as amended, Hernandez.
begin deleteHealth care coverage: cost sharing. end delete
Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA establishes annual limits on deductibles for employer-sponsored plans and defines bronze, silver, gold, and platinum levels of coverage for the nongrandfathered individual and small group markets.end delete
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 health insurers by the Department of Insurance.end delete
This bill would declare the intent of the legislature to enact legislation that would address cost sharing as contemplated by the PPACA.end delete
begin deleteno end delete.
State-mandated local program: begin deleteno end delete.
The people of the State of California do enact as follows:
A health care service plan and, if applicable, a specialized
4health care service plan shall meet the following requirements:
5(a) Facilities located in this state including, but not limited to,
6clinics, hospitals, and skilled nursing facilities to be utilized by
7the plan shall be licensed by the State Department of
begin delete Health where licensure is required by law.
9Facilities not located in this state shall conform to all licensing
10and other requirements of the jurisdiction in which they are located.
11(b) Personnel employed by or under contract to the plan shall
12be licensed or certified by their respective board or agency, where
13licensure or certification is required by law.
14(c) Equipment required to be licensed or registered by law shall
15be so licensed or registered, and the operating personnel for that
16equipment shall be licensed or certified as required by law.
17(d) The plan shall furnish services in a manner providing
18continuity of care and ready referral of patients to other providers
19at times as may be appropriate consistent with good professional
21(e) (1) All services shall be readily available at reasonable
22times to each enrollee consistent with good professional practice.
23To the extent feasible, the plan shall make all services readily
24accessible to all enrollees consistent with Section 1367.03.
25(2) To the extent that
begin delete telemedicineend delete services are
26appropriately provided through
begin delete telemedicine,end delete as defined
27in subdivision (a) of Section 2290.5 of the Business and Professions
28Code, these services shall be considered in determining compliance
29with Section 1300.67.2 of Title 28 of the California Code of
P4 1(3) The plan shall make all services accessible and appropriate
2consistent with Section 1367.04.
3(f) The plan shall employ and utilize allied health manpower
4for the furnishing of services to the extent permitted by law and
5consistent with good medical practice.
6(g) The plan shall have the organizational and administrative
7capacity to provide services to subscribers and enrollees. The plan
8shall be able to demonstrate to the department that medical
9decisions are rendered by qualified medical providers, unhindered
10by fiscal and administrative management.
11(h) (1) Contracts with subscribers and enrollees, including
12group contracts, and contracts with providers, and other persons
13furnishing services, equipment, or facilities to or in connection
14with the plan, shall be fair, reasonable, and consistent with the
15objectives of this chapter. All contracts with providers shall contain
16provisions requiring a fast, fair, and cost-effective dispute
17resolution mechanism under which providers may submit disputes
18to the plan, and requiring the plan to inform its providers upon
19contracting with the plan, or upon change to these provisions, of
20the procedures for processing and resolving disputes, including
21the location and telephone number where information regarding
22disputes may be submitted.
A health care service plan shall ensure that a dispute
24resolution mechanism is accessible to noncontracting providers
25for the purpose of resolving billing and claims disputes.
26(3) On and after January 1, 2002, a health care service plan
27shall annually submit a report to the department regarding its
28dispute resolution mechanism. The report shall include information
29on the number of providers who utilized the dispute resolution
30mechanism and a summary of the disposition of those disputes.
31(i) A health care service plan contract shall provide to
32subscribers and enrollees all of the basic health care services
33included in subdivision (b) of Section 1345, except that the director
34may, for good cause, by rule or order exempt a plan contract or
35any class of plan contracts from that requirement. The director
36shall by rule define the scope of each basic health care service that
37health care service plans are required to provide as a minimum for
38licensure under this chapter. Nothing in this chapter shall prohibit
39a health care service plan from charging subscribers or enrollees
40a copayment or a deductible for a basic health care service
P5 1 or from setting forth, by contract,
6limitations on maximum coverage of basic health care services,
7provided that the
begin delete copayments, deductibles, orend delete limitations are
8reported to, and held unobjectionable by, the director and set forth
9to the subscriber or enrollee pursuant to the disclosure provisions
10of Section 1363.
11(j) A health care service plan shall not require registration under
12the Controlled Substances Act of 1970 (21 U.S.C. Sec. 801 et seq.)
13as a condition for participation by an optometrist certified to use
14therapeutic pharmaceutical agents pursuant to Section 3041.3 of
15the Business and Professions Code.
16Nothing in this section shall be construed to permit the director
17to establish the rates charged subscribers and enrollees for
18contractual health care services.
enforcement of Article 3.1 (commencing with
20Section 1357) shall not be deemed to establish the rates charged
21subscribers and enrollees for contractual health care services.
22The obligation of the plan to comply with this
begin delete sectionend delete
23 shall not be waived when the plan delegates any services that it is
24required to perform to its medical groups, independent practice
25associations, or other contracting entities.
It is the intent of the Legislature to enact
25legislation to address cost sharing as contemplated by the federal
26Patient Protection and Affordable Care Act.