BILL NUMBER: AB 2012 CHAPTERED
BILL TEXT
CHAPTER 756
FILED WITH SECRETARY OF STATE SEPTEMBER 29, 2006
APPROVED BY GOVERNOR SEPTEMBER 29, 2006
PASSED THE ASSEMBLY AUGUST 24, 2006
PASSED THE SENATE AUGUST 22, 2006
AMENDED IN SENATE AUGUST 17, 2006
AMENDED IN SENATE JUNE 1, 2006
AMENDED IN ASSEMBLY APRIL 19, 2006
INTRODUCED BY Assembly Member Emmerson
(Coauthors: Assembly Members Aghazarian and Koretz)
(Coauthor: Senator Migden)
FEBRUARY 9, 2006
An act to amend Section 1367.18 of the Health and Safety Code, and
to amend Section 10123.7 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2012, Emmerson Orthotic and prosthetic devices.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the 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 requires health
care service plans and health insurers to provide coverage for
orthotic and prosthetic devices under terms and conditions that may
be agreed upon between the subscriber and plan or policyholder and
insurer, and requires that the device be prescribed by a physician or
ordered by a licensed health care provider acting within the scope
of his or her license.
This bill would specify that a doctor of podiatric medicine,
acting within the scope of his or her license, may prescribe the
orthotic or prosthetic devices covered by the plan or insurer. The
bill would, on and after July 1, 2007, require the amount of the
benefit for orthotic and prosthetic devices and services to be, for
health care service plans, no less than the annual and lifetime
benefit maximums applicable to basic health care services and, for
insurance policies, no less than the annual lifetime benefit maximums
applicable to all benefits in the policy. The bill would also limit
out-of-pocket amounts for covered orthotic and prosthetic devices and
services.
Because a willful violation of this bill's provisions relating to
health care service plans would be a crime, it 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.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.18 of the Health and Safety Code is
amended to read:
1367.18. (a) Every health care service plan, except a specialized
health care service plan, that covers hospital, medical, or surgical
expenses on a group basis shall offer coverage for orthotic and
prosthetic devices and services under the terms and conditions that
may be agreed upon between the group subscriber and the plan. Every
plan shall communicate the availability of that coverage to all group
contractholders and to all prospective group contractholders with
whom they are negotiating. Any coverage for prosthetic devices shall
include original and replacement devices, as prescribed by a
physician and surgeon or doctor of podiatric medicine acting within
the scope of his or her license. Any coverage for orthotic devices
shall provide for coverage when the device, including original and
replacement devices, is prescribed by a physician and surgeon or
doctor of podiatric medicine acting within the scope of his or her
license, or is ordered by a licensed health care provider acting
within the scope of his or her license. Every plan shall have the
right to conduct a utilization review to determine medical necessity
prior to authorizing these services.
(b) Notwithstanding subdivision (a), on and after July 1, 2007,
the amount of the benefit for orthotic and prosthetic devices and
services shall be no less than the annual and lifetime benefit
maximums applicable to the basic health care services required to be
provided under Section 1367. If the contract does not include any
annual or lifetime benefit maximums applicable to basic health care
services, the amount of the benefit for orthotic and prosthetic
devices and services shall not be subject to an annual or lifetime
maximum benefit level. Any copayment, coinsurance, deductible, and
maximum out-of-pocket amount applied to the benefit for orthotic and
prosthetic devices and services shall be no more than the most common
amounts applied to the basic health care services required to be
provided under Section 1367.
SEC. 2. Section 10123.7 of the Insurance Code is amended to read:
10123.7. (a) On or after January 1, 1986, every insurer issuing
group health insurance shall offer coverage for orthotic and
prosthetic devices and services under the terms and conditions that
may be agreed upon between the group policyholder and the insurer.
Every insurer shall communicate the availability of that coverage to
all group policyholders and to all prospective group policyholders
with whom they are negotiating. Any coverage for prosthetic devices
shall include original and replacement devices, as prescribed by a
physician and surgeon or doctor of podiatric medicine acting within
the scope of his or her license. Any coverage for orthotic devices
shall provide for coverage when the device, including original and
replacement devices, is prescribed by a physician and surgeon or
doctor of podiatric medicine acting within the scope of his or her
license, or is ordered by a licensed health care provider acting
within the scope of his or her license. Every insurer shall have the
right to conduct a utilization review to determine medical necessity
prior to authorizing these services.
(b) Notwithstanding subdivision (a), on and after July 1, 2007,
the amount of the benefit for orthotic and prosthetic devices and
services shall be no less than the annual and lifetime benefit
maximums applicable to all benefits in the policy. Any copayment,
coinsurance, deductible, and maximum out-of-pocket amount applied to
the benefit for orthotic and prosthetic devices and services shall be
no more than the most common amounts contained in the policy.
(c) This section shall not apply to Medicare supplement,
short-term limited duration health insurance, vision-only,
dental-only, or CHAMPUS supplement insurance, or to hospital
indemnity, hospital-only, accident-only, or specified disease
insurance that does not pay benefits on a fixed benefit, cash payment
only basis.
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.