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.
This bill would prohibitbegin delete a health facility orend delete a provider groupbegin insert or clinic, as defined,end insert frombegin delete holding itself out as beingend deletebegin insert stating, verbally or in writing, that it isend insert
within a plan network or a provider network unless all of the individual providers providing servicesbegin delete at the facility orend delete with the provider groupbegin insert or clinicend insert are within the plan network or providerbegin delete 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 theend deletebegin insert network. The bill would require aend insert provider groupbegin delete recommendsend deletebegin insert
or clinic to recommendend insert 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 provider network. Those provisions would not apply to emergency services and care.begin delete Byend delete
begin insert This bill would also require a hospital, before providing nonemergency services and care, to provide a specified written notice to the patient stating that individual providers providing services within the hospital may not be in the patient’s plan network or provider network, except as specified. Byend insert 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) begin insert(1)end insertbegin insert end insert A provider groupbegin insert or end insertbegin insertclinicend insert shall notbegin delete hold itself begin insert state, verbally or in writing, that it isend insert within abegin insert
patient’send insert
4out as beingend delete
5 plan network orbegin delete aend delete provider network unlessbegin delete one of the following
6applies:end delete
7begin delete(1)end deletebegin delete end deletebegin deleteAllend deletebegin insert allend insert of the individual providers providing services with
8the provider groupbegin insert or clinicend insert are within that plan network or
9provider network.
10(2) Thebegin delete provider group acknowledges to the patient in writing
11or verbally that individual providers within the provider group
12may be outside the patient’s plan network or
provider network and
13theend deletebegin delete recommendsend deletebegin insert or clinic shall recommend end insert that
14the patient contact his or her health care service plan or health
15insurer for information about providers who are within the patient’s
16plan network or provider network.
17(b) For purposes of this section, the following definitions shall
18apply:
19(1) “Hold itself out” means advertise, refer to, use materials to
20indicate, let itself be known, assume the
appearance of, act as if it
21is by claiming or presenting to accept payments from, or represent
22itself as continuing to be in.
P3 1(1) “Clinic” means a surgical center as defined in paragraph
2(1) of subdivision (b) of Section 1204 of the Health and Safety
3Code, an outpatient setting as defined in paragraph (1) of
4subdivision (b) of Section 1248 of the Health and Safety Code, or
5an ambulatory surgical center certified to participate in the
6Medicare Program under Title XVIII of the federal Social Security
7Act (42 U.S.C. Sec. 1395 et seq.).
8(2) “Plan network” means any entity, group of providers, or
9individual providers contracted with a preferred provider
10organization plan contract or point-of-service plan contract.
11(3) “Provider network” means any entity, group of providers,
12or providerbegin delete contactedend deletebegin insert
contractedend insert with a preferred provider
13organization health insurance policy.
14(4) “Provider group” means a medical group, independent
15practice association, or any other similar organization.
16(c) This section shall not apply to emergency services and care.
Section 1250.04 is added to the Health and Safety
18Code, to read:
(a) A health facility shall not hold itself out as being
20within a plan network or a provider network unless one of the
21following applies:
22(1) All of the individual providers providing services within the
23health facility are within that plan network or provider network.
(a) (1) Prior to providing nonemergency services
25and care to a patient, a hospital shall provide a written notice to
26the patient stating that individual providers providing services
27within the hospital may not be in the patient’s plan network or
28provider network.
29(2) Thebegin delete health facility acknowledges to the patient in writing
30or verbally that individual providers providing services within the
31health facility may be outside the patient’s
plan network or provider
32network and the health facility recommendsend delete
33recommendend insert that the patient contact his or her health care service
34plan or health insurer for information about providers who are
35within the patient’s plan network or provider network.
36(b) For purposes of this section, the following definitions shall
37apply:
38(1) begin delete“Health
facility” end delete
begin delete health facilityend deletebegin insert general
39acute care hospitalend insert as defined in subdivision (a) of Section 1250.
P4 1(2) “Hold itself out” means advertise, refer to, use materials to
2indicate, let itself be known, assume the appearance of, act as if it
3is by claiming or presenting to accept payments from, or represent
4itself as continuing to be in.
5(3)
end delete
6begin insert(end insertbegin insert2)end insert “Plan network” means any entity, group of providers, or
7individual providers contracted with a preferred provider
8organization plan contract or point-of-service plan contract.
9(4) Provider
end delete
10begin insert(3)end insertbegin insert end insertbegin insert“Providerend insert network” means any entity, group of providers,
11
or providerbegin delete contactedend deletebegin insert
contractedend insert with a preferred provider
12organization health insurance policy.
13(c) This section shall not apply to emergency services and care.
begin insert
14(d) This section shall not apply if all of the providers providing
15services within the hospital are within the same plan network or
16provider network as the hospital.
No reimbursement is required by this act pursuant to
18Section 6 of Article XIII B of the California Constitution because
19the only costs that may be incurred by a local agency or school
20district will be incurred because this act creates a new crime or
21infraction, eliminates a crime or infraction, or changes the penalty
22for a crime or infraction, within the meaning of Section 17556 of
23the Government Code, or changes the definition of a crime within
24the meaning of Section 6 of Article XIII B of the California
25Constitution.
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