Amended in Senate August 17, 2016

Amended in Senate June 27, 2016

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 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:

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 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
P3    1wide variances in health benefit plans regarding referral
2requirements for reproductive and sexual health care services, and
3women 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.

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.

begin insert

27
(2) For the purposes of this section, “reproductive and sexual
28health care services” do not include the services subject to a health
29care service plan’s referral procedures as required by subdivisions
30(a) and (b) of Section 1374.16.

end insert
begin delete

31(2)

end delete

32begin insert(3)end insert This section applies whether or not the patient is a minor.

33(c) In implementing this section, a health care service plan may
34establish reasonable provisions governing utilization protocols for
35obtaining reproductive and sexual health care services, as provided
36for in subdivision (a), from health care providers participating in,
37or contracting with, the plan network, medical group, or
38independent practice association, provided that these provisions
39shall be consistent with the intent of this section and shall be those
40customarily applied to other health care providers, such as primary
P4    1care physicians and surgeons, to whom the enrollee has direct
2access, and shall not be more restrictive for the provision of
3reproductive and sexual health care services. An enrollee shall not
4be required to obtain prior approval from another physician, another
5provider, or the health care service plan prior to obtaining direct
6access to reproductive and sexual health care services. A health
7care service plan may establish reasonable provisions governing
8communication with the enrollee’s primary care physician and
9surgeon regarding the enrollee’s condition, treatment, and any
10need forbegin delete follow-upend deletebegin insert followupend insert care.

11(d) This section shall not apply to a health care service plan
12contract that does not require enrollees to obtain a referral from
13their primary care physician prior to seeking covered health care
14services from a specialist.

15(e) A health care service plan shall not impose utilization
16protocols related to contraceptive drugs, supplies, and devices
17beyond the provisions outlined in Section 1367.25 of this code or
18Section 14132 of the Welfare and Institutions Code.

19(f) This section shall not apply to specialized health care service
20plan contracts or any health care service plan that is governed by
21Section 14131 of the Welfare and Institutions Code.

22

SEC. 4.  

Section 10123.202 is added to the Insurance Code, to
23read:

24

10123.202.  

(a) Every health insurance policy issued, amended,
25renewed, or delivered on or after January 1, 2017, excluding
26specialized health insurance policies, shall be prohibited from
27requiring an insured to receive a referral prior to receiving coverage
28or services for reproductive and sexual health care.

29(b) (1) For the purposes of this section, “reproductive and sexual
30health care services” are all reproductive and sexual health services
31described in Sections 6925, 6926, 6927, and 6928 of the Family
32Code, or Section 121020 of the Health and Safety Code, obtained
33by a patient.

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

35(c) In implementing this section, a health insurer may establish
36reasonable provisions governing utilization protocols for obtaining
37reproductive and sexual health care services, as provided for in
38subdivision (a), provided that these provisions shall be consistent
39with the intent of this section and shall be those customarily applied
40to other health care providers, such as primary care physicians and
P5    1surgeons, to whom the insured has direct access, and shall not be
2more restrictive for the provision of reproductive and sexual health
3care services. An insured shall not be required to obtain prior
4approval from another physician, another provider, or the insurer
5prior to obtaining direct access to reproductive and sexual health
6care services. An insurer may establish reasonable provisions
7governing communication with the insured’s primary care
8physician and surgeon regarding the insured’s condition, treatment,
9and any need for followup care.

10(d) This section shall not apply to a health insurance policy that
11does not require insureds to obtain a referral from their primary
12care physician prior to seeking covered health care services from
13a specialist.

14(e)  A health insurer shall not impose utilization protocols
15related to contraceptive drugs, supplies, and devices beyond the
16provisions outlined in Section 10123.196.

17(f) This section shall not apply to specialized health insurance,
18Medicare supplement insurance, short-term limited duration health
19insurance, CHAMPUS supplement insurance, orbegin delete TRI-CAREend delete
20begin insert TRICAREend insert supplement insurance, or to hospital indemnity,
21accident-only, or specified disease insurance.

22

SEC. 5.  

No reimbursement is required by this act pursuant to
23Section 6 of Article XIII B of the California Constitution because
24the only costs that may be incurred by a local agency or school
25district will be incurred because this act creates a new crime or
26infraction, eliminates a crime or infraction, or changes the penalty
27for a crime or infraction, within the meaning of Section 17556 of
28the Government Code, or changes the definition of a crime within
29the meaning of Section 6 of Article XIII B of the California
30Constitution.



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