[Approved by Governor September 23, 2016. Filed with Secretary of State September 23, 2016.]
AB 1954, 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.
The people of the State of California do enact as follows:
This act shall be known and may be cited as the Direct Access to Reproductive Health Care Act.
(a) The Legislature hereby finds and declares all of the following:
(1) For many women, reproductive health care may be the only contact they have with the health care system.
(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 3 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.
(6) Recognizing the importance of timely access to comprehensive reproductive and sexual health care services, the Legislature and the United States Congress passed measures to enable women to access care provided by an obstetrician and gynecologist without a referral. Despite these advances, there are wide variances in health benefit plans regarding referral requirements for reproductive and sexual health care services, and women across the state are obtaining these vital services from other licensed provider types, including family practice physicians, nurse practitioners, physician assistants, and certified nurse-midwives.
(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 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.
Section 1367.31 is added to the Health and Safety Code, to read:
(a) 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.
(b) (1) For the purposes of this section, “reproductive and sexual health care services” are all reproductive and sexual health services described in Sections 6925, 6926, 6927, and 6928 of the Family Code, or Section 121020 of the Health and Safety Code, obtained by a patient.
(2) For the purposes of this section, “reproductive and sexual health care services” do not include the services subject to a health care service plan’s referral procedures as required by subdivisions (a) and (b) of Section 1374.16.
(3) This section applies whether or not the patient is a minor.
(c) In implementing this section, a health care service plan may establish reasonable provisions governing utilization protocols for obtaining reproductive and sexual health care services, as provided for in subdivision (a), from health care providers participating in, or contracting with, the plan network, medical group, or independent practice association, provided that these provisions shall be consistent with the intent of this section and shall be those customarily applied to other health care providers, such as primary care physicians and surgeons, to whom the enrollee has direct access, and shall not be more restrictive for the provision of reproductive and sexual health care services. An enrollee shall not be required to obtain prior approval from another physician, another provider, or the health care service plan prior to obtaining direct access to reproductive and sexual health care services. A health care service plan may establish reasonable provisions governing communication with the enrollee’s primary care physician and surgeon regarding the enrollee’s condition, treatment, and any need for followup care.
(d) This section shall not apply to a health care service plan contract that does not require enrollees to obtain a referral from their primary care physician prior to seeking covered health care services from a specialist.
(e) A health care service plan shall not impose utilization protocols related to contraceptive drugs, supplies, and devices beyond the provisions outlined in Section 1367.25 of this code or Section 14132 of the Welfare and Institutions Code.
(f) This section shall not apply to specialized health care service plan contracts or any health care service plan that is governed by Section 14131 of the Welfare and Institutions Code.
Section 10123.202 is added to the Insurance Code, to read:
(a) Every health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, excluding specialized health insurance policies, shall be prohibited from requiring an insured to receive a referral prior to receiving coverage or services for reproductive and sexual health care.
(b) (1) For the purposes of this section, “reproductive and sexual health care services” are all reproductive and sexual health services described in Sections 6925, 6926, 6927, and 6928 of the Family Code, or Section 121020 of the Health and Safety Code, obtained by a patient.
(2) This section applies whether or not the patient is a minor.
(c) In implementing this section, a health insurer may establish reasonable provisions governing utilization protocols for obtaining reproductive and sexual health care services, as provided for in subdivision (a), provided that these provisions shall be consistent with the intent of this section and shall be those customarily applied to other health care providers, such as primary care physicians and surgeons, to whom the insured has direct access, and shall not be more restrictive for the provision of reproductive and sexual health care services. An insured shall not be required to obtain prior approval from another physician, another provider, or the insurer prior to obtaining direct access to reproductive and sexual health care services. An insurer may establish reasonable provisions governing communication with the insured’s primary care physician and surgeon regarding the insured’s condition, treatment, and any need for followup care.
(d) This section shall not apply to a health insurance policy that does not require insureds to obtain a referral from their primary care physician prior to seeking covered health care services from a specialist.
(e) A health insurer shall not impose utilization protocols related to contraceptive drugs, supplies, and devices beyond the provisions outlined in Section 10123.196.
(f) This section shall not apply to specialized health insurance, Medicare supplement insurance, short-term limited duration health insurance, CHAMPUS supplement insurance, or TRICARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.
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.
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