BILL NUMBER: AB 1086	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Dababneh

                        FEBRUARY 27, 2015

   An act to add Section 1371.34 to the Health and Safety Code, and
to add Section 10133.75 to the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 1086, as introduced, Dababneh. Assignment of reimbursement
rights.
   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 and makes a willful
violation of that act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
    Existing law requires, on and after January 1, 1994, every group
health care service plan, that provides hospital, medical, or
surgical expense benefits for plan members and their dependents to
authorize and permit assignment of the enrollee's or subscriber's
right to any reimbursement for health care services covered under the
plan contract to the State Department of Health Care Services when
health care services, excepting specified contracted services, are
provided to a Medi-Cal beneficiary.
   This bill would prohibit certain health care service plans and
disability insurers from prohibiting an enrollee, subscriber, or
insured from making an assignment of his or her reimbursement rights
for covered health care services to the physician and surgeon who
furnished those services. The bill would require a physician and
surgeon seeking payment from a health care service plan or disability
insurer under the provisions of the bill to provide the plan or
insurer with specified documentation and information, including an
itemized bill for service. This bill would require the physician and
surgeon to provide a written agreement authorizing the assignment of
the enrollee's, subscriber's, or insured's reimbursement rights, and
would specify the form and content of that agreement.
   Because a willful violation of the bill's requirements relative to
health care service plans 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 1371.34 is added to the Health and Safety Code,
to read:
   1371.34.  (a) A health care service plan that provides medical or
surgical expense benefits for plan members and their dependents shall
not prohibit an enrollee or subscriber from making an assignment of
the enrollee's or subscriber's right to any reimbursement for health
care services covered under the plan contract to the physician and
surgeon who furnished the health care services.
   (b) When seeking payment from a health care service plan pursuant
to subdivision (a), a physician and surgeon shall provide the plan
with the physician and surgeon's itemized bill for service, the name
and address of the person to be reimbursed, and the name and contract
number of the enrollee.
   (c) The written agreement authorizing assignment of the enrollee's
or subscriber's right to any reimbursement for health care services
covered under subdivision (a) shall do all of the following:
   (1) Be written in plain language.
   (2) Be made available by the physician and surgeon in the primary
languages of the two largest groups seen by the physician and surgeon
who either do not speak English or who are unable to effectively
communicate in English because it is not their native language, and
who comprise 5 percent or more of the patients served by the
physician.
   (3) Be printed in at least 12-point font. The agreement shall
disclose in boldface type or a font a minimum of two points larger
than the rest of the agreement, exclusive of the heading, all of the
following information:
   (A) "The enrollee or subscriber remains responsible for costs,
including any provider fees, copayments, and coinsurance exceeding
the amount of the benefit covered by the policy and paid by the
health plan."
   (B) "The enrollee or subscriber is entitled to a summary of
benefits and coverage from the health care service plan pursuant to
Section 300gg-15 of Title 42 of the United States Code to help in
better understanding benefit design, level of financial protection,
and costs related to out-of-network services."
   (C) "The enrollee or subscriber is entitled to information from
the health care service plan that explains how the health plan
determines the amount it pays for out-of-network services. Your
actual out-of-pocket costs may vary based on factors specific to your
health plan. Some plans base their reimbursement rates on a
percentage of "usual, customary, and reasonable" charges, which is
referred to as "UCR." Others use a formula based on the Medicare fee
schedule that is published by the United States Department of Health
and Human Services. To learn how your health plan determines
out-of-network reimbursement rates and covered services, call the
number listed on the back of your insurance card. Then, to estimate
your out-of-pocket costs, visit the following Internet Web site
http://fairhealthconsumer.org, which will, using the method that your
plan uses to calculate reimbursement, allow you to estimate your
out-of- pocket costs."
   (4) Be signed and dated by the enrollee or subscriber.
   (d) This section applies only to a preferred provider
organization, point of service plan, or any other plan contract that
provides for out-of-network coverage and services. This section does
not apply to a plan providing benefits pursuant to a specialized
health care service plan contract, as defined in subdivision (o) of
Section 1345.
  SEC. 2.  Section 10133.75 is added to the Insurance Code, to read:
   10133.75.  (a) On and after January 1, 2013, a disability insurer
shall pay individual insurance benefits contingent upon, or for
expenses incurred on account of, medical or surgical aid to the
physician and surgeon having provided the medical or surgical aid
where that physician and surgeon has qualified for reimbursement by
submitting the items and information specified in subdivision (b).
   (b) When seeking payment from a disability insurer pursuant to
subdivision (a), a person shall provide the insurer with the provider'
s itemized bill for service, the name and address of the person to be
reimbursed, and the name and policy number of the insured.
   (c) The written agreement authorizing assignment of the insured's
right to any reimbursement for health care services covered under
subdivision (a) shall do all of the following:
   (1) Be written in plain language.
   (2) Be made available by the physician and surgeon in the primary
languages of the two largest groups seen by the physician and surgeon
who either do not speak English or who are unable to effectively
communicate in English because it is not their native language, and
who comprise 5 percent or more of the patients served by the
physician and surgeon.
   (3) Be printed in at least 12-point font. The agreement shall
disclose in boldface type or a font a minimum of two points larger
than the rest of the agreement, exclusive of the heading, the
following information:
   (A) "The insured remains responsible for costs, including any
provider fees, copayments, and coinsurance exceeding the amount of
the benefit covered by the policy and paid by the insurer."
   (B) "The insured is entitled to a summary of benefits and coverage
from the insurer pursuant to Section 300gg-15 of Title 42 of the
United States Code to help in better understanding benefit design,
level of financial protection, and costs related to out-of-network
services."
   (C) "The insured is entitled to information from the insurer that
explains how the insurer determines the amount it pays for
out-of-network services. Your actual out-of-pocket costs may vary
based on factors specific to your health plan. Some plans base their
reimbursement rates on a percentage of "usual, customary, and
reasonable" charges, which is referred to as "UCR." Others use a
formula based on the Medicare fee schedule that is published by the
United States Department of Health and Human Services. To learn how
your health plan determines out of-network reimbursement rates and
covered services, call the number listed on the back of your
insurance card. Then, to estimate your out-of-pocket costs, visit the
following Internet Web site http://fairhealthconsumer.org, which
will, using the method that your plan uses to calculate
reimbursement, allow you to estimate your out-of-pocket costs."
   (4) Be signed and dated by the insured.
   (d) This section shall not apply to an insurer providing benefits
pursuant to a specialized health insurance policy, as defined in
subdivision (c) of Section 106.
  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.