BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 533
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|AUTHOR: |Bonta |
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|VERSION: |September 4, 2015 |
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|HEARING DATE: |September 9, | | |
| |2015 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Health care coverage: out-of-network coverage.
PURSUANT TO SENATE RULE 29.10
SUMMARY : This bill requires the Department of Managed Health Care
(DMHC) and the California Department of Insurance (CDI) to
establish a binding independent dispute resolution process for
claims for non-emergency covered services provided at contracted
health facilities by a non-contracting health care professional.
This bill limits enrollee and insured cost sharing for these
covered services to no more than the cost sharing required had
the services been provided by a contracting health professional.
Existing law:
1)Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) under the Knox-Keene Act and for
health insurers by California Department of Insurance (CDI)
under the Insurance Code.
2)Requires contracts between providers and health plans to be in
writing and prohibits, except for applicable copayments and
deductibles, a provider from invoicing or balance billing a
plan's enrollee for the difference between the provider's
billed charges and the reimbursement paid by the plan or the
plan's capitated provider for any covered benefit.
3)Prohibits a provider, in the event that a contract has not
been reduced to writing, or does not contain the prohibition
above, from collecting or attempting to collect from the
subscriber or enrollee sums owed by the plan. Prohibits a
contracting provider, agent, trustee or assignee from taking
action at law against a subscriber or enrollee to collect sums
AB 533 (Bonta) Page 2 of ?
owed by the plan.
4)Allows a non-contracted provider to dispute the
appropriateness of a health plan's computation of the
reasonable and customary value and requires the health plan to
respond to the dispute through the plan's mandated provider
dispute resolution process.
5)Prohibits a hospital which contracts with an insurer,
nonprofit hospital service plan, or health plan from
determining or conditioning medical staff membership or
clinical privileges upon the basis of a physician and
surgeon's or podiatrist's participation or nonparticipation in
a contract with that insurer, hospital service plan or health
plan.
This bill:
1)Requires DMHC and CDI to each establish an independent dispute
resolution process (IDRP) for the purpose of processing and
resolving a claim dispute between a health plan or insurer and
a non-contracting individual health professional for
non-emergency services provided at a contracting health
facility. Makes the determination obtained through IDRP
binding on both parties.
2)Requires both parties to participate in the IDRP if initiated
by either party.
3)Permits DMHC and CDI to contract with one or more independent
organizations for the IDRP and requires the departments to
establish additional requirements, including
conflict-of-interest standards.
4)Requires, unless otherwise provided in this bill or otherwise
agreed by the non-contracting health professional and the plan
or insurer, the plan or insurer to base reimbursement for
covered services on the amount the individual health
professional would have been reimbursed by Medicare for the
same or similar services in the geographic area in which the
services were rendered.
5)Requires, if non-emergency services are provided by a
noncontracting individual health professional to an enrollee
who has voluntarily chosen to use his or her out-of-network
benefit for services covered by a preferred provider
AB 533 (Bonta) Page 3 of ?
organization or a point of service plan, unless otherwise
agreed to by the plan and the health professional, the amount
paid shall be the amount set forth in the enrollee's evidence
of coverage.
6)Limits enrollee or insured cost sharing under a health plan
contract or health insurance policy issued, amended, or
renewed on or after July 1, 2016, when an enrollee or insured
obtains care from a contracting health facility at which, or
as a result of which, the enrollee or insured receives
services provided by a non-contracting health professional, to
the same cost sharing that the enrollee or insured would pay
for the same covered benefits received from a contracting
health professional.
7)Requires the plan or insurer to inform the non-contracting
health professional of the in-network cost sharing owed by the
enrollee or insured. Requires the non-contracting health
professional to refund any overpayment within 30 working days
of receiving the in-network cost sharing amount. Requires, if
overpayment is not refunded within 30 working days, interest
to accrue at the rate of 15% per annum beginning with the
first calendar day after the 30-working day period and the
health professional to automatically include the interest with
the refund.
8)Prohibits payment of a non-contracting health professional if
any amount owed by the enrollee or insured has advanced to
collections. Requires a non-contracting health professional
to affirm in writing that he or she has not advanced to
collections any payment owed by the enrollee or insured when
submitting a claim to the plan or insurer. Permits any
in-network cost sharing to advance to collections after
payment by the plan or insurer if the enrollee or insured
fails to pay the amount owed.
9)Requires enrollee or insured cost sharing arising from
services received by a non-contracting health professional at
a contracting facility to be counted toward any limit on
annual out-of-pocket expenses and any deductible in the same
manner as cost sharing would be attributed to a contracting
health professional.
10)Defines "contracted health facility" as a health facility
that is contracted to provide services under the enrollee's
AB 533 (Bonta) Page 4 of ?
health plan contract or insured's health insurance policy and
includes: hospital, skilled nursing facility, ambulatory
services or other outpatient settings, as specified,
laboratory, radiology or imaging, facilities providing mental
health or substance abuse treatment, and any other provider as
the DMHC or CDI may by regulation define as a health facility
for purpose of this bill.
11)Defines "individual health professional" as a California
licensed physician or surgeon.
12)Permits an enrollee or insured to voluntarily consent to the
use of a non-contracting individual health professional if, in
at least three business days in advance of the receipt of
services, the enrollee or insured is provided a written
estimate of the cost of care and consents in writing to both
the use of a non-contracting individual health professional
and payment of the estimated additional cost.
13)Defines "emergency services and care" as medical screening,
examination, and evaluation by a physician and surgeon, or, to
the extent permitted by applicable law, by other appropriate
licensed persons under the supervision of a physician and
surgeon, to determine if an emergency medical condition,
active labor exists, or psychiatric emergency medical care,
and, if it does, the care, treatment, and surgery, if within
the scope of that person's license, necessary to relieve or
eliminate the emergency medical condition, within the
capability of the facility.
FISCAL
EFFECT : According to the Senate Appropriations Committee, as
amended August 18, 2015:
One-time costs of about $500,000 for the development of
regulations and review of plan filings by the Department of
Managed Health Care (Managed Care Fund).
Annual costs of $1.5 million to $3 million per year for the
independent dispute resolution process that the Department of
Managed Health Care convenes to settle a dispute between a
provider and a health plan (Managed Care Fund).
One-time costs of about $550,000 for the development of
regulations and review of plan filings by the Department of
AB 533 (Bonta) Page 5 of ?
Insurance (Insurance Fund).
Annual costs of $900,000 per year for the independent dispute
resolution process that the Department of Insurance convenes
to settle a dispute between a provider and a health plan
(Insurance Fund).
PRIOR
VOTES :
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|Assembly Floor: |74 - 1 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |17 - 0 |
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COMMENTS :
1)Author's statement. According to the author, this bill will
protect patients who do the right thing by seeking care in an
in-network facility, only to later receive a surprise bill
from an out-of-network provider that had been called in to
provide service. Surprise bills cost consumers substantial
sums of money, placing an undeserved and unreasonable
financial burden upon them. Consumers should not be placed in
the middle of billing conflicts and disputes between
out-of-network providers and plans or insurers, particularly
when they sought in-network care but were seen by an
out-of-network provider through no fault of their own. While
California has been at the forefront of the federal Patient
Protection and Affordable Care Act implementation, the state
needs to catch up to other states that have taken the lead in
fully protecting consumers from surprise bills. It is the
state's responsibility to ensure full consumer protection for
all of our patients, and this bill is a critical measure to
ensure patients are safeguarded from hidden costs unfairly
imposed upon them when they have followed the rules.
2)Out-of-network services and surprise bills. A recent survey
commissioned by the Consumer Reports National Research Center
found that nearly one third of privately insured Americans
received a surprise medical bill where their health plan paid
less than expected in the past two years. Among the 2,200
AB 533 (Bonta) Page 6 of ?
adult U.S. respondents, nearly one out of four got a bill from
a doctor they did not expect to get a bill from. Survey
findings also suggest that consumers overall seem largely
confused when it comes to their rights to fight surprise
bills. Based on the California respondents to this survey,
one in four privately insured Californians faced surprise
medical bills. One quarter of Californians who had hospital
visits or surgery in the past two years were charged an
out-of-network rate when they thought the provider was
in-network. Sixty-three percent assume doctors at an
in-network hospital are also in-network.
3)Unfair claims practices. AB 1455 (Scott, Chapter 1827,
Statutes of 2000) prohibits unfair claims practices, and the
resulting regulations detailed requirements health plans must
meet in processing and paying claims for both contracting and
non-contracting providers. The AB 1455 regulations define
reimbursement of a claim for non-contracting providers as the
"reasonable and customary value," based on statistically
credible information that is updated at least annually, and
that takes into consideration the following specified
criteria: a) the provider's training, qualifications, and
length of time in practice; b) the nature of the services
provided; c) the fees usually charged by the provider; d)
prevailing provider rates charged in the general geographic
area in which the services were rendered; e) other aspects of
the economics of the medical provider's practice that are
relevant; and, f) any unusual circumstances in the case.
These regulations codified the factors for determining
non-contracted provider reimbursement as outlined in Gould v.
Workers' Compensation Appeals Board, City of Los Angeles,
(1992) 4 Cal.App.4th 1059, 1071. Consequently, the AB 1455
regulations are often referred to as requiring payments for
non-contracting providers according to the "Gould criteria."
More recently in Children's Hospital Central California v.
Blue Cross of California et.al, (2014) 226 Cal.App4th 1260,
172. the appellate court determined that the Gould criteria
includes more than the charges billed by the provider.
Charges are just one data point and payments and rates
accepted by other payors could also be considered. Because of
this decision, the criteria proposed in this bill are slightly
modified from the Gould criteria in that they include
"prevailing provider rates charged or paid in the general
geographic area in which the services were rendered."
AB 533 (Bonta) Page 7 of ?
4)Medicare Data. The Centers for Medicare & Medicaid Services
(CMS) Physician Fee Schedule Search Tool provides Medicare
payment information on more than 10,000 services, including
pricing, the associated Relative Value Units (RVUs), and
various payment policies. The Medicare Physician Fee Schedule
(MPFS) is the primary method of payment for enrolled health
care professionals. Specifically, Medicare uses this fee
schedule when paying the following services: Professional
services of physicians and other enrolled health care
professionals in private practice; Services covered incident
to physicians' services (other than certain drugs covered as
incident to services); Diagnostic tests (other than clinical
laboratory tests); and Radiology services. For services paid
under the MPFS, there is a 5% reduction in the
Medicare-approved amounts for nonparticipants, and there is a
limit on what the health care professional/supplier may charge
the beneficiary. This limiting charge equals 115% of the fee
schedule amount and is the maximum the nonparticipant may
charge a beneficiary.
5)IDRP. Both CDI and DMHC have IDRPs. CDI advises providers to
first attempt to resolve disputes with the insurance company.
According to CDI the insurer is required to resolve each
provider dispute consistent with applicable law and issue a
written determination within 45 working days after the date of
receipt of the provider dispute. CDI requires the following
information to be included with a disputed claim: 1) the
patient's Assignment of Benefits, if applicable, 2) claim
forms submitted to the insurance company, 3) all
correspondence between the provider and the insurance company
(including all related Explanation of Benefits (EOBs) and
Dispute Resolution Process determination letter), 4) the
patient's insurance identification card - both sides, and 5)
the provider's contract with the insurance company, if any.
According to the DMHC, participation in IDRP is voluntary and
non-binding. Parties are encouraged to comply with the
decision issued by the IDRP External Reviewer. Non-contracted
providers who deliver EMTALA-required emergency services
("Providers") working with health plans or capitated providers
("Payers") are eligible to submit a IDRP concerning the
"reasonable and customary" value of services rendered. A
provider may request review through the IDRP for an individual
claim or for multiple claims (up to a total of 50
substantially similar claims.) Eligible claim disputes are
AB 533 (Bonta) Page 8 of ?
those disputes that are subject to DMHC jurisdiction and meet
each of the following four criteria: 1) the disputed claim is
limited to emergency services rendered by non-contracted
physicians or hospitals, 2) the services were rendered within
the last four years, 3) the dispute is limited to disagreement
concerning the reasonable and customary value of the services
rendered, and 4) the Provider has completed the Payer's
dispute resolution process.
6)Prior legislation. AB 1579 (Campos, 2012) would have required
issuers to pay a non-contracting dental provider directly for
covered services rendered to an enrollee or insured in certain
circumstances. AB 1579 was set for hearing in the Senate
Health Committee, but not heard per the request of the author.
SB 1373 (Lieu, 2012), would have required, when an enrollee or
insured seeks care from a non-contracting provider, the
provider to provide a specified written notice to the enrollee
or insured informing the enrollee or insured that the provider
is not in the enrollee's or insured's plan or provider
network, as specified. Would have prohibited a health
facility or a provider group from holding itself out as being
within a plan network unless all of the individual providers
providing services at the facility or with the provider group
are within the plan network. This bill failed passage by the
Senate Health Committee.
SB 981 (Perata, 2008), would have prohibited non-contracting
hospital ER physicians from directly billing enrollees of
health plans licensed by DMHC under the Knox-Keene Health Care
Service Plan Act of 1975, other than allowable copayments and
deductibles, and would have established statutory standards
and requirements for claims payment and dispute resolution
related to non-contracting ER physician claims, including an
IDRP. SB 981 was vetoed by Governor Schwarzenegger. The veto
message is below:
This bill does not solve the problem facing California
patients and only serves to highlight one of the many
reasons I introduced my comprehensive health care
reform proposal. Californians are paying a hidden tax
on their health care which subsidizes care for the
uninsured and allows providers to shift costs when
they are not fully reimbursed by their payers. The
insured population bears the brunt of this hidden tax
AB 533 (Bonta) Page 9 of ?
and the larger it gets, fewer people are able to
afford coverage.
This bill, in essence, asks for California to embrace
this cost-shift, reward non-contracting physicians by
assuring their continued financial slice of the pie,
and allow the status quo to continue. I cannot agree
to a measure that is a piecemeal approach to our
broken health care system.
Our health care system relies on physicians, hospitals
and health plans to work together. The patient that
pays health insurance premiums should not be part of a
payment dispute between these sophisticated market
players. It is unfortunate that this bill takes sides
in the dispute within the health care industry instead
of taking the side of patients.
Until the Legislature can send me legislation that
removes that patient from all disputes involving these
parties, I direct my Department of Managed Health Care
to aggressively continue in its efforts to identify
unfair payment practices and keep patients from being
caught in the middle.
AB 1203 (Salas, Chapter 603, Statutes of 2008), established
uniform requirements governing communications between health
plans and non-contracting hospitals related to
post-stabilization care following an emergency, and prohibits
a non-contracting hospital from billing a patient who is a
health plan enrollee for post-stabilization services, except
as specified.
AB 2220 (Jones, 2008), would have allowed parties to a
contract negotiation between ER physicians and health care
service plans or their contracting risk bearing organization
to, on a one-time basis per contract negotiation, invoke a
mandatory mediation process to assist in resolving any
remaining issues in the contract negotiations, as specified.
AB 2220 was vetoed by Governor Schwarzenegger. The veto
message is below:
I applaud the author for seeking to address one of the
most important consumer issues facing patients today.
AB 533 (Bonta) Page 10 of ?
This bill attempts to change the market dynamic in a
way that encourages contracts between health plans and
providers. It is a good starting point. Unfortunately,
it does not contain the comprehensive solution that
patients need and deserve when it comes to addressing
the disgraceful practice of balance billing.
I believe the author and Administration can work
together to solve this issue next year. I look forward
to our combined efforts that will take the patient out
of the middle of these payment disputes.
AB 2839 (Huffman, 2008), would have prohibited a health plan
or health insurer from requiring providers to execute unfair
and unreasonable contracts, as specified, as a condition of
entering into negotiations with the health plan or insurer.
AB 2839 was held on the Assembly Appropriations Committee
Suspense file.
SB 389 (Yee, 2008), would have prohibited a hospital-based
physician, as defined, from seeking payment from individual
enrollees for services rendered and would have required such
physicians to seek reimbursement solely from the enrollee's
health care service plan or the contracting risk-bearing
organization. Also the bill would have required DMHC and CDI,
on or before March 1, 2008, to implement an independent
provider dispute resolution system, in consultation with
representatives of health plans or insurers, providers, and
consumer representatives. SB 389 died in the Senate without a
committee hearing.
SB 697 (Yee, Chapter 606, Statutes of 2008), prohibits a
health care service provider from seeking reimbursement for
services furnished to a person enrolled in the Healthy
Families Program or the Access for Infants and Mothers Program
from other than the participating health plan covering that
person.
AB 1X 1 (Nunez, 2008), would have enacted the Health Care
Security and Cost Reduction Act, a comprehensive health reform
proposal. Among other provisions related to health insurance
markets and hospital financing, AB 1X 1 would have prohibited
a non-contracting hospital from billing any patient, who has
coverage for emergency and poststabilization health care
services, for those services, as defined, except for
AB 533 (Bonta) Page 11 of ?
applicable copayments and cost sharing. AB 1X 1 died in the
Senate Health Committee.
SB 417 (Ortiz, 2005), would have prohibited a hospital-based
physician, as defined, from engaging in a pattern of billing a
patient for covered services in excess of applicable
co-payments, deductibles or coinsurance, unless specified
conditions are met, and required providers to provide specific
notice requirements when they send a bill or statement to a
patient. SB 417 died in Assembly Health Committee.
SB 364 (Perata, 2005), would have allowed an emergency
physician who has a contract with a health plan, but does not
have a contract with a medical group or other entity that has
been assigned responsibility for paying claims by the health
plan, to submit a claim to the plan, and requires the plan to
pay the claim to the terms of the contract. SB 364 died on
Assembly floor.
AB 1321 (Yee, 2005), would have prohibited hospital-based
anesthesiologists, radiologists, pathologists, and emergency
room physicians, or a group of such physicians, from seeking
payment for services, other than allowable copayments and
deductibles; from individual enrollees of a health plan. AB
1321 was held on the Assembly Appropriations Suspense File.
SB 367 (Speier, Chapter 723, Statutes of 2005), enacted the
Patient and Provider Protection Act in the Insurance Code and
revises the way complaints from health care providers about
health insurers are handled by CDI.
AB 755 (Chan, 2005), would have required provider contracts
entered into with contracting agents, as defined, to include
specific provisions and would have prohibited contracting
agents from selling, leasing, assigning, transferring, or
conveying a list of contracted providers and their discounted
rates to any entity that is not a payer. AB 757 died on the
Assembly Appropriations Suspense file.
AB 1686 (Pacheco, 2004), would have encouraged county medical
societies to establish a process to resolve billing disputes
between a contracting provider group and a non-contracting
provider group. AB 1686 died in the Assembly.
AB 2389 (Koretz, 2003), would have required a health plan or
AB 533 (Bonta) Page 12 of ?
health insurer that owns a preferred provider organization to
pay non-contracting physicians a reasonable and customary fee
for hospital-based anesthesiology, radiology, or pathology
services provided to the plan's enrollees. Would have
prohibited those physicians from balance billing an enrollee
for any charge that exceeds the reasonable and customary fee.
AB 2389 died in the Senate.
AB 2907 (Cohn, Chapter 925, Statutes of 2002), established the
Health Care Providers Bill of Rights and prohibits certain
provisions in contracts between a health plan or a health
insurer and a health care provider.
AB 1455 (Scott, 2000), bars health plans from engaging in
unfair payment patterns in the reimbursement of providers. AB
1455 also includes a number of other provisions regarding
payment practices of health plans, including requiring health
plans to make their dispute resolution process available to
non-contracting providers.
7)Support. According to Health Access California, even the most
careful consumers can end up being treated by an
out-of-network provider and then receiving a surprise bill for
the difference between the provider's charge and what the
health plan is willing to pay. The difference can be hundreds
and sometimes thousands of dollars. A consumer who goes to an
in-network imaging center, only to discover that a
non-contracting radiologist the consumer never met and did not
select was responsible for reviewing the consumer's imaging or
a consumer who selects an in-network surgeon for surgery at an
in-network hospital or surgery center but discovers that the
anesthesiologist is a non-contracting provider only when they
get the bill from the anesthesiologist. This bill holds
consumers harmless for surprise bills from out-of-network
charges that were outside of their control. Consumers should
not get stuck in the middle of business disputes between
health plans and providers. The California Association of
Health Underwriters writes that agents and brokers act as
advocates for policyholders when disputes arise and supports a
strict prohibition on balance billing. CalPERS believes this
bill provides an important consumer protection by preventing
CalPERS members and other insured Californians that use
in-network health facilities from being balance billed by
out-of-network health professionals.
AB 533 (Bonta) Page 13 of ?
8)Opposition. The California Orthopaedic Association writes
that the issue of patients who unknowingly receive care which
will not be paid for by their health plan needs to be
addressed on the front end. Insurers and plans must maintain
adequate networks of providers, and pay rates that are
adequate to sustain those networks. This bill will penalize
those providers who cannot accept inadequate rates and will
provide no incentive for plans to negotiate fair contracts.
The California Radiological Society and California Society of
Pathologists indicate that they would prefer to contract with
plans and insurers but the absence of contracts may be due to
plans that provide contract terms on a "take it or leave it"
attitude. They do not oppose protections on patient cost
exposure but would suggest that plans be required to create a
process to treat this similarly to an out-of-network referral
for medically necessary services. The California Chapter of
the American College of Emergency Physicians writes even if
emergency physicians are exempt, they remain opposed because
it is bad policy to adopt a framework that hands all the power
to insurers and leaves providers at their mercy for payment.
The California Medical Association (CMA) writes that this bill
creates government rate setting for physician services in
commercial plans, reduces access to care as providers will be
less willing to accept out-of-network patients, the payment
standard established in AB 533 is significantly below existing
contract rates and will result in health plans dropping
contracts or reducing contract rates, the current structure of
the bill will force hundreds of thousands of claims to go
through the IDRP because of a legislatively-imposed, unfair
payment standard, the low rate set by the bill takes effect
immediately, but the IDRP will take months or years to be
established by the departments, resulting in physicians being
underpaid and without any recourse, fundamentally changes PPO
product by requiring three business days' advanced consent
before accessing out-of-network benefits, and there are
numerous substantive drafting errors in the bill which remain
unaddressed and will disrupt implementation.
9)Policy Comment. The main objective of this bill as
articulated in the author's statement is to protect consumers
from being placed in the middle of payment disputes between
health plans and providers. Sections three and four, as
passed by the Assembly, set up explicit protections for
patients from cost sharing that is higher than what is
expected. The remainder of this bill, sets up payment rates
AB 533 (Bonta) Page 14 of ?
and appeals processes to address payment issues between plans
and non-contracted providers for services provided to
enrollees. The details of these provisions have major
significance for both plans and providers. Finding the right
balance of a fair payment that does not create a disincentive
for providers to contract is the challenge. It is difficult
to know what impact there will be on provider payments if
balance billing is banned as proposed in this bill. A 2014
study on California's balance billing ban for California
emergency providers concluded that payment rates by
subcontracted risk-bearing organizations for non-contracted
emergency department professional services declined
significantly following the ban, whereas payment rates by
health plans remained relatively stable. Based on this study,
it is unclear if the ban will have an impact on provider rates
paid by health plans, or if as in the case of emergency room
physicians, rates will be significantly reduced from
risk-bearing organizations.
SUPPORT AND OPPOSITION :
Support: Health Access California (sponsor)
AARP
America's Health Insurance Plans
American Cancer Society Cancer Action Network
American Federation of State, County and Municipal
Employees
Anthem Blue Cross
Association of California Life and Health Insurance
Companies
California Association of Health Plans
California Association of Health Underwriters
California Association of Physician Groups
California Black Health Network
California Labor Federation
California Pan-Ethnic Health Network
California Primary Care Association
California Public Employees Retirement System Board of
Administration
California School Employees Association
California State Council of the Service Employees
International Union
California Teachers Association
CALPIRG
Children Now
AB 533 (Bonta) Page 15 of ?
Children's Defense Fund California
City of Oakland
Cigna
Community Clinic Association of Los Angeles County
Consumers Union
International Alliance of Theatrical Stage Employees
Local 80
Leukemia & Lymphoma Society
LIUNA Local 777
LIUNA Local 792
NAMI California
National Health Law Program
National Multiple Sclerosis Society - California
Action Network
The Children's Partnership
Western Center on Law and Poverty
Oppose: California Chapter of the American College of
Cardiology
California Chapter of the American College of
Emergency Physicians
California Medical Association
California Orthopaedic Association
California Radiological Society
California Society of Anesthesiologists
California Society of Pathologists
California Society of Plastic Surgeons
Osteopathic Physicians and Surgeons of California
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