BILL NUMBER: SB 266 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 3, 2013
AMENDED IN SENATE MARCH 18, 2013
INTRODUCED BY Senator Lieu
FEBRUARY 13, 2013
An act to add Section 687 to the Business and Professions Code,
and to add Section 1250.04 to the Health and Safety Code, relating to
health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
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 prohibit a health facility or
a provider group or clinic, as defined, from
holding itself out as being stating, verbally or in
writing, that it is within a plan network or a provider network
unless all of the individual providers providing services
at the facility or with the provider group or clinic
are within the plan network 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
network. The bill would require a provider group
recommends or clinic to recommend 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. By
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. 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 1. Section 687 is added to the Business and Professions
Code, to read:
687. (a) (1) A provider group or
clinic shall not hold itself out as being
state, verbally or in writing, that it is within
a patient's plan network or a provider
network unless one of the following applies:
(1) All
all of the individual providers providing services with
the provider group or clinic are within that plan network
or provider network.
(2) 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
or clinic shall recommend 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.
(b) For purposes of this section, the following definitions shall
apply:
(1) "Hold itself out" means advertise, refer to, use materials to
indicate, let itself be known, assume the appearance of, act as if it
is by claiming or presenting to accept payments from, or represent
itself as continuing to be in.
(1) "Clinic" means a surgical center as defined in paragraph (1)
of subdivision (b) of Section 1204 of the Health and Safety Code, an
outpatient setting as defined in paragraph (1) of subdivision (b) of
Section 1248 of the Health and Safety Code, or an ambulatory surgical
center certified to participate in the Medicare Program under Title
XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et
seq.).
(2) "Plan network" means any entity, group of providers, or
individual providers contracted with a preferred provider
organization plan contract or point-of-service plan contract.
(3) "Provider network" means any entity, group of providers, or
provider contacted contracted with a
preferred provider organization health insurance policy.
(4) "Provider group" means a medical group, independent practice
association, or any other similar organization.
(c) This section shall not apply to emergency services and care.
SEC. 2. Section 1250.04 is added to the Health and Safety Code, to
read:
1250.04. (a) A health facility shall not hold itself out as being
within a plan network or a provider network unless one of the
following applies:
(1) All of the individual providers providing services within the
health facility are within that plan network or provider network.
1250.04. (a) (1) Prior to providing nonemergency
services and care to a patient, a hospital shall provide a 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.
(2) The health facility acknowledges to the patient in
writing or verbally that individual providers providing services
within the health facility may be outside the patient's plan network
or provider network and the health facility recommends
hospital notice shall recommend 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.
(b) For purposes of this section, the following definitions shall
apply:
(1) "Health facility" "Hospital
" means a health facility general
acute care hospital as defined in subdivision (a) of Section
1250.
(2) "Hold itself out" means advertise, refer to, use materials to
indicate, let itself be known, assume the appearance of, act as if it
is by claiming or presenting to accept payments from, or represent
itself as continuing to be in.
(3)
( 2) "Plan network" means any entity, group
of providers, or individual providers contracted with a preferred
provider organization plan contract or point-of-service plan
contract.
(4) Provider
(3) "Provider network" means any
entity, group of providers, or provider contacted
contracted with a preferred provider organization health
insurance policy.
(c) This section shall not apply to emergency services and care.
(d) This section shall not apply if all of the providers providing
services within the hospital are within the same plan network or
provider network as the hospital.
SEC. 3. 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.