Amended in Assembly April 13, 2016

California Legislature—2015–16 Regular Session

Assembly Bill No. 1954

Introduced by Assembly Member Burke

February 12, 2016

An act to add Section 1367.31 to the Health and Safety Code, and to add Section 10123.202 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 1954, as amended, 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 begin delete require end delete begin insert prohibit end insert every health care service plan contract or health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, begin delete 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 end delete begin insert with exceptions, end insert from requiring an enrollee or insured to receive a referral in order to receive reproductive or sexual health care begin delete services. end delete begin insert services, as defined. end insert 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:

SECTION 1.  

This act shall be known and may be cited as the
Direct Access to Reproductive Health Care Act.

SEC. 2.  

(a) The Legislature hereby finds and declares all of
the following:

(1) For many women, reproductive health care is primary health
care.

(2) According to the Guttmacher Institute, one-half of all
pregnancies in the United States each year, more than three million
pregnancies, are unintended. By 45 years of age, more than one-half
of all women in the United States will have experienced an
unintended pregnancy, and three in 10 will have had an abortion.

(3) The inability to access comprehensive reproductive health
care in a timely manner can lead to negative health outcomes
including increased risk for unintended pregnancy, sexually
transmitted diseases, and delayed care for critical and time-sensitive
reproductive health services.

(4) Providing timely access to comprehensive reproductive
health services is cost effective.

(5) California has a long history of, and commitment to,
expanding access to services that aim to reduce the risk of
unintended pregnancies, improve reproductive and sexual health
outcomes, and reduce costs.

begin delete

(6) Recognizing the importance of timely access to
comprehensive reproductive health services, the Legislature and
the United States Congress passed measures to allow Medi-Cal
enrollees to go out-of-network for sensitive services and enable
women to access care provided by an obstetrician/gynecologist
(OB/GYN) without a referral.

end delete begin delete

(7)

end delete

begin insert (6) end insert  The Legislature has also passed measures to help health plan
enrollees and insureds access timely health care by setting
standards and policies regarding wait times for an appointment.

begin delete

(8) Despite these advances, there are wide variances in network
adequacy and health care service plan contracts and health
insurance policies regarding referral requirements for reproductive
and sexual health care services.

end delete

(b) It is hereby the intent of the Legislature in enacting this act
to build on current state and federal law to increase timely, equal,
and direct access to time-sensitive and comprehensive reproductive
and sexual health care services for enrollees in health care service
plans or insureds under health insurance policies by begin delete doing both of
the following: end delete begin insert prohibiting health care service plans or insurers
from requiring an enrollee or insured to secure a referral from a
primary care provider prior to receiving in-network reproductive
and sexual health care services. end insert

begin delete

(1) Allowing enrollees or insureds to seek care from an
out-of-network provider if access to an appropriate reproductive
and sexual health provider is unavailable in-network in a timely
manner.

end delete begin delete

(2) Prohibiting health care service plans or insurers from
requiring an enrollee or insured to secure a referral from a primary
care provider prior to receiving reproductive and sexual health
care services.

end delete

SEC. 3.  

Section 1367.31 is added to the Health and Safety
Code, to read:

begin delete

1367.31.  

(a) Every health care service plan contract issued,
amended, renewed, or delivered on or after January 1, 2017, shall
provide coverage for reproductive and sexual health care services
provided by an out-of-network provider in an enrollee’s service
region under either of the following circumstances:

(1) Access to an appropriate provider is unavailable in-network
in the enrollee’s service region within 10 days after the enrollee’s
initial request for reproductive and sexual health care services, or
sooner if a medical provider indicates an earlier appointment is
medically necessary.

(2) An in-network provider is not available within a reasonable
distance of the enrollee’s work or home address.

(b)

end delete

begin insert

begin insert 1367.31. end insert   

end insert

begin insert (a) end insert  Every health care service plan contract issued,
amended, renewed, or delivered on or after January 1, 2017, shall
be prohibited from requiring an enrollee to receive a referral prior
to receiving coverage or services for reproductive and sexual health
care.

begin delete

(c) For the purposes of this section:

(1) “Appropriate provider” means either of the following:

(A) A provider with the training and licensure necessary to
ably provide the covered time-sensitive reproductive and sexual
health care services, treatment, and devices requested by the
enrollee in the clinical setting in which he or she practices.

(B) A provider that meets the standards set forth in subparagraph
(A), and is selected by an enrollee based on the provider’s gender
and the enrollee’s preference to be treated by a provider of that
gender.

(2) “Reasonable distance” is the distance defined by the
Department of Managed Health Care.

(3) “Reproductive and sexual health care services” are all
reproductive and sexual health services described in Sections 6924,
6925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections
121020 and 124260 of the Health and Safety Code, obtained by a
patient at or above the minimum age specified in that section.

end delete begin insert

(b) For the purposes of this section, “reproductive and sexual
health care services” are all reproductive and sexual health
services described in Sections 6924, 6925, 6926, 6927, 6928, and
6929 of the Family Code, or Sections 121020 and 124260 of the
Health and Safety Code, obtained by a patient at or above the
minimum age specified in that section.

end insert begin delete

(d)

end delete

begin insert (c) end insert  This section shall not apply to begin insert specialized health care service
plan contracts or end insert any health care service plan that is governed by
Section 14131 of the Welfare and Institutions Code.

SEC. 4.  

Section 10123.202 is added to the Insurance Code, to
read:

begin delete

10123.202.  

(a) Every health insurance policy issued, amended,
renewed, or delivered on or after January 1, 2017, shall provide
coverage for reproductive and sexual health care services provided
by an out-of-network provider in an insured’s service region under
either of the following circumstances:

(1) Access to an appropriate provider is unavailable in-network
in the insured’s service region within 10 days after the insured’s
initial request for reproductive and sexual health care services, or
sooner if a medical provider indicates an earlier appointment is
medically necessary.

(2) An in-network provider is not available within a reasonable
distance of the insured’s work or home address.

(b)

end delete

begin insert

begin insert 10123.202. end insert   

end insert

begin insert (a) end insert  Every health insurance policy issued, amended,
renewed, or delivered on or after January 1, 2017, begin insert excluding
specialized health insurance policies, end insert shall be prohibited from
requiring an insured to receive a referral prior to receiving coverage
or services for reproductive and sexual health care.

begin delete

(c) For the purposes of this section:

(1) “Appropriate provider” means either of the following:

(A) A provider with the training and licensure necessary to ably
provide the covered time-sensitive reproductive and sexual health
care services, treatment, and devices requested by the insured in
the clinical setting in which he or she practices.

(B) A provider that meets the standards set forth in subparagraph
(A), and is selected by an insured based on the provider’s gender
and the insured’s preference to be treated by a provider of that
gender.

(2) “Reasonable distance” is the distance defined by the
Department of Insurance.

(3) “Reproductive and sexual health care services” are all
reproductive and sexual health services described in Sections 6924,
6925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections
121020 and 124260 of the Health and Safety Code, obtained by a
patient at or above the minimum age specified in that section.

end delete begin insert

(b) For the purposes of this section, “reproductive and sexual
health care services” are all reproductive and sexual health
services described in Sections 6924, 6925, 6926, 6927, 6928, and
6929 of the Family Code, or Sections 121020 and 124260 of the
Health and Safety Code, obtained by a patient at or above the
minimum age specified in that section.

end insert

SEC. 5.  

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.