BILL NUMBER: AB 533	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Bonta

                        FEBRUARY 23, 2015

   An act to add Section 1371.9 to the Health and Safety Code, and to
add Section 10112.8 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   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 1.  Section 1371.9 is added to the Health and Safety Code,
to read:
   1371.9.  (a) (1) A health care service plan contract issued,
amended, or renewed on or after January 1, 2016, shall provide that
if an enrollee obtains care from a participating facility at which,
or as a result of which, the enrollee receives services provided by a
nonparticipating provider, the enrollee shall pay the
nonparticipating provider no more than the same cost sharing that the
enrollee would have paid for the same covered benefits received from
a participating provider.
   (2) Except as provided in subdivision (d), the plan shall not
reimburse a nonparticipating provider for services provided to the
enrollee if the nonparticipating provider obtains, or seeks to
obtain, more than the in-network cost sharing from the enrollee.
   (b) (1) Any cost sharing paid by the enrollee for the services
provided by a nonparticipating provider at the participating facility
shall count toward the limit on annual out-of-pocket expenses
established under Section 1367.006.
   (2) Cost sharing shall be counted toward any deductible in the
same manner as cost sharing would be attributed to a participating
provider.
   (c) For purposes of this section, the following definitions shall
apply:
   (1) "Cost sharing" includes any copayment, coinsurance, or
deductible, or any other form of cost sharing paid by the enrollee
other than premium or share of premium.
   (2) "Nonparticipating provider" means a provider who is not
contracted with the enrollee's health care service plan to provide
services under the enrollee's plan contract.
   (3) "Participating facility" means a health facility provider who
is contracted with the enrollee's health care service plan to provide
services under the enrollee's plan contract. A facility shall
include the following providers:
   (A) Licensed hospital.
   (B) Skilled nursing facility.
   (C) Ambulatory surgery.
   (D) Laboratory.
   (E) Radiology or imaging.
   (F) Facilities providing mental health or substance abuse
treatment.
   (G) Any other provider as the department may by regulation define
as a facility for purposes of this section.
   (4) "Provider" means a health facility or any person who is
licensed by the state to deliver or furnish health care services.
   (d) An enrollee may voluntarily consent to the use of a
nonparticipating provider. For purposes of this section, consent
shall be voluntary if at least 24 hours in advance of the receipt of
services, the enrollee is provided a written estimate of the cost of
care by the nonparticipating provider and the enrollee consents in
writing to both the use of a nonparticipating provider and the
estimated additional cost for the services to be provided by the
nonparticipating provider. The consent shall inform the enrollee that
the cost of the services of the nonparticipating provider will not
accrue to the limit on annual out-of-pocket expenses.
   (e) This section shall not be construed to require a plan to cover
services or provide benefits that are not otherwise covered under
the terms and conditions of the plan contract.
  SEC. 2.  Section 10112.8 is added to the Insurance Code, to read:
   10112.8.  (a) (1) A health insurance policy issued, amended, or
renewed on or after January 1, 2016, shall provide that if an insured
obtains care from a participating facility at which, or as a result
of which, the insured receives services provided by a
nonparticipating provider, the insured shall pay the nonparticipating
provider no more than the same cost sharing that the insured would
have paid for the same covered benefits received from a participating
provider.
   (2) Except as provided in subdivision (d), the insurer shall not
reimburse a nonparticipating provider for services provided to the
insured if the nonparticipating provider obtains, or seeks to obtain,
more than the in-network cost sharing from the insured.
   (3) This section shall only apply to 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.
   (b) (1) Any cost sharing paid by the insured for the services
provided by a nonparticipating provider at the participating facility
shall count toward the limit on annual out-of-pocket expenses
established under Section 10112.28.
   (2) Cost sharing shall be counted toward any deductible in the
same manner as cost sharing would be attributed to a participating
provider.
   (c) For purposes of this section, the following definitions shall
apply:
   (1) "Cost sharing" includes any copayment, coinsurance, or
deductible, or any other form of cost sharing paid by the insured
other than premium or share of premium.
   (2) "Nonparticipating provider" means a provider who is not
contracted with the insured's health insurer to provide services
under the insured's policy.
   (3) "Participating facility" means a health facility provider who
is contracted with the insured's health insurer to provide services
under the insured's policy. A facility shall include the following
providers:
   (A) Licensed hospital.
   (B) Skilled nursing facility.
   (C) Ambulatory surgery.
   (D) Laboratory.
   (E) Radiology or imaging.
   (F) Facilities providing mental health or substance abuse
treatment.
   (G) Any other provider as the department may by regulation define
as a facility for purposes of this section.
   (4) "Provider" means a health facility or any person who is
licensed by the state to deliver or furnish health care services.
   (d) An insured may voluntarily consent to the use of a
nonparticipating provider. For purposes of this section, consent
shall be voluntary if at least 24 hours in advance of the receipt of
services, the insured is provided a written estimate of the cost of
care by the nonparticipating provider and the insured consents in
writing to both the use of a nonparticipating provider and the
estimated additional cost for the services to be provided by the
nonparticipating provider. The consent shall inform the insured that
the cost of the services of the nonparticipating provider will not
accrue to the limit on annual out-of-pocket expenses.
   (e) This section shall not be construed to require an insurer to
cover services or provide benefits that are not otherwise covered
under the terms and conditions of the policy.
  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.