Amended in Senate June 13, 2016

Amended in Assembly May 9, 2016

Amended in Assembly April 25, 2016

Amended in Assembly April 13, 2016

California Legislature—2015–16 Regular Session

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

P2    1

SECTION 1.  

This act shall be known and may be cited as the
2Direct Access to Reproductive Health Care Act.

3

SEC. 2.  

(a) The Legislature hereby finds and declares all of
4the following:

5(1) For many women, reproductive health carebegin delete is primary health
6care.end delete
begin insert may be the only contact they have with the health care system.end insert

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, andbegin delete threeend deletebegin insert 3end insert 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.

begin delete

23(6) The Legislature has also passed measures to help health plan
24enrollees and insureds access timely health care by setting
25standards and policies regarding wait times for an appointment.

end delete
begin insert

26
(6) Recognizing the importance of timely access to
27comprehensive reproductive and sexual health care services, the
28Legislature and the United States Congress passed measures to
29enable women to access care provided by an obstetrician and
30gynecologist without a referral. Despite these advances, there are
P3    1wide variances in health benefit plans regarding referral
2requirements for reproductive and sexual health care services,
3and women across the state are obtaining these vital services from
4other licensed provider types, including family practice physicians,
5nurse practitioners, physician assistants, and certified
6nurse-midwives.

end insert

7(b) It is hereby the intent of the Legislature in enacting this act
8to build on current state and federal law to increase timely, equal,
9and direct access to time-sensitive and comprehensive reproductive
10and sexual health care services for enrollees in health care service
11plans or insureds under health insurance policies by prohibiting
12health care service plans or insurers from requiring an enrollee or
13insured to secure a referral from a primary care provider prior to
14receiving in-network reproductive and sexual health care services.

15

SEC. 3.  

Section 1367.31 is added to the Health and Safety
16Code
, to read:

17

1367.31.  

(a) Every health care service plan contract issued,
18amended, renewed, or delivered on or after January 1, 2017, shall
19be prohibited from requiring an enrollee to receive a referral prior
20to receiving coverage or services for reproductive and sexual health
21care.

22(b) (1) For the purposes of this section, “reproductive and sexual
23health care services” are all reproductive and sexual health services
24described in Sections 6925, 6926, 6927, and 6928 of the Family
25Code, or Section 121020 of the Health and Safety Code, obtained
26by a patient.

27(2) This section applies whether or not the patient is a minor.

begin insert

28
(c) In implementing this section, a health care service plan may
29establish reasonable provisions governing utilization protocols
30for obtaining reproductive and sexual health care services, as
31provided for in subdivision (a), from health care providers
32participating in, or contracting with, the plan network, medical
33group, or independent practice association, provided that these
34provisions shall be consistent with the intent of this section and
35shall be those customarily applied to other health care providers,
36such as primary care physicians and surgeons, to whom the
37enrollee has direct access, and shall not be more restrictive for
38the provision of reproductive and sexual health care services. An
39enrollee shall not be required to obtain prior approval from
40another physician, another provider, or the health care service
P4    1plan prior to obtaining direct access to reproductive and sexual
2health care services. A health care service plan may establish
3provisions governing communication with the enrollee’s primary
4care physician and surgeon regarding the enrollee’s condition,
5treatment, and any need for follow-up care.

end insert
begin insert

6
(d) A health care service plan subject to this section shall not
7impose utilization protocols related to contraceptive drugs,
8supplies, and devices beyond the provisions outlined in Section
91367.25 of this code or Section 14132 of the Welfare and
10Institutions Code.

end insert
begin delete

11(c)

end delete

12begin insert(e)end insert This section shall not apply to specialized health care service
13plan contracts or any health care service plan that is governed by
14Section 14131 of the Welfare and Institutions Code.

15

SEC. 4.  

Section 10123.202 is added to the Insurance Code, to
16read:

17

10123.202.  

(a) Every health insurance policy issued, amended,
18renewed, or delivered on or after January 1, 2017, excluding
19specialized health insurance policies, shall be prohibited from
20requiring an insured to receive a referral prior to receiving coverage
21or services for reproductive and sexual health care.

22(b) (1) For the purposes of this section, “reproductive and sexual
23health care services” are all reproductive and sexual health services
24described in Sections 6925, 6926, 6927, and 6928 of the Family
25Code, or Section 121020 of the Health and Safety Code, obtained
26by a patient.

27 (2) This section applies whether or not the patient is a minor.

begin insert

28
(c) In implementing this section, a health insurer may establish
29reasonable provisions governing utilization protocols for obtaining
30reproductive and sexual health care services, as provided for in
31subdivision (a), provided that these provisions shall be consistent
32with the intent of this section and shall be those customarily applied
33to other health care providers, such as primary care physicians
34and surgeons, to whom the insured has direct access, and shall
35not be more restrictive for the provision of reproductive and sexual
36health care services. An insured shall not be required to obtain
37prior approval from another physician, another provider, or the
38insurer prior to obtaining direct access to reproductive and sexual
39health care services. An insurer may establish provisions governing
40communication with the insured’s primary care physician and
P5    1surgeon regarding the insured’s condition, treatment, and any
2need for followup care.

end insert
begin insert

3
(d)  A health insurer subject to this section shall not impose
4utilization protocols related to contraceptive drugs, supplies, and
5devices beyond the provisions outlined in Section 10123.196.

end insert
begin insert

6
(e) This section shall not apply to specialized health insurance,
7Medicare supplement insurance, short-term limited duration health
8insurance, CHAMPUS supplement insurance, or TRI-CARE
9supplement insurance, or to hospital indemnity, accident-only, or
10specified disease insurance.

end insert
11

SEC. 5.  

No reimbursement is required by this act pursuant to
12Section 6 of Article XIII B of the California Constitution because
13the only costs that may be incurred by a local agency or school
14district will be incurred because this act creates a new crime or
15infraction, eliminates a crime or infraction, or changes the penalty
16for a crime or infraction, within the meaning of Section 17556 of
17the Government Code, or changes the definition of a crime within
18the meaning of Section 6 of Article XIII B of the California
19Constitution.



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