BILL NUMBER: AB 1086	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 23, 2015

INTRODUCED BY   Assembly Member Dababneh
    (   Coauthor:   Senator   Pan
  ) 

                        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 amended, 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.   require certain health
  care service plans, on and after January 1, 2016, to
authorize and permit an enrollee or subscriber to assign the enrollee
or subscriber's right to reimbursement for health care services
covered under the plan contract by a noncontracting physician and
surgeon who furnished the services, as specified. The bill would
require certain disability insurers to pay group insurance benefits
to a physician and surgeon rendering health care services to an
insured upon obtaining written consent of the insured. The bill would
require a noncontracting physician and surgeon who renders services
to an enrollee or an insured to give the enrollee or the insured a
written estimate of the cost of care and a notice regarding, among
other things, the estimated cost of care and the enrollee's or
subscriber's, and the plan's or the insurer's responsibility for
payment of the cost of care, as specified. The bill would prohibit a
noncontracting physician and surgeon who accepts an assignment of
benefits from collecting more than the   estimated cost of
care from the enrollee or insured. The bill would prohibit a
noncontracting physician and surgeon from accepting an assignment of
benefits from a patient with whom the physician and surgeon or an
employee of the physician and surgeon communicates in a language
other than English or one of specified languages, unless the notice
described above is given in that language. 
   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. 
    1371.34.    (a) On or after January 1, 2016, a
health care service plan that provides out-of-network services as a
covered benefit for plan members and their dependents shall 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 a noncontracting physician and surgeon who furnishes the
health care services. This section shall not apply to emergency
services covered under Section 1371.4, poststabilization services as
defined in Section 1371.4, or urgent care as defined in paragraph (2)
of subdivision (h) of Section 1367.01. 
   (b) When seeking payment from a health care service plan pursuant
to subdivision (a), a  noncontracting  physician and surgeon
shall provide the plan with the  noncontracting  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.  The noncontracting physician and surgeon shall also
retain on file, and provide upon request to the health care service
plan, documentation showing the notice required in paragraph (2) of
subdivision (c) was provided in a timely manner, as required by
paragraph (1) of subdivision (c).  
   (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.  
   (c) (1) A noncontracting physician and surgeon accepting an
assignment of benefits shall give the enrollee the notice described
in paragraph (2) and obtain a signature from the enrollee. The notice
shall be in 12-point type, on a single page, without any additional
information other than that specified in the statutory notice. 

   (A) The notice shall be provided to the enrollee at least 24 hours
prior to providing care.  
   (B) For health care services offered to the enrollee within the
same business day from the time an appointment is requested by the
enrollee, the notice shall be provided to the enrollee prior to
providing care.  
   (2) The notice provided pursuant to paragraph (1) shall be in the
following form: 
     (Noncontracting physician and surgeon may add 
   office logo and office contact information here.) 
 ASSIGNMENT OF BENEFITS 
 I, (patient name) agree to receive medical 
 services from (physician and surgeon's name) at 
 (business name and location). My signature below 
 means I have read and understand the following: 
   44{44{/ORN The physician and surgeon listed 
 }             above is not part of my health 
                plan's network. 
   44{44{/ORN My health plan may pay some of the 
 }             cost, or none at all. I will be 
                responsible for most of the cost. 
   44{44{/ORN My health plan must help me get care 
 }             from an in-network physician and 
                surgeon if I call the health plan at 
                the telephone number on my 
                membership card. I am likely to pay 
                less if I use a physician and 
                surgeon that is in my health plan's 
                network. 
   44{44{/ORN My health plan may not cover the 
 }             costs of other care ordered by this 
                physician and surgeon. Examples of 
                care that the physician and surgeon 
                might order include lab tests, 
                imaging, and referrals to other 
                providers. 
   44{44{/ORN State law does not require any 
 }             payments I make to this physician 
                and surgeon to count toward my 
                annual out-of-pocket maximum. I can 
                call my health plan at the telephone 
                number on my membership card to find 
                out the remaining costs before I 
                reach my out-of-pocket maximum. My 
                costs will also be in addition to my 
                share of premium for this year. 
   44{44{/ORN I have received this notice and a 
 }             written estimate of the cost for 
                care from (physician and surgeon's 
                name). 
   44{44{/ORN The estimate cost of treatment may 
 }             be up to (amount), and the estimate 
                is attached to this notice. I will 
                receive another notice if the cost 
                is more than $100 higher, or more 
                than 10 % higher, than the original 
                estimate, whichever is the larger 
                change. 
   44{44{/ORN The estimate is limited to services 
 }             provided by (physician and surgeon's 
                name) and may not include services 
                from other providers, such as 
                facility charges. 
   44{44{/ORN I have the right to confirm health 
 }             plan benefit information from my 
                health plan before beginning 
                treatment. 
 __________________ 
 Date                                    Signature 
 ___________________ 
 Time                                   Print name 


   (d) (1) The noncontracting physician and surgeon shall provide the
enrollee a written estimate of the cost of care at the time of
providing the notice required by paragraph (2) of subdivision (c).
The estimate shall include each anticipated service to be provided
and the estimated cost of each service. The noncontracting physician
and surgeon shall attach the written estimate, along with any
explanation of the cost estimate, to the notice.  
   (2) If, upon further examination, the care costs more than the
greater of one hundred dollars ($100) more than, or more than 10
percent higher than, the physician and surgeon's initial estimate of
the cost of care, the physician and surgeon shall provide a revised
estimate of the cost of care in writing as soon as practicable. 

   (e) A noncontracting physician and surgeon shall not accept an
assignment of benefits from a patient with whom the noncontracting
physician and surgeon, or an employee or agent of that physician and
surgeon, communicates primarily in a language other than English, or
in a Medi-Cal threshold language, as defined by the regulations
adopted pursuant to Section 14680 of the Welfare and Institutions
Code, unless the written notice required by paragraph (2) of
subdivision (c) is also provided in that language.  
   (f) (1) A noncontracting physician and surgeon who accepts an
assignment of benefits from an enrollee may collect no more than the
estimated cost of care from the enrollee.  
   (2) After receiving the direct payment from the enrollee's plan, a
noncontracting physician and surgeon shall refund any overpayment to
the enrollee within 30 business days if the payment from the plan is
more than the estimated payment.  
   (g) This section shall only apply to health care service plans
that offer out-of-network covered benefits. Nothing in this section
shall be construed to require a health care service plan to cover
out-of-network benefits not otherwise required by this article. 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.  
   (h) Nothing in this section shall be construed to exempt a health
care service plan from the requirements of paragraph (2) of
subdivision (h) of Section 1367, or Section 1371.4, or 1371.37, or to
exempt a health care provider from the requirements of Section 1317,
1371.39, or 1379. 
  SEC. 2.  Section 10133.75 is added to the Insurance Code, to read:
   10133.75.  (a)  On   Notwithstanding Section
10133, 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).
  2016, upon written consent of the insured first
obtained with respect to a particular claim, a disability insurer
shall pay group benefits contingent upon, or for expenses incurred on
account of, hospitalization or medical or sur   gical aid
to a physician and surgeon furnishing the hospitalization or medical
or surgical aid, but the amount of that payment shall not exceed the
amount of benefit provided by the policy with respect to the service
or billing of the physician and surgeon, and the amount of the
payments pursuant to one or more assignments shall not exceed the
amount of expenses incurred on account of the hospitalization or
medical or surgical aid. Payments so made shall discharge the insurer'
s obligation with respect to the amount so paid. 
   (b) When seeking payment from a disability insurer pursuant to
subdivision (a),  a person   a noncontracting
physician and surgeon  shall provide the insurer with the
 provider's   physician and surgeon's 
itemized bill for service, the name and address of the person to be
reimbursed, and the name and policy number of the insured.  The
noncontracting physician and surgeon shall also retain on file, and
provide upon request to the insurer, documentation showing the notice
required in paragraph (2) of subdivision (c) was provided in a
timely manner, as required by paragraph (1) of subdivision (c). 

   (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.  
   (c) (1) A noncontracting physician and surgeon accepting an
assignment of benefits shall give the insured with the notice
described in paragraph (2) and obtain a signature from the insured.
The notice shall be in 12-point type, on a single page, without any
additional information other than that specified in the statutory
notice.  
   (A) The notice shall be provided to the insured at least 24 hours
prior to providing care.  
   (B) For health care services offered to the insured within the
same business day from the time an appointment is requested by the
insured, the notice shall be provided to the insured prior to
providing care.  
   (2) The notice provided pursuant to paragraph (1) shall be in the
following form: 
     (Noncontracting physician and surgeon may add 
   office logo and office contact information here.) 
 ASSIGNMENT OF BENEFITS 
 I, (patient name) agree to receive medical 
 services from (physician and surgeon's name) at 
 (business name and location). My signature below 
 means I have read and understand the following: 
   44{44{/ORN The physician and surgeon listed 
 }             above is not part of my health 
                plan's network. 
   44{44{/ORN My health plan may pay some of the 
 }             cost, or none at all. I will be 
                responsible for most of the cost. 
   44{44{/ORN My health plan must help me get care 
 }             from an in-network physician and 
                surgeon if I call the health plan at 
                the telephone number on my 
                membership card. I am likely to pay 
                less if I use a physician and 
                surgeon that is in my health plan's 
                network. 
   44{44{/ORN My health plan may not cover the 
 }             costs of other care ordered by this 
                physician and surgeon. Examples of 
                care that the physician and surgeon 
                might order include lab tests, 
                imaging, and referrals to other 
                providers. 
   44{44{/ORN State law does not require any 
}             payments I make to this physician 
                and surgeon to count toward my 
                annual out-of-pocket maximum. I can 
                call my health plan at the telephone 
                number on my membership card to find 
                out the remaining costs before I 
                reach my out-of-pocket maximum. My 
                costs will also be in addition to my 
                share of premium for this year. 
   44{44{/ORN I have received this notice and a 
 }             written estimate of the cost for 
                care from (physician and surgeon's 
                name). 
   44{44{/ORN The estimate cost of treatment may 
 }             be up to (amount), and the estimate 
                is attached to this notice. I will 
                receive another notice if the cost 
                is more than $100 higher, or more 
                than 10 % higher, than the original 
                estimate, whichever is the larger 
                change. 
   44{44{/ORN The estimate is limited to services 
 }             provided by (physician and surgeon's 
                name) and may not include services 
                from other providers, such as 
                facility charges. 
   44{44{/ORN I have the right to confirm health 
 }             plan benefit information from my 
                health plan before beginning 
                treatment. 
 __________________ 
 Date                                    Signature 
 ___________________ 
Time                                   Print name 


   (d) (1) The noncontracting physician and surgeon shall provide the
insured a written estimate of the cost of care at the time of
providing the notice required by paragraph (2) of subdivision (c).
The estimate shall include each anticipated service to be provided
and the estimated cost of each service. The noncontracting physician
and surgeon shall attach the written estimate, along with any
explanation of the cost estimate, to the notice.  
   (2) If, upon further examination, the care costs more than the
greater of one hundred dollars ($100) more than, or more than 10
percent higher than, the physician and surgeon's initial estimate of
the cost of care, the physician and surgeon shall provide a revised
estimate of the cost of care in writing as soon as practicable. 

   (e) A noncontracting physician and surgeon shall not accept an
assignment of benefits from a patient with whom the noncontracting
physician and surgeon, or an employee or agent of that physician and
surgeon, communicates primarily in a language other than English, or
in a Medi-Cal threshold language, as defined by the regulations
adopted pursuant to Section 14680 of the Welfare and Institutions
Code, unless the written notice required by paragraph (2) of
subdivision (c) is also provided in that language.  
   (f) (1) A noncontracting physician and surgeon who accepts an
assignment of benefits from an insured may collect no more than the
estimated cost of care from the insured.  
   (2) After receiving the direct payment from the insured's insurer,
a noncontracting physician and surgeon shall refund any overpayment
to the insured within 30 business days if the payment from the
insurer is more than the estimated payment.  
   (g) This section shall only apply to an insurer that offers
out-of-network covered benefits. Nothing in this section shall be
construed to require an insurer to cover out-of-network benefits not
otherwise required by this article. This section does not apply to an
insurer providing benefits pursuant to a specialized health
insurance policy, as defined in subdivision (c) of Section 106. 

   (h) Nothing in this section shall be construed to exempt an
insurer from the requirements of subdivision (b) of Section
10123.137, or Section 10123.147. 
  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.