when an
enrollee in the opinion of the treating provider requires necessary
medical care following stabilization of an emergency medical
condition, including appropriate timeframes for a health care service
plan to respond to a request for treatment authorization from a
treating provider who has a contract with a plan.
   (i) The definitions set forth in Section 1317.1 shall control the
construction of this section.
   (j) (1) A health care service plan that is contacted by a hospital
pursuant to Section 1262.8 shall, within 30 minutes of the time the
hospital makes the initial telephone call requesting information,
either authorize poststabilization care or inform the hospital that
it will arrange for the prompt transfer of the enrollee to another
hospital.
   (2) A health care service plan that is contacted by a hospital
pursuant to Section 1262.8 shall reimburse the hospital for
poststabilization care rendered to the enrollee if any of the
following occur:
   (A) The health care service plan authorizes the hospital to
provide poststabilization care.
   (B) The health care service plan does not respond to the hospital'
s initial contact or does not make a decision regarding whether to
authorize poststabilization care or to promptly transfer the enrollee
within the timeframe set forth in paragraph (1).
   (C) There is an unreasonable delay in the transfer of the
enrollee, and the noncontracting physician and surgeon determines
that the enrollee requires poststabilization care.
   (3) A health care service plan shall not require a hospital
representative or a noncontracting physician and surgeon to make more
than one telephone call pursuant to Section 1262.8 to the number
provided in advance by the health care service plan. The
representative of the hospital that makes the telephone call may be,
but is not required to be, a physician and surgeon.
   (4) An enrollee who is billed by a hospital in violation of
Section 1262.8 may report receipt of the bill to the health care
service plan and the department. The department shall forward that
report to the State Department of Public Health.
   (5) For purposes of this section, "poststabilization care" means
medically necessary care provided after an emergency medical
condition has been stabilized.