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 abegin delete providerend deletebegin insert medicalend insert group or clinic, as defined, from stating, verbally or in writing, that it is within a plan network or a provider network unless all of the individual providers providing services with thebegin delete providerend deletebegin insert
medicalend insert group or clinic are within the plan network or provider network. The bill would require a provider group 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 orbegin delete providerend deletebegin insert medicalend insert
networkbegin insert if any of the providers in that medical group or clinic are not within the plan network or provider networkend insert. Those provisions would not apply to emergency services and care.
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 687 is added to the Business and
2Professions Code, to read:
(a) (1) Abegin delete providerend deletebegin insert medicalend insert group or clinic shall not state,
4verbally or in writing, that it is within a patient’s plan network or
5provider network unless all of the individual providers providing
6services with thebegin delete providerend deletebegin insert medicalend insert group or clinic are within that
7plan network or provider network.
8(2) begin deleteThe provider end deletebegin insertIf
any of the providers are not within the plan
9network or provider network, then the medical end insertgroup or clinic shall
10recommend that the patient contact his or her health care service
11plan or health insurer for information about providers who are
12within the patient’s plan network orbegin delete providerend deletebegin insert medicalend insert network.
13(b) For purposes of this section, the following definitions shall
14apply:
15(1) “Clinic” means a surgical center as defined in paragraph (1)
16of subdivision (b) of Section 1204 of the Health and Safety Code,
17an outpatient setting as defined in paragraph (1) of subdivision (b)
18of Section 1248 of the
Health and Safety Code, or an ambulatory
19surgical center certified to participate in the Medicare Program
20under Title XVIII of the federal Social Security Act (42 U.S.C.
21Sec. 1395 et seq.).
P3 1(2) “Plan network” means any entity, group of providers, or
2individual providers contracted with a preferred provider
3organization plan contract or point-of-service plan contract.
4(3) “Provider network” means any entity, group of providers,
5or provider contracted with a preferred provider organization health
6insurance policy.
7(4) begin delete“Provider end deletebegin insert“Medical end insertgroup” meansbegin delete a medical group, begin insert
any entity, group of providers,end insert
8independent practice association,end delete
9 or any other similar organizationbegin insert that contracts with a preferred
10provider organizationend insert.
11(c) This section shall not apply to emergency services and care.
Section 1250.04 is added to the Health and Safety
13Code, to read:
(a) (1) Prior to providing nonemergency services
15and care to a patient, a hospital shall provide a written notice to
16the patient stating that individual providers providing services
17within the hospital may not be in the patient’s plan network or
18provider network.
19(2) The hospital notice shall recommend that the patient contact
20his or her health care service plan or health insurer for information
21about providers who are within the patient’s plan network or
22provider network.
23(b) For purposes of this section, the following definitions shall
24apply:
25(1) “Hospital” means a general acute care hospital as defined
26in subdivision (a) of Section 1250.
27(2) “Plan network” means any entity, group of providers, or
28individual providers contracted with a preferred provider
29organization plan contract or point-of-service plan contract.
30(3) “Provider network” means any entity, group of providers,
31
or provider contracted with a preferred provider organization health
32insurance policy.
33(c) This section shall not apply to emergency services and care.
34(d) This section shall not apply if all of the providers providing
35services within the hospital are within the same plan network or
36provider network as the hospital.
No reimbursement is required by this act pursuant to
38Section 6 of Article XIII B of the California Constitution because
39the only costs that may be incurred by a local agency or school
40district will be incurred because this act creates a new crime or
P4 1infraction, eliminates a crime or infraction, or changes the penalty
2for a crime or infraction, within the meaning of Section 17556 of
3the Government Code, or changes the definition of a crime within
4the meaning of Section 6 of Article XIII B of the California
5Constitution.
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