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 care services, as provided. 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 may be the only
6contact they have with the health care system.
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 3 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 and sexual health care services, the
25Legislature and the United States Congress passed
measures to
26enable women to access care provided by an obstetrician and
27gynecologist without a referral. Despite these advances, there are
28wide variances in health benefit plans regarding referral
P3 1requirements for reproductive and sexual health care services, and
2women across the state are obtaining these vital services from
3other licensed provider types, including family practice physicians,
4nurse practitioners, physician assistants, and certified
5nurse-midwives.
6(b) It is hereby the intent of the Legislature in enacting this act
7to build on current state and federal law to increase timely, equal,
8and direct access to time-sensitive and comprehensive reproductive
9and sexual health care services for enrollees in health care service
10plans or insureds under health insurance policies by prohibiting
11health care service plans or insurers
from requiring an enrollee or
12insured to secure a referral from a primary care provider prior to
13receiving in-network reproductive and sexual health care services.
Section 1367.31 is added to the Health and Safety
15Code, to read:
(a) Every health care service plan contract issued,
17amended, renewed, or delivered on or after January 1, 2017, shall
18be prohibited from requiring an enrollee to receive a referral prior
19to receiving coverage or services for reproductive and sexual health
20care.
21(b) (1) For the purposes of this section, “reproductive and sexual
22health care services” are all reproductive and sexual health services
23described in Sections 6925, 6926, 6927, and 6928 of the Family
24Code, or Section 121020 of the Health and Safety Code, obtained
25by a patient.
26(2) This section applies whether or not the patient is a minor.
27(c) In implementing this section, a health care service plan may
28establish reasonable provisions governing utilization protocols for
29obtaining reproductive and sexual health care services, as provided
30for in subdivision (a), from health care providers participating in,
31or contracting with, the plan network, medical group, or
32independent practice association, provided that these provisions
33shall be consistent with the intent of this section and shall be those
34customarily applied to other health care providers, such as primary
35care physicians and surgeons, to whom the enrollee has direct
36access, and shall not be more restrictive for the provision of
37reproductive and sexual health care services. An enrollee shall not
38be required to obtain prior approval from another physician, another
39provider, or the health care service plan
prior to obtaining direct
40access to reproductive and sexual health care services. A health
P4 1care service plan may establishbegin insert reasonableend insert provisions governing
2communication with the enrollee’s primary care physician and
3surgeon regarding the enrollee’s condition, treatment, and any
4need for follow-up care.
5
(d) This section shall not apply to a health care service plan
6contract that does not require enrollees to obtain a referral from
7their primary care physician prior to seeking covered health care
8services from a specialist.
9(d)
end delete
10begin insert(e)end insert A health care service planbegin delete subject to this sectionend delete shall not
11impose utilization protocols related to contraceptive drugs,
12supplies, and devices beyond the provisions outlined in Section
131367.25 of this code or Section 14132 of the Welfare and
14Institutions Code.
15(e)
end delete
16begin insert(f)end insert This section shall not apply to specialized health care service
17plan contracts or any health care
service plan that is governed by
18Section 14131 of the Welfare and Institutions Code.
Section 10123.202 is added to the Insurance Code, to
20read:
(a) Every health insurance policy issued, amended,
22renewed, or delivered on or after January 1, 2017, excluding
23specialized health insurance policies, shall be prohibited from
24requiring an insured to receive a referral prior to receiving coverage
25or services for reproductive and sexual health care.
26(b) (1) For the purposes of this section, “reproductive and sexual
27health care services” are all reproductive and sexual health services
28described in Sections 6925, 6926, 6927, and 6928 of the Family
29Code, or Section 121020 of the Health and Safety Code, obtained
30by a patient.
31 (2) This section applies whether or not the patient is a minor.
32(c) In implementing this section, a health insurer may establish
33reasonable provisions governing utilization protocols for obtaining
34reproductive and sexual health care services, as provided for in
35subdivision (a), provided that these provisions shall be consistent
36with the intent of this section and shall be those customarily applied
37to other health care providers, such as primary care physicians and
38surgeons, to whom the insured has direct access, and shall not be
39more restrictive for the provision of reproductive and sexual health
40care services. An insured shall not be required to obtain prior
P5 1approval from another physician, another provider, or the insurer
2prior to obtaining direct access to reproductive and sexual health
3care services. An insurer may establishbegin insert
reasonableend insert provisions
4governing communication with the insured’s primary care
5physician and surgeon regarding the insured’s condition, treatment,
6and any need for followup care.
7
(d) This section shall not apply to a health insurance policy that
8does not require insureds to obtain a referral from their primary
9care physician prior to seeking covered health care services from
10a specialist.
11(d)
end delete
12begin insert(e)end insert A
health insurerbegin delete subject to this sectionend delete
shall not impose
13 utilization protocols related to contraceptive drugs, supplies, and
14devices beyond the provisions outlined in Section 10123.196.
15(e)
end delete
16begin insert(f)end insert This section shall not apply to specialized health insurance,
17Medicare supplement insurance, short-term limited duration health
18insurance, CHAMPUS supplement insurance, or TRI-CARE
19supplement insurance, or to hospital indemnity, accident-only, or
20specified disease insurance.
No reimbursement is required by this act pursuant to
22Section 6 of Article XIII B of the California Constitution because
23the only costs that may be incurred by a local agency or school
24district will be incurred because this act creates a new crime or
25infraction, eliminates a crime or infraction, or changes the penalty
26for a crime or infraction, within the meaning of Section 17556 of
27the Government Code, or changes the definition of a crime within
28the meaning of Section 6 of Article XIII B of the California
29Constitution.
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