BILL NUMBER: AB 12	ENROLLED
	BILL TEXT

	PASSED THE SENATE   SEPTEMBER 9, 1999
	PASSED THE ASSEMBLY   SEPTEMBER 9, 1999
	AMENDED IN SENATE   SEPTEMBER 7, 1999
	AMENDED IN SENATE   AUGUST 24, 1999
	AMENDED IN SENATE   AUGUST 16, 1999
	AMENDED IN SENATE   JULY 1, 1999
	AMENDED IN ASSEMBLY   MAY 25, 1999

INTRODUCED BY   Assembly Member Davis
   (Coauthor:  Assembly Member Correa)

                        DECEMBER 7, 1998

   An act to add Section 1383.15 to the Health and Safety Code, and
to add Section 10123.68 to the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 12, Davis.  Health care coverage:  second opinions.
   Under existing law, the Knox-Keene Health Care Service Plan Act of
1975, health care service plans are regulated by the Commissioner of
Corporations.  Existing law provides that disability insurers are
regulated by the Insurance Commissioner.  Willful violation of the
law regulating health care service plans is a crime.
   Existing law requires health care service plans and certain
disability insurers to file a written policy describing the manner in
which the plans or insurers determine if a 2nd medical opinion is
medically necessary and appropriate.
   This bill would require a health care service plan and certain
disability insurers to provide or authorize a 2nd opinion by an
appropriately qualified health care professional if requested by an
enrollee or an insured, or a participating or contracting health
professional who is treating an enrollee or insured.  The bill would
also specify reasons for a 2nd opinion to be provided or authorized
if, among other things, any one of 5 specified conditions occurs.
The bill would also specify the mechanism for obtaining a 2nd opinion
and the eligible providers for rendering a 2nd opinion.
   This bill would also require an authorization or denial to be
provided in an expeditious manner and would prescribe the conditions
under which a second opinion must be rendered within 72 hours, would
require that the plan or insurer file timelines for responding to
requests for 2nd opinions, as described, by July 1, 2000, with the
appropriate state agency, and would require that the timelines be
made available to the public upon request.  This bill would not apply
to health care service plan contracts that provide benefits to
enrollees through preferred provider contracting arrangements and
that do not limit 2nd medical opinions, to disability insurers that
do not limit 2nd medical opinions, or to certain other specialized
types of health insurance.
   By changing the definition of a crime regarding health care
service plans, 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.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 1383.15 is added to the Health and Safety Code,
immediately following Section 1383.1, to read:
   1383.15.  (a) When requested by an enrollee or participating
health professional who is treating an enrollee, a health care
service plan shall provide or authorize a second opinion by an
appropriately qualified health care professional.  Reasons for a
second opinion to be provided or authorized shall include, but are
not limited to, the following:
   (1) If the enrollee questions the reasonableness or necessity of
recommended surgical procedures.
   (2) If the enrollee questions a diagnosis or plan of care for a
condition that threatens loss of life, loss of limb, loss of bodily
function, or substantial impairment, including, but not limited to, a
serious chronic condition.
   (3) If the clinical indications are not clear or are complex and
confusing, a diagnosis is in doubt due to conflicting test results,
or the treating health professional is unable to diagnose the
condition, and the enrollee requests an additional diagnosis.
   (4) If the treatment plan in progress is not improving the medical
condition of the enrollee within an appropriate period of time given
the diagnosis and plan of care, and the enrollee requests a second
opinion regarding the diagnosis or continuance of the treatment.
   (5) If the enrollee has attempted to follow the plan of care or
consulted with the initial provider concerning serious concerns about
the diagnosis or plan of care.
   (b) For purposes of this section, an appropriately qualified
health care professional is a primary care physician or a specialist
who is acting within his or her scope of practice and who possesses a
clinical background, including training and expertise, related to
the particular illness, disease, condition or conditions associated
with the request for a second opinion.
   (c) If an enrollee or participating health professional who is
treating an enrollee requests a second opinion pursuant to this
section, an authorization or denial shall be provided in an
expeditious manner.  When the enrollee's condition is such that the
enrollee faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or
other major bodily function, or lack of timeliness that would be
detrimental to the enrollee's ability to regain maximum function, the
second opinion shall be rendered in a timely fashion appropriate for
the nature of the enrollee's condition, not to exceed 72 hours after
the plan's receipt of the request, whenever possible.  Each plan
shall file with the Department of Managed Care timelines for
responding to requests for second opinions for cases involving
emergency needs, urgent care, and other requests by July 1, 2000, and
within 30 days of any amendment to the timelines.  The timelines
shall be made available to the public upon request.
   (d) If a health care service plan approves a request by an
enrollee for a second opinion, the enrollee shall be responsible only
for the costs of applicable copayments that the plan requires for
similar referrals.
   (e) If the enrollee is requesting a second opinion about care from
his or her primary care physician, the second opinion shall be
provided by an appropriately qualified health care professional of
the enrollee's choice within the same physician organization.
   (f) If the enrollee is requesting a second opinion about care from
a specialist, the second opinion shall be provided by any provider
of the enrollee's choice from any independent practice association or
medical group within the network of the same or equivalent
specialty.  If the specialist is not within the same physician
organization, the plan shall incur the cost or negotiate the fee
arrangements of that second opinion, beyond the applicable copayments
which shall be paid by the enrollee.  If not authorized by the plan,
additional medical opinions not within the original physician
organization shall be the responsibility of the enrollee.
   (g) If there is no participating plan provider within the network
who meets the standard specified in subdivision (b), then the plan
shall authorize a second opinion by an appropriately qualified health
professional outside of the plan's provider network.  In approving a
second opinion either inside or outside of the plan's provider
network, the plan shall take into account the ability of the enrollee
to travel to the provider.
   (h) The health care service plan shall require the second opinion
health professional to provide the enrollee and the initial health
professional with a consultation report, including any recommended
procedures or tests that the second opinion health professional
believes appropriate.  Nothing in this section shall be construed to
prevent the plan from authorizing, based on its independent
determination, additional medical opinions concerning the medical
condition of an enrollee.
   (i) If the health care service plan denies a request by an
enrollee for a second opinion, it shall notify the enrollee in
writing of the reasons for the denial and shall inform the enrollee
of the right to file a grievance with the plan.  The notice shall
comply with subdivision (b) of Section 1368.02.
   (j) Unless authorized by the plan, in order for services to be
covered the enrollee shall obtain services only from a provider who
is participating in, or under contract with, the plan pursuant to the
specific contract under which the enrollee is entitled to health
care services.  The plan may limit referrals to its network of
providers if there is a participating plan provider who meets the
standard specified in subdivision (b).
   (k) This section shall not apply to health care service plan
contracts that provide benefits to enrollees through preferred
provider contracting arrangements if, subject to all other terms and
conditions of the contract that apply generally to all other
benefits, access to and coverage for second opinions are not limited.

  SEC. 2.  Section 10123.68 is added to the Insurance Code,
immediately following Section 10123.67, to read:
   10123.68.  (a) When requested by an insured or contracting health
professional who is treating an insured, a disability insurer that
covers hospital, medical, or surgical expenses shall authorize a
second opinion by an appropriately qualified health care
professional.  Reasons for a second opinion to be provided or
authorized shall include, but are not limited to, the following:
   (1) If the insured questions the reasonableness or necessity of
recommended surgical procedures.
   (2) If the insured questions a diagnosis or plan of care for a
condition that threatens loss of life, loss of limb, loss of bodily
function, or substantial impairment, including, but not limited to, a
serious chronic condition.
   (3) If clinical indications are not clear or are complex and
confusing, a diagnosis is in doubt due to conflicting test results,
or the treating health professional is unable to diagnose the
condition and the insured requests an additional diagnosis.
   (4) If the treatment plan in progress is not improving the medical
condition of the insured within an appropriate period of time given
the diagnosis and plan of care, and the insured requests a second
opinion regarding the diagnosis or continuance of the treatment.
   (5) If the insured has attempted to follow the plan of care or
consulted with the initial provider concerning serious concerns about
the diagnosis or plan of care.
   (b) For purposes of this section, an appropriately qualified
health care professional is a primary care physician or a specialist
who is acting within his or her scope of practice and who possesses a
clinical background, including training and expertise, related to
the particular illness, disease, condition or conditions associated
with the request for a second opinion.
   (c) If an insured or participating health professional who is
treating an insured requests a second opinion pursuant to this
section, an authorization or denial shall be provided in an
expeditious manner.  When the insured's condition is such that the
insured faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or
other major bodily function, or lack of timeliness that would be
detrimental to the insured's life or health or could jeopardize the
insured's ability to regain maximum function, the second opinion
shall be rendered in a timely fashion appropriate to the nature of
the insured's condition, no to exceed 72 hours after the insurer's
receipt of the request, whenever possible.  Each insurer shall file
with the Department of Insurance timelines for responding to requests
for second opinions for cases involving emergency needs, urgent
care, and other requests by July 1, 2000, and within 30 days of any
amendment to the timelines.  The timelines shall be made available to
the public upon request.
   (d) If an insurer approves a request by an insured for a second
opinion, the insured shall be responsible only for the costs of
applicable copayments that the insurer requires for similar
referrals.
   (e) If the insured is requesting a second opinion about care from
his or her primary care physician, the second opinion shall be
provided by an appropriately qualified health care professional of
the insured's choice who is contracted with the insurer.
   (f) If the insured is requesting a second opinion about care from
a specialist, the second opinion shall be provided by any provider of
the same or equivalent specialty, of the insured's choice, within
the insurer's provider network, if the insurance contract limits
second opinions to within a network.
   (g) The insurer may limit second opinions to its network of
providers if the insurance contract limits the benefit to within a
network of providers and there is a participating provider who meets
the standard specified in subdivision (b).  If there is no
participating provider who meets this standard, then the insurer
shall authorize a second opinion by an appropriately qualified health
professional outside of the insurer's provider network.  In
approving a second opinion either inside or outside of the insurer's
provider network, the insurer shall take into account the ability of
the insured to travel to the provider.
   (h) The insurer shall require the second opinion health
professional to provide the insured and the initial health
professional with a consultation report, including any recommended
procedures or tests that the second opinion health professional
believes appropriate.  Nothing in this section shall be construed to
prevent the insurer from authorizing, based on its independent
determination, additional medical opinions concerning the medical
condition of an insured.
   (i) If the insurer denies a request by an insured for a second
opinion, it shall notify the insured in writing of the reasons for
the denial and shall inform the insured of the right to dispute the
denial, and the procedures for exercising that right.
   (j) If the insurance contract limits health care services to
within a network of providers, in order for coverage to be in force,
the insured shall obtain services only from a provider who is
participating in, or under contract with, the insurer pursuant to the
specific insurance contract under which the insured is entitled to
health care service benefits.
   (k) This section shall not apply to any policy or contract of
disability insurance that covers hospital, medical, or surgical
expenses and that does not limit second opinions, subject to all
other terms and conditions of the contract.
   (l) This section shall not apply to accident-only, specified
disease, or hospital indemnity health insurance policies.
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB 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 XIIIB of the California Constitution.