Senate Bill No. 289

Introduced by Senator Mitchell

February 23, 2015

An act to add Section 1374.14 to the Health and Safety Code, and to add Section 10123.855 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 289, as introduced, Mitchell. Telephonic and electronic patient management 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 also provides for the regulation of health insurers by the Insurance Commissioner. Existing law prohibits a health care service plan or health insurer from requiring in-person contact between a health care provider and a patient before payment is made for covered services appropriately provided through telehealth, which is defined to mean the mode of delivering health care services via information and communication technologies, as specified.

This bill would require a health care service plan or a health insurer, with respect to plan contracts and policies issued, amended, or renewed on or after January 1, 2016, to cover telephonic and electronic patient management services, as defined, provided by a physician or nonphysician health care provider and reimburse those services based on their complexity and time expenditure. The bill would provide that a health care service plan or a health insurer is not required to reimburse separately for specified telephonic or electronic visits, including a telephonic or electronic visit provided as part of a bundle of services reimbursed in a specified manner. Because a willful violation of the bill’s requirements by a health care service plan would be a crime, this 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 1374.14 is added to the Health and Safety
Code, to read:

1374.14.  

(a) A health care service plan shall, with respect to
plan contracts issued, amended, or renewed on or after January 1,
2016, cover telephonic and electronic patient management services
provided by a physician or nonphysician health care provider and
reimburse those services based on their complexity and time
expenditure.

(b) This section shall not be construed to authorize a health care
service plan to require the use of telephonic and electronic patient
management services when the physician or nonphysician health
care provider has determined that those services are not medically
appropriate.

(c) This section shall not be construed to alter the scope of
practice of a health care provider or authorize the delivery of health
care services in a setting, or in a manner, that is not otherwise
authorized by law.

(d) All laws regarding the confidentiality of health information
and a patient’s rights to his or her medical information shall apply
to telephonic and electronic patient management services.

(e) This section shall not apply to a patient under the jurisdiction
of the Department of Corrections and Rehabilitation or any other
correctional facility.

(f) Notwithstanding subdivision (a), a health care service plan
shall not be required to reimburse separately for any of the
following:

(1) A telephonic or electronic visit that is related to a service or
procedure provided to an established patient within a reasonable
period of time prior to the telephonic or electronic visit, as
recognized by the American Medical Association, Current
Procedural Terminology codes.

(2) A telephonic or electronic visit that leads to a related service
or procedure provided to an established patient within a reasonable
period of time, or within an applicable postoperative period, as
recognized by the American Medical Association, Current
Procedural Terminology codes.

(3) A telephonic or electronic visit provided as part of a bundle
of services for which reimbursement is provided for on a prepaid
basis, including capitation, or for which reimbursement is provided
for using an episode-based payment methodology.

(4) A telephonic or electronic visit that is not initiated by the
established patient, or the parents or guardians of a minor who is
an established patient, or an established patient’s legally recognized
health care decisionmaker.

(g) Nothing in this section shall be construed to prohibit a health
care service plan from requiring documentation reasonably relevant
to a telephonic or electronic visit, as recognized by the American
Medical Association, Current Procedural Terminology codes.

(h) For purposes of this section, the following definitions apply:

(1) “Established patient” means a patient who, within three
years immediately preceding the telephonic or electronic visit, has
received professional services from the provider or another provider
of the exact same specialty and subspecialty who belongs to the
same group practice.

(2) “Nonphysician health care provider” means a provider, other
than a physician, who is licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions
Code.

(3) “Telephonic and electronic patient management services”
means the use of electronic communication tools to enable treating
physicians to evaluate and manage established patients in a manner
that meets all of the following criteria:

(A) Do not require a face-to-face visit with the physician or
nonphysician health care provider.

(B) Are initiated by the established patient, the parents or
guardians of a minor who is an established patient, or an established
patient’s legally recognized health care decisionmaker. For
purposes of this section, “initiated by the established patient”
excludes a visit for which a provider or staff contacts a patient to
initiate a service.

(C) Are recognized by the American Medical Association,
Current Procedural Terminology codes.

SEC. 2.  

Section 10123.855 is added to the Insurance Code, to
read:

10123.855.  

(a) A health insurer shall, with respect to health
insurance policies issued, amended, or renewed on or after January
1, 2016, cover telephonic and electronic patient management
services provided by a physician or nonphysician health care
provider and reimburse those services based on their complexity
and time expenditure.

(b) This section shall not be construed to authorize a health
insurer to require the use of telephonic and electronic patient
management services when the physician or nonphysician health
care provider has determined that those services are not medically
appropriate.

(c) This section shall not be construed to alter the scope of
practice of a health care provider or authorize the delivery of health
care services in a setting, or in a manner, that is not otherwise
authorized by law.

(d) All laws regarding the confidentiality of health information
and a patient’s rights to his or her medical information shall apply
to telephonic and electronic patient management services.

(e) This section shall not apply to a patient under the jurisdiction
of the Department of Corrections and Rehabilitation or any other
correctional facility.

(f) Notwithstanding subdivision (a), a health insurer shall not
be required to reimburse separately for any of the following:

(1) A telephonic or electronic visit that is related to a service or
procedure provided to an established patient within a reasonable
period of time prior to the telephonic or electronic visit, as
recognized by the American Medical Association, Current
Procedural Terminology codes.

(2) A telephonic or electronic visit that leads to a related service
or procedure provided to an established patient within a reasonable
period of time, or within an applicable postoperative period, as
recognized by the American Medical Association, Current
Procedural Terminology codes.

(3) A telephonic or electronic visit provided as part of a bundle
of services for which separate reimbursement is not consistent
with the American Medical Association, Current Procedural
Terminology codes.

(4) A telephonic or electronic visit that is not initiated by the
established patient, the parents or guardians of a minor who is an
established patient, or an established patient’s legally recognized
health care decisionmaker.

(g) Nothing in this section shall be construed to prohibit a health
insurer from requiring documentation reasonably relevant to a
telephonic or electronic visit, as recognized by the American
Medical Association, Current Procedural Terminology codes.

(h) For purposes of this section, the following definitions apply:

(1) “Established patient” means a patient who, within the three
years immediately preceding the telephonic or electronic visit, has
received professional services from the provider, or another
provider of the exact same specialty and subspecialty who belongs
to the same group practice.

(2) “Nonphysician health care provider” means a provider, other
than a physician, who is licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions
Code.

(3) “Telephonic and electronic patient management services”
means the use of electronic communication tools to enable treating
physicians to evaluate and manage established patients in a manner
that meets all of the following criteria:

(A) Do not require a face-to-face visit with the physician or
nonphysician health care provider.

(B) Are initiated by the established patient, the parents or
guardians of a minor who is an established patient, or an established
patient’s legally recognized health care decisionmaker. For
purposes of this section, “initiated by the established patient”
excludes a visit for which a provider or staff contacts a patient to
initiate a service.

(C) Are recognized by the American Medical Association,
Current Procedural Terminology codes.

SEC. 3.  

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.