BILL NUMBER: SB 1100	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Hernandez

                        FEBRUARY 19, 2014

   An act to amend Section 1373.96 of the Health and Safety Code, and
to amend Section 10133.56 of the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 1100, as introduced, Hernandez. Continuity of care.
   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.
Existing law requires a health care service plan or a health insurer
to provide for the completion of covered services by a terminated
provider for enrollees or insureds who were receiving services from
the provider for a specified condition at the time of the provider
termination. Existing law also requires a health care service plan to
provide for the completion of covered services by a nonparticipating
provider to a newly covered enrollee who, at the time his or her
coverage became effective, was receiving services from that provider
for a specified condition. Existing law requires a health care
service plan to provide a disclosure form regarding the benefits,
services, and terms of a plan contract and requires the disclosure
form to include a description of how an enrollee can request
continuity of care under the provisions described above.
   This bill would also require a health care service plan to include
notice of the process to obtain continuity of care in every evidence
of coverage issued after January 1, 2015. The bill would also
require a plan to provide a written copy of this information to its
contracting providers and provider groups, as well as a copy to its
enrollees upon request. The bill would make other technical changes
to the provisions governing health insurers and continuity of care.
Because a willful violation of the bill's requirements by a health
care service plan would be a crime, the 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 1373.96 of the Health and Safety Code is
amended to read:
   1373.96.  (a) A health care service plan shall at the request of
an enrollee, provide the completion of covered services as set forth
in this section by a terminated provider or by a nonparticipating
provider.
   (b) (1) The completion of covered services shall be provided by a
terminated provider to an enrollee who at the time of the contract's
termination, was receiving services from that provider for one of the
conditions described in subdivision (c).
   (2) The completion of covered services shall be provided by a
nonparticipating provider to a newly covered enrollee who, at the
time his or her coverage became effective, was receiving services
from that provider for one of the conditions described in subdivision
(c).
   (c) The health care service plan shall provide for the completion
of covered services for the following conditions:
   (1) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
   (2) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health care service plan in consultation with the enrollee and the
terminated provider or nonparticipating provider and consistent with
good professional practice. Completion of covered services under this
paragraph shall not exceed 12 months from the contract termination
date or 12 months from the effective date of coverage for a newly
covered enrollee.
   (3) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
   (4) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date or 12 months from the
effective date of coverage for a new enrollee.
   (5) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date or 12 months from the
effective date of coverage for a newly covered enrollee.
   (6) Performance of a surgery or other procedure that is authorized
by the plan as part of a documented course of treatment and has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date or within 180 days of the
effective date of coverage for a newly covered enrollee.
   (d) (1) The plan may require the terminated provider whose
services are continued beyond the contract termination date pursuant
to this section to agree in writing to be subject to the same
contractual terms and conditions that were imposed upon the provider
prior to termination, including, but not limited to, credentialing,
hospital privileging, utilization review, peer review, and quality
assurance requirements. If the terminated provider does not agree to
comply or does not comply with these contractual terms and
conditions, the plan is not required to continue the provider's
services beyond the contract termination date.
   (2) Unless otherwise agreed by the terminated provider and the
plan or by the individual provider and the provider group, the
services rendered pursuant to this section shall be compensated at
rates and methods of payment similar to those used by the plan or the
provider group for currently contracting providers providing similar
services who are not capitated and who are practicing in the same or
a similar geographic area as the terminated provider. Neither the
plan nor the provider group is required to continue the services of a
terminated provider if the provider does not accept the payment
rates provided for in this paragraph.
   (e) (1) The plan may require a nonparticipating provider whose
services are continued pursuant to this section for a newly covered
enrollee to agree in writing to be subject to the same contractual
terms and conditions that are imposed upon currently contracting
providers providing similar services who are not capitated and who
are practicing in the same or a similar geographic area as the
nonparticipating provider, including, but not limited to,
credentialing, hospital privileging, utilization review, peer review,
and quality assurance requirements. If the nonparticipating provider
does not agree to comply or does not comply with these contractual
terms and conditions, the plan is not required to continue the
provider's services.
   (2) Unless otherwise agreed upon by the nonparticipating provider
and the plan or by the nonparticipating provider and the provider
group, the services rendered pursuant to this section shall be
compensated at rates and methods of payment similar to those used by
the plan or the provider group for currently contracting providers
providing similar services who are not capitated and who are
practicing in the same or a similar geographic area as the
nonparticipating provider. Neither the plan nor the provider group is
required to continue the services of a nonparticipating provider if
the provider does not accept the payment rates provided for in this
paragraph. 
   (f) Notice as to the process by which an enrollee may request
completion of covered services pursuant to this section shall be
provided in every disclosure form as required under Section 1363 and
in any evidence of coverage issued after January 1, 2015. A plan
shall provide a written copy of this information to its contracting
providers and provider groups. A plan shall also provide a copy to
its enrollees upon request.  
   (f) 
    (g)  The amount of, and the requirement for payment of,
copayments, deductibles, or other cost sharing components during the
period of completion of covered services with a terminated provider
or a nonparticipating provider are the same as would be paid by the
enrollee if receiving care from a provider currently contracting with
or employed by the plan. 
   (g) 
    (h)  If a plan delegates the responsibility of complying
with this section to a provider group, the plan shall ensure that
the requirements of this section are met. 
   (h) 
    (i)  This section shall not require a plan to provide
for completion of covered services by a provider whose contract with
the plan or provider group has been terminated or not renewed for
reasons relating to a medical disciplinary cause or reason, as
defined in paragraph (6) of subdivision (a) of Section 805 of the
Business and Profession Code, or fraud or other criminal activity.

   (i) 
    (j)  This section shall not require a plan to cover
services or provide benefits that are not otherwise covered under the
terms and conditions of the plan contract. This section shall not
apply to a newly covered enrollee covered under an individual
subscriber agreement who is undergoing a course of treatment on the
effective date of his or her coverage for a condition described in
subdivision (c). 
   (j) 
    (k)  This section shall not apply to a newly covered
enrollee who is offered an out-of-network option or to a newly
covered enrollee who had the option to continue with his or her
previous health plan or provider and instead voluntarily chose to
change health plans. 
   (k) 
    (l)  The provisions contained in this section are in
addition to any other responsibilities of a health care service plan
to provide continuity of care pursuant to this chapter. Nothing in
this section shall preclude a plan from providing continuity of care
beyond the requirements of this section. 
   (  l  )
    (m)  The following definitions apply for the purposes of
this section:
   (1) "Individual provider" means a person who is a licentiate, as
defined in Section 805 of the Business and Professions Code, or a
person licensed under Chapter 2 (commencing with Section 1000) of
Division 2 of the Business and Professions Code.
   (2) "Nonparticipating provider" means a provider who is not
contracted with a health care service plan.
   (3) "Provider" shall have the same meaning as set forth in
subdivision (i) of Section 1345.
   (4) "Provider group" means a medical group, independent practice
association, or any other similar organization.
  SEC. 2.  Section 10133.56 of the Insurance Code is amended to read:

   10133.56.  (a) A health insurer that enters into a contract with a
professional or institutional provider to provide services at
alternative rates of payment pursuant to Section 10133 shall, at the
request of an insured, arrange for the completion of covered services
by a terminated provider, if the insured is undergoing a course of
treatment for any of the following conditions:
   (1) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
   (2) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health insurer in consultation with the insured and the terminated
provider and consistent with good professional practice. Completion
of covered services under this paragraph shall not exceed 12 months
from the contract termination date.
   (3) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
   (4) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date.
   (5) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date.
   (6) Performance of a surgery or other procedure that has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date.
   (b) The insurer may require the terminated provider whose services
are continued beyond the contract termination date pursuant to this
 section,   section  to agree in writing to
be subject to the same contractual terms and conditions that were
imposed upon the provider prior to termination, including, but not
limited to, credentialing, hospital privileging, utilization review,
peer review, and quality assurance requirements. If the terminated
provider does not agree to comply or does not comply with these
contractual terms and conditions, the insurer is not required to
continue the provider's services beyond the contract termination
date.
   (c) Unless otherwise agreed upon between the terminated provider
and the insurer or between the terminated provider and the provider
group, the agreement shall be construed to require a rate and method
of payment to the terminated provider, for the services rendered
pursuant to this section, that are the same as the rate and method of
payment for the same services while under contract with the insurer
and at the time of termination. The provider shall accept the
reimbursement as payment in full and shall not bill the insured for
any amount in excess of the reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (e).
   (d) Notice as to the process by which an insured may request
completion of covered services pursuant to this section shall be
provided in any insurer evidence of coverage and disclosure form
issued after March 31, 2004. An insurer shall provide a written copy
of this information to its contracting providers and provider groups.
An insurer shall also provide a copy to its insureds upon request.
   (e) The payment of copayments, deductibles, or other cost-sharing
components by the insured during the period of completion of covered
services with a terminated provider shall be the same copayments,
deductibles, or other cost-sharing components that would be paid by
the insured when receiving care from a provider currently contracting
with the insurer.
   (f) If an insurer delegates the responsibility of complying with
this section to its contracting entities, the insurer shall ensure
that the requirements of this section are met.
   (g) For the purposes of this section, the following  terms
have the following meanings:   definitions apply: 

   (1) "Provider" means a person who is a licentiate as defined in
Section 805 of the Business and Professions Code or a person licensed
under Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code.
   (2) "Terminated provider" means a provider whose contract to
provide services to insureds is terminated or not renewed by the
insurer or one of the insurer's contracting provider groups. A
terminated provider is not a provider who voluntarily leaves the
insurer or contracting provider group.
   (3) "Provider group" includes a medical group, independent
practice association, or any other similar organization.
   (h) This section shall not require an insurer or provider group to
provide for the completion of covered services by a provider whose
contract with the insurer or provider group has been terminated or
not renewed for reasons relating to medical disciplinary cause or
reason, as defined in paragraph (6) of subdivision (a) of Section 805
of the Business and Professions Code, or fraud or other criminal
activity.
   (i) This section shall not require an insurer to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the insurer contract.
   (j) The provisions contained in this section are in addition to
any other responsibilities of insurers to provide continuity of care
pursuant to this chapter. Nothing in this section shall preclude an
insurer from providing continuity of care beyond the requirements of
this section.
  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.