California Legislature—2015–16 Regular Session

Assembly Bill No. 2372

Introduced by Assembly Member Burke

(Principal coauthor: Assembly Member Waldron)

(Principal coauthor: Senator Hertzberg)

February 18, 2016

An act to amend Section 1367.03 of, and to add Section 1367.693 to, the Health and Safety Code, and to amend Section 10133.5 of, and to add Section 10123.833 to, the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 2372, as introduced, Burke. Health care coverage: HIV specialists.

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. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would define for these purposes “specialty physician” and “professional provider,” respectively, to include a physician who meets the criteria for an HIV specialist, as specified. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2017, to include an HIV specialist, as defined, as an eligible primary care physician, provided that he or she meets the plan’s or health insurer’s eligibility criteria for all specialists seeking primary care physician status. Because a willful violation of these requirements 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:

SECTION 1.  

Section 1367.03 of the Health and Safety Code
is amended to read:

1367.03.  

(a)  begin delete Not later than January 1, 2004, the end delete begin insert The end insert department
shall develop and adopt regulations to ensure that enrollees have
access to needed health care services in a timely manner. In
developing these regulations, the department shall develop
indicators of timeliness of access to care and, in so doing, shall
consider the following as indicators of timeliness of access to care:

(1) Waiting times for appointments with physicians, including
primary care and specialty physicians.

(2) Timeliness of care in an episode of illness, including the
timeliness of referrals and obtaining other services, if needed.

(3) Waiting time to speak to a physician, registered nurse, or
other qualified health professional acting within his or her scope
of practice who is trained to screen or triage an enrollee who may
need care.

(b) In developing these standards for timeliness of access, the
department shall consider the following:

(1) Clinical appropriateness.

(2) The nature of the specialty.

(3) The urgency of care.

(4) The requirements of other provisions of law, including
Section 1367.01 governing utilization review, that may affect
timeliness of access.

(c) The department may adopt standards other than the time
elapsed between the time an enrollee seeks health care and obtains
care. If the department chooses a standard other than the time
elapsed between the time an enrollee first seeks health care and
obtains it, the department shall demonstrate why that standard is
more appropriate. In developing these standards, the department
shall consider the nature of the plan network.

(d) The department shall review and adopt standards, as needed,
concerning the availability of primary care physicians, specialty
physicians, hospital care, and other health care, so that consumers
have timely access to care. In so doing, the department shall
consider the nature of physician practices, including individual
and group practices as well as the nature of the plan network. The
department shall also consider various circumstances affecting the
delivery of care, including urgent care, care provided on the same
day, and requests for specific providers. If the department finds
that health care service plans and health care providers have
difficulty meeting these standards, the department may make
recommendations to the Assembly Committee on Health and the
Senate Committee on Insurance of the Legislature pursuant to
subdivision (i).

(e) In developing standards under subdivision (a), the department
shall consider requirements under federal law, requirements under
other state programs, standards adopted by other states, nationally
recognized accrediting organizations, and professional associations.
The department shall further consider the needs of rural areas,
specifically those in which health facilities are more than 30 miles
apart and any requirements imposed by the State Department of
Health Care Services on health care service plans that contract
with the State Department of Health Care Services to provide
Medi-Cal managed care.

(f) (1) Contracts between health care service plans and health
care providers shall ensure compliance with the standards
developed under this section. These contracts shall require
reporting by health care providers to health care service plans and
by health care service plans to the department to ensure compliance
with the standards.

(2) Health care service plans shall report annually to the
department on compliance with the standards in a manner specified
by the department. The reported information shall allow consumers
to compare the performance of plans and their contracting providers
in complying with the standards, as well as changes in the
compliance of plans with these standards.

(3) The department may develop standardized methodologies
for reporting that shall be used by health care service plans to
demonstrate compliance with this section and any regulations
adopted pursuant to it. The methodologies shall be sufficient to
determine compliance with the standards developed under this
section for different networks of providers if a health care service
plan uses a different network for Medi-Cal managed care products
than for other products or if a health care service plan uses a
different network for individual market products than for small
group market products. The development and adoption of these
methodologies shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code) until January 1,
2020. The department shall consult with stakeholders in developing
standardized methodologies under this paragraph.

(g) (1) When evaluating compliance with the standards, the
department shall focus more upon patterns of noncompliance rather
than isolated episodes of noncompliance.

(2) The director may investigate and take enforcement action
against plans regarding noncompliance with the requirements of
this section. Where substantial harm to an enrollee has occurred
as a result of plan noncompliance, the director may, by order,
assess administrative penalties subject to appropriate notice of,
and the opportunity for, a hearing in accordance with Section 1397.
The plan may provide to the director, and the director may
consider, information regarding the plan’s overall compliance with
the requirements of this section. The administrative penalties shall
not be deemed an exclusive remedy available to the director. These
penalties shall be paid to the Managed Care Administrative Fines
and Penalties Fund and shall be used for the purposes specified in
Section 1341.45. The director shall periodically evaluate grievances
to determine if any audit, investigative, or enforcement actions
should be undertaken by the department.

(3) The director may, after appropriate notice and opportunity
for hearing in accordance with Section 1397, by order, assess
administrative penalties if the director determines that a health
care service plan has knowingly committed, or has performed with
a frequency that indicates a general business practice, either of the
following:

(A) Repeated failure to act promptly and reasonably to assure
timely access to care consistent with this chapter.

(B) Repeated failure to act promptly and reasonably to require
contracting providers to assure timely access that the plan is
required to perform under this chapter and that have been delegated
by the plan to the contracting provider when the obligation of the
plan to the enrollee or subscriber is reasonably clear.

(C) The administrative penalties available to the director
pursuant to this section are not exclusive, and may be sought and
employed in any combination with civil, criminal, and other
administrative remedies deemed warranted by the director to
enforce this chapter.

(4) The administrative penalties shall be paid to the Managed
Care Administrative Fines and Penalties Fund and shall be used
for the purposes specified in Section 1341.45.

(h) The department shall work with the patient advocate to
assure that the quality of care report card incorporates information
provided pursuant to subdivision (f) regarding the degree to which
health care service plans and health care providers comply with
the requirements for timely access to care.

(i) The department shall annually review information regarding
compliance with the standards developed under this section and
shall make recommendations for changes that further protect
enrollees. Commencing no later than December 1, 2015, and
annually thereafter, the department shall post its final findings
from the review on its Internet Web site.

(j) The department shall post on its Internet Web site any
waivers or alternative standards that the department approves under
this section on or after January 1, 2015.

begin insert

(k) For purposes of this section, “specialty physician” includes
a physician who meets the criteria for an HIV specialist as
published by the American Academy of HIV Medicine or the HIV
Medicine Association, or who is contracted to provide outpatient
medical care under the federal Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act of 1990 (Public Law 101-381).

end insert

SEC. 2.  

Section 1367.693 is added to the Health and Safety
Code, immediately following Section 1367.69, to read:

1367.693.  

(a) Every health care service plan contract that is
issued, amended, or renewed on or after January 1, 2017, that
provides hospital, medical, or surgical coverage shall include an
HIV specialist as an eligible primary care physician, provided he
or she meets the health care service plan’s eligibility criteria for
all specialists seeking primary care physician status.

(b) For purposes of this section, “primary care physician” means
a physician, as defined in Section 14254 of the Welfare and
Institutions Code, who has the responsibility for providing initial
and primary care to patients, for maintaining the continuity of
patient care, and for initiating referral for specialist care. This
means providing care for the majority of health care problems,
including, but not limited to, preventive services, acute and chronic
conditions, and psychosocial issues.

(c) For purposes of this section, “HIV specialist” means a
physician or a nurse practitioner who meets the criteria for an HIV
specialist as published by the American Academy of HIV Medicine
or the HIV Medicine Association, or who is contracted to provide
outpatient medical care under the federal Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990
(Public Law 101-381).

SEC. 3.  

Section 10123.833 is added to the Insurance Code, immediately following Section 10123.83, to read:

10123.833.  

(a) Every health insurance policy that is issued,
amended, or renewed on or after January 1, 2017, that provides
hospital, medical, or surgical coverage shall include an HIV
specialist as an eligible primary care physician, provided he or she
meets the health insurer’s eligibility criteria for all specialists
seeking primary care physician status.

(b) For purposes of this section, “primary care physician” means
a physician, as defined in Section 14254 of the Welfare and
Institutions Code, who has the responsibility for providing initial
and primary care to patients, for maintaining the continuity of
patient care, and for initiating referral for specialist care. This
means providing care for the majority of health care problems,
including, but not limited to, preventive services, acute and chronic
conditions, and psychosocial issues.

(c) For purposes of this section, “HIV specialist” means a
physician or a nurse practitioner who meets the criteria for an HIV
specialist as published by the American Academy of HIV Medicine
or the HIV Medicine Association, or who is contracted to provide
outpatient medical care under the federal Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990
(Public Law 101-381).

SEC. 4.  

Section 10133.5 of the Insurance Code is amended to
read:

10133.5.  

(a) The commissioner begin delete shall, on or before January 1,
2004, end delete begin insert shall end insert promulgate regulations applicable to health insurers
begin delete which end delete begin insert that end insert contract with providers for alternative rates pursuant
to Section 10133 to ensure that insureds have the opportunity to
access needed health care services in a timely manner.

(b) These regulations shall be designed to begin delete assure end delete begin insert ensure end insert
accessibility of provider services in a timely manner to individuals
comprising the insured or contracted group, pursuant to benefits
covered under the policy or contract. The regulations shall begin delete insure: end delete
begin insert ensure: end insert

begin delete

1. Adequacy

end delete

begin insert (1) end insert begin insert   end insert begin insert Adequacy end insert of number and locations of institutional facilities
and professional providers, and consultants in relationship to the
size and location of the insured group and that the services offered
are available at reasonable times.

begin delete

2. Adequacy

end delete

begin insert (2) end insert begin insert   end insert begin insert Adequacy end insert of number of professional providers, and license
classifications of such providers, in relationship to the projected
demands for services covered under the group policy or plan. The
department shall consider the nature of the specialty in determining
the adequacy of professional providers.

begin delete

3. The

end delete

begin insert (3) end insert begin insert   end insert begin insert The end insert policy or contract is not inconsistent with standards of
good health care and clinically appropriate care.

begin delete

4. 

end delete

begin insert (4) end insert begin insert   end insert All contracts begin insert , end insert including contracts with providers, and other
persons furnishing services begin delete , end delete or facilities begin insert , end insert shall be fair and
reasonable.

(c) In developing standards under subdivision (a), the department
shall also consider requirements under federal law; requirements
under other state programs and law, including utilization review;
and standards adopted by other states, national accrediting
organizations begin insert , end insert and professional associations. The department shall
further consider the accessability to provider services in rural areas.

(d) In designing the regulations begin insert , end insert the commissioner shall consider
the regulations in Title 28 begin delete , end delete of the California begin delete Administrative end delete Code
of Regulations, commencing with Section 1300.67.2, which are
applicable to Knox-Keene plans, and all other relevant guidelines
in an effort to accomplish maximum accessibility within a begin delete cost
efficient end delete begin insert cost-efficient end insert system of indemnification. The department
shall consult with the Department of Managed Health Care
concerning regulations developed by that department pursuant to
Section 1367.03 of the Health and Safety Code and shall seek
public input from a wide range of interested parties.

(e) Health insurers that contract for alternative rates of payment
with providers shall report annually on complaints received by the
insurer regarding timely access to care. The department shall
review these complaints and any complaints received by the
department regarding timeliness of care and shall make public this
information.

(f) The department shall report to the Assembly Committee on
Health and the Senate Committee on Insurance of the Legislature
on March 1, 2003, and on March 1, 2004, regarding the progress
towards the implementation of this section.

(g) Every three years, the commissioner shall review the latest
version of the regulations adopted pursuant to subdivision (a) and
shall determine if the regulations should be updated to further the
intent of this section.

begin insert

(h) For purposes of this section, “professional provider”
includes a physician who meets the criteria for an HIV specialist
as published by the American Academy of HIV Medicine or the
HIV Medicine Association, or who is contracted to provide
outpatient medical care under the federal Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990
(Public Law 101-381).

end insert

SEC. 5.  

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.