BILL NUMBER: AB 1203	CHAPTERED
	BILL TEXT

	CHAPTER  603
	FILED WITH SECRETARY OF STATE  SEPTEMBER 30, 2008
	APPROVED BY GOVERNOR  SEPTEMBER 30, 2008
	PASSED THE SENATE  AUGUST 27, 2008
	PASSED THE ASSEMBLY  AUGUST 29, 2008
	AMENDED IN SENATE  AUGUST 21, 2008
	AMENDED IN SENATE  AUGUST 19, 2008
	AMENDED IN SENATE  AUGUST 12, 2008
	AMENDED IN SENATE  JUNE 30, 2008
	AMENDED IN SENATE  JUNE 12, 2008
	AMENDED IN ASSEMBLY  JANUARY 17, 2008
	AMENDED IN ASSEMBLY  JANUARY 9, 2008
	AMENDED IN ASSEMBLY  JANUARY 7, 2008

INTRODUCED BY   Assembly Member Salas

                        FEBRUARY 23, 2007

   An act to amend Sections 1317.1, 1371.4, and 1386 of, and to
repeal and add Section 1262.8 of, the Health and Safety Code,
relating to health care.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 1203, Salas. Health care service plans: noncontracting
hospitals: poststabilization 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
licensure and regulation of health facilities by the State Department
of Public Health and makes a violation of those provisions a
misdemeanor.
   Existing law provides that for purposes of specified provisions
governing the stabilization of patient care, a patient is "stabilized"
or "stabilization" has occurred when, in the opinion of the treating
provider, the patient's medical condition is such that, within
reasonable probability, no material deterioration of the patient's
condition is likely to result from, or occur during, a transfer of
the patient, as provided.
   This bill would also provide that, for purposes of these
provisions a patient is "stabilized" or "stabilization" has occurred
when, in the opinion of the treating provider, no such material
deterioration of the patient's condition is likely to result from, or
occur during, the release of the patient, as provided.
   Existing law requires a noncontracting hospital to contact an
enrollee's health care service plan to obtain the enrollee's medical
record information prior to admitting the enrollee as an inpatient
for poststabilization care, transferring an enrollee to a
noncontracting hospital for poststabilization care, or providing
poststabilization care to an enrollee admitted for medically
necessary care, under specified conditions. Existing law requires a
health care service plan contacted by a hospital under these
circumstances to, among other things, discuss the enrollee's medical
record with an appropriate hospital representative and transmit any
appropriate and requested portion of the enrollee's medical record to
the hospital representative. Existing law requires a health care
service plan, or its contracting medical providers, to provide
24-hour access for providers to obtain timely authorization for
medically necessary care in specified circumstances. Existing law
also prohibits a noncontracting hospital that is required to contact
an enrollee's health care service plan, and fails to do so, from
billing the enrollee for poststabilization care.
   This bill would recast those provisions to provide that if a
patient with an emergency medical condition, as defined, is covered
by a health care service plan that requires prior authorization for
poststabilization care, a noncontracting hospital, except as
provided, shall, once the emergency medical condition has been
stabilized, but prior to providing poststabilization care, retrieve
information from the patient and the patient's health care service
plan or the health plan's contracting medical provider, and provide
information to the plan or provider about the patient, as specified.
The bill would provide that certain provisions governing
poststabilization care shall not apply to minor treatment procedures
if specified conditions apply. The bill would prohibit a
noncontracting hospital from billing that patient for
poststabilization care, except for applicable copayments,
coinsurance, and deductibles, unless the patient assumes financial
responsibility for the care, as specified, or the hospital is unable
to obtain the health care service plan's name and contact
information, as specified. The bill would delete the requirement that
a health care service plan contacted for poststabilization care
authorization discuss the enrollee's medical record with an
appropriate hospital representative and would, instead, provide that
if poststabilization care has been authorized by the health care
service plan, that the noncontracting hospital request the patient's
medical record from the patient's plan or its contracting medical
provider. In addition, the bill would specifically require that a
health care service plan, or its contracting medical providers,
provide 24-hour access for noncontracting hospitals to obtain timely
authorization for poststabilization care, as specified. The bill
would enact other related provisions.
   Existing law authorizes the Director of the Department of Managed
Health Care, after notice and opportunity for a hearing, to suspend
or revoke a license or assess administrative penalties if the
director determines that the licensee committed an act or omission
constituting grounds for disciplinary action, as specified.
   This bill would add a plan that violates the above provisions
relating to poststabilization care to the list of acts or omissions
that constitute grounds for disciplinary action.
   Because a violation of the bill's provisions 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.
   This bill would make additional changes to Section 1317.1 of the
Health and Safety Code made by AB 2861, contingent upon the prior
enactment of AB 2861.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1262.8 of the Health and Safety Code is
repealed.
  SEC. 2.  Section 1262.8 is added to the Health and Safety Code, to
read:
   1262.8.  (a) A noncontracting hospital shall not bill a patient
who is an enrollee of a health care service plan for
poststabilization care, except for applicable copayments,
coinsurance, and deductibles, unless one of the following conditions
are met:
   (1) The patient or the patient's spouse or legal guardian refuses
to consent, pursuant to subdivision (f), for the patient to be
transferred to the contracting hospital as requested and arranged for
by the patient's health care service plan.
   (2) The hospital is unable to obtain the name and contact
information of the patient's health care service plan as provided in
subdivision (c).
   (b) If a patient with an emergency medical condition, as defined
by Section 1317.1, is covered by a health care service plan that
requires prior authorization for poststabilization care, a
noncontracting hospital, except as provided in subdivision (n),
shall, prior to providing poststabilization care, do all of the
following once the emergency medical condition has been stabilized,
as defined by Section 1317.1:
   (1) Seek to obtain the name and contact information of the patient'
s health care service plan. The hospital shall document its attempt
to ascertain this information in the patient's medical record, which
shall include requesting the patient's health care service plan
member card or asking the patient, or a family member or other person
accompanying the patient, if he or she can identify the patient's
health care service plan, or any other means known to the hospital
for accurately identifying the patient's health care service plan.
   (2) Contact the patient's health care service plan, or the health
plan's contracting medical provider, for authorization to provide
poststabilization care, if identification of the plan was obtained
pursuant to paragraph (1).
   (A) The hospital shall make the contact described in this
subparagraph by either following the instructions on the patient's
health care service plan member card or using the contact information
provided by the patient's health care service plan pursuant to
subdivision (j) or (k).
   (B) A representative of the hospital shall not be required to make
more than one telephone call to the health care service plan, or its
contracting medical provider, provided that in all cases the health
care service plan, or its contracting medical provider, shall be able
to reach a representative of the hospital upon returning the call,
should the plan, or its contracting medical provider, need to call
back. The representative of the hospital who makes the telephone call
may be, but is not required to be, a physician and surgeon.
   (3) Upon request of the patient's health care service plan, or the
health plan's contracting medical provider, provide to the plan, or
its contracting medical provider, the treating physician and surgeon'
s diagnosis and any other relevant information reasonably necessary
for the health care service plan or the plan's contracting medical
provider to make a decision to authorize poststabilization care or to
assume management of the patient's care by prompt transfer.
   (c) A noncontracting hospital that is not able to obtain the name
and contact information of the patient's health care service plan
pursuant to subdivision (b) is not subject to the requirements of
this section.
   (d) (1) A health care service plan, or its contracting medical
provider, that is contacted by a noncontracting hospital pursuant to
paragraph (2) of subdivision (b), shall, within 30 minutes from the
time the noncontracting hospital makes the initial contact, do either
of the following:
   (A) Authorize poststabilization care.
   (B) Inform the noncontracting hospital that it will arrange for
the prompt transfer of the enrollee to another hospital.
   (2) If the health care service plan, or its contracting medical
provider, does not notify the noncontracting hospital of its decision
pursuant to paragraph (1) within 30 minutes, the poststabilization
care shall be deemed authorized, and the health care service plan, or
its contracting medical provider, shall pay charges for the care, in
accordance with the Knox-Keene Health Care Service Plan Act of 1975
(Chapter 2.2 (commencing with Section 1340) of Division 2) and any
regulation adopted thereunder.
   (3) If the health care service plan, or its contracting medical
provider, notified the noncontracting hospital that it would assume
management of the patient's care by prompt transfer, but either the
health care service plan or its contracting medical provider fails to
transfer the patient within a reasonable time, the poststabilization
care shall be deemed authorized, and the health care service plan,
or its contracting medical provider, shall pay charges, in accordance
with the Knox-Keene Health Care Service Plan Act of 1975 (Chapter
2.2 (commencing with Section 1340) of Division 2 of the Health and
Safety Code) and any regulation adopted thereunder, for the care
until the enrollee is transferred.
   (4) If the health care service plan, or its contracting medical
provider, provides authorization to the noncontracting hospital for
specified poststabilization care and services, the health care
service plan, or its contracting medical provider, shall be
responsible to pay for that authorized care.
   (e) If a health care service plan, or its contracting medical
provider, decides to assume management of the patient's care by
prompt transfer, the health care service plan, or its contracting
medical provider, shall do all of the following:
   (1) Arrange and pay the reasonable charges associated with the
transfer of the patient.
   (2) Pay for all of the immediately required medically necessary
care rendered to the patient prior to the transfer in order to
maintain the patient's clinical stability.
   (3) Be responsible for making all arrangements for the patient's
transfer, including, but not limited to, finding a contracted
facility available for the transfer of the patient.
   (f) (1) If the patient, or the patient's spouse or legal guardian
refuses to consent to the patient's transfer under subdivision (e),
the noncontracting hospital shall promptly provide a written notice
to the patient or the patient's spouse or legal guardian indicating
that the patient will be financially responsible for any further
poststabilization care provided by the hospital.
   (2) For patients whose primary language is one of the Medi-Cal
threshold languages, the notice shall be delivered to them in their
primary language.
   (3) The Department of Managed Health Care shall translate the
notice required by this subdivision in all Medi-Cal threshold
languages and make the translations available to the hospitals
subject to this section.
   (4) The written notice provided pursuant to this subdivision shall
include the following statement:

   THIS NOTICE MUST BE PROVIDED TO YOU UNDER CALIFORNIA LAW

   "You have received emergency care at a hospital that is not a part
of your health plan's provider network. Under state law, emergency
care must be paid by your health plan no matter where you get that
care. The doctor who is caring for you has decided that you may be
safely moved to another hospital for the additional care you need.
Because you no longer need emergency care, your health plan has not
authorized further care at this hospital. Your health plan has
arranged for you to be moved to a hospital that is in your health
plan's provider network.
   If you agree to be moved, your health plan will pay for your care
at that hospital. You will only have to pay for your deductible,
copayments, or coinsurance for care. You will not have to pay for
your deductible, copayments, or coinsurance for transportation costs
to another hospital that is covered by your health plan.
   IF YOU CHOOSE TO STAY AT THIS HOSPITAL FOR YOUR ADDITIONAL CARE,
YOU WILL HAVE TO PAY THE FULL COST OF CARE NOW THAT YOU NO LONGER
NEED EMERGENCY CARE. This cost may include the cost of the doctor or
doctors, the hospital, and any laboratory, radiology, or other
services that you receive.
   If you do not think you can be safely moved, talk to the doctor
about your concerns. If you would like additional help, you may
contact:
   Your health plan member services department. Look on your health
plan member card for that phone number. You can file a grievance with
your plan.
   The HMO Helpline at 888-HMO-2219. The HMO Helpline is available 24
hours a day, 7 days a week. The HMO Helpline can work with your
health plan to address your concerns, but you may still have to pay
the full cost of care at this hospital if you stay."


   (5) The hospital shall give one copy of the written notice
required by this subdivision to the patient, or the patient's spouse
or legal guardian, for signature and may retain a copy in the patient'
s medical record.
   (6) The hospital shall ensure prompt delivery of the notice to the
patient or his or her spouse or legal guardian. The hospital shall
obtain signed acceptance of the written notice required by this
subdivision, and signed acceptance of any other documents the
hospital requires for any further poststabilization care, from the
patient or the patient's spouse or legal guardian, and shall provide
the health care service plan, or its contracting medical provider,
with confirmation of the patient's, or his or her spouse or legal
guardian's, receipt of the written notice.
   (7) If the noncontracting hospital fails to meet the requirements
of this subdivision, the hospital shall not bill the patient or the
patient's health care service plan, or its contracting medical
provider, for poststabilization care provided to the patient.
   (8) If the patient, or the patient's spouse or legal guardian,
refuses to sign the notice, the noncontracting hospital shall
document in the patient's medical record that the notice was provided
and signature was refused. Upon the patient's refusal to sign, the
patient shall assume financial responsibility for any further
poststabilization care provided by the hospital.
   (9) The Department of Managed Health Care may, by regulation,
modify the wording of the notice required under this subdivision for
clarity, readability, and accuracy of the information provided.
   (10) The Department of Managed Health Care may, in conjunction
with consumer groups, health care service plans, and hospitals,
modify the wording of the notice to include language regarding
Medicare beneficiaries, if appropriate under Medicare rules. The
initial modification shall not be subject to the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340, et. seq.)
of Part 1 of Division 3 of Title 2 of the Government Code).
   (g) If poststabilization care has been authorized by the health
care service plan, the noncontracting hospital shall request the
patient's medical record from the patient's health care service plan
or its contracting medical provider.
   (h) The health care service plan, or its contracting medical
provider, shall, upon conferring with the noncontracting hospital,
transmit any appropriate portion of the patient's medical record, if
the records are in the plan's possession, via facsimile transmission
or electronic mail, whichever method is requested by the
noncontracting hospital's representative or the noncontracting
physician and surgeon. The health care service plan, or its
contracting medical provider, shall transmit the patient's medical
record in a manner that complies with all legal requirements to
protect the patient's privacy.
   (i) A health care service plan, or its contracting medical
provider, that requires prior authorization for poststabilization
care shall provide 24-hour access for patients and providers,
including noncontracting hospitals, to obtain timely authorization
for medically necessary poststabilization care.
   (j) A health care service plan shall provide all noncontracting
hospitals in the state with specific contact information needed to
make the contact required by this section. The contact information
provided to hospitals shall be updated as necessary, but no less than
once a year.
   (k) In addition to meeting the requirements of subdivision (j), a
health care service plan shall provide the contact information
described in subdivision (j) to the Department of Managed Health
Care. The contact information provided pursuant to this subdivision
shall be updated as necessary, but no less than once a year. The
receiving department shall post this contact information on its
Internet Web site no later than January 1 of each calendar year.
   (l) This section shall only apply to a noncontracting hospital.
   (m) For purposes of this section, the following definitions shall
apply:
   (1) "Health care service plan" means a health care service plan
licensed pursuant to Chapter 2.2 (commencing with Section 1340) of
Division 2 that covers hospital, medical, or surgical expenses.
   (2) "Noncontracting hospital" means a general acute care hospital,
as defined in subdivision (a) of Section 1250 or an acute
psychiatric hospital, as defined in subdivision (b) of Section 1250,
that does not have a written contract with the patient's health care
service plan to provide health care services to the patient.
   (3) "Poststabilization care" means medically necessary care
provided after an emergency medical condition has been stabilized, as
defined by subdivision (j) of Section 1317.1.
   (4) "Contracting medical provider" means a medical group,
independent practice association, or any other similar organization
that, pursuant to a signed written contract, has agreed to accept
responsibility for provision or reimbursement of a noncontracting
hospital for emergency and poststabilization services provided to a
health plan's enrollees.
   (n) Subdivisions (b) to (h), inclusive, shall not apply to minor
treatment procedures, if all of the following apply:
   (1) The procedure is provided in the treatment area of the
emergency department.
   (2) The procedure concludes the treatment of the presenting
emergency medical condition of a patient and is related to that
condition, even though the treatment may not resolve the underlying
medical condition.
   (3) The procedure is performed according to accepted standards of
practice.
   (4) The procedure would result in the direct discharge or release
of the patient from the emergency department following this care.
   (o) Nothing in this section is intended to prevent a health care
service plan or its contracting medical provider from assuming
management of the patient's care at any time after the initial
provision of poststabilization care by the noncontracting hospital
before the patient has been discharged. Upon the request of the
health care service plan or its contracting medical provider, the
noncontracting hospital shall provide the health care service plan or
its contracting medical provider with any information specified in
paragraph (3) of subdivision (b).
   (p) Nothing in this section shall authorize a provider of health
care services to bill a Medi-Cal beneficiary enrolled in a Medi-Cal
managed care plan or otherwise alter the provisions of subdivision
(a) of Section 14019.3 of the Welfare and Institutions Code.
  SEC. 3.  Section 1317.1 of the Health and Safety Code, as amended
by Section 1 of Chapter 544 of the Statutes of 1999, is amended to
read:
   1317.1.  Unless the context otherwise requires, the following
definitions shall control the construction of this article and
Section 1371.4:
   (a) (1) "Emergency services and care" means medical screening,
examination, and evaluation by a physician, or, to the extent
permitted by applicable law, by other appropriate personnel under the
supervision of a physician, to determine if an emergency medical
condition or active labor exists and, if it does, the care,
treatment, and surgery by a physician necessary to relieve or
eliminate the emergency medical condition, within the capability of
the facility.
   (2) (A) "Emergency services and care" also means an additional
screening, examination, and evaluation by a physician, or other
personnel to the extent permitted by applicable law and within the
scope of their licensure and clinical privileges, to determine if a
psychiatric emergency medical condition exists, and the care and
treatment necessary to relieve or eliminate the psychiatric emergency
medical condition, within the capability of the facility.
   (B) For the purposes of Section 1371.4, emergency services and
care as defined in this paragraph shall not apply to services
provided under managed care contracts with the Medi-Cal program to
the extent that those services are excluded from coverage under the
contract.
   (C) This paragraph does not expand, restrict, or otherwise affect,
the scope of licensure or clinical privileges for clinical
psychologists or other medical personnel.
   (b) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical
attention could reasonably be expected to result in any of the
following:
   (1) Placing the patient's health in serious jeopardy.
   (2) Serious impairment to bodily functions.
   (3) Serious dysfunction of any bodily organ or part.
   (c) "Active labor" means a labor at a time at which either of the
following would occur:
   (1) There is inadequate time to effect safe transfer to another
hospital prior to delivery.
   (2) A transfer may pose a threat to the health and safety of the
patient or the unborn child.
   (d) "Hospital" means all hospitals with an emergency department
licensed by the state department.
   (e) "State department" means the State Department of Public
Health.
   (f) "Medical hazard" means a material deterioration in medical
condition in, or jeopardy to, a patient's medical condition or
expected chances for recovery.
   (g) "Board" means the Medical Board of California.
   (h) "Within the capability of the facility" means those
capabilities which the hospital is required to have as a condition of
its emergency medical services permit and services specified on
Services Inventory Form 7041 filed by the hospital with the Office of
Statewide Health Planning and Development.
   (i) "Consultation" means the rendering of an opinion, advice, or
prescribing treatment by telephone and, when determined to be
medically necessary jointly by the emergency and specialty
physicians, includes review of the patient's medical record,
examination, and treatment of the patient in person by a specialty
physician who is qualified to give an opinion or render the necessary
treatment in order to stabilize the patient.
   (j) A patient is "stabilized" or "stabilization" has occurred
when, in the opinion of the treating provider, the patient's medical
condition is such that, within reasonable medical probability, no
material deterioration of the patient's condition is likely to result
from, or occur during, the release or transfer of the patient as
provided for in Section 1317.2, Section 1317.2a, or other pertinent
statute.
  SEC. 3.5.  Section 1317.1 of the Health and Safety Code, as amended
by Section 1 of Chapter 544 of the Statutes of 1999, is amended to
read:
   1317.1.  Unless the context otherwise requires, the following
definitions shall control the construction of this article and
Section 1371.4:
   (a) (1) "Emergency services and care" means medical screening,
examination, and evaluation by a physician, or, to the extent
permitted by applicable law, by other appropriate personnel under the
supervision of a physician, to determine if an emergency medical
condition or active labor exists and, if it does, the care,
treatment, and surgery by a physician necessary to relieve or
eliminate the emergency medical condition, within the capability of
the facility.
   (2) "Emergency services and care" also means an additional
screening, examination, and evaluation by a physician, or other
personnel to the extent permitted by applicable law and within the
scope of their licensure and clinical privileges, to determine if a
psychiatric emergency medical condition exists, and the care and
treatment necessary to relieve or eliminate the psychiatric emergency
medical condition, within the capability of the facility.
   (A) The care and treatment necessary to relieve or eliminate a
psychiatric emergency medical condition may include admission or
transfer to a psychiatric unit within a general acute care hospital,
as defined in subdivision (a) of Section 1250, or to an acute
psychiatric hospital, as defined in subdivision (b) of Section 1250,
pursuant to subdivision (k).
   (B) For the purposes of Section 1371.4, emergency services and
care, as defined in this paragraph, shall not apply to services
provided under managed care contracts with the Medi-Cal program to
the extent that those services are excluded from coverage under the
contract.
   (3) "Psychiatric emergency medical condition" means a mental
disorder that manifests itself by acute symptoms of sufficient
severity as to render the patient as either of the following:
   (A) An immediate danger to himself or herself or to others.
   (B) Immediately unable to provide for, or utilize, food, shelter,
or clothing due to the mental disorder.
   (4) This subdivision does not expand, restrict, or otherwise
affect, the scope of licensure or clinical privileges for clinical
psychologists or other medical personnel.
   (b) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical
attention could reasonably be expected to result in any of the
following:
   (1) Placing the patient's health in serious jeopardy.
   (2) Serious impairment to bodily functions.
   (3) Serious dysfunction of any bodily organ or part.
   (c) "Active labor" means a labor at a time at which either of the
following would occur:
   (1) There is inadequate time to effect safe transfer to another
hospital prior to delivery.
   (2) A transfer may pose a threat to the health and safety of the
patient or the unborn child.
   (d) "Hospital" means all hospitals with an emergency department
licensed by the state department.
   (e) "State department" means the State Department of Public
Health.
   (f) "Medical hazard" means a material deterioration in medical
condition in, or jeopardy to, a patient's medical condition or
expected chances for recovery.
   (g) "Board" means the Medical Board of California.
   (h) "Within the capability of the facility" means those
capabilities which the hospital is required to have as a condition of
its emergency medical services permit and services specified on
Services Inventory Form 7041 filed by the hospital with the Office of
Statewide Health Planning and Development.
   (i) "Consultation" means the rendering of an opinion, advice, or
prescribing treatment by telephone and, when determined to be
medically necessary jointly by the emergency and specialty
physicians, includes review of the patient's medical record,
examination, and treatment of the patient in person by a specialty
physician who is qualified to give an opinion or render the necessary
treatment in order to stabilize the patient.
   (j) A patient is "stabilized" or "stabilization" has occurred
when, in the opinion of the treating provider, the patient's medical
condition is such that, within reasonable medical probability, no
material deterioration of the patient's condition is likely to result
from, or occur during, the release or transfer of the patient as
provided for in Section 1317.2, Section 1317.2a, or other pertinent
statute.
   (k) (1) Notwithstanding subdivision (j), a patient may be
transferred for admission to a psychiatric unit within a general
acute care hospital, as defined in subdivision (a) of Section 1250,
or an acute psychiatric hospital, as defined in subdivision (b) of
Section 1250, for care and treatment that is solely necessary to
relieve or eliminate a psychiatric emergency medical condition, as
defined in paragraph (3) of subdivision (a), provided that, in the
opinion of the treating provider, the patient's psychiatric emergency
medical condition is such that, within reasonable medical
probability, no material deterioration of the patient's psychiatric
emergency medical condition is likely to result from, or occur
during, a transfer of the patient. A provider shall notify the
patient's health care service plan, or the health plan's contracting
medical provider of the need for the transfer if identification of
the plan is obtained pursuant to subparagraph (A) of paragraph (2).
   (2) A hospital that transfers a patient pursuant to paragraph (1)
shall do both of the following:
   (A) Seek to obtain the name and contact information of the patient'
s health care service plan. The hospital shall document its attempt
to ascertain this information in the patient's medical record. The
hospital's attempt to ascertain the information shall include
requesting the patient's health care service plan member card, asking
the patient, the patient's family member, or other person
accompanying the patient if he or she can identify the patient's
health care service plan, or using other means known to the hospital
to accurately identify the patient's health care service plan.
   (B) Notify the patient's health care service plan or the health
plan's contracting medical provider of the transfer, provided that
the identification of the plan was obtained pursuant to subparagraph
(A). The hospital shall provide the plan or its contracting medical
provider with the name of the patient, the patient's member
identification number, if known, the location and contact
information, including a telephone number, for the location where the
patient will be admitted, and the preliminary diagnosis.
   (3) (A) A hospital shall make the notification described in
subparagraph (B) of paragraph (2) by either following the
instructions on the patient's health care service plan member card or
by using the contact information provided by the patient's health
care service plan. A health care service plan shall provide all
noncontracting hospitals in the state to which one of its members
would be transferred pursuant to subparagraph (A) of paragraph (2) of
subdivision (a) with specific contact information needed to make the
contact required by this section. The contact information provided
to hospitals shall be updated as necessary, but no less than once a
year.
                   (B) A hospital making the transfer pursuant to
paragraph (1) shall not be required to make more than one telephone
call to the health care service plan, or its contracting medical
provider, provided that in all cases the health care service plan, or
its contracting medical provider, shall be able to reach a
representative of the provider upon returning the call, should the
plan, or its contracting medical provider, need to call back. The
representative of the hospital who makes the telephone call may be,
but is not required to be, a physician and surgeon.
   (4) If a transfer made pursuant to paragraph (1) is made to a
facility that does not have a contract with the patient's health care
service plan or health insurer, the plan or insurer may subsequently
require and make provision for the transfer of the patient receiving
services pursuant to this subdivision and subdivision (a) from the
noncontracting facility to a general acute care hospital, as defined
in subdivision (a) of Section 1250, or an acute psychiatric hospital,
as defined in subdivision (b) of Section 1250, that has a contract
with the plan or its delegated payer, provided that in the opinion of
the treating provider the patient's psychiatric emergency medical
condition is such that, within reasonable medical probability, no
material deterioration of the patient's psychiatric emergency medical
condition is likely to result from, or occur during, the transfer of
the patient.
   (5) Upon admission, the hospital to which the patient was
transferred shall notify the health care service plan of the
transfer, provided that the facility has the name and contact
information of the patient's health care service plan. The facility
shall not be required to make more than one telephone call to the
health care service plan, or its contracting medical provider,
provided that in all cases the health care service plan, or its
contracting medical provider, shall be able to reach a representative
of the facility upon returning the call, should the plan, or its
contracting medical provider, need to call back. The representative
of the facility who makes the telephone call may be, but is not
required to be, a physician and surgeon.
   (6) Nothing in this subdivision shall be construed to require
providers to seek authorization to provide emergency services and
care, as defined in paragraph (2) of subdivision (a), to a patient
who has a psychiatric emergency medical condition, as defined in
paragraph (3) of subdivision (a), that is not otherwise required by
law.
  SEC. 4.  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
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.
  SEC. 5.  Section 1386 of the Health and Safety Code is amended to
read:
   1386.  (a) The director may, after appropriate notice and
opportunity for a hearing, by order suspend or revoke any license
issued under this chapter to a health care service plan or assess
administrative penalties if the director determines that the licensee
has committed any of the acts or omissions constituting grounds for
disciplinary action.
   (b) The following acts or omissions constitute grounds for
disciplinary action by the director:
   (1) The plan is operating at variance with the basic
organizational documents as filed pursuant to Section 1351 or 1352,
or with its published plan, or in any manner contrary to that
described in, and reasonably inferred from, the plan as contained in
its application for licensure and annual report, or any modification
thereof, unless amendments allowing the variation have been submitted
to, and approved by, the director.
   (2) The plan has issued, or permits others to use, evidence of
coverage or uses a schedule of charges for health care services that
do not comply with those published in the latest evidence of coverage
found unobjectionable by the director.
   (3) The plan does not provide basic health care services to its
enrollees and subscribers as set forth in the evidence of coverage.
This subdivision shall not apply to specialized health care service
plan contracts.
   (4) The plan is no longer able to meet the standards set forth in
Article 5 (commencing with Section 1367).
   (5) The continued operation of the plan will constitute a
substantial risk to its subscribers and enrollees.
   (6) The plan has violated or attempted to violate, or conspired to
violate, directly or indirectly, or assisted in or abetted a
violation or conspiracy to violate any provision of this chapter, any
rule or regulation adopted by the director pursuant to this chapter,
or any order issued by the director pursuant to this chapter.
   (7) The plan has engaged in any conduct that constitutes fraud or
dishonest dealing or unfair competition, as defined by Section 17200
of the Business and Professions Code.
   (8) The plan has permitted, or aided or abetted any violation by
an employee or contractor who is a holder of any certificate,
license, permit, registration, or exemption issued pursuant to the
Business and Professions Code or this code that would constitute
grounds for discipline against the certificate, license, permit,
registration, or exemption.
   (9) The plan has aided or abetted or permitted the commission of
any illegal act.
   (10) The engagement of a person as an officer, director, employee,
associate, or provider of the plan contrary to the provisions of an
order issued by the director pursuant to subdivision (c) of this
section or subdivision (d) of Section 1388.
   (11) The engagement of a person as a solicitor or supervisor of
solicitation contrary to the provisions of an order issued by the
director pursuant to Section 1388.
   (12) The plan, its management company, or any other affiliate of
the plan, or any controlling person, officer, director, or other
person occupying a principal management or supervisory position in
the plan, management company, or affiliate, has been convicted of or
pleaded nolo contendere to a crime, or committed any act involving
dishonesty, fraud, or deceit, which crime or act is substantially
related to the qualifications, functions, or duties of a person
engaged in business in accordance with this chapter. The director may
revoke or deny a license hereunder irrespective of a subsequent
order under the provisions of Section 1203.4 of the Penal Code.
   (13) The plan violates Section 510, 2056, or 2056.1 of the
Business and Professions Code or Section 1375.7.
   (14) The plan has been subject to a final disciplinary action
taken by this state, another state, an agency of the federal
government, or another country for any act or omission that would
constitute a violation of this chapter.
   (15) The plan violates the Confidentiality of Medical Information
Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil
Code).
   (16) The plan violates Section 806 of the Military and Veterans
Code.
   (17) The plan violates Section 1262.8.
   (c) (1) The director may prohibit any person from serving as an
officer, director, employee, associate, or provider of any plan or
solicitor firm, or of any management company of any plan, or as a
solicitor, if either of the following applies:
   (A) The prohibition is in the public interest and the person has
committed, caused, participated in, or had knowledge of a violation
of this chapter by a plan, management company, or solicitor firm.
   (B) The person was an officer, director, employee, associate, or
provider of a plan or of a management company or solicitor firm of
any plan whose license has been suspended or revoked pursuant to this
section and the person had knowledge of, or participated in, any of
the prohibited acts for which the license was suspended or revoked.
   (2) A proceeding for the issuance of an order under this
subdivision may be included with a proceeding against a plan under
this section or may constitute a separate proceeding, subject in
either case to subdivision (d).
   (d) A proceeding under this section shall be subject to
appropriate notice to, and the opportunity for a hearing with regard
to, the person affected in accordance with subdivision (a) of Section
1397.
  SEC. 6.  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.
  SEC. 7.  Section 3.5 of this bill incorporates amendments to
Section 1317.1 of the Health and Safety Code proposed by both this
bill and AB 2861. It shall only become operative if (1) both bills
are enacted and become effective on or before January 1, 2009, (2)
each bill amends Section 1317.1 of the Health and Safety Code, and
(3) this bill is enacted after AB 2861, in which case Section 3 of
this bill shall not become operative.