California Legislature—2015–16 Regular Session

Assembly BillNo. 2081

Introduced by Assembly Member Grove

February 17, 2016

An act to amend Section 1367 of the Health and Safety Code, relating to health care.


AB 2081, as introduced, Grove. Health care service plans.

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. Existing law requires health care service plans and, if applicable, specialized health care service plans, to meet specified criteria, including requiring the appropriate licensure of facilities and personnel. Willful violation of that act a crime.

This bill would make technical, nonsubstantive changes to these provisions.

Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.

The people of the State of California do enact as follows:

P1    1


Section 1367 of the Health and Safety Code is
2amended to read:



A health care service plan and, if applicable, a specialized
4health care service plan shall meet the following requirements:

5(a) Facilities located in thisbegin delete stateend deletebegin insert state,end insert including, but not limited
6to, clinics, hospitals, and skilled nursing facilities to be utilized by
P2    1the plan shall be licensed by the State Department of Public Health,
2where licensure is required by law. Facilities not located in this
3state shall conform to all licensing and other requirements of the
4jurisdiction in which they are located.

5(b) Personnel employedbegin delete byend deletebegin insert by,end insert or under contractbegin delete toend deletebegin insert with,end insert the
6plan shall be licensed or certified by their respective board or
7agency, where licensure or certification is required by law.

8(c) Equipment required to be licensed or registered by law shall
9be so licensed or registered, and the operating personnel for that
10equipment shall be licensed or certified as required by law.

11(d) The plan shall furnish services in a manner providing
12continuity of care and ready referral of patients to other providers
13at times as may be appropriate consistent with good professional

15(e) (1) All services shall be readily available at reasonable times
16to each enrollee consistent with good professional practice. To the
17extent feasible, the plan shall make all services readily accessible
18to all enrollees consistent with Section 1367.03.

19(2) To the extent that telehealth services are appropriately
20provided through telehealth, as defined in subdivision (a) of Section
212290.5 of the Business and Professions Code, these services shall
22be considered in determining compliance with Section 1300.67.2
23of Title 28 of the California Code of Regulations.

24(3) The plan shall make all services accessible and appropriate
25consistent with Section 1367.04.

26(f) The plan shall employ and utilize allied health manpower
27for the furnishing of services to the extent permitted by law and
28consistent with good medical practice.

29(g) The plan shall have the organizational and administrative
30capacity to provide services to subscribers and enrollees. The plan
31shall be able to demonstrate to the department that medical
32decisions are rendered by qualified medical providers, unhindered
33by fiscal and administrative management.

34(h) (1) Contracts with subscribers and enrollees, including
35group contracts, and contracts with providers, and other persons
36furnishing services, equipment, or facilitiesbegin delete toend deletebegin insert to,end insert or in connection
37begin delete withend deletebegin insert with,end insert the plan, shall be fair, reasonable, and consistent with
38the objectives of this chapter. All contracts with providers shall
39contain provisions requiring a fast, fair, and cost-effective dispute
40resolution mechanism under which providers may submit disputes
P3    1to the plan, and requiring the plan to inform its providers upon
2contracting with thebegin delete plan,end deletebegin insert planend insert or upon change to these provisions,
3of the procedures for processing and resolving disputes, including
4the location and telephone number where information regarding
5disputes may be submitted.

6(2) A health care service plan shall ensure that a dispute
7resolution mechanism is accessible to noncontracting providers
8for the purpose of resolving billing and claims disputes.

9(3) begin deleteOn and after January 1, 2002, a end deletebegin insertA end inserthealth care service plan
10shall annually submit a report to the department regarding its
11dispute resolution mechanism. The report shall include information
12on the number of providers who utilized the dispute resolution
13mechanism and a summary of the disposition of those disputes.

14(i) A health care service plan contract shall provide to
15subscribers and enrollees all of the basic health care services
16included in subdivision (b) of Section 1345, except that the director
17may, for good cause, by rule or order exempt a plan contract or
18any class of plan contracts from that requirement. The director
19shall by rule define the scope of each basic health care service that
20health care service plans are required to provide as a minimum for
21licensure under this chapter. Nothing in this chapter shall prohibit
22a health care service plan from charging subscribers or enrollees
23a copayment or a deductible for a basic health care service
24consistent with Section 1367.006 or 1367.007, provided that the
25copayments, deductibles, or other cost sharing are reported to the
26director and set forth to the subscriber or enrollee pursuant to the
27disclosure provisions of Section 1363. Nothing in this chapter shall
28prohibit a health care service plan from setting forth, by contract,
29limitations on maximum coverage of basic health care services,
30provided that the limitations are reported to, and held
31unobjectionable by, the director and set forth to the subscriber or
32enrollee pursuant to the disclosure provisions of Section 1363.

33(j) begin insert(1)end insertbegin insertend insert A health care service plan shall not require registration
34under the federal Controlled Substances Act (21 U.S.C. Sec. 801
35et seq.) as a condition for participation by an optometrist certified
36to use therapeutic pharmaceutical agents pursuant to Section 3041.3
37of the Business and Professions Code.

begin delete

38Nothing in this

end delete

P4    1begin insert(2)end insertbegin insertend insertbegin insertThisend insert section shallbegin insert notend insert be construed to permit the director to
2establish the rates charged subscribers and enrollees for contractual
3health care services.

begin delete

4 The

end delete

5begin insert(3)end insertbegin insertend insertbegin insertTheend insert director’s enforcement of Article 3.1 (commencing with
6Section 1357) shall not be deemed to establish the rates charged
7subscribers and enrollees for contractual health care services.

begin delete

8 The

end delete

9begin insert(4)end insertbegin insertend insertbegin insertTheend insert obligation of the plan to comply with this chapter shall
10not be waived when the plan delegatesbegin delete anyend delete services that it is
11required to perform to its medical groups, independent practice
12associations, or other contracting entities.