AB 533, as introduced, Bonta. Health care coverage: out-of-network coverage.
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. A willful violation of the act is a crime. Existing law requires a health care service plan to reimburse providers for emergency services and care provided to its enrollees, until the care results in stabilization of the enrollee. Existing law prohibits a plan from requiring a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee’s emergency medical care, as specified.
Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health insurance policy issued, amended, or renewed on or after January 1, 2014, that provides or covers benefits with respect to services in an emergency department of a hospital to cover emergency services without the need for prior authorization, regardless of whether the provider is a participating provider, and subject to the same cost sharing required if the services were provided by a participating provider, as specified.
This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2016, to provide that if an enrollee obtains care from a participating facility, as defined, at which, or as a result of which, the enrollee receives covered services provided by a nonparticipating provider, as defined, the enrollee is required to pay the nonparticipating provider only the same cost sharing required if the services were provided by a participating provider. Because a willful violation of the bill’s provisions by a health care service plan would be 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 1371.9 is added to the Health and Safety
2Code, to read:
(a) (1) A health care service plan contract issued,
4amended, or renewed on or after January 1, 2016, shall provide
5that if an enrollee obtains care from a participating facility at which,
6or as a result of which, the enrollee receives services provided by
7a nonparticipating provider, the enrollee shall pay the
8nonparticipating provider no more than the same cost sharing that
9the enrollee would have paid for the same covered benefits received
10from a participating provider.
11(2) Except as provided in subdivision (d), the plan shall not
12reimburse a nonparticipating provider for services provided to the
13enrollee if the nonparticipating provider obtains, or seeks to obtain,
14more than the in-network cost sharing from the
enrollee.
15(b) (1) Any cost sharing paid by the enrollee for the services
16provided by a nonparticipating provider at the participating facility
17shall count toward the limit on annual out-of-pocket expenses
18established under Section 1367.006.
P3 1(2) Cost sharing shall be counted toward any deductible in the
2same manner as cost sharing would be attributed to a participating
3provider.
4(c) For purposes of this section, the following definitions shall
5apply:
6(1) “Cost sharing” includes any copayment, coinsurance, or
7deductible, or any other form of cost sharing paid by the enrollee
8other than premium or share of premium.
9(2) “Nonparticipating provider” means a provider who is
not
10contracted with the enrollee’s health care service plan to provide
11services under the enrollee’s plan contract.
12(3) “Participating facility” means a health facility provider who
13is contracted with the enrollee’s health care service plan to provide
14services under the enrollee’s plan contract. A facility shall include
15the following providers:
16(A) Licensed hospital.
17(B) Skilled nursing facility.
18(C) Ambulatory surgery.
19(D) Laboratory.
20(E) Radiology or imaging.
21(F) Facilities providing mental health or substance abuse
22treatment.
23(G) Any other provider as the department may by regulation
24define as a facility for purposes of this section.
25(4) “Provider” means a health facility or any person who is
26licensed by the state to deliver or furnish health care services.
27(d) An enrollee may voluntarily consent to the use of a
28nonparticipating provider. For purposes of this section, consent
29shall be voluntary if at least 24 hours in advance of the receipt of
30services, the enrollee is provided a written estimate of the cost of
31care by the nonparticipating provider and the enrollee consents in
32writing to both the use of a nonparticipating provider and the
33estimated additional cost for the services to be provided by the
34nonparticipating provider. The consent shall inform the enrollee
35that the cost of the services of the nonparticipating provider will
36not
accrue to the limit on annual out-of-pocket expenses.
37(e) This section shall not be construed to require a plan to cover
38services or provide benefits that are not otherwise covered under
39the terms and conditions of the plan contract.
Section 10112.8 is added to the Insurance Code, to
2read:
(a) (1) A health insurance policy issued, amended,
4or renewed on or after January 1, 2016, shall provide that if an
5insured obtains care from a participating facility at which, or as a
6result of which, the insured receives services provided by a
7nonparticipating provider, the insured shall pay the nonparticipating
8provider no more than the same cost sharing that the insured would
9have paid for the same covered benefits received from a
10participating provider.
11(2) Except as provided in subdivision (d), the insurer shall not
12reimburse a nonparticipating provider for services provided to the
13insured if the nonparticipating provider obtains, or seeks to obtain,
14more than the in-network cost sharing from the insured.
15(3) This section shall only apply to a health insurer that enters
16into a contract with a professional or institutional provider to
17provide services at alternative rates of payment pursuant to Section
1810133.
19(b) (1) Any cost sharing paid by the insured for the services
20provided by a nonparticipating provider at the participating facility
21shall count toward the limit on annual out-of-pocket expenses
22established under Section 10112.28.
23(2) Cost sharing shall be counted toward any deductible in the
24same manner as cost sharing would be attributed to a participating
25provider.
26(c) For purposes of this section, the following definitions shall
27apply:
28(1) “Cost sharing” includes
any copayment, coinsurance, or
29deductible, or any other form of cost sharing paid by the insured
30other than premium or share of premium.
31(2) “Nonparticipating provider” means a provider who is not
32contracted with the insured’s health insurer to provide services
33under the insured’s policy.
34(3) “Participating facility” means a health facility provider who
35is contracted with the insured’s health insurer to provide services
36under the insured’s policy. A facility shall include the following
37providers:
38(A) Licensed hospital.
39(B) Skilled nursing facility.
40(C) Ambulatory surgery.
P5 1(D) Laboratory.
2(E) Radiology or imaging.
3(F) Facilities providing mental health or substance abuse
4treatment.
5(G) Any other provider as the department may by regulation
6define as a facility for purposes of this section.
7(4) “Provider” means a health facility or any person who is
8licensed by the state to deliver or furnish health care services.
9(d) An insured may voluntarily consent to the use of a
10nonparticipating provider. For purposes of this section, consent
11shall be voluntary if at least 24 hours in advance of the receipt of
12services, the insured is provided a written estimate of the cost of
13care by the nonparticipating provider and the insured consents in
14writing to both the use of a nonparticipating
provider and the
15estimated additional cost for the services to be provided by the
16nonparticipating provider. The consent shall inform the insured
17that the cost of the services of the nonparticipating provider will
18not accrue to the limit on annual out-of-pocket expenses.
19(e) This section shall not be construed to require an insurer to
20cover services or provide benefits that are not otherwise covered
21under the terms and conditions of the policy.
No reimbursement is required by this act pursuant to
23Section 6 of Article XIII B of the California Constitution because
24the only costs that may be incurred by a local agency or school
25district will be incurred because this act creates a new crime or
26infraction, eliminates a crime or infraction, or changes the penalty
27for a crime or infraction, within the meaning of Section 17556 of
28the Government Code, or changes the definition of a crime within
29the meaning of Section 6 of Article XIII B of the California
30Constitution.
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