California Legislature—2013–14 Regular Session

Assembly Bill No. 671

Introduced by Assembly Member Logue

February 21, 2013

An act to amend Section 1367 of the Health and Safety Code, relating to health care service plans.

LEGISLATIVE COUNSEL’S DIGEST

AB 671, as introduced, Logue. Health care service plans.

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 requires a health care service plan to meet specified requirements.

This bill would make a technical, nonsubstantive change to that provision.

Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.

The people of the State of California do enact as follows:

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 begin insert Public end insert Health
begin delete Services end delete , where licensure is required by law. Facilities not located
in begin delete this state end delete begin insert California end insert 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.