BILL NUMBER: AB 533	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 23, 2015
	AMENDED IN ASSEMBLY  APRIL 15, 2015

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 amended, 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 or insured obtains
care from a contracting health facility, as defined, at which, or as
a result of which, the enrollee or insured receives covered services
provided by a noncontracting individual health professional, as
defined, the enrollee or insured is required to pay the
noncontracting individual health professional only the same cost
sharing required if the services were provided by a contracting
individual health professional. The bill would prohibit an enrollee
or insured from owing the noncontracting individual health
professional at the contracting health facility more than the
in-network cost sharing amount if the noncontracting individual
health professional receives reimbursement for services provided to
the enrollee or insured at a contracting health facility from the
plan or health insurer. The bill would require a noncontracting
individual health professional who collects more than the in-network
cost sharing amount from the enrollee or insured to refund any
overpayment to the enrollee or insured, as specified, and would
provide that interest on any amount overpaid by, and not refunded to,
the enrollee or insured shall accrue at 15% per annum, as specified.
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 contracting health facility at
which, or as a result of which, the enrollee receives services
provided by a noncontracting individual health professional, the
enrollee shall pay the noncontracting individual health professional
no more than the same cost sharing that the enrollee would have paid
for the same covered benefits received from a contracting individual
health professional. This amount shall be referred to as the
"in-network cost sharing."
   (2) At the time of payment by the plan to the noncontracting
individual health professional, the plan shall inform the
noncontracting individual health professional of the in-network cost
sharing owed by the enrollee. If a noncontracting individual health
professional receives reimbursement for services provided to the
enrollee at a contracting health facility from the plan, an enrollee
shall not owe the noncontracting individual health professional at
the contracting health facility more than the in-network cost
sharing.
   (3) Except as provided in subdivision (d), if the noncontracting
individual health professional collects more than the in-network cost
sharing from the enrollee, the noncontracting individual health
professional shall refund any overpayment to the enrollee within 30
working days of receiving notice from the plan of the in-network cost
sharing amount owed by the enrollee pursuant to paragraph (2). If
the noncontracting individual health professional does not refund
 an   any  overpayment within 30 working
days after being informed of the enrollee's in-network cost sharing,
interest shall accrue at the rate of 15 percent per annum beginning
with the first calendar day after the 30-working day period. A
noncontracting individual health professional shall automatically
include in his or her refund of the overpayment all interest that has
accrued pursuant to this section without requiring the enrollee to
submit a request for the interest amount.
   (4) If the noncontracting individual health professional has
advanced to collections any amount owed by the enrollee, the plan
shall not reimburse the noncontracting individual health professional
for services provided to the enrollee by the noncontracting
individual health professional at a contracting health facility. In
submitting a claim to the plan, the noncontracting individual health
professional at a contracting health facility shall affirm in writing
that he or she has not advanced to collections any payment owed by
the enrollee. A noncontracting individual health professional shall
not attempt to collect more than the in-network cost sharing from the
enrollee after receiving payment from the plan. Once the
noncontracting individual health professional receives payment from
the plan, the noncontracting individual health professional may
advance to collections any in-network cost sharing owed by the
enrollee if the enrollee fails to pay the in-network cost sharing
after the plan has informed the noncontracting individual health
professional of the amount owed by the enrollee pursuant to paragraph
(2).
   (b) (1) Any cost sharing paid by the enrollee for the services
provided by a noncontracting individual health professional at the
contracting health facility shall count toward the limit on annual
out-of-pocket expenses established under Section 1367.006.
   (2) Cost sharing arising from services received by a
noncontracting individual health professional at a contracting health
facility shall be counted toward any deductible in the same manner
as cost sharing would be attributed to a contracting individual
health professional.
   (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) "Health facility" means a health facility provider who is
licensed by this state to deliver or furnish health care services. A
health 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  health  facility for purposes of this section.
   (3)  "Individual Health Professional"  
"Individual health professional"  means a physician or surgeon
or other professional who is licensed by this state to deliver or
furnish health care services.
   (d) An enrollee may voluntarily consent to the use of a
noncontracting individual health professional. 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 noncontracting individual health
professional and the enrollee consents in writing to both the use of
a noncontracting individual health professional and  payment of
 the estimated additional cost for the services to be provided
by the noncontracting individual health professional. The consent
shall inform the enrollee that the cost of the services of the
noncontracting individual health professional will not accrue to the
limit on annual out-of-pocket expenses or the enrollee's deductible,
if any.
   (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.
   (f) This section shall not be construed to exempt a plan from the
requirements under Section 1373.96 or Section 1371.4, nor abrogate
the holding in Prospect Medical Group v. Northridge Emergency Medical
Group et al., (2009) 45 Cal.4th 497, that an emergency room
physician is prohibited from billing an enrollee of a health care
service plan directly for sums that the health care service plan has
failed to pay for the enrollee's emergency room treatment.
  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 contracting health facility at which, or as a
result of which, the insured receives services provided by a
noncontracting individual health professional, the insured shall pay
the noncontracting individual health professional no more than the
same cost sharing that the insured would have paid for the same
covered benefits received from a contracting individual health
professional. This amount shall be referred to as the "in-network
cost sharing."
   (2) At the time of payment by the health insurer to the
noncontracting individual health professional, the health insurer
shall inform the noncontracting individual health professional of the
in-network cost sharing owed by the insured. If a noncontracting
individual health professional receives reimbursement for services
provided to the insured at a contracting health facility from the
health insurer, an insured shall not owe the noncontracting
individual health professional at the contracting health facility
more than the in-network cost sharing.
   (3) Except as provided in subdivision (d), if the noncontracting
individual health professional collects more than the in-network cost
sharing from the insured, the noncontracting individual health
professional shall refund any overpayment to the insured within 30
working days of receiving notice from the health insurer of the
in-network cost sharing amount owed by the insured pursuant to
paragraph (2). If the noncontracting individual health professional
does not refund  an   any  overpayment
within 30 working days after being informed of the insured's
in-network cost sharing, interest shall accrue at the rate of 15
percent per annum beginning with the first calendar day after the
30-working day period. A noncontracting individual health
professional shall automatically include in his or her refund of the
overpayment all interest that has accrued pursuant to this section
without requiring the insured to submit a request for the interest
amount.
   (4) If the noncontracting individual health professional has
advanced to collections any amount owed by the insured, the health
insurer shall not reimburse the noncontracting individual health
professional for services provided to the insured by the
noncontracting individual health professional at a contracting health
facility. In submitting a claim to the health insurer, the
noncontracting individual health professional at a contracting health
facility shall affirm in writing that he or she has not advanced to
collections any payment owed by the insured. A noncontracting
individual health professional shall not attempt to collect more than
the in-network cost sharing from the insured after receiving payment
from the health insurer. Once the noncontracting individual health
professional receives payment from the health insurer, the
noncontracting individual health professional may advance to
collections any in-network cost sharing owed by the insured if the
insured fails to pay the in-network cost sharing after the health
insurer has informed the noncontracting individual health
professional of the amount owed by the insured pursuant to paragraph
(2).
   (5) 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 noncontracting individual health professional at the
contracting health facility shall count toward the limit on annual
out-of-pocket expenses established under Section 10112.28.
   (2) Cost sharing arising from services received by a
noncontracting individual health professional at a contracting health
facility shall be counted toward any deductible in the same manner
as cost sharing would be attributed to a contracting individual
health professional.
   (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) "Health facility" means a health facility provider who is
licensed by this state to deliver or furnish health care services. A
 health  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 commissioner may by regulation
define as a  health  facility for purposes of this section.
   (3) "Individual health professional" means a physician or surgeon
or other professional who is licensed by this state to deliver or
furnish health care services.
   (d) An insured may voluntarily consent to the use of a
noncontracting individual health professional. 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 noncontracting individual health
professional and the insured consents in writing to both the use of a
noncontracting individual health professional and  payment of
 the estimated additional cost for the services to be provided
by the noncontracting individual health professional. The consent
shall inform the insured that the cost of the services of the
noncontracting individual health professional will not accrue to the
limit on annual out-of-pocket expenses or the insured's deductible,
if any.
   (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.
   (f) This section shall not be construed to exempt a health insurer
from the requirements under Section 10112.7 or Section 10133.56.
  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.