BILL NUMBER: SB 1543 AMENDED
BILL TEXT
AMENDED IN SENATE MARCH 27, 2012
INTRODUCED BY Senator Emmerson
FEBRUARY 24, 2012
An act to amend Section 1367 of the Health and Safety
Code, relating to health care service plans. An act to
amend Sections 1158 and 1563 of the Evidence Code, and to amend
Sections 123105 and 123110 of the Health and Safety Code, relating to
patient records.
LEGISLATIVE COUNSEL'S DIGEST
SB 1543, as amended, Emmerson. Health care service plans.
Patient records: inspection and copies.
(1) Existing law authorizes an attorney or his or her
representative to review and obtain certain patient records prior to
filing any legal action if written authorization is given by the
patient. Further, existing law prohibits the medical provider from
copying the records if the attorney has employed a private
photocopying service, as specified.
This bill would prescribe the fees for a health care provider or
medical records management company to charge when providing copies of
medical records to an attorney. This bill would also provide that an
electronic copy of a medical record is required only if the entire
request can be reproduced from an electronic health record system and
can be delivered electronically. Further, the bill would require the
Secretary of California Health and Human Services to make annual
determinations concerning any increase or decrease in the fees in
accordance with the Consumer Price Index prepared by the United
States Department of Labor.
(2) Existing law authorizes issuance of a subpoena for the
personal records of any consumer, as defined, including medical and
employment records. The party requesting the records is only required
to pay one witness fee and one mileage fee to a witness or witness'
business when requesting business records.
This bill would require a requesting party to pay a witness fee
and mileage fee whenever a subpoena requires a witness, and would
require the requesting party to pay for records produced in response
to a subpoena duces tecum, including when those records are allowed
in lieu of a witness appearance. This bill would also prescribe the
costs to be paid in advance by the requesting party. Further, this
bill would authorize the Secretary of California Health and Human
Services to make annual determinations concerning any increase or
decrease in those fees in accordance with the Consumer Price Index
prepared by the United States Department of Labor.
(3) Existing law requires that, following a written request to his
or her health care provider, a patient or his or her representative
may inspect and obtain copies of patient records after paying a
specified fee. If the patient or patient's representative presents
proof to the provider that the records are needed to support an
appeal regarding eligibility for a public benefit program, the health
care provider must provide one copy of the relevant portion of the
patient's record at no charge under specified circumstances. A
willful violation of this requirement by certain health care
providers is an infraction.
This bill would prescribe an hourly charge for a health care
provider when the provider locates a patient's medical records, makes
those records available, and supervises any inspection of the
records by the patient or patient's representative, as defined.
Further, this bill would prescribe the reproduction costs for the
copies of the records, and would provide that an electronic copy of a
medical record is only required if the entire request can be
reproduced from an electronic health record system and the record can
be delivered electronically. This bill would also permit a patient
or patient's representative to obtain multiple copies of the relevant
portion of the patient's medical record at no charge in public
benefit eligibility appeals. Additionally, this bill would require
the Secretary of California Health and Human Services to make annual
determinations concerning any increase or decrease in the fees in
accordance with the Consumer Price Index prepared by the United
States Department of Labor.
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
health care service plans to meet certain requirements, including,
but not limited to, having the organizational and administrative
capacity to provide services to subscribers and enrollees and
providing basic health care services, as defined, to those
subscribers and enrollees.
This bill would make technical, nonsubstantive changes to that
provision.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1158 of the Evidence
Code is amended to read:
1158. (a) Whenever , prior to the
filing of any action or the appearance of a defendant in an action,
an attorney at law attorney at law
or his or her representative agent
presents a written authorization therefor
signed by an adult patient, by the guardian or conservator of his or
her person or estate, or, in the case of a minor, by a parent or
guardian of the minor, or by the personal representative or an heir
of a deceased patient, or a copy thereof, a physician and surgeon,
dentist, registered nurse, dispensing optician, registered physical
therapist, podiatrist, licensed psychologist, osteopathic physician
and surgeon, chiropractor, clinical laboratory bioanalyst, clinical
laboratory technologist, or pharmacist or pharmacy, duly licensed as
such under the laws of the state, or a licensed hospital, shall make
all of , or shall have its medical records
management company make, a copy of the patient's records under
his, hers or its the person's or entity's
custody or control available for inspection and
copying by the attorney at law
attorney at law or his , or her ,
representative, agent promptly upon the
presentation of the written authorization.
Failure to make the records available may subject the person or
entity having custody or control of the records to liability for all
reasonable expenses, including attorney's fees incurred in any
proceeding to enforce this section.
(b) Fees for copies of medical records shall be as follows:
(1) For a request by an attorney, a search and retrieval fee of
thirty dollars ($30), plus a fee of fifty cents ($0.50) per page for
the first 25 pages, and twenty-five cents ($0.25) for each additional
page.
(2) An electronic copy of a patient's medical record shall only be
required if the entire request can be reproduced from an electronic
health record system and, if it is requested, can be delivered
electronically. If a requester receives the records electronically,
no postage may be charged.
(c) On January 1 of each year beginning in 2013, all amounts in
subdivision (b) shall be increased or decreased by the average
percentage of increase or decrease in the Consumer Price Index for
All Urban Consumers (United States city average, all items), prepared
by the United States Department of Labor, Bureau of Labor
Statistics, for the 12-calendar-month period prior to the immediately
preceding first day of January over the immediately preceding
12-calendar-month period, as reported by the bureau. The Secretary of
California Health and Human Services shall make this determination
and adjust the amounts accordingly. The secretary shall provide a
list of the adjusted amounts to any party upon request, and the
California Health and Human Services Agency shall make the list
available to the public on its Internet Web site no later than
December 31 of each calendar year.
(d) A health care provider or medical records management company
may enter into a contract with a patient's representative for the
copying of medical records at a fee other than as provided in
subdivision (b). Nothing in this section requires or precludes the
distribution of medical records at a contractual cost or fee to
insurers authorized to provide health, sickness, or property or
casualty insurance in this state, or to corporations having a
certificate of authority holding a certificate of authority under
applicable law.
(e) A patient who wishes to examine all or part of his or her
medical record shall submit a written request to the health provider
pursuant to Section 123110 of the Health and Safety Code.
No copying may be performed by any medical provider or employer
enumerated above, or by an agent thereof, when the requesting
attorney has employed a professional photocopier or anyone identified
in Section 22451 of the Business and Professions Code as his or her
representative to obtain or review the records on his or her behalf.
The presentation of the authorization by the agent on behalf of the
attorney shall be sufficient proof that the agent is the attorney's
representative.
Failure to make the records available, during business hours,
within five days after the presentation of the written authorization,
may subject the person or entity having custody or control of the
records to liability for all reasonable expenses, including attorney'
s fees, incurred in any proceeding to enforce this section.
All reasonable costs incurred by any person or entity enumerated
above in making patient records available pursuant to this section
may be charged against the person whose written authorization
required the availability of the records.
"Reasonable cost," as used in this section, shall include, but not
be limited to, the following specific costs: ten cents ($0.10) per
page for standard reproduction of documents of a size 81/2 by 14
inches or less; twenty cents ($0.20) per page for copying of
documents from microfilm; actual costs for the reproduction of
oversize documents or the reproduction of documents requiring special
processing which are made in response to an authorization;
reasonable clerical costs incurred in locating and making the records
available to be billed at the maximum rate of sixteen dollars ($16)
per hour per person, computed on the basis of four dollars ($4) per
quarter hour or fraction thereof; actual postage charges; and actual
costs, if any, charged to the witness by a third person for the
retrieval and return of records held by that third person.
Where the records are delivered to the attorney or the attorney's
representative for inspection or photocopying at the record custodian'
s place of business, the only fee for complying with the
authorization shall not exceed fifteen dollars ($15), plus actual
costs, if any, charged to the record custodian by a third person for
retrieval and return of records held offsite by the third person.
SEC. 2. Section 1563 of the Evidence
Code is amended to read:
1563. (a) This article shall not be interpreted to
require tender or payment of more than A requesting
party shall pay one witness fee and one mileage fee or other
charge , to a witness or witness' business, unless
there is an agreement to the contrary between the witness and the
requesting party. A requesting party shall also pay for the
reproduction of records produced in response to a subpoena or if
allowed in lieu of appearance.
(b) All reasonable costs incurred in a civil proceeding by any
witness which is not a party with respect to the
production of all or any part of business records the production of
which is requested pursuant to a subpoena duces tecum may
shall be charged against
paid in advance by the party serving the subpoena duces tecum.
(1) "Reasonable cost," costs, "
as used in this section, shall include, but not be limited to,
the following specific costs : ten cents ($0.10) per page
for standard reproduction of documents of a size 8
1/2 by 14 inches or less; twenty ,
and shall apply to all documents reproduced in response to a
subpoena:
(A) Twenty-five cents
($0.20) ($0.25) per page for copying of
documents from microfilm actual stored on
paper or electronically.
(B) Fifty cents ($0.50) per page for
reproduction of documents stored on microfilm.
(C) Actual costs for the
reproduction of oversize documents or the reproduction of documents
requiring special processing which are made in response to a
subpoena; reasonable clerical .
(D) Thirty dollars ($30) for
costs incurred in locating and making the records available
to be billed at the maximum rate of twenty-four dollars
($24) per hour per person, computed on the basis of six dollars ($6)
per quarter hour or fraction thereof; , and actual
postage charges as provided by subparagraph (E).
(E) The actual postage charges
; and the if the record is requested to be
mailed.
(F) The actual cost, if any,
charged to the witness by a third person for the retrieval and return
of records held offsite by that third person.
(2) The requesting party, or the requesting party's deposition
officer, shall not be required to pay those costs or any estimate
thereof prior to the time the records are available for delivery
pursuant to the subpoena, but the witness may demand payment of costs
pursuant to this section simultaneous with actual delivery of the
subpoenaed records, and until payment is made, is under no obligation
to deliver the records.
(3) The witness shall submit an itemized statement for
the costs under this subdivision to the
requesting party, or the requesting party's deposition officer,
setting forth the reproduction and clerical costs incurred by the
witness. Should the costs exceed those authorized in paragraph (1),
or the witness refuses to produce an itemized statement of costs as
required by paragraph (3) this paragraph
, upon demand by the requesting party, or the requesting party'
s deposition officer, the witness shall furnish a statement setting
forth the actions taken by the witness in justification of the costs.
(4) The requesting party may petition the court in which the
action is pending to recover from the witness all or a part of the
costs paid to the witness, or to reduce all or a part of the costs
charged by the witness, pursuant to this subdivision, on the grounds
that those costs were excessive if those costs exceed the costs
set forth in paragraph (1) of subdivision (b) . Upon the filing
of the petition the court shall issue an order to show cause and
from the time the order is served on the witness the court has
jurisdiction over the witness. The court may hear testimony on the
order to show cause and if it finds that the costs demanded and
collected, or charged but not collected, exceed the amount authorized
by this subdivision, it shall order the witness to remit to the
requesting party, or reduce its charge to the requesting party by an
amount equal to, the amount of the excess. In the event that the
court finds the costs excessive and charged in bad faith by the
witness, the court shall order the witness to remit the full amount
of the costs demanded and collected, or excuse the requesting party
from any payment of costs charged but not collected, and the court
shall also order the witness to pay the requesting party the amount
of the reasonable expenses incurred in obtaining the order including
attorney's fees. If the court finds the costs were not excessive, the
court shall order the requesting party to pay the witness the amount
of the reasonable expenses incurred in defending the petition,
including attorney's fees.
(5) If a subpoena is served to compel the production of business
records and is subsequently withdrawn, or is quashed, modified or
limited on a motion made other than by the witness, the witness shall
be entitled to reimbursement pursuant to paragraph (1) for all costs
incurred in compliance with the subpoena to the time that the
requesting party has notified the witness that the subpoena has been
withdrawn or quashed, modified or limited. In the event the subpoena
is withdrawn or quashed, if those costs are not paid within 30 days
after demand therefor, the witness may file a motion in the court in
which the action is pending for an order requiring payment, and the
court shall award the payment of expenses and attorney's fees in the
manner set forth in paragraph (4).
(6) Where the records are delivered to the attorney, the attorney'
s representative, or the deposition officer for inspection or
photocopying at the witness' place of business, the only fee for
complying with the subpoena shall not exceed fifteen dollars
($15), the fees set forth in paragraph (1) of
subdivision (b) plus the actual cost, if any, charged to the
witness by a third person for retrieval and return of records held
offsite by that third person. If the records are retrieved from
microfilm, the reasonable cost, as defined in paragraph (1), shall
also apply.
(c) When the personal attendance of the custodian of a record or
other qualified witness is required pursuant to Section 1564, in a
civil proceeding, he or she shall be entitled to the same witness
fees and mileage permitted in a case where the subpoena requires the
witness to attend and testify before a court in which the action or
proceeding is pending and to any additional costs incurred as
provided by subdivision (b).
(d) On January 1 of each year beginning in 2013, all amounts under
subdivision (b) shall be increased or decreased by the average
percentage of increase or decrease in the Consumer Price Index for
All Urban Consumers (United States city average, all items), prepared
by the United States Department of Labor, Bureau of Labor
Statistics, for the 12-calendar-month period prior to the immediately
preceding first day of January over the immediately preceding
12-calendar-month period, as reported by the bureau. The Secretary of
California Health and Human Services shall make this determination
and adjust the amounts accordingly. The secretary shall provide a
list of the adjusted amounts to any party upon request, and the
California Health and Human Services Agency shall make the list
available to the public on its Internet Web site no later than
December 31 of each calendar year.
SEC. 3. Section 123105 of the Health
and Safety Code is amended to read:
123105. As used in this chapter:
(a) "Health care provider" means any of the following:
(1) A health facility licensed pursuant to Chapter 2 (commencing
with Section 1250) of Division 2.
(2) A clinic licensed pursuant to Chapter 1 (commencing with
Section 1200) of Division 2.
(3) A home health agency licensed pursuant to Chapter 8
(commencing with Section 1725) of Division 2.
(4) A physician and surgeon licensed pursuant to Chapter 5
(commencing with Section 2000) of Division 2 of the Business and
Professions Code or pursuant to the Osteopathic Act.
(5) A podiatrist licensed pursuant to Article 22 (commencing with
Section 2460) of Chapter 5 of Division 2 of the Business and
Professions Code.
(6) A dentist licensed pursuant to Chapter 4 (commencing with
Section 1600) of Division 2 of the Business and Professions Code.
(7) A psychologist licensed pursuant to Chapter 6.6 (commencing
with Section 2900) of Division 2 of the Business and Professions
Code.
(8) An optometrist licensed pursuant to Chapter 7 (commencing with
Section 3000) of Division 2 of the Business and Professions Code.
(9) A chiropractor licensed pursuant to the Chiropractic
Initiative Act.
(10) A marriage and family therapist licensed pursuant to Chapter
13 (commencing with Section 4980) of Division 2 of the Business and
Professions Code.
(11) A clinical social worker licensed pursuant to Chapter 14
(commencing with Section 4990) of Division 2 of the Business and
Professions Code.
(12) A physical therapist licensed pursuant to Chapter 5.7
(commencing with Section 2600) of Division 2 of the Business and
Professions Code.
(13) An occupational therapist licensed pursuant to Chapter 5.6
(commencing with Section 2570).
(14) A professional clinical counselor licensed pursuant to
Chapter 16 (commencing with Section 4999.10) of Division 2 of the
Business and Professions Code.
(b) "Mental health records" means patient records, or discrete
portions thereof, specifically relating to evaluation or treatment of
a mental disorder. "Mental health records" includes, but is not
limited to, all alcohol and drug abuse records.
(c) "Patient" means a patient or former patient of a health care
provider.
(d) "Patient records" means records in any form or medium
maintained by, or in the custody or control of, a health care
provider relating to the health history, diagnosis, or condition of a
patient, or relating to treatment provided or proposed to be
provided to the patient. "Patient records" includes only records
pertaining to the patient requesting the records or whose
representative requests the records. "Patient records" does not
include information given in confidence to a health care provider by
a person other than another health care provider or the patient, and
that material may be removed from any records prior to inspection or
copying under Section 123110 or 123115. "Patient records" does not
include information contained in aggregate form, such as indices,
registers, or logs.
(e) "Patient's representative" or "representative" means any of
the following:
(1) A parent or guardian of a minor who is a patient.
(2) The guardian or conservator of the person of an adult patient.
(3) An agent as defined in Section 4607 of the Probate Code, to
the extent necessary for the agent to fulfill his or her duties as
set forth in Division 4.7 (commencing with Section 4600) of the
Probate Code.
(4) The beneficiary as defined in Section 24 of the Probate Code
or personal representative as defined in Section 58 of the Probate
Code, of a deceased patient.
(5) The patient's personal representative as defined in Section
164.502(g) of Title 45 of the Code of Federal Regulations.
(f) "Alcohol and drug abuse records" means patient records, or
discrete portions thereof, specifically relating to evaluation and
treatment of alcoholism or drug abuse.
SEC. 4. Section 123110 of the Health
and Safety Code is amended to read:
123110. (a) Notwithstanding Section 5328 of the Welfare
and Institutions Code, and except as provided in Sections 123115 and
123120, any Any adult patient of a health care
provider, any minor patient authorized by law to consent to medical
treatment, and any patient patient's personal
representative shall be entitled to inspect patient records
upon presenting to the health care provider a written request for
those records and upon payment of reasonable clerical costs
a charge of twenty-five dollars ($25) per hour
incurred in locating and making the records available and in
supervising any inspection session . However, a patient who is
a minor shall be entitled to inspect patient records pertaining only
to health care of a type for which the minor is lawfully authorized
to consent. A health care provider shall permit this inspection
during business hours within five working days after receipt of the
written request. The inspection shall be conducted by the patient or
patient's personal representative requesting
the inspection, who may be accompanied by one other person of his or
her choosing.
(b) Additionally, any patient or patient's personal
representative shall be entitled to copies of all or any portion of
the patient records that he or she has a right to inspect, upon
presenting a written request to the health care provider specifying
the records to be copied, together with a fee to defray the
cost of copying for reproducing the records ,
that shall not exceed twenty-five cents ($0.25) per page or fifty
cents ($0.50) per page for records that are copied from microfilm and
any additional reasonable clerical costs incurred in making the
records available. The patient shall also pay for the
actual postage if the patient requests the records to be mailed to
him or her. The health care provider shall ensure that the
copies are transmitted to the patient within 15 days after
receiving the written request.
(1) An electronic copy of a patient's medical record shall only be
required if the entire request can be reproduced from an electronic
health record system. If a patient receives his or her records
electronically, no postage may be charged.
(2) On January 1 of each year beginning in 2013, all amounts under
subdivision (a) and this subdivision shall be increased or decreased
by the average percentage of increase or decrease in the Consumer
Price Index for all urban consumers (United States city average, all
items), prepared by the United States Department of Labor, Bureau of
Labor Statistics, for the 12-calendar-month period prior to the
immediately preceding first day of January over the immediately
preceding 12-calendar-month period, as reported by the bureau. The
Secretary of California Health and Human Services shall make this
determination and adjust the amounts accordingly. The secretary shall
provide a list of the adjusted amounts to any party upon request,
and the California Health and Human Services Agency shall make the
list available to the public on its Internet Web site no later than
December 31 of each calendar year.
(c) Copies of X-rays or tracings images
derived from electrocardiography, electroencephalography, or
electromyography need not be provided to the patient or patient's
personal representative under this section, if
provided that the original X-rays or
tracings images are transmitted to another
health care provider upon written request of the patient or patient's
personal representative and within 15 days after receipt
of the request. The request shall specify the name and address of the
health care provider to whom the records are to be delivered.
All reasonable costs, not exceeding actual costs, incurred
by a health care provider in providing copies pursuant to this
subdivision may The costs set forth in subdivision (b)
shall be charged to paid by the
patient or personal representative requesting the copies.
(d) (1) Notwithstanding any provision of this section, and except
as provided in Sections 123115 and 123120, any patient or former
patient or the patient's personal representative shall be
entitled to a copy, at no charge, of the relevant portion of the
patient's records, upon presenting to the provider a written request,
and accompanied by proof that the
records are needed to support an appeal regarding eligibility for a
public benefit program. These programs shall be the Medi-Cal program,
social security disability insurance benefits, and Supplemental
Security Income/State Supplementary Program for the Aged, Blind and
Disabled (SSI/SSP) benefits. For purposes of this subdivision,
"relevant portion of the patient's records" means those records
regarding services rendered to the patient during the time period
beginning with the date of the patient's initial application for
public benefits up to and including the date that a final
determination is made by the public benefits program with which the
patient's application is pending.
(2) Although a patient shall not be limited to a single request,
the patient or patient's representative shall be entitled to no more
than one copy of any relevant portion of his or her record free of
charge.
(3)
(2) This subdivision shall not apply to any patient who
is represented by a private attorney who is paying for the costs
related to the patient's appeal, pending the outcome of that appeal.
For purposes of this subdivision, "private attorney" means any
attorney not employed by a nonprofit legal services entity.
(e) If the patient's appeal regarding eligibility for a public
benefit program specified in subdivision (d) is successful,
the hospital or other health care provider may bill the
patient or the patient's personal representative shall pay the
hospital or other health care provider , at the rates specified
in subdivisions subdivision (b)
and (c) , for the copies of the
any medical records previously provided free of charge.
(f) If a patient or his or her the patient'
s personal representative requests a record pursuant to
subdivision (d), the health care provider shall ensure that the
copies are transmitted within 30 days after receiving the written
request.
(g) This section shall not be construed to preclude a
A health care provider from
requiring shall require reasonable verification
of identity prior to permitting inspection or copying of patient
records, provided this requirement is not used oppressively or
discriminatorily to frustrate or delay compliance with this section.
Nothing in this chapter shall be deemed to supersede any rights that
a patient or representative might otherwise have or exercise under
Section 1158 of the Evidence Code or any other provision of law.
Nothing in this chapter shall require a health care provider to
retain records longer than required by applicable statutes or
administrative regulations.
(h) This chapter shall not be construed to render a health care
provider liable for the quality of his or her records or the copies
provided in excess of existing law and regulations with respect to
the quality of medical records. A health care provider shall not be
liable to the patient or any other person for any consequences that
result from disclosure of patient records as required by this
chapter. A health care provider shall not discriminate against
classes or categories of providers in the transmittal of X-rays or
other patient records, or copies of these X-rays or records, to other
providers as authorized by this section.
Every health care provider shall adopt policies and establish
procedures for the uniform transmittal of X-rays and other patient
records that effectively prevent the discrimination described in this
subdivision. A health care provider may establish reasonable
conditions, including a reasonable deposit fee, to ensure the return
of original X-rays transmitted to another health care provider,
provided the conditions do not discriminate on the basis of, or in a
manner related to, the license of the provider to which the X-rays
are transmitted.
(i) Any health care provider described in paragraphs (4) to (10),
inclusive, of subdivision (a) of Section 123105 who willfully
violates this chapter is guilty of unprofessional conduct. Any health
care provider described in paragraphs (1) to (3), inclusive, of
subdivision (a) of Section 123105 that willfully violates this
chapter is guilty of an infraction punishable by a fine of not more
than one hundred dollars ($100). The state agency, board, or
commission that issued the health care provider's professional or
institutional license shall consider a violation as grounds for
disciplinary action with respect to the licensure, including
suspension or revocation of the license or certificate.
(j) This section shall be construed as prohibiting a health care
provider from withholding patient records or summaries of patient
records because of an unpaid bill for health care services. Any
health care provider who willfully withholds patient records or
summaries of patient records because of an unpaid bill for health
care services shall be subject to the sanctions specified in
subdivision (i).
SECTION 1. Section 1367 of the Health and Safety
Code is amended to read:
1367. A health care service plan and, if applicable, a
specialized health care service plan shall meet the following
requirements:
(a) Facilities located in this state including, but not limited
to, clinics, hospitals, and skilled nursing facilities to be utilized
by the plan shall be licensed by the State Department of Public
Health, where licensure is required by law. Facilities not located in
this state shall conform to all licensing and other requirements of
the jurisdiction in which they are located.
(b) Personnel employed by or under contract to the plan shall be
licensed or certified by their respective board or agency, where
licensure or certification is required by law.
(c) Equipment required to be licensed or registered by law shall
be so licensed or registered, and the operating personnel for that
equipment shall be licensed or certified as required by law.
(d) The plan shall furnish services in a manner providing
continuity of care and ready referral of patients to other providers
at times as may be appropriate, consistent with good professional
practice.
(e) (1) All services shall be readily available at reasonable
times to each enrollee consistent with good professional practice. To
the extent feasible, the plan shall make all services readily
accessible to all enrollees consistent with Section 1367.03.
(2) To the extent that telemedicine services are appropriately
provided through telemedicine, as defined in subdivision (a) of
Section 2290.5 of the Business and Professions Code, these services
shall be considered in determining compliance with Section 1300.67.2
of Title 28 of the California Code of Regulations.
(3) The plan shall make all services accessible and appropriate
consistent with Section 1367.04.
(f) The plan shall employ and utilize allied health manpower for
the furnishing of services to the extent permitted by law and
consistent with good medical practice.
(g) The plan shall have the organizational and administrative
capacity to provide services to subscribers and enrollees. The plan
shall be able to demonstrate to the department that medical decisions
are rendered by qualified medical providers, unhindered by fiscal
and administrative management.
(h) (1) Contracts with subscribers and enrollees, including group
contracts, and contracts with providers, and other persons furnishing
services, equipment, or facilities to or in connection with the
plan, shall be fair, reasonable, and consistent with the objectives
of this chapter. All contracts with providers shall contain
provisions requiring a fast, fair, and cost-effective dispute
resolution mechanism under which providers may submit disputes to the
plan, and requiring the plan to inform its providers upon
contracting with the plan, or upon change to these provisions, of the
procedures for processing and resolving disputes, including the
location and telephone number where information regarding disputes
may be submitted.
(2) A health care service plan shall ensure that a dispute
resolution mechanism is accessible to noncontracting providers for
the purpose of resolving billing and claims disputes.
(3) On and after January 1, 2002, a health care service plan shall
annually submit a report to the department regarding its dispute
resolution mechanism. The report shall include information on the
number of providers who utilized the dispute resolution mechanism and
a summary of the disposition of those disputes.
(i) A health care service plan contract shall provide to
subscribers and enrollees all of the basic health care services
included in subdivision (b) of Section 1345, except that the director
may, for good cause, by rule or order exempt a plan contract or any
class of plan contracts from that requirement. The director shall by
rule define the scope of each basic health care service that health
care service plans are required to provide as a minimum for licensure
under this chapter. Nothing in this chapter shall prohibit a health
care service plan from charging subscribers or enrollees a copayment
or a deductible for a basic health care service or from setting
forth, by contract, limitations on maximum coverage of basic health
care services, provided that the copayments, deductibles, or
limitations are reported to, and held unobjectionable by, the
director and set forth to the subscriber or enrollee pursuant to the
disclosure provisions of Section 1363.
(j) A health care service plan shall not require registration
under the Controlled Substances Act of 1970 (21 U.S.C. Sec. 801 et
seq.) as a condition for participation by an optometrist certified to
use therapeutic pharmaceutical agents pursuant to Section 3041.3 of
the Business and Professions Code.
Nothing in this section shall be construed to permit the director
to establish the rates charged subscribers and enrollees for
contractual health care services.
The director's enforcement of Article 3.1 (commencing with Section
1357) shall not be deemed to establish the rates charged subscribers
and enrollees for contractual health care services.
The obligation of the plan to comply with this section shall not
be waived when the plan delegates any services that it is required to
perform to its medical groups, independent practice associations, or
other contracting entities.