AB 1954, as introduced, Burke. Health care coverage: reproductive health care services.
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 the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.
This bill would require every health care service plan contract or health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, to provide coverage for reproductive and sexual health care services, as defined, through out-of-network providers under specified circumstances. The bill would prohibit those plan contracts or insurance policies from requiring an enrollee or insured to receive a referral in order to receive reproductive or sexual health care services. Because a willful violation of these provisions by a health care service plan would be a crime, the 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:
This act shall be known and may be cited as the
2Direct Access to Reproductive Health Care Act.
(a) The Legislature hereby finds and declares all of
4the following:
5(1) For many women, reproductive health care is primary health
6care.
7(2) According to the Guttmacher Institute, one-half of all
8pregnancies in the United States each year, more than three million
9pregnancies, are unintended. By 45 years of age, more than one-half
10of all women in the United States will have experienced an
11unintended pregnancy, and three in 10 will have had an abortion.
12(3) The inability to access comprehensive reproductive health
13care in a timely manner can lead to negative health outcomes
14including
increased risk for unintended pregnancy, sexually
15transmitted diseases, and delayed care for critical and time-sensitive
16reproductive health services.
17(4) Providing timely access to comprehensive reproductive
18health services is cost effective.
19(5) California has a long history of, and commitment to,
20expanding access to services that aim to reduce the risk of
21unintended pregnancies, improve reproductive and sexual health
22outcomes, and reduce costs.
23(6) Recognizing the importance of timely access to
24comprehensive reproductive health services, the Legislature and
25the United States Congress passed measures to allow Medi-Cal
26enrollees to go out-of-network for sensitive services and enable
27women to access care provided by an obstetrician/gynecologist
28(OB/GYN) without a referral.
29(7) The Legislature has also passed measures to help health plan
30enrollees and insureds access timely health care by setting
31standards and policies regarding wait times for an appointment.
32(8) Despite these advances, there are wide variances in network
33adequacy and health care service plan contracts and health
P3 1insurance policies regarding referral requirements for reproductive
2and sexual health care services.
3(b) It is hereby the intent of the Legislature in enacting this act
4to build on current state and federal law to increase timely, equal,
5and direct access to time-sensitive and comprehensive reproductive
6and sexual health care services for enrollees in health care service
7plans or insureds under health insurance policies by doing both of
8the following:
9(1) Allowing enrollees or insureds to seek care from an
10out-of-network provider if access to an appropriate reproductive
11and sexual health provider is unavailable in-network in a timely
12manner.
13(2) Prohibiting health care service plans or insurers from
14requiring an enrollee or insured to secure a referral from a primary
15care provider prior to receiving reproductive and sexual health
16care services.
Section 1367.31 is added to the Health and Safety
18Code, to read:
(a) Every health care service plan contract issued,
20amended, renewed, or delivered on or after January 1, 2017, shall
21provide coverage for reproductive and sexual health care services
22provided by an out-of-network provider in an enrollee’s service
23region under either of the following circumstances:
24(1) Access to an appropriate provider is unavailable in-network
25in the enrollee’s service region within 10 days after the enrollee’s
26initial request for reproductive and sexual health care services, or
27sooner if a medical provider indicates an earlier appointment is
28medically necessary.
29(2) An in-network provider is not available within a reasonable
30distance of the enrollee’s work or
home address.
31(b) Every health care service plan contract issued, amended,
32renewed, or delivered on or after January 1, 2017, shall be
33prohibited from requiring an enrollee to receive a referral prior to
34receiving coverage or services for reproductive and sexual health
35care.
36(c) For the purposes of this section:
37(1) “Appropriate provider” means either of the following:
38 (A) A provider with the training and licensure necessary to ably
39provide the covered time-sensitive reproductive and sexual health
P4 1care services, treatment, and devices requested by the enrollee in
2the clinical setting in which he or she practices.
3(B) A provider that meets the standards set forth in subparagraph
4(A), and
is selected by an enrollee based on the provider’s gender
5and the enrollee’s preference to be treated by a provider of that
6gender.
7(2) “Reasonable distance” is the distance defined by the
8Department of Managed Health Care.
9(3) “Reproductive and sexual health care services” are all
10reproductive and sexual health services described in Sections 6924,
116925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections
12121020 and 124260 of the Health and Safety Code, obtained by a
13patient at or above the minimum age specified in that section.
14(d) This section shall not apply to any health care service plan
15that is governed by Section 14131 of the Welfare and Institutions
16Code.
Section 10123.202 is added to the Insurance Code, to
18read:
(a) Every health insurance policy issued, amended,
20renewed, or delivered on or after January 1, 2017, shall provide
21coverage for reproductive and sexual health care services provided
22by an out-of-network provider in an insured’s service region under
23either of the following circumstances:
24(1) Access to an appropriate provider is unavailable in-network
25in the insured’s service region within 10 days after the insured’s
26initial request for reproductive and sexual health care services, or
27sooner if a medical provider indicates an earlier appointment is
28medically necessary.
29(2) An in-network provider is not available within a reasonable
30distance of the insured’s work or home
address.
31(b) Every health insurance policy issued, amended, renewed,
32or delivered on or after January 1, 2017, shall be prohibited from
33requiring an insured to receive a referral prior to receiving coverage
34or services for reproductive and sexual health care.
35(c) For the purposes of this section:
36(1) “Appropriate provider” means either of the following:
37(A) A provider with the training and licensure necessary to ably
38provide the covered time-sensitive reproductive and sexual health
39care services, treatment, and devices requested by the insured in
40the clinical setting in which he or she practices.
P5 1(B) A provider that meets the standards set forth in subparagraph
2(A), and is selected by an
insured based on the provider’s gender
3and the insured’s preference to be treated by a provider of that
4gender.
5(2) “Reasonable distance” is the distance defined by the
6Department of Insurance.
7(3) “Reproductive and sexual health care services” are all
8reproductive and sexual health services described in Sections 6924,
96925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections
10121020 and 124260 of the Health and Safety Code, obtained by a
11patient at or above the minimum age specified in that section.
No reimbursement is required by this act pursuant to
13Section 6 of Article XIII B of the California Constitution because
14the only costs that may be incurred by a local agency or school
15district will be incurred because this act creates a new crime or
16infraction, eliminates a crime or infraction, or changes the penalty
17for a crime or infraction, within the meaning of Section 17556 of
18the Government Code, or changes the definition of a crime within
19the meaning of Section 6 of Article XIII B of the California
20Constitution.
O
99