Bill Text: CA SB1340 | 2013-2014 | Regular Session | Chaptered
Bill Title: Health care coverage: provider contracts.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2014-07-07 - Chaptered by Secretary of State. Chapter 83, Statutes of 2014. [SB1340 Detail]
Download: California-2013-SB1340-Chaptered.html
BILL NUMBER: SB 1340 CHAPTERED
BILL TEXT
CHAPTER 83
FILED WITH SECRETARY OF STATE JULY 7, 2014
APPROVED BY GOVERNOR JULY 7, 2014
PASSED THE SENATE APRIL 28, 2014
PASSED THE ASSEMBLY JUNE 26, 2014
AMENDED IN SENATE MARCH 24, 2014
INTRODUCED BY Senator Hernandez
FEBRUARY 21, 2014
An act to amend Section 1367.49 of the Health and Safety Code, and
to amend Section 10133.64 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1340, Hernandez. Health care coverage: provider contracts.
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 by or on behalf of a
plan or insurer and a licensed hospital, as defined, or any other
licensed health care facility owned by a licensed hospital 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 hospital or facility
or the quality of services performed by the hospital or facility.
Existing law makes a contractual provision inconsistent with this
requirement void and unenforceable. Existing law requires a plan or
insurer to provide a hospital or facility at least 20 days to review
the methodology and data used before cost or quality information is
provided to subscribers or enrollees of the plan or to policyholders
or insureds of the insurer, as specified. Existing law also
establishes requirements applicable to information displayed on an
Internet Web site pursuant to these provisions by, or on behalf of, a
plan or insurer.
This bill would instead prohibit a contract between a plan or
insurer and a provider or supplier, as defined, from containing a
provision that restricts the ability of the plan or insurer to
furnish information to consumers or purchasers, as defined,
concerning the cost range of a procedure or full course of treatment
or the quality of services performed by the provider or supplier. The
bill would require a plan or insurer to provide a provider or
supplier with 30 days to review the methodology and data used and
would make related, conforming changes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.49 of the Health and Safety Code is
amended to read:
1367.49. (a) A contract issued, amended, renewed, or delivered on
or after January 1, 2015, by or on behalf of a health care service
plan and a provider or supplier shall not contain any provision that
restricts the ability of the health care service plan to furnish
consumers or purchasers information concerning any of the following:
(1) The cost range of a procedure or a full course of treatment,
including, but not limited to, facility, professional, and diagnostic
services, prescription drugs, durable medical equipment, and other
items and services related to the treatment.
(2) The quality of services performed by the provider or supplier.
(b) Any contractual provision inconsistent with this section shall
be void and unenforceable.
(c) A health care service plan shall provide the provider or
supplier an advance opportunity of 30 days to review the methodology
and data developed and compiled by the health care service plan, and
used pursuant to subdivision (a), before cost or quality information
is provided to consumers or purchasers, including material revisions
or additions of new information. At the time the health care service
plan provides a provider or supplier with the opportunity to review
the methodology and data, it shall also notify the provider or
supplier in writing of their opportunity to provide an Internet Web
site link pursuant to subdivision (f).
(d) If the information proposed to be furnished to enrollees and
subscribers on the quality of services performed by a provider or
supplier is data that the plan has developed and compiled, the plan
shall utilize 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 providers and suppliers.
(e) Any Internet Web site owned or controlled by a health care
service plan, or operated by another person or entity under contract
with or on behalf of a health care service plan, that displays the
information developed and compiled by the health care service plan as
referenced by this section shall prominently post the following
statement:
"Individual facilities or health care providers may disagree with
the methodology used to define the cost ranges, the cost data, or
quality measures. Many factors may influence cost or quality,
including, but not limited to, the cost of uninsured and charity
care, the type and severity of procedures, the case mix of a
facility, special services such as trauma centers, burn units,
medical and other educational programs, research, transplant
services, technology, payer mix, and other factors affecting
individual facilities and health care providers."
A health care service plan and a provider or supplier shall not be
precluded from mutually agreeing in writing to an alternative method
of conveying this statement.
(f) If a provider or supplier chooses to provide an Internet Web
site link where a response to the health care service plan's posting
may be found, it shall do so in a timely manner in order to satisfy
the requirements of this section. If a provider or supplier chooses
to provide a response, a plan shall post, in an easily identified
manner, a prominent link to the provider's or supplier's Internet Web
site where a response to the plan's posting may be found. A health
care service plan and a provider or supplier shall not be precluded
from mutually agreeing in writing to an alternative method to convey
a provider's or supplier's response.
(g) For the purposes of this section, the following definitions
shall apply:
(1) "Consumers" means enrollees or subscribers of the health care
service plan or beneficiaries of a self-funded health coverage
arrangement administered by the health care service plan or other
persons entitled to access services through a network established by
the health care service plan.
(2) "Provider" has the same meaning as that term is defined in
Section 1367.50.
(3) "Purchasers" means the sponsors of a self-funded health
coverage arrangement administered by the health care service plan.
(4) "Supplier" has the same meaning as that term is defined in
Section 1367.50.
(h) Section 1390 shall not apply for purposes of this section.
SEC. 2. Section 10133.64 of the Insurance Code is amended to read:
10133.64. (a) A contract issued, amended, renewed, or delivered
on or after January 1, 2015, by or on behalf of a health insurer and
a provider or supplier shall not contain any provision that restricts
the ability of the health insurer to furnish consumers or purchasers
information concerning any of the following:
(1) The cost range of a procedure or a full course of treatment,
including, but not limited to, facility, professional, and diagnostic
services, prescription drugs, durable medical equipment, and other
items and services related to the treatment.
(2) The quality of services performed by the provider or supplier.
(b) Any contractual provision inconsistent with this section shall
be void and unenforceable.
(c) A health insurer shall provide the provider or supplier an
advance opportunity of 30 days to review the methodology and data
developed and compiled by the health insurer, and used pursuant to
subdivision (a), before cost or quality information is provided to
consumers or purchasers, including material revisions or additions of
new information. At the time the health insurer provides a provider
or supplier with the opportunity to review the methodology and data,
it shall also notify the provider or supplier in writing of their
opportunity to provide an Internet Web site link pursuant to
subdivision (f).
(d) If the information proposed to be furnished to policyholders
and insureds on the quality of services performed by a provider or
supplier is data that the insurer has developed and compiled, the
insurer shall utilize 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 providers and suppliers.
(e) Any Internet Web site owned or controlled by a health insurer,
or operated by another person or entity under contract with or on
behalf of a health insurer, that displays the information developed
and compiled by the health insurer as referenced by this section
shall prominently post the following statement:
"Individual health care facilities or providers may disagree with
the methodology used to define the cost ranges, the cost data, or
quality measures. Many factors may influence cost or quality,
including, but not limited to, the cost of uninsured and charity
care, the type and severity of procedures, the case mix of a
facility, special services such as trauma centers, burn units,
medical and other educational programs, research, transplant
services, technology, payer mix, and other factors affecting
individual health care facilities and providers."
A health insurer and a provider or supplier shall not be precluded
from mutually agreeing in writing to an alternative method of
conveying this statement.
(f) If a provider or supplier chooses to provide an Internet Web
site link where a response to the health insurer's posting may be
found, it shall do so in a timely manner in order to satisfy the
requirements of this section. If a provider or supplier chooses to
provide a response, an insurer shall post, in an easily identified
manner, a prominent link to the provider's or supplier's Internet Web
site where a response to the health insurer's posting may be found.
A health insurer and a provider or supplier shall not be precluded
from mutually agreeing in writing to an alternative method to convey
a provider's or supplier's response.
(g) For the purposes of this section, the following definitions
shall apply:
(1) "Consumers" means policyholders or insureds of the health
insurer or beneficiaries of a self-funded health coverage arrangement
administered by the health insurer or other persons entitled to
access services through a network established by the health insurer.
(2) "Provider" has the same meaning as that term is defined in
Section 10117.52.
(3) "Purchasers" means the sponsors of a self-funded health
coverage arrangement administered by the health insurer.
(4) "Supplier" has the same meaning as that term is defined in
Section 10117.52.
