BILL NUMBER: SB 1300	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  AUGUST 12, 2008
	AMENDED IN ASSEMBLY  JUNE 26, 2008
	AMENDED IN ASSEMBLY  JUNE 11, 2008
	AMENDED IN SENATE  MAY 7, 2008
	AMENDED IN SENATE  APRIL 7, 2008
	AMENDED IN SENATE  APRIL 3, 2008
	AMENDED IN SENATE  MARCH 24, 2008

INTRODUCED BY   Senator Corbett

                        FEBRUARY 20, 2008

   An act to add  Sections 1262.55 and   Section
 1367.49 to the Health and Safety Code, and to add Section
10117.6 to the Insurance Code, relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1300, as amended, Corbett. 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 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 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. 
   This bill would prohibit a contract between a health care provider
and a health care service plan or a health insurer from containing a
provision that restricts the ability of the plan or insurer to
furnish information on the cost of procedures, as defined, or health
care quality information to subscribers, enrollees, policyholders, or
insureds. The bill would require health care service plans and
health insurers to involve health care providers in the development
of the health care quality information prior to furnishing it to
subscribers, enrollees, policyholders, or insureds, as specified, and
would also require quality of care data compiled by the plan or
insurer to include specified clinical guidelines and utilize risk
adjustment factors in a specified manner.
   Because a willful violation of the bill's provisions relating to
health care service plans would be a crime, this 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 1262.55 is added to the
Health and Safety Code, to read:
   1262.55.  (a) A contract between a health care provider and a
health care service plan or a health insurer that is issued, amended,
renewed, or delivered on or after January 1, 2009, shall not contain
a provision that restricts the ability of the health care service
plan or health insurer to furnish information on the cost of
procedures or health care quality information to subscribers or
enrollees of the plan or policyholders or insureds of the insurer. A
health care service plan or health insurer shall, in the manner
described in subdivision (b), involve health care providers in the
development of the health care quality information prior to
furnishing it to enrollees or subscribers of the plan or
policyholders or insureds of the insurer.
   (b) If the health care quality information that the health care
service plan or health insurer proposes to disclose pursuant to
subdivision (a) is quality of care data that the health care service
plan or the health insurer compiled, both of the following
requirements shall be satisfied:
   (1) The information shall include clinical guidelines established
by independent national medical and quality associations and utilize
risk adjustment factors to account for differences in the use of
health care resources among individual health care providers.
   (2) The health care service plan or health insurer shall, prior to
furnishing that information to enrollees or subscribers of the plan
or policyholders or insureds of the insurer, provide all of the
following to any affected health care provider:
   (A) At least 30 days written notice to review the information.
   (B) The criteria used in the development and evaluation of quality
measurements.
   (C) The opportunity to provide additional information or
corrections to the information.
   (c) Nothing in this section shall be construed to require a health
care service plan, health insurer, or health care provider to
disclose capitation rates or other prepaid arrangements.
   (d) Nothing in this section shall apply to dental insurers or to
specialized health care service plans covering dental benefits.
   (e) For purposes of this section, the following definitions shall
apply:
   (1) "Information on the cost of procedures" means information that
an enrollee or subscriber of a health care service plan, or
policyholders or insureds of a health insurer, may use to make
comparisons among individual health care providers or health care
facilities concerning the cost to the enrollee, subscriber,
policyholder, or insured of health care treatment options.
   (2) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, other than a long-term health care facility as defined in
Section 1418, or other person or institution licensed or authorized
by the state to deliver or furnish health care services. 
   SEC. 2.   SECTION 1.   Section 1367.49
is added to the Health and Safety Code, to read:
   1367.49.  (a) A contract between a health care service plan and a
health care provider that is issued, amended, renewed, or delivered
on or after January 1, 2009, shall not contain a provision that
restricts the ability of the health care service plan to furnish
information on the cost of procedures or health care quality
information to subscribers or enrollees of the plan. A health care
service plan shall, in the manner described in subdivision (b),
involve health care providers in the development of the health care
quality information prior to furnishing it to enrollees or
subscribers of the plan.
   (b) If the health care quality information that the health care
service plan proposes to disclose pursuant to subdivision (a) is
quality of care data that the health care service plan compiled,
 both   all  of the following requirements
shall be satisfied:
   (1) The information shall include clinical guidelines established
by independent national medical and quality associations and utilize
risk adjustment factors  , with appropriate and transparent
statistical techniques,  to account for differences in the use
of health care resources among individual health care providers. 

   (2) The information shall be updated at appropriate intervals.
 
   (2) 
    (3)  The health care service plan shall, prior to
furnishing that information to its enrollees or subscribers, provide
all of the following to any affected health care provider:
   (A) At least  30   45  days written
notice to review the information.
   (B) The criteria used in the development and evaluation of quality
measurements.  The criteria shall be sufficiently detailed and
reasonably understandable to allow the provider to verify the data
against   his or her records. 
   (C) The opportunity to provide additional information or
corrections  to the information   , and to
consider specific commen   ts and responses to the format
 .
   (c) Nothing in this section shall require a health care service
plan or health care provider to disclose capitation rates or other
prepaid arrangements.
   (d) Nothing in this section shall apply to specialized health care
service plans covering dental benefits. 
   (e) Any contractual provision inconsistent with this section shall
be void and unenforceable.  
   (e) 
    (f)  For purposes of this section, the following
definitions shall apply:
   (1) "Information on the cost of procedures" means information that
an enrollee or subscriber of a health care service plan may use to
make comparisons among individual health care providers or health
care facilities concerning the cost to the enrollee or subscriber of
health care treatment options.
   (2) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, other than a long-term health care facility as defined in
Section 1418, or other person or institution licensed or authorized
by the state to deliver or furnish health care services.
   SEC. 3.   SEC. 2.   Section 10117.6 is
added to the Insurance Code, to read:
   10117.6.  (a) A contract between a health insurer and a health
care provider that is issued, amended, renewed, or delivered on or
after January 1, 2009, shall not contain a provision that restricts
the ability of the health insurer to furnish information on the cost
of procedures or health care quality information to policyholders or
insureds of the insurer. A health insurer shall, in the manner
described in subdivision (b), involve health care providers in the
development of the health care quality information prior to
furnishing it to policyholders or insureds of the insurer.
   (b) If the health care quality information that the health insurer
proposes to disclose pursuant to subdivision (a) is quality of care
data that the health insurer compiled,  both  
all  of the following requirements shall be satisfied:
   (1) The information shall include clinical guidelines established
by independent national medical and quality associations and utilize
risk adjustment factors  , with appropriate and transparent
statistical techniques,  to account for differences in the use
of health care resources among individual health care providers. 

   (2) The information shall be updated at appropriate intervals.
 
   (2) 
    (3)  The health insurer shall, prior to furnishing that
information to its policyholders or insureds, provide all of the
following to any affected health care provider:
   (A) At least  30   45  days written
notice to review the information.
   (B) The criteria used in the development and evaluation of quality
measurements.  The criteria shall be sufficiently detailed and
reasonably understandable to allow the provider to verify the data
against his or her   records. 
   (C) The opportunity to provide additional information or
corrections  to the information   , and to
consider specific comments and responses to the format  .
   (c) Nothing in this section shall require a health insurer or
health care provider to disclose capitation rates or other prepaid
arrangements.
   (d) Nothing in this section shall apply to dental insurers. 
   (e) Any contractual provision inconsistent with this section shall
be void and unenforceable.  
   (e) 
    (f)  For purposes of this section, the following
definitions shall apply:
   (1) "Information on the cost of procedures" means information that
a policyholder or insured of a health insurer may use to make
comparisons among individual health care providers or health care
facilities concerning the cost to the policyholder or insured of
health care treatment options.
   (2) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, other than a long-term health care facility as defined in
Section 1418 of the Health and Safety Code, or other person or
institution licensed or authorized by the state to deliver or furnish
health care services.
   SEC. 4.   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.