BILL NUMBER: AB 369 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JANUARY 16, 2014
AMENDED IN ASSEMBLY JANUARY 6, 2014
INTRODUCED BY Assembly Member Pan
FEBRUARY 14, 2013
An act to amend Section 1373.96 of the Health and Safety Code, and
to amend Section 10133.56 of the Insurance Code, relating to health
care coverage , and declaring the urgency thereof, to take
effect immediately .
LEGISLATIVE COUNSEL'S DIGEST
AB 369, as amended, Pan. Continuity of 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
regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan , with some
exceptions, or a health insurer to provide for
the completion of covered services by a terminated provider
or a nonparticipating provider for enrollees or
insureds who were receiving services from the provider for
one of the a specified
conditions condition at the time of the contract
or policy termination or at the time a newly
covered enrollee's coverage became effective. Existing law requires a
health insurer, with some exceptions, to provide for the completion
of covered services by a terminated provider for insureds who were
receiving services from the provider for one of the specified
conditions at the time of the policy termination .
Existing law also requires a health care service plan to
provide for the completion of covered services by a nonparticipating
provider to a newly covered enrollee who, at the time his or her
coverage became effective, was receiving services from
that provider for a specified condition. Existing law specifies that
this provision does not apply to a newly covered enrollee under an
individual subscriber agreement.
Under the federal Patient Protection and Affordable Care Act
(PPACA), each state is required, by January 1, 2014, to establish an
American Health Benefit Exchange that makes available qualified
health plans to qualified individuals and small employers. Existing
state law establishes the California Health Benefit Exchange
(Exchange) within state government, specifies the powers and duties
of the board governing the Exchange, and requires the board to
facilitate the purchase of qualified health plans through the
Exchange by qualified individuals and small employers by January 1,
2014.
This bill would require a health insurer to arrange for
the completion of covered services by a nonparticipating provider at
the request of a newly covered insured under a group insurance
policy. The bill would require a health care service plan
and a health insurer to arrange for the completion of covered
services by a nonparticipating provider for a newly covered enrollee
and a newly covered insured under an individual health care service
plan contract or an individual health insurance policy
whose prior coverage was terminated withdrawn
from the market between January
December 1, 2013, and March 31, 2014, inclusive , as
specified .
Because a willful violation of these provisions by a health care
service plan would, in part, 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.
This bill would declare that it is to take effect immediately as
an urgency statute.
Vote: majority 2/3 . Appropriation:
no. Fiscal committee: yes. State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1373.96 of the Health and Safety Code is
amended to read:
1373.96. (a) A health care service plan shall at the request of
an enrollee, provide the completion of covered services as set forth
in this section by a terminated provider or by a nonparticipating
provider.
(b) (1) The completion of covered services shall be provided by a
terminated provider to an enrollee who at the time of the contract's
termination, was receiving services from that provider for one of the
conditions described in subdivision (c).
(2) The completion of covered services shall be provided by a
nonparticipating provider to a newly covered enrollee who, at the
time his or her coverage became effective, was receiving services
from that provider for one of the conditions described in subdivision
(c).
(c) The health care service plan shall provide for the completion
of covered services for the following conditions:
(1) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
(2) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health care service plan in consultation with the enrollee and the
terminated provider or nonparticipating provider and consistent with
good professional practice. Completion of covered services under this
paragraph shall not exceed 12 months from the contract termination
date or 12 months from the effective date of coverage for a newly
covered enrollee.
(3) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
(4) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date or 12 months from the
effective date of coverage for a new enrollee.
(5) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date or 12 months from the
effective date of coverage for a newly covered enrollee.
(6) Performance of a surgery or other procedure that is authorized
by the plan as part of a documented course of treatment and has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date or within 180 days of the
effective date of coverage for a newly covered enrollee.
(d) (1) The plan may require the terminated provider whose
services are continued beyond the contract termination date pursuant
to this section to agree in writing to be subject to the same
contractual terms and conditions that were imposed upon the provider
prior to termination, including, but not limited to, credentialing,
hospital privileging, utilization review, peer review, and quality
assurance requirements. If the terminated provider does not agree to
comply or does not comply with these contractual terms and
conditions, the plan is not required to continue the provider's
services beyond the contract termination date.
(2) Unless otherwise agreed by the terminated provider and the
plan or by the individual provider and the provider group, the
services rendered pursuant to this section shall be compensated at
rates and methods of payment similar to those used by the plan or the
provider group for currently contracting providers providing similar
services who are not capitated and who are practicing in the same or
a similar geographic area as the terminated provider. Neither the
plan nor the provider group is required to continue the services of a
terminated provider if the provider does not accept the payment
rates provided for in this paragraph.
(e) (1) The plan may require a nonparticipating provider whose
services are continued pursuant to this section for a newly covered
enrollee to agree in writing to be subject to the same contractual
terms and conditions that are imposed upon currently contracting
providers providing similar services who are not capitated and who
are practicing in the same or a similar geographic area as the
nonparticipating provider, including, but not limited to,
credentialing, hospital privileging, utilization review, peer review,
and quality assurance requirements. If the nonparticipating provider
does not agree to comply or does not comply with these contractual
terms and conditions, the plan is not required to continue the
provider's services.
(2) Unless otherwise agreed upon by the nonparticipating provider
and the plan or by the nonparticipating provider and the provider
group, the services rendered pursuant to this section shall be
compensated at rates and methods of payment similar to those used by
the plan or the provider group for currently contracting providers
providing similar services who are not capitated and who are
practicing in the same or a similar geographic area as the
nonparticipating provider. Neither the plan nor the provider group is
required to continue the services of a nonparticipating provider if
the provider does not accept the payment rates provided for in this
paragraph.
(f) The amount of, and the requirement for payment of, copayments,
deductibles, or other cost sharing components during the period of
completion of covered services with a terminated provider or a
nonparticipating provider are the same as would be paid by the
enrollee if receiving care from a provider currently contracting with
or employed by the plan.
(g) If a plan delegates the responsibility of complying with this
section to a provider group, the plan shall ensure that the
requirements of this section are met.
(h) This section shall not require a plan to provide for
completion of covered services by a provider whose contract with the
plan or provider group has been terminated or not renewed for reasons
relating to a medical disciplinary cause or reason, as defined in
paragraph (6) of subdivision (a) of Section 805 of the Business and
Profession Code, or fraud or other criminal activity.
(i) This section shall not require a plan to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the plan contract. Except as provided in subdivision
(k) (l) , this section shall not apply
to a newly covered enrollee covered under an individual subscriber
agreement who is undergoing a course of treatment on the effective
date of his or her coverage for a condition described in subdivision
(c).
(j) Subdivision (b) does not apply to a newly covered enrollee who
is offered an out-of-network option or to a newly covered enrollee
who had the option to continue with his or her previous health plan
or provider and instead voluntarily chose to change health plans.
(j)
(k) The provisions contained in this section are in
addition to any other responsibilities of a health care service plan
to provide continuity of care pursuant to this chapter. Nothing in
this section shall preclude a plan from providing continuity of care
beyond the requirements of this section.
(k)
(l) (1) A health care service plan shall, at the
request of a newly covered enrollee under an individual health care
service plan contract, arrange for the completion of covered services
by a nonparticipating provider for one of the conditions described
in subdivision (c) if the newly covered enrollee meets both of the
following:
(A) The newly covered enrollee's prior coverage was terminated
under paragraph (5) or (6) of subdivision (a) of Section 1365
between January December 1, 2013,
and March 31, 2014, inclusive.
(B) At the time his or her coverage became effective, the newly
covered enrollee was receiving services from that provider for one of
the conditions described in subdivision (c).
(2) The completion of covered services required to be provided
under this subdivision apply to services rendered to the newly
covered enrollee on and after the effective date of his or her new
coverage.
(2)
(3) A violation of this subdivision does not constitute
a crime under Section 1390.
( l )
(m) The following definitions apply for the purposes of
this section:
(1) "Individual provider" means a person who is a licentiate, as
defined in Section 805 of the Business and Professions Code, or a
person licensed under Chapter 2 (commencing with Section 1000) of
Division 2 of the Business and Professions Code.
(2) "Nonparticipating provider" means a provider who is not
contracted with a health care service plan. A
nonparticipating provider does not include a terminated provider.
(3) "Provider" shall have the same meaning as set forth in
subdivision (i) of Section 1345.
(4) "Provider group" means a medical group, independent practice
association, or any other similar organization.
(5) "Terminated provider" means a provider whose contract to
provide services to enrollees is terminated or not renewed by the
plan or one of the plan's contracting provider groups.
SEC. 2. Section 10133.56 of the Insurance Code is amended to read:
10133.56. (a) (1) A health insurer that
enters into a contract with a professional or institutional provider
to provide services at alternative rates of payment pursuant to
Section 10133 shall, at the request of an insured, arrange for the
completion of covered services by a terminated provider, if the
insured is undergoing a course of treatment for any of the following
conditions:
(1)
(A) An acute condition. An acute condition is a medical
condition that involves a sudden onset of symptoms due to an
illness, injury, or other medical problem that requires prompt
medical attention and that has a limited duration. Completion of
covered services shall be provided for the duration of the acute
condition.
(2)
(B) A serious chronic condition. A serious chronic
condition is a medical condition due to a disease, illness, or other
medical problem or medical disorder that is serious in nature and
that persists without full cure or worsens over an extended period of
time or requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health insurer in consultation with the insured and the terminated
provider and consistent with good professional practice. Completion
of covered services under this paragraph shall not exceed 12 months
from the contract termination date.
(3)
(C) A pregnancy. A pregnancy is the three trimesters of
pregnancy and the immediate postpartum period. Completion of covered
services shall be provided for the duration of the pregnancy.
(4)
(D) A terminal illness. A terminal illness is an
incurable or irreversible condition that has a high probability of
causing death within one year or less. Completion of covered services
shall be provided for the duration of a terminal illness, which may
exceed 12 months from the contract termination date.
(5)
(E) The care of a newborn child between birth and age
36 months. Completion of covered services under this paragraph shall
not exceed 12 months from the contract termination date.
(6)
(F) Performance of a surgery or other procedure that
has been recommended and documented by the provider to occur within
180 days of the contract's termination date.
(b)
(2) The insurer may require the terminated provider
whose services are continued beyond the contract termination date
pursuant to this section subdivision ,
to agree in writing to be subject to the same contractual terms and
conditions that were imposed upon the provider prior to termination,
including, but not limited to, credentialing, hospital privileging,
utilization review, peer review, and quality assurance requirements.
If the terminated provider does not agree to comply or does not
comply with these contractual terms and conditions, the insurer is
not required to continue the provider's services beyond the contract
termination date.
(c)
(3) Unless otherwise agreed upon between the terminated
provider and the insurer or between the terminated provider and the
provider group, the agreement shall be construed to require a rate
and method of payment to the terminated provider, for the services
rendered pursuant to this section subdivision
, that are the same as the rate and method of payment for the
same services while under contract with the insurer and at the time
of termination. The provider shall accept the reimbursement as
payment in full and shall not bill the insured for any amount in
excess of the reimbursement rate, with the exception of copayments
and deductibles pursuant to subdivision (e)
(c) .
(d)
(b) Notice as to the process by which an insured may
request completion of covered services pursuant to this section shall
be provided in any insurer evidence of coverage and disclosure form
issued after March 31, 2004. An insurer shall provide a written copy
of this information to its contracting providers and provider groups.
An insurer shall also provide a copy to its insureds upon request.
(e)
(c) The payment of copayments, deductibles, or other
cost-sharing components by the insured during the period of
completion of covered services with a terminated provider
pursuant to subdivision (a) or a nonparticipating provider pursuant
to subdivision (i) shall be the same copayments, deductibles,
or other cost-sharing components that would be paid by the insured
when receiving care from a provider currently contracting with the
insurer.
(f)
(d) If an insurer delegates the responsibility of
complying with this section to its contracting entities, the insurer
shall ensure that the requirements of this section are met.
(g)
(e) For the purposes of this section, the following
terms have the following meanings:
(1) "Provider" means a person who is a licentiate as defined in
Section 805 of the Business and Professions Code or a person licensed
under Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code.
(2) "Provider group" includes a medical group, independent
practice association, or any other similar organization.
(3) "Nonparticipating provider" means a provider who does not have
a contract with an insurer to provide services to insureds.
A nonparticipating provider does not include a terminated provider.
(4) "Terminated provider" means a provider whose contract to
provide services to insureds is terminated or not renewed by the
insurer or one of the insurer's contracting provider groups. A
terminated provider is not a provider who voluntarily leaves the
insurer or contracting provider group.
(h)
(f) This section shall not require an insurer or
provider group to provide for the completion of covered services by a
provider whose contract with the insurer or provider group has been
terminated or not renewed for reasons relating to medical
disciplinary cause or reason, as defined in paragraph (6) of
subdivision (a) of Section 805 of the Business and Professions Code,
or fraud or other criminal activity.
(i)
(g) This section shall not require an insurer to cover
services or provide benefits that are not otherwise covered under the
terms and conditions of the insurer contract.
(j)
(h) The provisions contained in this section are in
addition to any other responsibilities of insurers to provide
continuity of care pursuant to this chapter. Nothing in this section
shall preclude an insurer from providing continuity of care beyond
the requirements of this section.
(k) (1) A health insurer shall, at the request of a newly covered
insured under a group insurance policy, arrange for the completion of
covered services by a nonparticipating provider for one of the
conditions described in subdivision (a).
(2)
(i) (1) A health insurer shall,
at the request of a newly covered insured under an individual
insurance policy, arrange for the completion of covered services by a
nonparticipating provider for one of the conditions described in
subdivision (a) if the newly covered insured meets both of the
following:
(A) The newly covered insured's prior coverage was terminated
under subdivision (d) or (e) of Section 10273.6 between
January December 1, 2013, and March 31,
2014 , inclusive .
(B) At the time his or her coverage became effective, the newly
covered insured was receiving services from that provider for one of
the conditions described in subdivision (a).
(2) The completion of covered services required to be provided
under this subdivision shall apply to services rendered to the newly
covered insured on and after the effective date of his or her new
coverage.
(3) (A) The insurer may require a nonparticipating provider whose
services are continued pursuant to this section
subdivision for a newly covered insured to agree in
writing to be subject to the same contractual terms and conditions
that are imposed upon currently participating providers providing
similar services who are practicing in the same or a similar
geographic area as the nonparticipating provider, including, but not
limited to, credentialing, hospital privileging, utilization review,
peer review, and quality assurance requirements. If the
nonparticipating provider does not agree to comply or does not comply
with these contractual terms and conditions, the insurer is not
required to continue the provider's services.
(B) Unless otherwise agreed upon by the nonparticipating provider
and the insurer or by the nonparticipating provider and the
provider group , the services rendered pursuant to this
section subdivision shall be
compensated at rates and methods of payment similar to those used by
the insurer or the provider group for currently
participating providers providing similar services who are practicing
in the same or a similar geographic area as the nonparticipating
provider. Neither the insurer nor the provider group is required to
continue the services of a nonparticipating provider if the provider
does not accept the payment rates provided for in this paragraph.
The provider shall accept the reimbursement as payment in
full and shall not bill the insured for any amount in excess of the
reimbursement rate, with the exception of copayments and deductibles
pursuant to subdivision (e).
SEC. 3. It is the intent of the Legislature that a
nonparticipating provider whose services are continued pursuant to
Section 10133.56 of the Insurance Code accept the reimbursement
provided under that section as payment in full and not bill the
insured for any amount in excess of the reimbursement rate, with the
exception of copayments and deductibles pursuant to subdivision (c)
of Section 10133.56.
SEC. 3. SEC. 4. 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. 5. This act is an urgency statute
necessary for the immediate preservation of the public peace, health,
or safety within the meaning of Article IV of the Constitution and
shall go into immediate effect. The facts constituting the necessity
are:
Many health care service plans and health insurers terminated
health plans between December 1, 2013, and March 31, 2014, in
anticipation of compliance with the federal Patient Protection and
Affordable Care Act. In order to allow an individual enrolled in such
a plan who was receiving covered treatment under the plan from a
provider for a certain condition to continue to receive services from
that provider for the condition, it is necessary that this act take
effect immediately.