Senate Bill No. 931

Introduced by Senator Nguyen

February 1, 2016

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

LEGISLATIVE COUNSEL’S DIGEST

SB 931, as introduced, Nguyen. Health care service plans.

Under existing law, the Knox-Keene Health Care Service Plan Act of 1975, the Department of Managed Health Care licenses and regulates health care service plans. Existing law requires a health care service plan to meet certain requirements, including, but not limited to, having the organizational and administrative capacity to provide services to subscribers and enrollees and providing basic health care services, as defined, to those subscribers and enrollees, and having facilities licensed, as specified.

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

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

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

SECTION 1.  

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

1367.  

A health care service plan and, if applicable, a specialized
health care service plan shall meet begin insert all of end insert the following
requirements:

(a)  begin delete Facilities end delete begin insert A facility end insert located in this state including, but not
limited to, clinics, hospitals, and skilled nursing facilities to be
utilized by the plan shall be licensed by the State Department of
Public Health, begin delete where end delete begin insert if end insert licensure is required by law. begin delete Facilities end delete begin insert A
facility end insert not located in this state shall conform to all licensing and
other requirements of the jurisdiction in which begin delete they are end delete begin insert it is end insert located.

(b) Personnel employed by or under contract to the plan shall
be licensed or certified by their respective board or agency, begin delete where end delete
begin insert if end insert licensure or certification is required by law.

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

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

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

(2) To the extent that telehealth services are appropriately
provided through telehealth, as defined in subdivision (a) of Section
2290.5 of the Business and Professions Code, these services shall
be considered in determining compliance with Section 1300.67.2
of Title 28 of the California Code of Regulations.

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

(f) The plan shall employ and utilize allied health manpower
begin delete for the furnishing of end delete begin insert to furnish end insert services to the extent permitted by
law and consistent with good medical practice.

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

(h) (1) Contracts with subscribers and enrollees, including
group contracts, and contracts with providers, and other persons
furnishing services, equipment, or facilities to or in connection
with the plan, shall be fair, reasonable, and consistent with the
objectives of this chapter. All contracts with providers shall contain
provisions requiring a fast, fair, and cost-effective dispute
resolution mechanism under which providers may submit disputes
to the plan, and requiring the plan to inform its providers upon
contracting with the plan, or upon change to these provisions, of
the procedures for processing and resolving disputes, including
the location and telephone number where information regarding
disputes may be submitted.

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

(3)  begin delete On and after January 1, 2002, a end delete begin insert A end insert health care service plan
shall annually submit a report to the department regarding its
dispute resolution mechanism. The report shall include information
on the number of providers who utilized the dispute resolution
mechanism and a summary of the disposition of those disputes.

(i) A health care service plan contract shall provide to
subscribers and enrollees all of the basic health care services
included in subdivision (b) of Section 1345, except that the director
may, for good cause, by rule or order exempt a plan contract or
any class of plan contracts from that requirement. The director
shall by rule define the scope of each basic health care service that
health care service plans are required to provide as a minimum for
licensure under this chapter. begin delete Nothing in this chapter shall end delete begin insert This
chapter does not end insert prohibit a health care service plan from charging
subscribers or enrollees a copayment or a deductible for a basic
health care service consistent with Section 1367.006 or 1367.007,
provided that the copayments, deductibles, or other cost sharing
are reported to the director and set forth to the subscriber or
enrollee pursuant to the disclosure provisions of Section 1363.
begin delete Nothing in this chapter shall end delete begin insert This chapter does not end insert prohibit a health
care service plan from setting forth, by contract, limitations on
maximum coverage of basic health care services, provided that
the limitations are reported to, and held unobjectionable by, the
director and set forth to the subscriber or enrollee pursuant to the
disclosure provisions of Section 1363.

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

begin delete

Nothing in this

end delete

begin insert (k) end insert begin insert   end insert begin insert This end insert section shall begin insert not end insert be construed to permit the director to
establish the rates charged subscribers and enrollees for contractual
health care services.

begin delete

The

end delete

begin insert (l) end insert begin insert   end insert begin insert The end insert director’s enforcement of Article 3.1 (commencing with
Section 1357) begin delete shall not be deemed to end delete begin insert does not end insert establish the rates
charged begin insert to end insert subscribers and enrollees for contractual health care
services.

begin delete

The

end delete

begin insert (m) end insert begin insert   end insert begin insert The end insert obligation of the plan to comply with this chapter shall
not be waived when the plan delegates any services that it is
required to perform to its medical groups, independent practice
associations, or other contracting entities.