SB 266, as amended, Lieu. Health care coverage: out-of-network coverage.
Existing law provides for the licensure and regulation of health care practitioners by various healing arts boards within the Department of Consumer Affairs. Existing law also provides for the licensure and regulation of health facilities by the State Department of Public Health. A violation of these provisions is a crime.
The
end deletebegin insert This end insertbill would prohibit a health facility or a provider group from holding itself out as being within a plan network or a provider network unless all of the individual providers providing services at the facility or with the provider group are within the plan networkbegin insert or provider network, or the provider group acknowledges to the patient in writing or verbally that individual providers within the provider group may be outside the patient’s plan network or provider network and the provider group recommends that the patient contact his or her health care service plan or health insurer for information about providers who are within the patient’s plan network or end insertbegin insertprovider network. Those provisions would not apply to emergency services and careend insert. By expanding the scope of 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 687 is added to the Business and
2Professions Code, to read:
(a) A provider group shall not hold itself out as being
4within a plan network or a provider network unless one of the
5following applies:
6(1) All of the individual providers providing services with the
7provider group are within that plan network or provider network.
8(2) The provider group acknowledges to the patient in writing
9or verbally that individual providers within the provider group
10may be outside thebegin delete enrollee’send deletebegin insert patient’send insert plan network orbegin delete the
provider networkbegin insert and the provider group recommends
11insured’send delete
12that the patient contact his or her health care service plan or health
13insurer for information about providers who are within the
14patient’s plan network or provider networkend insert.
15(b) For purposes of this section,begin delete “providerend deletebegin insert the following
16definitions shall apply:end insert
17(1) “Hold itself out” means advertise, refer to, use materials
18to indicate, let itself be known, assume the
appearance of, act as
19if it is by claiming or presenting to accept payments from, or
20represent itself as continuing to be in.
21(2) “Plan network” means any entity, group of providers, or
22individual providers contracted with a preferred provider
23organization plan contract or point-of-service plan contract.
24(3) Provider network” means any entity, group of providers, or
25provider contacted with a preferred provider organization health
26insurance policy.
27begin insert(end insertbegin insert4)end insertbegin insert end insertbegin insert“end insertbegin insertProviderend insert
group” means a medical group, independent
28practice association, or any other similar organization.
29(c) This section shall not apply to emergency services and care.
end insertSection 1250.04 is added to the Health and Safety
2Code, to read:
(a) A health facility shall not hold itself out as being
4within a plan network or a provider network unless one of the
5following applies:
6(1) All of the individual providers providing services within the
7health facility are within that plan network or provider network.
8(2) The health facility acknowledges to the patient in writing
9or verbally that individual providers providing services within the
10health facility may be outside thebegin delete enrollee’send deletebegin insert patient’send insert
plan network
11begin insert or provider network and the health facility recommends that the
12patient contact his or her health care service plan or health insurer
13for information about providers who are within the patient’s plan
14network or end insertbegin insertprovider networkend insert.
15(b) For purposes of this section,begin delete “healthend deletebegin insert the following definitions
16shall apply:end insert
17begin insert(1)end insertbegin insert end insertbegin insert“end insertbegin insertHealthend insert
facility” means a health facility as defined in
18subdivision (a) of Section 1250.
19(2) “Hold itself out” means advertise, refer to, use materials
20to indicate, let itself be known, assume the appearance of, act as
21if it is by claiming or presenting to accept payments from, or
22represent itself as continuing to be in.
23(3) “Plan network” means any entity, group of providers, or
24individual providers contracted with a preferred provider
25organization plan contract or point-of-service plan contract.
26(4) Provider network” means any entity, group of providers, or
27provider contacted with a preferred provider organization health
28insurance policy.
29(c) This section shall not apply to emergency services and care.
end insertNo reimbursement is required by this act pursuant to
31Section 6 of Article XIII B of the California Constitution because
32the only costs that may be incurred by a local agency or school
33district will be incurred because this act creates a new crime or
34infraction, eliminates a crime or infraction, or changes the penalty
35for a crime or infraction, within the meaning of Section 17556 of
36the Government Code, or changes the definition of a crime within
37the meaning of Section 6 of Article XIII B of the California
38Constitution.
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