(a) (1) Except as provided in subdivision (c), a health
15care service plan contract issued, amended, or renewed on or after
16July 1, 2017, shall provide that if an enrollee receives covered
17services from a contracting health facility at which, or as a result
18of which, the enrollee receives services provided by a
19noncontracting individual health professional, the enrollee shall
20pay no more than the same cost sharing that the enrollee would
21pay for the same covered services received from a contracting
22individual health professional. This amount shall be referred to
23as the “in-network cost-sharing amount.”
(2) An enrollee shall not owe more than the in-network
25cost-sharing amount for services subject to this section. The
26care service plan shall collect the in-network cost-sharing amount
27from the enrollee.
(3) A noncontracting individual health professional shall not
29bill or collect any amount from the enrollee for services subject
30to this section. Any communication from the noncontracting
31individual health professional to the enrollee shall include a notice
32in 12-point bold type stating that the communication is not a bill.
(4) In submitting a claim to the plan, the noncontracting
34individual health professional shall affirm in writing to the plan
35that he or she has not attempted to collect any payment from the
(5) (A) If the noncontracting individual health professional has
38received any amount from the enrollee for services subject to this
39section, the noncontracting individual health
P9 1refund the amount to the enrollee after receiving payment from
(B) If the noncontracting individual health professional does
4not refund the amount collected from the enrollee after receiving
5payment from the plan, interest shall accrue at the rate of 15
6percent per annum beginning with the date payment was received
7from the enrollee.
(C) A noncontracting individual health professional shall
9automatically include in his or her refund to the enrollee all
10interest that has accrued pursuant to this section without requiring
11the enrollee to submit a request for the interest amount.
(b) Except for services subject to subdivision (c), the following
(1) Any cost sharing paid by the enrollee for the services
a noncontracting individual health professional at
16the contracting health facility shall count toward the limit on
17annual out-of-pocket expenses established under Section 1367.006.
(2) Cost sharing arising from services received by a
19noncontracting individual health professional at a contracting
20health facility shall be counted toward any deductible in the same
21manner as cost sharing would be attributed to a contracting
22individual health professional.
(3) The cost sharing paid by the enrollee pursuant to this section
24shall satisfy the enrollee’s obligation to pay cost sharing for the
25health service and shall constitute “applicable cost sharing owed
26by the enrollee” for the purpose of subdivision (e) of Section
(c) For services subject to this section, if an enrollee has a
29health care service plan that
includes coverage for out-of-network
30benefits, a noncontracting individual health professional may bill
31or collect from the enrollee the out-of-network cost sharing, if
32applicable, only when the enrollee consents in writing and that
33written consent satisfies all the following criteria:
(1) At least 24 hours in advance of care, the enrollee shall
35consent in writing to receive services from the identified
36noncontracting individual health professional.
(2) The consent shall be obtained by the noncontracting
38individual health professional separately from the consent for any
39other part of the care or procedure. The consent shall not be
40obtained by the facility or any representative of the facility. The
P10 1consent shall not be obtained at the time of admission or at any
2time when the enrollee is being prepared for surgery or any other
(3) At the time consent is provided, the noncontracting individual
5health professional shall give the enrollee a written estimate of
6the enrollee’s total out-of-pocket cost of care. The written estimate
7shall be based on the professional’s billed charges for the service
8to be provided. The noncontracting individual health professional
9shall not attempt to collect more than the estimated amount without
10receiving separate written consent from the enrollee or the
11enrollee’s authorized representative.
(4) The consent shall advise the enrollee that he or she may
13elect to seek care from a contracted provider or may contact the
14enrollee’s health care service plan in order to arrange to receive
15the health service from a contracted provider for
(5) The consent and estimate shall be provided to the
18in the language spoken by the enrollee.
(6) The consent shall also advise the enrollee that any costs
20incurred as a result of the enrollee’s use of the out-of-network
21benefit shall be in addition to in-network cost-sharing amounts
22and may not count toward the annual out-of-pocket maximum on
23in-network benefits or a deductible, if any, for in-network benefits.
(d) A noncontracting individual health professional who fails
25to comply with the requirements of subdivision (c) has not obtained
26written consent for purposes of this section. Under those
27circumstances, subdivisions (a) and (b) shall apply and subdivision
28(c) shall not apply.
(e) (1) A noncontracting individual health professional may
30advance to collections only the in-network cost-sharing amount,
31as determined by the plan pursuant
to subdivision (a) or the
32out-of-network cost-sharing amount owed pursuant to subdivision
33(c), that the enrollee has failed to pay.
(2) The noncontracting individual health professional, or any
35entity acting on his or her behalf, including any assignee of the
36debt, shall not report adverse information to a consumer credit
37reporting agency or commence civil action against the enrollee
38for 150 days after the initial billing regarding amounts owed by
39the enrollee under subdivision (a) or (c).
(3) With respect to an enrollee, the noncontracting individual
2health professional, or any entity acting on his or her behalf,
3including any assignee of the debt, shall not use wage garnishments
4or liens on primary residences as a means of collecting unpaid
5bills under this section.
(f) For purposes of this section and Sections
71371.31, the following definitions shall apply:
(1) “Contracting health facility” means a health facility that is
9contracted with the enrollee’s health care service plan to provide
10services under the enrollee’s plan contract. A contracting health
11care facility includes, but is not limited to, the following providers:
(A) A licensed hospital.
(B) An ambulatory surgery or other outpatient setting, as
14described in subdivision (a), (d), (e), (g), or (h) of Section 1248.1.
(C) A laboratory.
(D) A radiology or imaging center.
(E) Any other similar provider as the department may define,
18by regulation, as a health
facility for purposes of this section.
(2) “Cost sharing” includes any copayment, coinsurance, or
20deductible, or any other form of cost sharing paid by the enrollee
21other than premium or share of premium.
(3) “Individual health professional” means a physician and
23surgeon or other professional who is licensed by this state to
24deliver or furnish health care services. For this purpose, an
25“individual health professional” shall not include a dentist,
26licensed pursuant to the Dental Practice Act (Chapter 4
27(commencing with Section 1600) of Division 2 of the Business and
(4) “In-network cost-sharing amount” means an amount no
30more than the same cost sharing the enrollee would pay for the
31same covered service received from a contracting health
32professional. The in-network cost-sharing amount with respect
33an enrollee with coinsurance shall be based on the amount paid
34by the plan pursuant to paragraph (1) of subdivision (a) of Section
(5) “Noncontracting individual health professional” means a
37physician and surgeon or other professional who is licensed by
38the state to deliver or furnish health care services and who is not
39contracted with the enrollee’s health care service plan. For this
40purpose, a “noncontracting individual health professional” shall
P12 1not include a dentist, licensed pursuant to the Dental Practice Act
2(Chapter 4 (commencing with Section 1600) of Division 2 of the
3Business and Professions Code).
(g) This section shall not be construed to require a health care
5service plan to cover services not required by law or by the terms
6and conditions of the health care service plan contract.
section shall not be construed to exempt a plan or
8provider from the requirements under Section 1371.4 or 1373.96,
9nor abrogate the holding in Prospect Medical Group, Inc. v.
10Northridge Emergency Medical Group (2009) 45 Cal.4th 497, that
11an emergency room physician is prohibited from billing an enrollee
12of a health care service plan directly for sums that the health care
13service plan has failed to pay for the enrollee’s emergency room
(i) If a health care service plan delegates payment functions to
16a contracted entity, including, but not limited to, a medical group
17or independent practice association, the delegated entity shall
18comply with this section.
(j) This section shall not apply to a Medi-Cal managed health
20care service plan or any other entity that enters into a contract
21with the State Department of Health Care Services pursuant to
22Chapter 7 (commencing with
Section 14000), Chapter 8
23(commencing with Section 14200), and Chapter 8.75 (commencing
24with Section 14591) of Part 3 of Division 9 of the Welfare and
(k) This section shall not apply to emergency services and care,
27as defined in Section 1317.1.