BILL ANALYSIS Ó
AB 2372
Page 1
Date of Hearing: April 12, 2016
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Rudy Salas, Chair
AB 2372
(Burke) - As Introduced February 18, 2016
NOTE: This bill is double-referred, and if passed by this
Committee, it will be referred to the Assembly Committee on
Health.
SUBJECT: Health care coverage: HIV specialists.
SUMMARY: Requires a health care service plan contract or health
insurance policy that is issued, amended, or renewed on or after
January 1, 2017, to include a HIV specialist, as defined, as an
eligible primary care physician, provided that the physician
meets the plan's or health insurer's eligibility criteria for
all specialists seeking primary care physician status.
EXISTING LAW:
1)Requires the Department of Managed Health Care (DMHC) to adopt
regulations to ensure that enrollees have access to needed
health care services in a timely manner, as specified.
(Health and Safety Code (HSC) § 1367.03)
2)Provides that every health care service plan contract that
provides hospital, medical, or surgical coverage, that is
issued, amended, delivered, or renewed in this state, shall
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include obstetrician-gynecologists as eligible primary care
physicians, provided they meet the plan's eligibility criteria
for all specialists seeking primary care physician status.
(HSC § 1367.69(a))
3)Defines, for purposes of this section, "primary care
physician" as a physician, as defined in the Welfare and
Institutions Code (WIC) § 14254, 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. (HSC § 1367.69(b))
4)Requires the Insurance Commissioner to promulgate regulations
applicable to health insurers that contract with providers for
alternative rates for group policy holders to ensure that
insureds have the opportunity to access needed health care
services in a timely manner, as specified. (Insurance (INS)
§ 10133.5)
5)Provides that every policy of disability insurance that covers
hospital, medical, or surgical expenses and is issued,
amended, delivered, or renewed in this state shall include
obstetrician-gynecologists as eligible primary care physicians
provided they meet the insurer's written eligibility criteria
for all specialists seeking primary care physician status.
(INS § 10123.83(a))
6)Defines, for purposes of this section, "primary care
physician" as a physician, as defined in WIC § 14254, 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
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providing care for the majority of health care problems,
including, but not limited to, preventive services, acute and
chronic conditions, and psychosocial issues. (INS §
10123.83(b))
THIS BILL:
1)Defines "specialty physician," for purposes of the DMHC's
access regulations under HSC § 1367.03, as including a
physician who meets the criteria for a 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).
2)Provides that 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
a 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.
3)Defines, for purposes of this section, "primary care
physician" as a physician, as defined in WIC § 14254, 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.
4)Defines, for purposes of this section, "HIV specialist" as a
physician or a nurse practitioner who meets the criteria for a
HIV specialist as published by the American Academy of HIV
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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).
5)Defines, for purposes of the Insurance Commissioners group
policy access regulations, "professional provider" as a
physician who meets the criteria for a 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).
6)Provides that 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 a 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.
7)Defines, for purposes of this section, "primary care
physician" as a physician, as defined in WIC § 14254, 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.
8)Defines, for purposes of this section, "HIV specialist" as a
physician or a nurse practitioner who meets the criteria for a
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
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White Comprehensive AIDS Resources Emergency (CARE) Act of
1990 (Public Law 101-381).
FISCAL EFFECT: Unknown. This bill is keyed fiscal by the
Legislative Counsel.
COMMENTS:
Purpose. This bill is sponsored by the AIDS Healthcare
Foundation . According to the author, "Californians living with
HIV should have access to care from physicians and other
providers with the training and experience required to meet
their complex needs. While health plans currently include
infectious disease specialists in their provider networks, not
all infectious disease specialists are HIV specialists. Studies
have shown that patients with HIV who are managed by clinicians
with greater HIV experience and expertise have better health
outcomes and receive more appropriate and cost-effective care.
By clearly defining access to HIV specialists in statute,
including them in the category of specialty physicians, and
allowing HIV specialists to serve as primary care providers for
their patients, we can ensure that patients receive the care
they need."
Background. Existing law requires health plans and health
insurance carriers to meet network adequacy standards, which
ensure that beneficiaries and insured individuals have timely
access to care, including access to medically-necessary
specialists. According to the sponsor, there has been an issue
with health plans relying upon infectious disease specialists to
meet their network needs. The sponsor notes that, while "all
HIV specialists are infectious disease specialists, most
infectious disease specialists are not HIV specialists and do
not have the training or experience to treat the complex and
unique needs of patients living with HIV." As a result, this
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bill seeks to do two things: 1) require a health plan to use a
qualified HIV specialist as a PCP, and 2) include HIV specialist
physicians as a category of specialty physicians for purposes of
network adequacy.
HIV Specialist as a PCP. According to the author, "because of
the unique and life-long care provided by HIV specialists, many
of them become the patient's de facto primary care physician.
However, because the plans do not recognize them as a PCP, the
HIV specialist cannot order tests, make referrals to other
specialists or any of the other services a PCP can provide, even
though the plan PCP provided to the person with HIV does nothing
more than act as a proxy for the HIV specialist when authorizing
services for the patient with HIV."
To resolve the issue, this bill would require that health plans
and health insurance policies allow a HIV specialist to serve as
a primary care physician if the specialist meets the health plan
or carrier's requirements for a PCP. Because a physician's
scope of practice is unlimited, it would be up to the individual
specialist to determine whether serving as a HIV patient's
primary care physician is within the specialist's competence.
CHBRP Analysis. Because this bill creates a health plan
mandate, it is currently under review by the California Health
Benefits Review Program (CHBRP). The CHBRP responds to requests
from the State Legislature to provide independent analysis of
the medical, financial, and public health impacts of proposed
health insurance benefit mandates and repeals. The CHBRP
analysis is expected to be completed by the time this bill is
heard in the Assembly Health Committee.
Prior Related Legislation. AB 2168 (Gallegos), Chapter 426,
Statutes of 2000, required health plans to develop procedures
for standing referrals to an HIV specialist.
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AB 2493 (Speier), Chapter 759, Statutes of 1995, required that
health care service plan contracts, nonprofit hospital service
plan contracts, and disability insurance policies, that cover
hospital, medical, or surgical expenses, issued, amended,
delivered, or renewed in this state , include
obstetrician-gynecologists as primary care physicians or
providers, as defined, provided they meet certain eligibility
criteria.
IMPLEMENTATION ISSUES:
One of the goals of the bill is to include nurse practitioners
(NPs) as HIV specialists eligible for inclusion as primary care
physicians. However, because NPs are not physicians as defined
under WIC § 14254, the bill as written does not include them.
AMENDMENTS:
To address the implementation issue mentioned above, and provide
additional clarity, the author should make the following
amendments:
9)Strike all references to "primary care physician" and replace
with "primary care provider."
10)Add "or a nonphysician medical practitioner, as defined in
Section 14254 of the Welfare and Institutions Code" to the
definition of "primary care provider."
11)Include additional clarifying language specifying that a HIV
specialist must meet a health plan's network criteria for
inclusion as primary care provider before the health plan is
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required to include the specialist.
REGISTERED SUPPORT:
AIDS Healthcare Foundation (sponsor)
REGISTERED OPPOSITION:
None on file.
Analysis Prepared by:Vincent Chee / B. & P. / (916) 319-3301