Amended in Assembly April 25, 2016

Amended in Assembly April 13, 2016

California Legislature—2015–16 Regular Session

Assembly BillNo. 2372


Introduced by Assembly Member Burke

(Principal coauthor: Assembly Member Waldron)

(Principal coauthor: Senator Hertzberg)

February 18, 2016


An act tobegin delete amend Section 1367.03 of, and toend delete add Section 1367.693begin delete to,end deletebegin insert toend insert the Health and Safety Code, and tobegin delete amend Section 10133.5 of, and toend delete add Section 10123.833begin delete to,end deletebegin insert toend insert the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

AB 2372, as amended, 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.begin insert Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions.end insert 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 wouldbegin delete define for these purposes “specialty physician” and “professional provider,” respectively, to include a physician who meets the criteria for an HIV specialist, as specified.end deletebegin insert require access to HIV specialists to be subject to the regulations, standards, and reporting requirements developed pursuant to the above specified provisions.end insert 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 provider, as defined, if the provider requests primary care provider status and meets the plan’s or health insurer’s eligibility criteria for all specialists seeking primary care provider 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:

begin delete
P2    1

SECTION 1.  

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

3

1367.03.  

(a) The department shall develop and adopt
4regulations to ensure that enrollees have access to needed health
5care services in a timely manner. In developing these regulations,
6the department shall develop indicators of timeliness of access to
7care and, in so doing, shall consider the following as indicators of
8timeliness of access to care:

9(1) Waiting times for appointments with physicians, including
10primary care and specialty physicians.

11(2) Timeliness of care in an episode of illness, including the
12timeliness of referrals and obtaining other services, if needed.

P3    1(3) Waiting time to speak to a physician, registered nurse, or
2other qualified health professional acting within his or her scope
3of practice who is trained to screen or triage an enrollee who may
4need care.

5(b) In developing these standards for timeliness of access, the
6department shall consider the following:

7(1) Clinical appropriateness.

8(2) The nature of the specialty.

9(3) The urgency of care.

10(4) The requirements of other provisions of law, including
11Section 1367.01 governing utilization review, that may affect
12timeliness of access.

13(c) The department may adopt standards other than the time
14elapsed between the time an enrollee seeks health care and obtains
15care. If the department chooses a standard other than the time
16elapsed between the time an enrollee first seeks health care and
17obtains it, the department shall demonstrate why that standard is
18more appropriate. In developing these standards, the department
19shall consider the nature of the plan network.

20(d) The department shall review and adopt standards, as needed,
21concerning the availability of primary care physicians, specialty
22physicians, hospital care, and other health care, so that consumers
23have timely access to care. In so doing, the department shall
24consider the nature of physician practices, including individual
25and group practices as well as the nature of the plan network. The
26department shall also consider various circumstances affecting the
27delivery of care, including urgent care, care provided on the same
28day, and requests for specific providers. If the department finds
29that health care service plans and health care providers have
30difficulty meeting these standards, the department may make
31recommendations to the Assembly Committee on Health and the
32Senate Committee on Insurance of the Legislature pursuant to
33subdivision (i).

34(e) In developing standards under subdivision (a), the department
35shall consider requirements under federal law, requirements under
36other state programs, standards adopted by other states, nationally
37recognized accrediting organizations, and professional associations.
38The department shall further consider the needs of rural areas,
39specifically those in which health facilities are more than 30 miles
40apart and any requirements imposed by the State Department of
P4    1Health Care Services on health care service plans that contract
2with the State Department of Health Care Services to provide
3Medi-Cal managed care.

4(f) (1) Contracts between health care service plans and health
5care providers shall ensure compliance with the standards
6developed under this section. These contracts shall require
7reporting by health care providers to health care service plans and
8by health care service plans to the department to ensure compliance
9with the standards.

10(2) Health care service plans shall report annually to the
11department on compliance with the standards in a manner specified
12by the department. The reported information shall allow consumers
13to compare the performance of plans and their contracting providers
14in complying with the standards, as well as changes in the
15compliance of plans with these standards.

16(3) The department may develop standardized methodologies
17for reporting that shall be used by health care service plans to
18demonstrate compliance with this section and any regulations
19adopted pursuant to it. The methodologies shall be sufficient to
20determine compliance with the standards developed under this
21section for different networks of providers if a health care service
22plan uses a different network for Medi-Cal managed care products
23than for other products or if a health care service plan uses a
24different network for individual market products than for small
25group market products. The development and adoption of these
26methodologies shall not be subject to the Administrative Procedure
27Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
28Division 3 of Title 2 of the Government Code) until January 1,
292020. The department shall consult with stakeholders in developing
30standardized methodologies under this paragraph.

31(g) (1) When evaluating compliance with the standards, the
32department shall focus more upon patterns of noncompliance rather
33than isolated episodes of noncompliance.

34(2) The director may investigate and take enforcement action
35against plans regarding noncompliance with the requirements of
36this section. Where substantial harm to an enrollee has occurred
37as a result of plan noncompliance, the director may, by order,
38assess administrative penalties subject to appropriate notice of,
39and the opportunity for, a hearing in accordance with Section 1397.
40The plan may provide to the director, and the director may
P5    1consider, information regarding the plan’s overall compliance with
2the requirements of this section. The administrative penalties shall
3not be deemed an exclusive remedy available to the director. These
4penalties shall be paid to the Managed Care Administrative Fines
5and Penalties Fund and shall be used for the purposes specified in
6Section 1341.45. The director shall periodically evaluate grievances
7to determine if any audit, investigative, or enforcement actions
8should be undertaken by the department.

9(3) The director may, after appropriate notice and opportunity
10for hearing in accordance with Section 1397, by order, assess
11administrative penalties if the director determines that a health
12care service plan has knowingly committed, or has performed with
13a frequency that indicates a general business practice, either of the
14following:

15(A) Repeated failure to act promptly and reasonably to assure
16timely access to care consistent with this chapter.

17(B) Repeated failure to act promptly and reasonably to require
18contracting providers to assure timely access that the plan is
19required to perform under this chapter and that have been delegated
20by the plan to the contracting provider when the obligation of the
21plan to the enrollee or subscriber is reasonably clear.

22(C) The administrative penalties available to the director
23pursuant to this section are not exclusive, and may be sought and
24employed in any combination with civil, criminal, and other
25administrative remedies deemed warranted by the director to
26enforce this chapter.

27(4) The administrative penalties shall be paid to the Managed
28Care Administrative Fines and Penalties Fund and shall be used
29for the purposes specified in Section 1341.45.

30(h) The department shall work with the patient advocate to
31assure that the quality of care report card incorporates information
32provided pursuant to subdivision (f) regarding the degree to which
33health care service plans and health care providers comply with
34the requirements for timely access to care.

35(i) The department shall annually review information regarding
36compliance with the standards developed under this section and
37shall make recommendations for changes that further protect
38enrollees. Commencing no later than December 1, 2015, and
39annually thereafter, the department shall post its final findings
40from the review on its Internet Web site.

P6    1(j) The department shall post on its Internet Web site any
2waivers or alternative standards that the department approves under
3this section on or after January 1, 2015.

4(k) For purposes of this section, “specialty physician” includes
5a physician who meets the criteria for an HIV specialist as
6published by the American Academy of HIV Medicine or the HIV
7Medicine Association, or who is contracted to provide outpatient
8medical care under the federal Ryan White Comprehensive AIDS
9Resources Emergency (CARE) Act of 1990 (Public Law 101-381).

end delete
10

begin deleteSEC. 2.end delete
11
begin insertSECTION 1.end insert  

Section 1367.693 is added to the Health and Safety
12Code
, immediately following Section 1367.69, to read:

13

1367.693.  

(a) Every health care service plan contract that is
14issued, amended, or renewed on or after January 1, 2017, that
15provides hospital, medical, or surgicalbegin delete coverageend deletebegin insert coverage,
16excluding specialized health care service plan contracts,end insert
shall
17include an HIV specialist as an eligible primary care provider, if
18the provider requests primary care provider status and meets the
19health care service plan’s eligibility criteria for all specialists
20seeking primary care provider status.

21(b) For purposes of this section, “primary care provider” means
22a physician or a nonphysician medical practitioner, as each term
23is defined in Section 14254 of the Welfare and Institutions Code,
24who has the responsibility for providing initial and primary care
25to patients, for maintaining the continuity of patient care, and for
26initiating referral for specialist care. This means providing care
27for the majority of health care problems, including, but not limited
28to, preventive services, acute and chronic conditions, and
29psychosocial issues.

begin insert

30
(c) Access to HIV specialists shall be subject to the regulations
31developed pursuant to Section 1367.03 and shall be included in
32the reports and other information required under Section 1367.035,
33consistent with the specialty designation.

end insert
begin delete

22 34(c)

end delete

35begin insert(d)end insert For purposes of this section, “HIV specialist” means a
36begin delete physicianend deletebegin insert physician, physician assistant,end insert or a nurse practitioner
37who meets the criteria for an HIV specialist as published by the
38American Academy of HIV Medicine or the HIV Medicine
39Association, or who is contracted to provide outpatient medical
P7    1care under the federal Ryan White Comprehensive AIDS Resources
2Emergency (CARE) Act of 1990 (Public Law 101-381).

3

begin deleteSEC. 3.end delete
4
begin insertSEC. 2.end insert  

Section 10123.833 is added to the Insurance Code, 5immediately following Section 10123.83, to read:

6

10123.833.  

(a) Every health insurance policy that is issued,
7amended, or renewed on or after January 1, 2017, that provides
8hospital, medical, or surgicalbegin delete coverageend deletebegin insert coverage, excluding
9specialized health insurance policies,end insert
shall include an HIV
10specialist as an eligible primary care provider, if the provider
11requests primary care provider status and meets the health insurer’s
12eligibility criteria for all specialists seeking primary care provider
13status.

14(b) For purposes of this section, “primary care provider” means
15a physician or a nonphysician medical practitioner, as each term
16is defined in Section 14254 of the Welfare and Institutions Code,
17who has the responsibility for providing initial and primary care
18to patients, for maintaining the continuity of patient care, and for
19initiating referral for specialist care. This means providing care
20for the majority of health care problems, including, but not limited
21to, preventive services, acute and chronic conditions, and
22psychosocial issues.

begin insert

23
(c) Access to HIV specialists shall be subject to the regulations
24developed pursuant to Section 10133.5, consistent with the
25specialty designation.

end insert
begin delete

7 26(c)

end delete

27begin insert(d)end insert For purposes of this section, “HIV specialist” means a
28begin delete physicianend deletebegin insert physician, physician assistant,end insert or a nurse practitioner
29who meets the criteria for an HIV specialist as published by the
30American Academy of HIV Medicine or the HIV Medicine
31Association, or who is contracted to provide outpatient medical
32care under the federal Ryan White Comprehensive AIDS Resources
33Emergency (CARE) Act of 1990 (Public Law 101-381).

begin delete
34

SEC. 4.  

Section 10133.5 of the Insurance Code is amended to
35read:

36

10133.5.  

(a) The commissioner shall promulgate regulations
37applicable to health insurers that contract with providers for
38alternative rates pursuant to Section 10133 to ensure that insureds
39have the opportunity to access needed health care services in a
40timely manner.

P8    1(b) These regulations shall be designed to ensure accessibility
2of provider services in a timely manner to individuals comprising
3the insured or contracted group, pursuant to benefits covered under
4the policy or contract. The regulations shall ensure:

5(1) Adequacy of number and locations of institutional facilities
6and professional providers, and consultants in relationship to the
7size and location of the insured group and that the services offered
8are available at reasonable times.

9(2) Adequacy of number of professional providers, and license
10classifications of such providers, in relationship to the projected
11demands for services covered under the group policy or plan. The
12department shall consider the nature of the specialty in determining
13the adequacy of professional providers.

14(3) The policy or contract is not inconsistent with standards of
15good health care and clinically appropriate care.

16(4) All contracts, including contracts with providers, and other
17persons furnishing services or facilities, shall be fair and
18reasonable.

19(c) In developing standards under subdivision (a), the department
20shall also consider requirements under federal law; requirements
21under other state programs and law, including utilization review;
22and standards adopted by other states, national accrediting
23organizations, and professional associations. The department shall
24further consider the accessability to provider services in rural areas.

25(d) In designing the regulations, the commissioner shall consider
26the regulations in Title 28 of the California Code of Regulations,
27commencing with Section 1300.67.2, which are applicable to
28Knox-Keene plans, and all other relevant guidelines in an effort
29to accomplish maximum accessibility within a cost-efficient system
30of indemnification. The department shall consult with the
31Department of Managed Health Care concerning regulations
32developed by that department pursuant to Section 1367.03 of the
33Health and Safety Code and shall seek public input from a wide
34range of interested parties.

35(e) Health insurers that contract for alternative rates of payment
36with providers shall report annually on complaints received by the
37insurer regarding timely access to care. The department shall
38review these complaints and any complaints received by the
39department regarding timeliness of care and shall make public this
40information.

P9    1(f) The department shall report to the Assembly Committee on
2Health and the Senate Committee on Insurance of the Legislature
3on March 1, 2003, and on March 1, 2004, regarding the progress
4towards the implementation of this section.

5(g) Every three years, the commissioner shall review the latest
6version of the regulations adopted pursuant to subdivision (a) and
7shall determine if the regulations should be updated to further the
8intent of this section.

9(h) For purposes of this section, “professional provider” includes
10a physician who meets the criteria for an HIV specialist as
11published by the American Academy of HIV Medicine or the HIV
12Medicine Association, or who is contracted to provide outpatient
13medical care under the federal Ryan White Comprehensive AIDS
14Resources Emergency (CARE) Act of 1990 (Public Law 101-381).

end delete
15

begin deleteSEC. 5.end delete
16
begin insertSEC. 3.end insert  

No reimbursement is required by this act pursuant to
17Section 6 of Article XIII B of the California Constitution because
18the only costs that may be incurred by a local agency or school
19district will be incurred because this act creates a new crime or
20infraction, eliminates a crime or infraction, or changes the penalty
21for a crime or infraction, within the meaning of Section 17556 of
22the Government Code, or changes the definition of a crime within
23the meaning of Section 6 of Article XIII B of the California
24Constitution.



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