Amended in Assembly April 10, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 676

Introduced by Assembly Member Fox

February 21, 2013

An act to add Section 1367.52 to the Health and Safety Code, to add Section 10117.6 to the Insurance Code, and to add Section 14109.7 to the Welfare and Institutions Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 676, as amended, Fox. Health care coverage: postdischarge care needs.

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 insurers by the Department of Insurance. Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

This bill would prohibit health care service plans, health insurers, and the Department of Health Care Services or Medi-Cal managed care plans, as applicable, from causing an enrollee, insured, or beneficiary to remain in a general acute care hospital or an acute psychiatric hospital begin delete upon determination by end delete begin insert if end insert the attending physician on the medical staff begin insert has determined end insert that the individual no longer requires inpatient hospital care. The bill would require the health care service plan, health insurer, or the State Department of Health Care Services or Medi-Cal managed care plan to perform specified duties within 24 hours of receipt of notice of the discharge. The bill would provide that failure of the begin insert respective end insert health care service plan, health insurer, begin delete or end delete the State Department of Health Care Services begin insert , end insert or Medi-Cal managed care plan to begin delete transfer the patient within 72 hours from the health facility to an appropriate community setting end delete begin insert perform those duties within 72 hours of the receipt of a notice of discharge end insert would result in a daily penalty amount, as specified, to be paid within 10 days of the patient’s discharge.

Because a willful violation of these provisions by a health care service plan 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.

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 1367.52 is added to the Health and Safety
Code, to read:

1367.52.  

(a) A health care service plan that provides coverage
for inpatient hospital care shall not cause an enrollee to remain in
a health facility licensed under subdivision (a) or (b) of Section
1250, begin delete upon a determination by end delete begin insert if end insert the attending physician on the
medical staff begin insert has determined end insert that the enrollee no longer requires
inpatient hospital care. Within 24 hours of receipt of notice of
discharge, the health care service plan shall be in direct
communication with hospital staff to provide information, support,
and assistance to facilitate the ability of hospital personnel to do
all of the following:

(1) Locate and secure an appropriate community setting for the
enrollee that is consistent with postdischarge care needs.

(2) Ensure there is an appropriate arrangement to transfer the
enrollee to the community setting.

(3) Follow up with the enrollee or his or her designee to
coordinate postdischarge care needs.

(b) Failure of the health care service plan to begin delete transfer the enrollee
within 72 hours from a health facility described in subdivision (a)
to an appropriate community setting end delete begin insert satisfy the requirements of
subdivision (a) within 72 hours of receipt of the notice of discharge end insert
shall result in a daily penalty amount equal to begin insert 75 percent of end insert the
applicable inpatient rate, or pro rata calculated rate if case based,
or the diagnosis-related group rate. The penalty shall be paid by
the health care service plan to the health facility under the standard
billing cycle, and final payment of the penalty shall be paid within
10 days of the enrollee’s discharge.

SEC. 2.  

Section 10117.6 is added to the Insurance Code, to
read:

10117.6.  

(a) A health insurer that provides coverage for
inpatient hospital care shall not cause an insured to remain in a
health facility licensed under subdivision (a) or (b) of Section 1250
of the Health and Safety Code, begin delete upon a determination by end delete begin insert if end insert the
attending physician on the medical staff begin insert has determined end insert that the
insured no longer requires inpatient hospital care. Within 24 hours
of receipt of notice of discharge, the health insurer shall be in direct
communication with hospital staff to provide information, support,
and assistance to facilitate the ability of hospital personnel to do
all of the following:

(1) Locate and secure an appropriate community setting for the
insured that is consistent with postdischarge care needs.

(2) Ensure there is an appropriate arrangement to transfer the
insured to the community setting.

(3) Follow up with the insured or his or her designee to
coordinate postdischarge care needs.

(b) Failure of the health insurer to begin delete transfer the insured within
72 hours from a health facility described in subdivision (a) to an
appropriate community setting end delete begin insert satisfy the end insert begin insert requirements of
subdivision (a) within 72 hours of receipt of the notice of discharge end insert
shall result in a daily penalty amount equal to begin insert 75 percent of end insert the
applicable inpatient rate, or pro rata calculated rate if case based,
or the diagnosis-related group rate. The penalty shall be paid by
the health insurer to the health facility under the standard billing
cycle, and final payment of the penalty shall be paid within 10
days of the insured’s discharge.

SEC. 3.  

Section 14109.7 is added to the Welfare and
Institutions Code, to read:

14109.7.  

(a) The department, or the Medi-Cal managed care
plan, if applicable, shall not cause a Medi-Cal beneficiary to remain
in a health facility licensed under subdivision (a) or (b) of Section
1250 of the Health and Safety Code, begin delete upon a determination by end delete begin insert if end insert
the attending physician on the medical staff begin insert has determined end insert that
the beneficiary no longer requires inpatient hospital care. Within
24 hours of receipt of notice of discharge, the department or the
Medi-Cal managed care plan shall be in direct communication
with hospital staff to provide information, support, and assistance
to facilitate the ability of hospital personnel to do all of the
following:

(1) Locate and secure an appropriate community setting for the
beneficiary that is consistent with postdischarge care needs.

(2) Ensure there is an appropriate arrangement to transfer the
beneficiary to the community setting.

(3) Follow up with the beneficiary or his or her designee to
coordinate postdischarge care needs.

(b) Failure of the department or the Medi-Cal managed care
plan to begin delete transfer the beneficiary within 72 hours from a health
facility described in subdivision (a) to an appropriate community
setting end delete begin insert satisfy the requirements of subdivision (a) within 72 hours
of receipt of the notice of discharge end insert shall result in a daily penalty
amount equal to begin insert 75 percent of end insert the applicable inpatient rate, or pro
rata calculated rate if case based, or the diagnosis-related group
rate. The penalty shall be paid by the department or the Medi-Cal
managed care plan to the health facility under the standard billing
cycle, and final payment of the penalty shall be paid within 10
days of the beneficiary’s discharge.

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.