BILL NUMBER: AB 525 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 1, 1999
AMENDED IN ASSEMBLY APRIL 5, 1999
INTRODUCED BY Assembly Members Kuehl and Thomson
(Coauthors: Assembly Members Aroner, Calderon, Firebaugh, Honda,
Jackson, Keeley, Longville, Mazzoni, Romero, Shelley, and Wildman)
(Coauthors: Senators Figueroa, Hayden, and Solis)
FEBRUARY 18, 1999
An act to amend Sections 5914, 5917, and 5919 of the Corporations
Code, to amend Sections 15438.5, 15459, 22774, 22778, and 22790 of
the Government Code, to amend Sections 1345 , 1363, 1367.10,
and 129050 of, and to add Sections 1367.01, 1367.105,
1367.696, 1367.697, and 129021 to, the
Health and Safety Code, to amend Sections 10123.12, 10140,
10291.5, 10604, and 10705 and 10291.5 of, and to
add Sections 10123.01, 10123.22, 10123.89,
10198.71, 10604.1, and 10702.2
10702.2, and 10705.1 to, the Insurance Code, and to amend
Sections 14016.5, 14087.305, 14089, and 14165.6 of, and to add
Sections 14016.71, 14016.8, and 14016.9 to, the Welfare and
Institutions Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 525, as amended, Kuehl. Health benefits.
(1) Existing law requires a nonprofit corporation that is subject
to the public benefit corporation law and is a health facility to
give written notice to the Attorney General prior to entering into
any agreement or transaction to dispose of its assets to a for-profit
corporation or mutual benefit corporation when a material amount of
the assets of the public benefit corporation are involved in the
agreement or transaction. Written notice is also required to
transfer control, responsibility, or governance of a material amount
of assets or operations.
This bill would require, instead, written notice under this
provision from any foreign corporation, as defined, or public benefit
corporation that owns or controls a health facility or facility that
provides similar health care with regard to disposing of assets or
transferring control, responsibility or governance to any other
entity.
(2) Existing law authorizes the Attorney General to consent, give
conditional consent, or not consent to any agreement or transaction
under these provisions and requires the Attorney General to consider
certain factors in making a determination.
This bill would revise those factors and would entitle the
Attorney General to reimbursement for certain costs incurred in
monitoring compliance with the terms of the consent or conditional
consent.
(3) Existing law, the California Health Facilities Financing
Authority Act, empowers the California Health Facilities Financing
Authority to finance projects of health facilities that are operated
by a city, county, city and county, a district hospital, or a
private, nonprofit corporation or association. Existing law
authorizes the authority to issue revenue bonds for this purpose.
This bill would prohibit the authority and any local agency
from issuing revenue bonds under these provisions to any health
care facility that discriminates in the scope of health
services provided on the basis of race, color, religion,
national origin, ancestry, sex, or sexual orientation.
(4) Existing law requires, as a condition of the issuance of
revenue bonds to finance health facilities under these provisions
that each borrower give reasonable assurance to the authority that
the services of the health facility will be made available to all
persons residing or employed in the area served by the facility.
This bill would add a requirement that (a) the borrower give
reasonable assurance to the authority that the health facility does
not discriminate in the scope of health services provided
on the basis of race, color, religion, national origin, ancestry,
sex, or sexual orientation and (b) certain borrowers shall provide
directly , or arrange for the provision
of , or jointly provide in conjunction with another
licensed facility, certain designated reproductive health
services which that the facility
is licensed to does not provide.
(5) Existing law, the Public Employees' Medical and Hospital Care
Act, provides health benefits plan coverage for public employees and
annuitants meeting the eligibility requirements prescribed by the
Board of Administration of the Public Employees' Retirement System.
This bill would prohibit the board from approving any health
benefits plan contract with any carrier offering health benefit plans
that discriminates in the scope of health benefits provided
on the basis of race, color, religion, national origin,
ancestry, sex, or sexual orientation.
This bill would require the board to provide to employees
and annuitants written notice, as provided under this bill, on how
to access comprehensive reproductive health services, as defined.
The bill would prohibit the board from approving a health
benefits plan that contracts with a hospital or any other
designated entity licensed facility that
excludes, limits, or restricts the provision of reproductive health
services unless the plan also contracts with and makes available and
accessible to its enrollees a similar provider or
licensed facility that does not exclude, limit, or
restrict the service.
The bill would require the board to require any plan
approved under these provisions to provide to all employees and
annuitants written notice regarding access to comprehensive
reproductive health services. The bill would require health benefits
plans approved by the board and every contract entered into to
provide health benefits to employees and annuitants that covers tubal
ligations to ensure that voluntary tubal ligations are available at
the time of labor and delivery that provides a list of
providers to employees, annuitants, or contracting providers to
include as provided under the bill designated information in the
listing, including identifying those licensed hospitals and
ambulatory surgical centers that do not provide certain reproductive
health services .
(6) 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 Commissioner of Corporations. The willful
violation of the provisions governing health care service plans is a
crime.
Existing law requires each health care service plan to use a
disclosure form or materials containing designated information
regarding the benefits, services, and terms of the plan contract as
required by the commissioner. The disclosure form is required to
include the principal benefits and coverage of the plan, including
coverage for acute care and subacute care, and the exceptions,
reductions, and limitations that apply to the plan.
This bill would revise these disclosure requirements to
require disclosure of (a) comprehensive reproductive health services,
(b) the hospitals, clinics, ambulatory surgical centers, independent
physician associations, medical groups, pharmacies, and other
principal primary, ancillary, or specialty health care facilities
available in the health plan network, (c) exceptions, reductions, and
limitations on reproductive health services, and (d) hospitals and
designated entities that do not provide comprehensive reproductive
health services require a health care service plan
that provides a list of providers to potential enrollees, enrollees,
or contracting providers to include as provided under the bill
designated information in the listing, including identifying those
licensed hospitals and ambulatory surgical centers that do not
provide certain reproductive health services .
(7) Existing law requires additional disclosure by health
care service plans that describes how participation in the plan may
affect the choice of physician, hospital, or other health care
providers, the basic method of reimbursement, including the scope and
general methods of payment made to its contracting providers of
health care services, and whether financial bonuses or any other
incentives are used.
This bill would revise this disclosure requirement to include
disclosures related to a person's ability to access comprehensive
reproductive health services.
(8) Existing law prohibits a health care service plan
from refusing to enter into any contract or canceling or declining to
renew or reinstate any contract because of the race, color, national
origin, ancestry, religion, marital status, sexual orientation, or
age of any contracting party, prospective contracting party, or
person reasonably expected to benefit from that contract as a
subscriber, enrollee, member, or otherwise. Existing law also
prohibits discrimination with regard to the modification of any
contract and the benefits or coverage of any contract.
This bill would prohibit a health care service plan that issues,
provides, or administers any individual or group health care service
plan from refusing to cover, or refusing to continue to cover, or
limiting the amount, extent, or kind of coverage available to an
individual, or charging a different rate for the same coverage
because of race, color, religion, national origin, ancestry, sex, or
sexual orientation.
(9)
(8) Existing law requires every health care service plan to
meet certain requirements, including providing to subscribers and
enrollees basic health care services, as defined.
This bill would require, on and after July 1, 2000, certain health
care service plans that contract with a hospital or
designated entities licensed facility that offers some
reproductive health services but that exclude, limit,
or restrict excludes, limits, or restricts the
provision of reproductive health services to contract with and make
available and accessible to its enrollees a similar provider
or licensed facility that does not exclude,
limit, or restrict the service.
The bill would require a health care service plan to provide to
all enrollees certain written notice on how to access comprehensive
reproductive health services.
The bill would require that a health care service plan contract
issued, amended, or renewed on or after July 1, 2000, that covers
tubal ligations ensure that voluntary tubal ligations are available
at the time of labor and delivery, as provided under the bill.
This bill would define "comprehensive reproductive health services"
for purposes of the bill.
By changing the requirements of health care service plans, this
bill would change the definition of a crime, thereby imposing a
state-mandated local program.
(10)
(9) Existing law, the California Health Facility
Construction Loan Insurance Law, administered by the Office of
Statewide Health Planning and Development, provides for an insurance
program for public and nonprofit health facility construction,
improvement, and expansion loans.
This bill would prohibit the office from approving an application
or providing loan insurance under these provisions to any borrower
that discriminates in the scope of health services provided
on the basis of race, color, religion, national origin,
ancestry, sex, or sexual orientation. The bill would require each
borrower to give reasonable assurance to the office that the borrower
does not discriminate as provided under the bill. The bill would
require certain borrowers to provide directly or arrange for the
provision of designated reproductive health services that
it is licensed to they do not provide.
(11)
(10) Existing law provides for the regulation of insurance,
including disability insurers, insurers issuing policies of
disability insurance, and self-insured employee welfare benefit plans
that cover hospital, medical, or surgical expenses. These
provisions are administered by the Commissioner of Insurance.
This bill would set forth requirements of these insurers and plans
similar to those required under the bill for health care service
plans with regard to (a) disclosing information about the
insureds or enrollees ability to access comprehensive reproductive
health services providing a listing of providers that
identifies hospitals and ambulatory surgical centers that do not
provide certain reproductive health services , and
(b) making reproductive health services available and accessible
, (c) providing written notice about how to access
comprehensive reproductive health services, and (d) making voluntary
tubal ligations available at the time of labor and delivery
.
(12)
(11) Existing law prohibits any admitted insurer, licensed
to issue any policy of insurance, including disability insurance,
from failing or refusing to accept an application for, or issuing a
policy to an applicant for, insurance, or canceling the insurance,
under conditions less favorable to the insured than in other
comparable cases, except for reasons applicable alike to persons of
every marital status, sex, race, color, religion, national origin, or
ancestry and prohibits sex, race, color, religion, national origin,
or ancestry of itself from constituting a condition or risk for which
a higher rate, premium, or charge may be required of the insured for
insurance.
This bill would prohibit an insurer licensed to issue disability
insurance policies for, and a self-insured employee welfare benefit
plan that provides, hospital, medical, and surgical expenses from
offering or providing different terms, conditions, or benefits, or
placing a limitation on coverage under the insurance on the basis of
a person's race, color, religion, national origin, ancestry, sex, or
sexual orientation.
(13)
(12) Existing law prohibits the Insurance Commissioner from
approving any disability policy for insurance that does not conform
to specified requirements.
This bill would prohibit the commissioner from approving a
disability policy of insurance that discriminates on the basis of
race, color, religion, national origin, ancestry, sex, or sexual
orientation.
(14)
(13) Existing law provides for additional disclosure
requirements with regard to disability insurers that requires the
insurer to use a disclosure form that includes, among other things,
the principal benefits and coverage of the plan and the exceptions,
reductions, and limitations that apply to the plan.
This bill would revise these disclosure requirements to
require certain disability insurers to disclose comprehensive
reproductive health services and exceptions, reductions, and
limitations on comprehensive reproductive health services
require certain disability insurers that provide a list of
providers to prospective insureds, plan enrollees, or contracting
providers to include as provided under the bill designated
information in the listing, including identifying those licensed
hospitals and ambulatory surgical centers that do not provide certain
reproductive health services .
(15)
(14) Existing law provides a comprehensive program for
providing health insurance to small employer groups which sets forth
requirements of all carriers writing, issuing, or administering
health benefit plans that cover employees of small employers.
Existing law requires these carriers to prepare a brochure
and detailed evidence of coverage as specified.
This bill would prohibit these carriers from offering or providing
different terms, conditions, or benefits, or placing a limitation on
coverage under health benefit plans on the basis of an employee's
race, color, religion, national origin, ancestry, sex, or sexual
orientation. This bill would require the brochure and
evidence of coverage to include information related to comprehensive
reproductive health services certain carriers that
provide a list of providers to small employers, employees, agents,
brokers, or contracting providers to include as provided under the
bill designated information in the listing, including identifying
those licensed hospitals and ambulatory surgical centers that do not
provide certain reproductive health services .
(16)
(15) Existing law provides for the Medi-Cal program which is
administered by the State Department of Health Services, pursuant to
which medical benefits are provided to public assistance recipients
and certain other low-income persons. Under existing law, Medi-Cal
services may be provided to a beneficiary or eligible applicant by an
individual provider, or through a prepaid managed health care plan,
pilot project, or fee-for-service case management provider.
This bill would require, on or after July 1, 2000, that
(a) Medi-Cal managed health care plan contracts with
hospitals and designated other entities
licensed facilities that exclude, limit, or restrict the
provision of reproductive health services, contract with and make
available and accessible to enrollees a similar provider or
licensed facility that does not exclude, limit,
or restrict the service , (b) Medi-Cal managed health care
plans make voluntary tubal ligations available as provided under the
bill, and (c) Medi-Cal managed health care plans provide specified
written notice about how to access comprehensive reproductive health
services . The bill would define "managed health care
plans" for purposes of these provisions.
(17)
(16) Existing law requires that the county ensure that each
Medi-Cal beneficiary or eligible applicant be provided with
information as to health care and managed care options, including
certain provider information.
This bill would require that certain information be
provided in the manner specified in the bill to each Medi-Cal
applicant or beneficiary related to the principal benefits and
coverage of the plan, including comprehensive reproductive health
services, hospitals and other entities available in the health plan
network, the exceptions, reductions, and limitations, that apply to
the plan, including those related to comprehensive reproductive
health services, and the hospitals and other entities that do not
provide comprehensive reproductive health services the
materials with provider information described above to identify as
provided under the bill those licensed hospitals and ambulatory
centers that do not provide certain reproductive health services
. The bill would require a county organized health system to
provide the same materials and information to Medi-Cal
applicants and beneficiaries and would define "county organized
health systems" for this purpose. Because the bill would impose new
duties upon county officials, the bill would impose a state-mandated
local program.
(18)
(17) Existing law declares the purpose of the Waxman-Duffy
Prepaid Health Plan Act is to afford persons eligible to receive
Medi-Cal benefits the opportunity to enroll as regular subscribers in
prepaid health plans, without reference to the race, sex, age,
religion, creed, color, national origin, or ancestry of any eligible
person.
This bill would prohibit all managed health care plans from
discriminating against Medi-Cal beneficiaries and enrollees as
provided in the bill.
(19)
(18) Existing law establishes the California Medical
Assistance Commission to contract with health care delivery systems
for provision of health care services to recipients under the
Medi-Cal program.
This bill would require that all contracts negotiated by the
commission prohibit discrimination against Medi-Cal beneficiaries and
enrollees in the terms, conditions, or benefits and prohibit any
limitation on coverage or the provision of services on the basis of
race, color, religion, national origin, ancestry, sex, or sexual
orientation.
(20)
(19) 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, including the creation of a State
Mandates Claims Fund to pay the costs of mandates that do not exceed
$1,000,000 statewide and other procedures for claims whose statewide
costs exceed $1,000,000.
This bill would provide that with regard to certain mandates no
reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that,
if the Commission on State Mandates determines that the bill contains
costs so mandated by the state, reimbursement for those costs shall
be made pursuant to the statutory provisions noted above.
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 5914 of the Corporations Code is amended to
read:
5914. (a) Any foreign corporation, as defined in Section 5053, or
public benefit corporation that owns or controls a health facility,
as defined in Section 1250 of the Health and Safety Code, or owns or
controls a facility that provides similar health care, shall be
required to provide written notice to, and to obtain the written
consent of, the Attorney General prior to entering into any agreement
or transaction to do either of the following:
(1) Sell, transfer, lease, exchange, option, convey, or otherwise
dispose of, its assets to any other entity when a material amount of
the assets of the foreign corporation or public benefit corporation
are involved in the agreement or transaction.
(2) Transfer control, responsibility, or governance of a material
amount of the assets or operations of the foreign corporation or
public benefit corporation to any other entity.
(b) The notice to the Attorney General provided for in this
section shall include and contain the information the Attorney
General determines is required.
(c) This article shall not apply to a public benefit corporation
if the agreement or transaction is in the usual and regular course of
its activities or if the Attorney General has given the corporation
a written waiver of this article as to the proposed agreement or
transaction.
SEC. 2. Section 5917 of the Corporations Code is amended to read:
5917. The Attorney General shall have discretion to consent to,
give conditional consent to, or not consent to any agreement or
transaction described in subdivision (a) of Section 5914. In making
the determination, the Attorney General shall consider any factors
that the Attorney General deems relevant, including, but not limited
to, whether any of the following apply:
(a) The terms and conditions of the agreement or transaction are
fair and reasonable to the nonprofit public benefit corporation.
(b) The agreement or transaction will result in inurement to any
private person or entity.
(c) Any agreement or transaction that is subject to this article
is at fair market value. In this regard, "fair market value" means
the most likely price that the assets being sold would bring in a
competitive and open market under all conditions requisite to a fair
sale, the buyer and seller, each acting prudently, knowledgeably and
in their own best interest, and a reasonable time being allowed for
exposure in the open market.
(d) The market value has been manipulated by the actions of the
parties in a manner that causes the value of the assets to decrease.
(e) The proposed use of the proceeds from the agreement or
transaction is consistent with the charitable trust on which the
assets are held by the health facility or by the affiliated nonprofit
health system, which charitable trust shall be determined by the
review of, among other things, the original articles of corporation
and any amendments thereto, any express trusts, donative, or other
legal instruments, and by review of the history of charitable
operations.
(f) The agreement or transaction involves or constitutes any
breach of trust.
(g) The Attorney General has been provided, pursuant to Section
5250, with sufficient information and data by the nonprofit public
benefit corporation to evaluate adequately the agreement or
transaction or the effects thereof on the public.
(h) The agreement or transaction may create or perpetuate a
significant effect on the availability or accessibility of health
care services to the affected community. In this review process, the
Attorney General shall separately consider the access and
availability to the affected community of reproductive health
services, emergency or urgent care services, and indigent care
services.
(i) The proposed agreement or transaction is in the public
interest.
SEC. 3. Section 5919 of the Corporations Code is amended to read:
5919. (a) Within the time periods designated in Section 5915 and
relating to those factors specified in Section 5917, the Attorney
General may do the following:
(1) Contract with, consult, and receive advice from any state
agency on those terms and conditions that the Attorney General deems
appropriate.
(2) In his or her sole discretion, contract with experts or
consultants to assist in reviewing the proposed agreement or
transaction.
(b) Contract costs shall not exceed an amount that is reasonable
and necessary to conduct the review and evaluation. Any contract
entered into under this section shall be on a noncompetitive bid
basis and shall be exempt from Chapter 2 (commencing with Section
10290) of Part 2 of Division 2 of the Public Contract Code. The
nonprofit public benefit corporation, upon request, shall pay the
Attorney General promptly for all contract costs.
(c) The Attorney General shall be entitled to reimbursement from
the foreign corporation or nonprofit public benefit corporation for
all actual, reasonable, direct costs incurred in reviewing,
evaluating, and making the determination referred to in this article,
including administrative costs. The foreign corporation or nonprofit
public benefit corporation shall promptly pay the Attorney General,
upon request, for all of these costs.
(d) If the Attorney General consents or conditionally consents to
an agreement or transaction described in subdivision (a) of Section
5914, the Attorney General shall be entitled to reimbursement for all
actual, reasonable, and direct costs incurred in monitoring
compliance with the terms of the consent or conditional consent,
including administrative costs from the entity that assumes any of
the charitable trust obligations of the transferring entity.
SEC. 4. Section 15438.5 of the Government Code is amended to read:
15438.5. (a) It is the intent of the Legislature in enacting this
part to provide financing only, and, except as provided in
subdivisions (b), (c), and (d), only to health facilities which can
demonstrate the financial feasibility of their projects without
regard to the more favorable interest rates anticipated through the
issuance of revenue bonds under this part. It is further the intent
of the Legislature that all or part of any savings experienced by a
participating health institution, as a result of that tax-exempt
revenue bond funding, be passed on to the consuming public through
lower charges or containment of the rate of increase in hospital
rates. It is not the intent of the Legislature in enacting this part
to encourage unneeded health facility construction. Further, it is
not the intent of the Legislature to authorize the authority to
control or participate in the operation of hospitals, except where
default occurs or appears likely to occur.
(b) When determining the financial feasibility of projects for
county health facilities, the authority shall consider the more
favorable interest rates reasonably anticipated through the issuance
of revenue bonds under this part. It is the intent of the
Legislature that the authority attempt in whatever ways possible to
assist counties to arrange projects which will meet the financial
feasibility standards developed under this part.
(c) The authority may issue revenue bonds pursuant to this part to
finance the development of a multilevel facility, or any portion of
a multilevel facility, including the portion licensed as a
residential facility for the elderly, if the skilled nursing
facility, intermediate care facility, or general acute care hospital
is operated or provided by an eligible participating health
institution.
(d) The authority may issue revenue bonds pursuant to this part,
if the bonds rank in either of the two highest rating categories
established by a nationally recognized bond rating organization, to
finance working capital for a participating health institution
provided or operated by a city, city and county, county, or district
hospital authorized by the laws of this state to provide or operate a
health facility and which, pursuant to this part, undertakes
financing or refinancing as provided in this part.
(e) The financing or refinancing of projects or working capital
for cities, cities and counties, counties, or hospital districts may
be provided pursuant to this part by means other than revenue bonds,
at the discretion of the authority, including, without limitation,
through certificates of participation, or other interests, in bonds,
loans, leases, installment sales or other agreements of the cities,
city and county, counties or hospital districts. In this connection,
the authority may do all things and execute and deliver all
documents and instruments as may be necessary or desirable in
connection with issuance of the certificates of participation or
other means of financing or refinancing.
(f) Any self-insurance pooling program entered into by
participating health institutions which are cities, counties, cities
and counties, or hospital districts which is funded or financed in
whole or in part with proceeds of the sale of revenue bonds or
certificates of participation pursuant to this part shall not be
subject to regulation of any kind under the Insurance Code or
otherwise as insurance, but only any conditions and restrictions as
may be imposed by the authority.
(g) If a health facility seeking financing for a project pursuant
to this part does not meet the guidelines established by the
authority with respect to bond rating, the authority may nonetheless
give special consideration, on a case-by-case basis, to financing the
project if the health facility demonstrates to the satisfaction of
the authority the financial feasibility of the project, and the
performance of significant community service. For the purposes of
this part, a health facility which performs a significant community
service is one that contracts with Medi-Cal or that can demonstrate,
with the burden of proof being on the health facility, that it has
fulfilled at least two of the following criteria:
(1) On or before January 1, 1991, has established, and agrees to
maintain, a 24-hour basic emergency medical service open to the
public with a physician and surgeon on duty, or is a children's
hospital as defined in Section 14087.21 of the Welfare and
Institutions Code, which jointly provides basic or comprehensive
emergency services in conjunction with another licensed hospital.
This criterion shall not be utilized in a circumstance where a small
and rural hospital, as defined in Section 442.2 of the Health and
Safety Code, has not established a 24-hour basic emergency medical
service with a physician and surgeon on duty; or will operate a
designated trauma center on a continuing basis during the life of the
revenue bonds issued by the authority.
(2) Has adopted, and agrees to maintain on a continuing basis
during the life of the revenue bonds issued by the authority, a
policy, approved and recorded by the facility's board of directors,
of treating all patients without regard to ability to pay, including,
but not limited to, emergency room walk-in patients.
(3) Has provided and agrees to provide care, on a continuing basis
during the life of the revenue bonds issued by the authority, to
Medi-Cal and uninsured patients in an amount not less than 5 percent
of the facility's adjusted inpatient days as reported on an annual
basis to the Office of Statewide Health Planning and Development.
(4) Has budgeted at least 5 percent of its net operating income to
meeting the medical needs of uninsured patients and to providing
other services, including, but not limited to, community education,
primary care outreach in ambulatory settings, and unmet nonmedical
needs, such as food, shelter, clothing, or transportation for
vulnerable populations in the community, and agrees to continue that
policy during the life of the revenue bonds issued by the authority.
On or before January 1, 1992, the authority shall report to the
Legislature regarding the implementation of this subdivision. The
report shall provide information on the number of applications for
financing sought under this subdivision, the number of applications
approved and denied under this subdivision, and a brief summary of
the reason for any denial of an application submitted under this
subdivision.
(h) Enforcement of the conditions under which the authority issues
bonds pursuant to this section shall be governed by the enforcement
conditions under Section 15459.4.
(i) Notwithstanding any other provision of law, the authority
shall not issue revenue bonds pursuant to this part to any health
care facility that discriminates in the scope of the health
services provided on the basis of race, color, religion,
national origin, ancestry, sex, or sexual orientation.
SEC. 5. Section 15459 of the Government Code is amended to read:
15459. (a) As a condition of the issuance of revenue bonds,
whether by the authority or any local agency, to finance the
construction, expansion, remodeling, renovation, furnishing, or
equipping of a health facility or the acquisition of a health
facility, the following shall apply:
(1) Each borrower shall give reasonable assurance to the authority
that the services of the health facility will be made available to
all persons residing or employed in the area served by the facility.
(2) Each borrower, notwithstanding any other provision of law,
shall give reasonable assurance to the authority that the health
facility does not discriminate in the scope of health services
provided on the basis of race, color, religion, national
origin, ancestry, sex, or sexual orientation.
(3) Each borrower, notwithstanding any other provision of law,
that is a general acute care hospital, special health care facility
that delivers general health some but not all
reproductive health services enumerated in subdivision (c) of
Section 1345 of the Health and Safety Code through inpatient or
outpatient care, as defined in Section 15432, shall provide directly
, or arrange for the provision of,
or jointly provide in conjunction with another licensed
facility, those reproductive health services, as defined in
subdivision (c) of Section 1345, which the entity is licensed to
provide. Nothing in this paragraph shall be construed to require a
borrower to furnish services for which it is not licensed to provide.
those reproductive health services that the entity
does not provide. Nothing in this paragraph shall be construed to
require a borrower to do either of the following:
(A) Provide services directly.
(B) Furnish services that it is not licensed to provide.
It is the intent of the Legislature that the facility shall have
flexibility in establishing procedures, mechanisms, or contractual
relationships that ensure that patients obtain reproductive health
services in a manner that is timely, in compliance with professional
medical standards of care, and not burdensome to the patient.
(b) For the purposes of this section and Sections 15459.1,
15459.2, 15459.3, and 15459.4, all of the following definitions
apply:
(1) "Borrower" means each local agency or nonprofit corporation or
association which operates or provides the health facility and
receives the benefit of the issuance of revenue bonds.
(2) "Local agency" means any public district, public corporation,
authority, agency, board, commission, county, city and county, city,
school district, or any other public entity.
(3) "Revenue bond" means any bonds, warrants, notes, lease, or
installment sale obligations evidenced by certificates of
participation, or other evidence of indebtedness issued by the
authority or by a local agency payable from funds other than the
proceeds of ad valorem taxes or the proceeds of assessments levied
without limitation as to rate or amount by the local agency upon
property in the local agency.
SEC. 6. Section 22774 of the Government Code is amended to read:
22774. (a) The board shall, in accordance with this part, approve
health benefits plans and may contract with carriers offering health
benefits plans.
(b) Notwithstanding any other provision of law, the board shall
not approve any health benefits plan or contract with any carrier
offering health benefit plans that discriminates in the scope of
health benefits provided on the basis of race, color,
religion, national origin, ancestry, sex, or sexual orientation.
(c) Irrespective of the provisions of Sections 1090 and 1091, the
board member who is an officer of a life insurer may participate in
all board activities in administering the provisions of this part,
except that he or she shall not vote on the question of whether a
contract should be entered into or approval should be given
concerning any plan.
SEC. 7. Section 22778 of the Government Code is amended to read:
22778. (a) The board shall make available to employees and
annuitants eligible to enroll in any health benefit plan pursuant to
this part information, in the form that it may deem satisfactory, as
will enable the employees or annuitants to exercise an informed
choice among the various types of health benefits plans which have
been contracted for or approved. Each employee or annuitant enrolled
in a health benefits plan shall be issued an appropriate document
setting forth or summarizing the services or benefits to which the
employee or annuitant or family members are entitled to thereunder,
the procedure for obtaining benefits, and the principal provisions of
the plan affecting the employee, annuitant, or family members.
(b) Notwithstanding subdivision (a), and Section 22779, the board
shall provide to employees and annuitants written notice in readily
understood language and in a clearly organized format on how to
access comprehensive reproductive health services, as defined in
subdivision (c) of Section 1345 of the Health and Safety Code. This
written notice shall be provided, commencing March 1, 2000, upon the
employee's or annuitant's enrollment, and annually thereafter. In
addition, the plan shall provide this written notice to all pregnant
enrollees during the course of prenatal care if the plan received
notice, whether by receipt of a claim, a request for preauthorization
for pregnancy-related services, or other actual notice that the
enrollee is pregnant.
(c)
(b) The board shall compile and provide data regarding age,
sex, family composition, and geographical distribution of employees
and annuitants and make continuing study of the operation of this
part, including, but not necessarily limited to, surveys and reports
on plans, medical and hospital benefits, the standard of care
available to employees and annuitants, and the experience of plans
receiving contributions under this part with respect to matters such
as gross and net cost, administrative cost, benefits, utilization of
benefits, and the portion of actual personal expenditure of employees
and annuitants for health care which is being met by prepaid
benefits; provided, however, that this section shall not be construed
to require any plan to provide accounting data or statistical data
which is not acquired in the normal operation of the plan.
(d)
(c) The board shall, with the advice of and in consultation
and cooperation with, professional medical organizations and
individuals or organizations having special skills or experience in
the organization and provision of health care services on a prepaid
basis, study methods of evaluating and improving the quality and cost
of medical and hospital care provided under this part.
SEC. 8. Section 22790 of the Government Code is amended to read:
22790. (a) The board may contract with carriers for health
benefits plans for employees and annuitants and major medical plans
or approve health benefit plans offered by employee organizations,
provided that the carriers have operated successfully in the prepaid
hospital and medical care field prior to the contracting for or
approval thereof. The plans may include hospital benefits, surgical
benefits, in-hospital medical benefits, outpatient benefits, and
obstetrical benefits, and benefits offered by a bona fide church,
sect, denomination or organization whose principles include healing
entirely by prayer or spiritual means. The board shall contract with
a sufficient number of carriers and plans that provide chiropractic
services so that every employee and annuitant shall have a reasonable
opportunity to enroll in a plan that provides chiropractic services
without prior referral by a physician. The board may contract with
health maintenance organizations approved under Title XIII of the
federal Public Health Services Act (42 U.S.C. Sec. 201 et seq.).
(b) Notwithstanding any other provision of this part, the board
also may contract with health plans offering unique or specialized
health services.
(c) The board shall approve any employee association health
benefits plan which was approved by the board in the 1987-88 contract
year or any year prior to that date, provided the plan continues to
meet the minimum standards prescribed by the board.
(d) The board shall provide and administer any health benefits or
other coverage extended at county cost under Section 77208, upon
receipt of a resolution from a county board of supervisors electing
to come under the administrative provisions of this part for the
coverage specified in the resolution.
(e) The board shall not approve a health benefits plan that
contracts with a hospital, clinic, medical group,
independent physician association, ambulatory surgical center,
pharmacy, or other primary, ancillary, or specialty health care
facility or provider that excludes, licensed facility
that excludes, limits, or restricts the provision of any of the
reproductive health services enumerated in subdivision (c) of
Section 1345 of the Health and Safety Code, unless the plan also
contracts with and makes available and accessible to its enrollees a
similar provider or licensed facility
that does not exclude, limit, or restrict the service. These
services shall be available and accessible within reasonable
proximity to the residence or place of business of the employees and
annuitants, except when no such facility exists, in which case, the
insurer shall provide cover medically
appropriate transportation. Nothing in this section
chapter shall be construed to permit any plan to
apply a higher deductible or copayment for services provided under
this section.
(f) The board shall require that any health benefits plan approved
under this section shall provide to all employees and annuitants
written notice in readily understood language and in a clearly
organized format on how to access comprehensive reproductive health
services, as defined in subdivision (c) of Section 1345 of the Health
and Safety Code. This written notice shall be provided, commencing
March 1, 2000, upon the employee's or annuitant's enrollment, and
annually thereafter. In addition, the plan shall provide this
written notice to all pregnant employees or annuitants during the
course of prenatal care if the plan received notice, whether by
receipt of a claim, a request for preauthorization for
pregnancy-related services, or other actual notice that the employee
or annuitant is pregnant.
(g) Every health benefits plan approved by the board and every
contract entered into to provide health benefits to employees and
annuitants that covers tubal ligations shall ensure that voluntary
tubal ligations are available at the time of labor and delivery.
These services shall be available and accessible within reasonable
proximity to the residence or place of business of the enrollee,
except when no such facility exists, in which case, the insurer shall
provide transportation. Nothing in this subdivision shall be
construed to permit any carriers to apply a higher deductible or
copayment for services provided under this section.
(f) (1) On and after July 1, 2000, where a health benefits plan
provides a list of providers to employees, annuitants, or contracting
providers, the board shall require the health benefits plan to list
all licensed facilities with which the health benefits plan is
contracting. This listing shall be updated at least annually and
shall include a membership services telephone number for purposes of
complying with the consumer notice in paragraph (3).
(2) The listing described in paragraph (1) shall indicate with an
asterisk (*) those licensed hospitals and ambulatory surgical centers
that do not provide sterilizations, emergency contraception for rape
victims, or abortions.
(3) The provider listing described in paragraphs (1) and (2) shall
include a statement on each page where a facility is identified with
an asterisk (*), as required under paragraph (2), in no less than
12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
SEC. 9. Section 1345 of the Health and Safety Code is amended to
read:
1345. As used in this chapter:
(a) "Advertisement" means any written or printed communication or
any communication by means of recorded telephone messages or by
radio, television, or similar communications media, published in
connection with the offer or sale of plan contracts.
(b) "Basic health care services" means all of the following:
(1) Physician services, including consultation and referral.
(2) Hospital inpatient services and ambulatory care services.
(3) Diagnostic laboratory and diagnostic and therapeutic
radiologic services.
(4) Home health services.
(5) Preventive health services.
(6) Emergency health care services, including ambulance and
ambulance transport services and out-of-area coverage. "Basic health
care services" includes ambulance and ambulance transport services
provided through the "911" emergency response system.
(c) "Comprehensive reproductive health services" means
preconception counseling and care, pregnancy-related services,
fertility management, abortion, emergency contraception, voluntary
sterilization, including voluntary tubal ligation at the time of
delivery, family planning, including all services and supplies
approved by the federal Food and Drug Administration, both
prescription and nonprescription, diagnosis and treatment of sexually
transmitted diseases, and diagnosis of breast and gynecological
cancers.
(c) "Comprehensive reproductive health services" means all
services relating to patient counseling, diagnosis, and treatment for
reproductive health including, but not limited to, any of the
following:
(1) Preconception services.
(2) Pregnancy-related services, including prenatal care, surgical,
and medical abortion, and surgical and medical sterilization,
including, if medically appropriate, at the time of labor and
delivery.
(3) Fertility management.
(4) Sexually transmitted infections.
(5) Emergency contraception.
(6) Breast and reproductive health cancers.
(7) Coverage for federal Food and Drug Administration (FDA)
approved prescription and nonprescription contraceptive methods.
(d) "Enrollee" means a person who is enrolled in a plan and who is
a recipient of services from the plan.
(e) "Evidence of coverage" means any certificate, agreement,
contract, brochure, or letter of entitlement issued to a subscriber
or enrollee setting forth the coverage to which the subscriber or
enrollee is entitled.
(f) "Group contract" means a contract which by its terms limits
the eligibility of subscribers and enrollees to a specified group.
(g) "Health care service plan" or "specialized health care service
plan" means either of the following:
(1) Any person who undertakes to arrange for the provision of
health care services to subscribers or enrollees, or to pay for or to
reimburse any part of the cost for those services, in return for a
prepaid or periodic charge paid by or on behalf of the subscribers or
enrollees.
(2) Any person, whether located within or outside of this state,
who solicits or contracts with a subscriber or enrollee in this state
to pay for or reimburse any part of the cost of, or who undertakes
to arrange or arranges for, the provision of health care services
that are to be provided wholly or in part in a foreign country in
return for a prepaid or periodic charge paid by or on behalf of the
subscriber or enrollee.
(h) "License" means, and "licensed" refers to, a license as a plan
pursuant to Section 1353.
(i) "Out-of-area coverage," for purposes of paragraph (6) of
subdivision (b), means coverage while an enrollee is anywhere outside
the service area of the plan, and shall also include coverage for
urgently needed services to prevent serious deterioration of an
enrollee's health resulting from unforeseen illness or injury for
which treatment cannot be delayed until the enrollee returns to the
plan's service area.
(j) "Provider" means any professional person, organization, health
facility, or other person or institution licensed by the state to
deliver or furnish health care services.
(k) "Person" means any person, individual, firm, association,
organization, partnership, business trust, foundation, labor
organization, corporation, limited liability company, public agency,
or political subdivision of the state.
(l) "Service area" means a geographical area designated by the
plan within which a plan shall provide health care services.
(m) "Solicitation" means any presentation or advertising conducted
by, or on behalf of, a plan, where information regarding the plan,
or services offered and charges therefor, is disseminated for the
purpose of inducing persons to subscribe to, or enroll in, the plan.
(n) "Solicitor" means any person who engages in the acts defined
in subdivision (m) of this section.
(o) "Solicitor firm" means any person, other than a plan, who
through one or more solicitors engages in the acts defined in
subdivision (m) of this section.
(p) "Specialized health care service plan contract" means a
contract for health care services in a single specialized area of
health care, including dental care, for subscribers or enrollees, or
which pays for or which reimburses any part of the cost for those
services, in return for a prepaid or periodic charge paid by or on
behalf of the subscribers or enrollees.
(q) "Subscriber" means the person who is responsible for payment
to a plan or whose employment or other status, except for family
dependency, is the basis for eligibility for membership in the plan.
(r) Unless the context indicates otherwise, "plan" refers to
health care service plans and specialized health care service plans.
(s) "Plan contract" means a contract between a plan and its
subscribers or enrollees or a person contracting on their behalf
pursuant to which health care services, including basic health care
services, are furnished; and unless the context otherwise indicates
it includes specialized health care service plan contracts; and
unless the context otherwise indicates it includes group contracts.
(t) All references in this chapter to financial statements,
assets, liabilities, and other accounting items mean those financial
statements and accounting items prepared or determined in accordance
with generally accepted accounting principles, and fairly presenting
the matters which they purport to present, subject to any specific
requirement imposed by this chapter or by the commissioner.
SEC. 10. Section 1363 of the Health and Safety Code is amended to
read:
1363. (a) The commissioner shall require the use by each plan of
disclosure forms or materials containing information regarding the
benefits, services, and terms of the plan contract as the
commissioner may require, so as to afford the public, subscribers,
and enrollees with a full and fair disclosure of the provisions of
the plan in readily understood language and in a clearly organized
manner. The commissioner may require that the materials be presented
in a reasonably uniform manner so as to facilitate comparisons
between plan contracts of the same or other types of plans. Nothing
contained in this chapter shall preclude the commissioner from
permitting the disclosure form to be included with the evidence of
coverage or plan contract.
The disclosure form shall provide for at least the following
information, in concise and specific terms, relative to the plan,
together with additional information as may be required by the
commissioner, in connection with the plan or plan contract:
(1) The principal benefits and coverage of the plan, including
coverage for acute care, subacute care, and comprehensive
reproductive health services, as defined in subdivision (c) of
Section 1345, and the hospitals, clinics, ambulatory surgical
centers, independent physician associations, medical groups,
pharmacies, and other principal primary, ancillary, or specialty
health care facilities available in the health plan network.
(2) The exceptions, reductions, and limitations that apply to the
plan, including exceptions, reductions, and limitations on
reproductive health services and the hospitals, ambulatory surgical
centers, pharmacies, independent physician associations, medical
groups and other primary, ancillary, or specialty health care
facilities that do not provide comprehensive reproductive health
services, as defined in subdivision (c) of Section 1345.
(3) The full premium cost of the plan.
(4) Any copayment, coinsurance, or deductible requirements that
may be incurred by the member or the member's family in obtaining
coverage under the plan.
(5) The terms under which the plan may be renewed by the plan
member, including any reservation by the plan of any right to change
premiums.
(6) A statement that the disclosure form is a summary only, and
that the plan contract itself should be consulted to determine
governing contractual provisions. The first page of the disclosure
form shall contain a notice that conforms with all of the following
conditions:
(A) (i) States that the evidence of coverage discloses the terms
and conditions of coverage.
(ii) States, with respect to individual plan contracts, small
group plan contracts, and any other group plan contracts for which
health care services are not negotiated, that the applicant has a
right to view the evidence of coverage prior to enrollment, and, if
the evidence of coverage is not combined with the disclosure form,
the notice shall specify where the evidence of coverage can be
obtained prior to enrollment.
(B) Includes a statement that the disclosure and the evidence of
coverage should be read completely and carefully and that individuals
with special health care needs, including reproductive health care
needs, should read carefully those sections that apply to them.
(C) Includes the plan's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the plan or a statement where the telephone number or
numbers are located in the disclosure form.
(D) For individual contracts, and small group plan contracts as
defined in Article 3.1 (commencing with Section 1357), the disclosure
form shall state where the health plan benefits and coverage matrix
is located.
(E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
(7) A statement as to when benefits shall cease in the event of
nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon an enrollee who is hospitalized or undergoing
treatment for an ongoing condition.
(8) To the extent that the plan permits a free choice of provider
to its subscribers and enrollees, the statement shall disclose the
nature and extent of choice permitted and the financial liability
which is, or may be, incurred by the subscriber, enrollee, or a third
party by reason of the exercise of that choice.
(9) A summary of the provisions required by subdivision (g) of
Section 1373, if applicable.
(10) If the plan utilizes arbitration to settle disputes, a
statement of that fact.
(11) A summary of, and a notice of the availability of, the
process the plan uses to authorize or deny health care services under
the benefits provided by the plan, pursuant to Section 1363.5.
(12) A description of any limitations on the patient's choice of
primary care or specialty care physician based on service area and
limitations on the patient's choice of acute care hospital care,
subacute or transitional inpatient care, or skilled nursing facility.
(13) General authorization requirements for referral by a primary
care physician to a specialty care physician.
(14) Conditions and procedures for disenrollment.
(15) A description as to how an enrollee may request continuity of
care as required by Section 1373.96.
(b) (1) As of July 1, 1999, the commissioner shall require each
plan offering a contract to an individual or small group to provide
with the disclosure form for individual and small group plan
contracts a uniform health plan benefits and coverage matrix
containing the plan's major provisions in order to facilitate
comparisons between plan contracts. The uniform matrix shall include
the following category descriptions together with the corresponding
copayments and limitations in the following sequence:
(A) Deductibles.
(B) Lifetime maximums.
(C) Professional services.
(D) Outpatient services.
(E) Hospitalization services.
(F) Emergency health coverage.
(G) Ambulance services.
(H) Prescription drug coverage.
(I) Durable medical equipment.
(J) Mental health services.
(K) Chemical dependency services.
(L) Home health services.
(M) Comprehensive reproductive health services, as defined in
subdivision (c) of Section 1345.
(N) Other.
(2) The following statement shall be placed at the top of the
matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN
CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE
BENEFITS AND LIMITATIONS.
(c) Nothing in this section shall prevent a plan from using
appropriate footnotes or disclaimers to reasonably and fairly
describe coverage arrangements in order to clarify any part of the
matrix that may be unclear.
(d) All plans, solicitors, and representatives of a plan shall,
when presenting any plan contract for examination or sale to an
individual prospective plan member, provide the individual with a
properly completed disclosure form, as prescribed by the commissioner
pursuant to this section for each plan so examined or sold.
(e) In the case of group contracts, the completed disclosure form
and evidence of coverage shall be presented to the contractholder
upon delivery of the completed health care service plan agreement.
(f) Group contractholders shall disseminate copies of the
completed disclosure form to all persons eligible to be a subscriber
under the group contract at the time those persons are offered the
plan. Where the individual group members are offered a choice of
plans, separate disclosure forms shall be supplied for each plan
available. Each group contractholder shall also disseminate or cause
to be disseminated copies of the evidence of coverage to all
applicants, upon request, prior to enrollment and to all subscribers
enrolled under the group contract.
(g) In the case of conflicts between the group contract and the
evidence of coverage, the provisions of the evidence of coverage
shall be binding upon the plan notwithstanding any provisions in the
group contract which may be less favorable to subscribers or
enrollees.
(h) In addition to the other disclosures required by this section,
every health care service plan and any agent or employee of the plan
shall, when presenting a plan for examination or sale to any
individual purchaser or the representative of a group consisting of
25 or fewer individuals, disclose in writing the ratio of premium
costs to health services paid for plan contracts with individuals and
with groups of the same or similar size for the plan's preceding
fiscal year. A plan may report that information by geographic area,
provided the plan identifies the geographic area and reports
information applicable to that geographic area.
(i) Subdivision (b) shall not apply to any coverage provided by a
plan for the Medi-Cal program or the Medicare program pursuant to
Title XVIII and Title XIX of the Social Security Act.
(j) This section shall become operative July 1, 1999.
SEC. 11.
SEC. 10. Section 1367.01 is added to the Health and Safety
Code, to read:
1367.01. Notwithstanding any other provision of law, no plan
issuing, providing, or administering any individual or group health
care service plan shall refuse to cover, or refuse to continue to
cover, or limit the amount, extent, or kind of coverage available to
an individual, or charge a different rate for the same coverage
because of race, color, religion, national origin, ancestry, sex, or
sexual orientation.
SEC. 12. Section 1367.10 of the Health and Safety Code is amended
to read:
1367.10. (a) Every health care service plan shall include within
its disclosure form and within its evidence of coverage a statement
clearly describing how participation in the plan may affect the
choice of physician, hospital, or other health care providers, the
basic method of reimbursement, including the scope and general
methods of payment made to its contracting providers of health care
services, and whether financial bonuses or any other incentives are
used. The disclosure form and evidence of coverage shall indicate
that if an enrollee wishes to know more about these issues, the
enrollee may request additional information from the health care
service plan, the enrollee's provider, or the provider's medical
group or independent practice association regarding the information
required pursuant to subdivision (b).
(b) If a plan, medical group, independent practice association, or
participating health care provider uses or receives financial
bonuses or any other incentives, the plan, medical group, independent
practice association, or health care provider shall provide a
written summary to any person who requests it that includes all of
the following:
(1) A general description of the bonus and any other incentive
arrangements used in its compensation agreements. Nothing in this
section shall be construed to require disclosure of trade secrets or
commercial or financial information that is privileged or
confidential, such as payment rates, as determined by the
commissioner, pursuant to state law.
(2) A description regarding whether, and in what manner, the
bonuses and any other incentives are related to a provider's use of
referral services.
(c) The statements and written information provided pursuant to
subdivisions (a) and (b) shall be communicated in clear and simple
language that enables consumers to evaluate and compare health care
service plans.
(d) (1) The plan shall clearly inform prospective enrollees that
participation in that plan will affect the person's choice of
provider by placing the following statement in a conspicuous place on
all material required to be given to prospective enrollees including
promotional and descriptive material, disclosure forms, and
certificates and evidences of coverage:
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED
It is not the intent of this section to require that the names of
individual health care providers be enumerated to prospective
enrollees.
If the health care service plan provides a list of providers to
patients or contracting providers, the plan shall include within the
provider listing a notification that enrollees may contact the plan
in order to obtain a list of the facilities with which the health
care service plan is contracting for subacute care and/or
transitional inpatient care.
(2) The plan shall clearly inform prospective enrollees that the
choice of certain hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, or pharmacies
will affect the person's ability to access comprehensive reproductive
health services, as defined in subdivision (c) of Section 1345, by
placing the following statement in a conspicuous place on all
materials required to be given to prospective enrollees, including
promotional and descriptive materials, disclosure forms, and
certificates and evidences of coverage.
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW WHICH
FACILITIES AND GROUPS OF PROVIDERS RESTRICT ACCESS TO COMPREHENSIVE
REPRODUCTIVE HEALTH CARE SERVICES
SEC. 13.
SEC. 11. Section 1367.105 is added to the Health and Safety Code,
to read:
1367.105. (a) On and after July 1, 2000, where a health care
service plan provides a list of providers to potential enrollees,
enrollees, or contracting providers, the health care service plan
shall list all licensed facilities with which the health care service
plan is contracting. This listing shall be updated at least
annually and shall include a membership services telephone number for
purposes of complying with the consumer notice in subdivision (c).
(b) The provider listing described in subdivision (a) shall
indicate with an asterisk (*) those licensed hospitals and ambulatory
surgical centers that do not provide sterilizations, emergency
contraception for rape victims, or abortions.
(c) The provider listing described in subdivisions (a) and (b)
shall include a statement on each page where a facility is identified
with an asterisk (*), as required in subdivision (b), in no less
than 12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
SEC. 12. Section 1367.696 is added to the Health and Safety
Code, to read:
1367.696. (a) On and after July 1, 2000,
notwithstanding any other provision of law, whenever a health care
service plan, except a specialized health care service plan,
contracts with a hospital, clinic, ambulatory surgical
center, independent physician association, medical group, pharmacy,
or other primary, ancillary, or specialty health care facility or
provider that excludes, licensed facility that offers
some reproductive health services but that excludes, limits, or
restricts the provision of reproductive health services enumerated
in subdivision (c) of Section 1345, it shall also contract with and
make available and accessible to its enrollees, a similar
provider or licensed facility that does not
exclude, limit, or restrict the service. These services shall be
available and accessible within reasonable proximity to the residence
or place of business of the enrollee, except when no such facility
exists, in which case, the plan shall provide transportation.
(b) A health care service plan shall provide to all enrollees
written notice in readily understood language and in a clearly
organized format on how to access comprehensive reproductive health
services, as defined in subdivision (c) of Section 1345. This
written notice shall be provided, commencing March 1, 2000, upon the
enrollee's enrollment, and annually thereafter. In addition, the
plan shall provide this written notice to all pregnant enrollees
during the course of prenatal care if the plan received notice,
whether by receipt of a claim, a request for preauthorization for
pregnancy-related services, or other actual notice that the enrollee
is pregnant.
SEC. 14. Section 1367.697 is added to the Health and Safety Code,
to read:
1367.697. Notwithstanding any other provision of law, every
health care service plan contract issued, amended, or renewed on or
after July 1, 2000, that covers tubal ligations shall ensure that
voluntary tubal ligations are available at the time of labor and
delivery, including by providing transportation if necessary to
access services. Nothing in this section shall be construed to
permit a plan to apply a higher deductible or copayment for services
provided under this section.
SEC. 15.
SEC. 13. Section 129021 is added to the Health and Safety
Code, to read:
129021. Notwithstanding any other provision of law, the office
shall not approve an application or provide loan insurance under this
chapter to any borrower that discriminates in the scope of
health services provided on the basis of race, color, religion,
national origin, ancestry, sex, or sexual orientation.
SEC. 16.
SEC. 14. Section 129050 of the Health and Safety Code is
amended to read:
129050. A loan shall be eligible for insurance under this chapter
if all of the following conditions are met:
(a) When the borrower is a nonprofit corporation, the loan shall
be secured by a mortgage, first lien, trust indenture, or other
security agreement that the office may require subject only to those
conditions, covenants and restrictions, easements, taxes, and
assessments of record approved by the office. When the borrower is
a political
subdivision, the loan may be evidenced by a duly authorized bond
issue. A loan to a local hospital district or county may meet the
requirement of this subdivision by either method.
(b) The borrower obtains an American Land Title Association title
insurance policy with the office designated as beneficiary, with
liability equal to the amount of the loan insured under this chapter,
and with additional endorsements that the office may reasonably
require.
(c) The proceeds of the loan shall be used exclusively for the
construction, improvement, or expansion of the health facility, as
approved by the office under Section 129020. However, loans insured
pursuant to this chapter may include loans to refinance another prior
loan, whether or not state insured and without regard to the date of
the prior loan, if the office determines that the prior loan would
have been eligible for insurance under this chapter at the time it
was made. The office may not insure a loan for a health facility
that is not needed as determined by the state plan developed under
the authorization of Section 129020.
(d) The loan shall have a maturity date not exceeding 30 years
from the date of the beginning of amortization of the loan, except as
authorized by subdivision (e), or 75 percent of the office's
estimate of the economic life of the health facility, whichever is
the lesser.
(e) The loan shall contain complete amortization provisions
requiring periodic payments by the borrower not in excess of its
reasonable ability to pay as determined by the office. The office
shall permit a reasonable period of time during which the first
payment to amortization may be waived on agreement by the lender and
borrower. The office may, however, waive the amortization
requirements of this subdivision and of subdivision (g) of this
section when a term loan would be in the borrower's best interest.
(f) The loan shall bear interest on the amount of the principal
obligation outstanding at any time at a rate, as negotiated by the
borrower and lender, as the office finds necessary to meet the loan
money market. As used in this chapter, "interest" does not include
premium charges for insurance and service charges if any. Where a
loan is evidenced by a bond issue of a political subdivision, the
interest thereon may be at any rate the bonds may legally bear.
(g) The loan shall provide for the application of the borrower's
periodic payments to amortization of the principal of the loan.
(h) The loan shall contain those terms and provisions with respect
to insurance, repairs, alterations, payment of taxes and
assessments, foreclosure proceedings, anticipation of maturity,
additional and secondary liens, and other matters the office may in
its discretion prescribe.
(i) The loan shall have a principal obligation not in excess of an
amount equal to 90 percent of the total construction cost. Where
the borrower is a political subdivision, the office may fully insure
loans equal to the total construction cost.
(j) The borrower shall offer reasonable assurance that the
services of the health facility will be made available to all persons
residing or employed in the area served by the facility.
(k) A certificate of need or certificate of exemption has been
issued for the project to be financed pursuant to Chapter 1
(commencing with Section 127125) of Part 2, unless the project is not
subject to this requirement.
(l) In the case of acquisitions, a project loan shall be
guaranteed only for transactions not in excess of the fair market
value of the acquisition.
Fair market value shall be determined, for purposes of this
subdivision, pursuant to the following procedure, that shall be
utilized during the state review of a loan guarantee application:
(1) Completion of a property appraisal by an appraisal firm
qualified to make appraisals, as determined by the office, before
closing a loan on the project.
(2) Evaluation of the appraisal in conjunction with the book value
of the acquisition by the office. When acquisitions involve
additional construction, the office shall evaluate the proposed
construction to determine that the costs are reasonable for the type
of construction proposed. In those cases where this procedure
reveals that the cost of acquisition exceeds the current value of a
facility, including improvements, then the acquisition cost shall be
deemed in excess of fair market value.
(m) Notwithstanding subdivision (i), any loan in the amount of
five million dollars ($5,000,000) or less may be insured up to 95
percent of the total construction cost.
(n) In determining financial feasibility of projects of counties
pursuant to this section, the office shall take into consideration
any assistance for the project to be provided under Sections 14085.5
and 16715 of the Welfare and Institutions Code or from other sources.
It is the intent of the Legislature that the office endeavor to
assist counties in whatever ways are possible to arrange loans that
will meet the requirements for insurance prescribed by this section.
(o) (1) Each borrower, notwithstanding any other provision of law,
shall give reasonable assurance to the office that the borrower does
not discriminate in the scope of health services provided
on the basis of race, religion, national origin, ancestry, sex, or
sexual orientation.
(2) Each borrower, notwithstanding any other provision of law,
that is a general acute care hospital, special health care facility
that delivers general health services, community clinic, or any other
facility that provides some but not all reproductive health
services enumerated in subdivision (c) of Section 1345 of the Health
and Safety Code through inpatient or outpatient care, as
defined in Section 15432 of the Government Code, shall provide
directly , or arrange for the provision of
, or jointly provide in conjunction with another licensed
facility, those reproductive health services, as defined in
subdivision (c) of Section 1345, which the entity is licensed to
provide.
SEC. 17. those reproductive health services that
the entity does not provide. Nothing in this paragraph shall be
construed to require the facility to do either of the following:
(A) Provide services directly.
(B) Furnish services that it is not licensed to provide.
It is the intent of the Legislature that the facility shall have
flexibility in establishing procedures, mechanisms or contractual
relationships that ensure that patients obtain reproductive health
services in a manner that is timely, in compliance with professional
medical standards of care, and not burdensome to the patient.
SEC. 15. Section 10123.01 is added to the Insurance Code, to
read:
10123.01. Notwithstanding any other provision of law, no
self-insured employee welfare benefit plan that provides hospital,
medical, or surgical expenses shall offer or provide different terms,
conditions, or benefits, or place a limitation on coverage under
that insurance on the basis of a person's race, color, religion,
national origin, ancestry, sex, or sexual orientation.
SEC. 18.
SEC. 16. Section 10123.12 of the Insurance Code is amended
to read:
10123.12. (a) Every disability insurer, including those insurers
that contract for alternative rates of payment pursuant to Section
10133, and every self-insured employee welfare benefit plan, which
will affect the choice of physician, hospital, or other health care
providers shall include within its disclosure form and within its
evidence or certificate of coverage a statement clearly describing
how participation in the policy or plan may affect the choice of
physician, hospital, or other health care providers, and shall
clearly inform prospective insureds or plan enrollees that
participation in the policy or plan will affect the person's choice
in this regard by placing the following statement in a conspicuous
place on all material required to be given to prospective insureds or
plan enrollees including promotional and descriptive material,
disclosure forms, and certificates and evidences of coverage:
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED
It is not the intent of this section to require that the names of
individual health care providers be enumerated to prospective
enrollees.
If a disability insurer providing coverage for hospital, medical,
or surgical expenses provides a list of facilities to patients or
contracting providers, the insurer shall include within the provider
listing a notification that enrollees may contact the insurer in
order to obtain a list of the facilities with which the disability
insurer is contracting for subacute care and/or transitional
inpatient care.
(b) Every disability insurer, self-insured employee welfare
benefit plan, and insurer issuing group or individual policies of
disability insurance that covers hospital, medical, or surgical
expenses shall clearly inform prospective insureds or plan enrollees
that the choice of certain hospitals, clinics, ambulatory surgical
centers, independent physician associations, medical groups, or
pharmacies will affect the person's ability to access comprehensive
reproductive health services, as defined in subdivision (c) of
Section 1345 of the Health and Safety Code, by placing the following
statement in a conspicuous place on all material required to be given
to prospective insureds or plan enrollees, including promotional and
descriptive materials, disclosure forms, and certificates and
evidences of coverage:
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW WHICH
FACILITIES AND GROUPS OF PROVIDERS RESTRICT ACCESS TO COMPREHENSIVE
REPRODUCTIVE HEALTH CARE SERVICES
SEC. 19.
(b) (1) On and after July 1, 2000, where a disability insurer,
self-insured employee welfare benefit plan, and insurer issuing group
or individual policies of disability insurance that covers hospital,
medical or surgical expenses provides a list of providers to
prospective insureds, plan enrollees, or contracting providers, the
disability insurer, self-insured employee welfare benefit plan, and
insurer shall list all contracting licensed facilities. This listing
shall be updated at least annually and shall include a membership
services telephone number for purposes of complying with the consumer
notice in paragraph (3).
(2) The listing described in paragraph (1) shall indicate with an
asterisk (*) those licensed hospitals and ambulatory surgical centers
that do not provide sterilizations, emergency contraception for rape
victims, or abortion.
(3) The provider listing described in paragraphs (1) and (2) shall
include a statement on each page where a facility is identified with
an asterisk (*), as required in paragraph (2), in no less than
12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
SEC. 17. Section 10123.22 is added to the Insurance Code,
immediately following Section 10123.21, to read:
10123.22. (a) On and after July 1, 2000,
notwithstanding any other provision of law, whenever a disability
insurer or an insurer issuing group or individual policies of
disability insurance that provides coverage for hospital, medical, or
surgical expenses contracts with a hospital, clinic,
medical group, independent physician association, ambulatory surgical
center, pharmacy, or other primary, ancillary, or specialty health
care facility licensed facility that excludes,
limits, or restricts the provision of reproductive health services
enumerated in subdivision (c) of Section 1345 of the Health and
Safety Code, it shall also contract with and make available and
accessible to its insureds, a similar provider or
licensed facility that does not exclude, limit, or
restrict the service. These services shall be available and
accessible within reasonable proximity to the residence or place of
business of the insured, except when no such facility exists, in
which case, the insurer shall provide cover
medically appropriate transportation. Nothing in this section
shall be construed to permit any insurer to apply a higher deductible
or copayment for services provided under this section.
(b) On and after July 1, 2000, notwithstanding any other provision
of law, whenever a self-insured employee welfare benefit plan that
provides coverage for hospital, medical, or surgical expenses
contracts with a hospital, clinic, medical group, independent
physician association, ambulatory surgical center, pharmacy, or other
primary, ancillary, or specialty health care facility that excludes,
limits, or restricts the provision of reproductive health services
enumerated in subdivision (c) of Section 1345 of the Health and
Safety Code, it shall also contract with and make available and
accessible to its enrollees, a similar provider or facility that does
not exclude, limit, or restrict the service. These services shall
be available and accessible within reasonable proximity to the
residence or place of business of the enrollee, except when no such
facility exists, in which case, the plan shall provide
transportation. Nothing in this section shall be construed to permit
any plan to apply a higher deductible or copayment for services
provided under this section.
(c) A disability insurer, self-insured employee welfare benefit
plan, and insurer issuing group or individual policies of disability
insurance that provides coverage for hospital, medical, or surgical
expenses shall provide to all insureds or enrollees written notice in
readily understood language and in a clearly organized format on how
to access comprehensive reproductive health services, as defined in
subdivision (c) of Section 1345 of the Health and Safety Code. This
written notice shall be provided, commencing March 1, 2000, upon the
insured's or enrollee's enrollment, and annually thereafter. In
addition, the insurer or plan shall provide this written notice to
all pregnant insureds or enrollees during the course of prenatal care
if the plan received notice, whether by receipt of a claim, a
request for preauthorization for pregnancy-related services, or other
actual notice that the insured or enrollee is pregnant.
SEC. 20. Section 10123.89 is added to the Insurance Code,
immediately following Section 10123.88, to read:
10123.89. Commencing July 1, 2000, notwithstanding any other
provision of law, every disability insurer, self-insured employee
welfare benefit plan, and insurer issuing group or individual
policies of insurance that covers hospital, medical, or surgical
expenses and that covers tubal ligations shall ensure that voluntary
tubal ligations are available at the time of labor and delivery.
These services shall be available and accessible within reasonable
proximity to the residence or place of business of the insured or
enrollee, except when no such facility exists, in which case, the
insurer or plan shall provide transportation. Nothing in this
section shall be construed to permit any insurer or plan to apply a
higher deductible or copayment for services provided under this
section.
SEC. 21.
SEC. 18. Section 10140 of the Insurance Code is amended to
read:
10140. (a) No admitted insurer, licensed to issue life or
disability insurance, shall fail or refuse to accept an application
for that insurance, to issue that insurance to an applicant therefor,
or issue or cancel that insurance, under conditions less favorable
to the insured than in other comparable cases, except for reasons
applicable alike to persons of every race, color, religion, national
origin, ancestry, or sexual orientation. Race, color, religion,
national origin, ancestry, or sexual orientation shall not, of
itself, constitute a condition or risk for which a higher rate,
premium, or charge may be required of the insured for that insurance.
(b) Except as otherwise permitted by law, no admitted insurer,
licensed to issue disability insurance policies for hospital,
medical, and surgical expenses, shall fail or refuse to accept an
application for that insurance, fail or refuse to issue that
insurance to an applicant therefor, cancel that insurance, refuse to
renew that insurance, charge a higher rate or premium for that
insurance, or offer or provide different terms, conditions, or
benefits, or place a limitation on coverage under that insurance, on
the basis of a person's genetic characteristics that may, under some
circumstances, be associated with disability in that person or that
person's offspring.
(c) No admitted insurer, licensed to issue disability insurance
for hospital, medical, and surgical expenses, shall seek information
about a person's genetic characteristics for any nontherapeutic
purpose.
(d) No discrimination shall be made in the fees or commissions of
agents or brokers for writing or renewing a policy of disability
insurance, other than disability income, on the basis of a person's
genetic characteristics that may, under some circumstances, be
associated with disability in that person or that person's offspring.
(e) It shall be deemed a violation of subdivision (a) for any
insurer to consider sexual orientation in its underwriting criteria
or to utilize marital status, living arrangements, occupation,
gender, beneficiary designation, ZIP Codes or other territorial
classification within this state, or any combination thereof for the
purpose of establishing sexual orientation or determining whether to
require a test for the presence of the human immunodeficiency virus
or antibodies to that virus, where that testing is otherwise
permitted by law. Nothing in this section shall be construed to
alter, expand, or limit in any manner the existing law respecting the
authority of insurers to conduct tests for the presence of human
immunodeficiency virus or evidence thereof.
(f) This section shall not be construed to limit the authority of
the commissioner to adopt regulations prohibiting discrimination
because of sex, marital status, or sexual orientation or to enforce
these regulations, whether adopted before or on or after January 1,
1991.
(g) "Genetic characteristics" as used in this section shall have
the same meaning as defined in Section 10123.3.
(h) Notwithstanding any other provision of law, no admitted
insurer licensed to issue disability insurance policies for hospital,
medical, and surgical expenses shall offer or provide different
terms, conditions, or benefits, or place a limitation on coverage
under that insurance on the basis of a person's race, color,
religion, national origin, ancestry, sex, or sexual orientation.
SEC. 22.
SEC. 19. Section 10198.71 is added to the Insurance Code, to
read:
10198.71. Notwithstanding any other provision of law, no health
benefit plan, as defined in subdivision (a) of Section 10198.6, shall
offer or provide different terms, conditions, or benefits, or place
a limitation on coverage under that insurance on the basis of a
person's race, color, religion, national origin, ancestry, sex, or
sexual orientation.
SEC. 23.
SEC. 20. Section 10291.5 of the Insurance Code is amended to
read:
10291.5. (a) The purpose of this section is to achieve both of
the following:
(1) Prevent, in respect to disability insurance, fraud, unfair
trade practices, and insurance economically unsound to the insured.
(2) Assure that the language of all insurance policies can be
readily understood and interpreted.
(b) The commissioner shall not approve any disability policy for
insurance or delivery in this state in any of the following
circumstances:
(1) If the commissioner finds that it contains any provision, or
has any label, description of its contents, title, heading, backing,
or other indication of its provisions which is unintelligible,
uncertain, ambiguous, or abstruse, or likely to mislead a person to
whom the policy is offered, delivered or issued.
(2) If it contains any provision for payment at a rate, or in an
amount (other than the product of rate times the periods for which
payments are promised) for loss caused by particular event or events
(as distinguished from character of physical injury or illness of the
insured) more than triple the lowest rate, or amount, promised in
the policy for the same loss caused by any other event or events
(loss caused by sickness, loss caused by accident, and different
degrees of disability each being considered, for the purpose of this
paragraph, a different loss); or if it contains any provision for
payment for any confining loss of time at a rate more than six times
the least rate payable for any partial loss of time or more than
twice the least rate payable for any nonconfining total loss of time;
or if it contains any provision for payment for any nonconfining
total loss of time at a rate more than three times the least rate
payable for any partial loss of time.
(3) If it contains any provision for payment for disability caused
by particular event or events (as distinguished from character of
physical injury or illness of the insured) payable for a term more
than twice the least term of payment provided by the policy for the
same degree of disability caused by any other event or events; or if
it contains any benefit for total nonconfining disability payable for
lifetime or for more than 12 months and any benefit for partial
disability, unless the benefit for partial disability is payable for
at least three months; or if it contains any benefit for total
confining disability payable for lifetime or for more than 12 months,
unless it also contains benefit for total nonconfining disability
caused by the same event or events payable for at least three months,
and, if it also contains any benefit for partial disability, unless
the benefit for partial disability is payable for at least three
months. The provisions of this paragraph shall apply separately to
accident benefits and to sickness benefits.
(4) If it contains any provision or provisions which would have
the effect, upon any termination of the policy, of reducing or ending
the liability that the insurer would have, but for the termination,
for loss of time resulting from accident occurring while the policy
is in force or for loss of time commencing while the policy is in
force and resulting from sickness contracted while the policy is in
force or for other losses resulting from accident occurring or
sickness contracted while the policy is in force, and also contains
any provision or provisions reserving to the insurer the right to
cancel or refuse to renew the policy, unless it also contains other
provision or provisions the effect of which is that termination of
the policy as the result of the exercise by the insurer of the right
to cancel or refuse to renew the policy shall not reduce or end the
liability in respect to the hereinafter specified losses as the
insurer would have had under the policy, including its other
limitations, conditions, reductions, and restrictions, had the policy
not been so terminated.
The specified losses referred to in the preceding paragraph are:
(i) Loss of time that commences while the policy is in force and
results from sickness contracted while the policy is in force.
(ii) Loss of time that commences within 20 days following and
results from accident occurring while the policy is in force.
(iii) Losses that result from accident occurring or sickness
contracted while the policy is in force and arise out of the care or
treatment of illness or injury and which occur within 90 days from
the termination of the policy or during a period of continuous
compensable loss or losses which period commences prior to the end of
the 90 days.
(iv) Losses other than those specified in clause (i), (ii), or
(iii) that result from accident occurring or sickness contracted
while the policy is in force and which losses occur within 90 days
following the accident or the contraction of the sickness.
(5) If by any caption, label, title, or description of contents
the policy states, implies, or infers without reasonable
qualification that it provides loss of time indemnity for lifetime,
or for any period of more than two years, if the loss of time
indemnity is made payable only when house confined or only under
special contingencies not applicable to other total loss of time
indemnity.
(6) If it contains any benefit for total confining disability
payable only upon condition that the confinement be of an abnormally
restricted nature unless the caption of the part containing the
benefit is accurately descriptive of the nature of the confinement
required and unless, if the policy has a description of contents,
label, or title, at least one of them contain reference to the nature
of the confinement required.
(7) (A) If, irrespective of the premium charged therefor, any
benefit of the policy is, or the benefits of the policy as a whole
are, not sufficient to be of real economic value to the insured.
(B) In determining whether benefits are of real economic value to
the insured, the commissioner shall not differentiate between
insureds of the same or similar economic or occupational classes and
shall give due consideration to all of the following:
(i) The right of insurers to exercise sound underwriting judgment
in the selection and amounts of risks.
(ii)
Amount of benefit, length of time of benefit, nature or extent of
benefit, or any combination of those factors.
(iii) The relative value in purchasing power of the benefit or
benefits.
(iv) Differences in insurance issued on an industrial or other
special basis.
(C) To be of real economic value, it shall not be necessary that
any benefit or benefits cover the full amount of any loss that might
be suffered by reason of the occurrence of any hazard or event
insured against.
(8) If it substitutes a specified indemnity upon the occurrence of
accidental death for any benefit of the policy, other than a
specified indemnity for dismemberment, which would accrue prior to
the time of that death or if it contains any provision that has the
effect, other than at the election of the insured exercisable within
not less than 20 days in the case of benefits specifically limited to
the loss by removal of one or more fingers or one or more toes or
within not less than 90 days in all other cases, of doing any of the
following:
(A) Of substituting, upon the occurrence of the loss of both
hands, both feet, one hand and one foot, the sight of both eyes or
the sight of one eye and the loss of one hand or one foot, some
specified indemnity for any or all benefits under the policy unless
the indemnity so specified is equal to or greater than the total of
the benefit or benefits for which the specified indemnity is
substituted and which, assuming in all cases that the insured would
continue to live, could possibly accrue within four years from the
date of the dismemberment under all other provisions of the policy
applicable to the particular event or events (as distinguished from
character of physical injury or illness) causing the dismemberment.
(B) Of substituting, upon the occurrence of any other
dismemberment some specified indemnity for any or all benefits under
the policy unless the indemnity so specified is equal to or greater
than one-fourth of the total of the benefit or benefits for which the
specified indemnity is substituted and which, assuming in all cases
that the insured would continue to live, could possibly accrue within
four years from the date of the dismemberment under all other
provisions of the policy applicable to the particular event or events
(as distinguished from character of physical injury or illness)
causing the dismemberment.
(C) Of substituting a specified indemnity upon the occurrence of
any dismemberment for any benefit of the policy which would accrue
prior to the time of dismemberment.
As used in this section, loss of a hand shall be severance at or
above the wrist joint, loss of a foot shall be severance at or above
the ankle joint, loss of an eye shall be the irrecoverable loss of
the entire sight thereof, loss of a finger shall mean at least one
entire phalanx thereof and loss of a toe, the entire toe.
(9) If it contains provision, other than as provided in Section
10369.3, reducing any original benefit more than 50 percent on
account of age of the insured.
(10) If the insuring clause or clauses contain no reference to the
exceptions, limitations, and reductions (if any) or no specific
reference to, or brief statement of, each abnormally restrictive
exception, limitation, or reduction.
(11) If it contains benefit or benefits for loss or losses from
specified diseases only unless:
(A) All of the diseases so specified in each provision granting
the benefits fall within some general classification based upon the
following:
(i) The part or system of the human body principally subject to
all of the diseases.
(ii) The similarity in nature or cause of the diseases.
(iii) In case of diseases of an unusually serious nature and
protracted course of treatment, the common characteristics of all of
the diseases with respect to severity of affliction and cost of
treatment.
(B) The policy is entitled and each provision granting the
benefits is separately captioned in clearly understandable words so
as to accurately describe the classification of diseases covered and
expressly point out, when that is the case, that not all diseases of
the classification are covered.
(12) If it does not contain provision for a grace period of at
least the number of days specified below for the payment of each
premium falling due after the first premium, during which grace
period the policy shall continue in force provided, that the grace
period to be included in the policy shall be not less than seven days
for policies providing for weekly payment of premium, not less than
10 days for policies providing for monthly payment of premium and not
less than 31 days for all other policies.
(13) If it fails to conform in any respect with any law of this
state.
(14) If it discriminates on the basis of race, color, religion,
national origin, ancestry, sex, or sexual orientation as prohibited
in subdivision (h) of Section 10140.
(c) The commissioner shall not approve any disability policy
covering hospital, medical, or surgical expenses unless the
commissioner finds that the application conforms to both of the
following requirements:
(1) All applications for disability insurance covering hospital,
medical, or surgical expenses, except that which is guaranteed issue,
which include questions relating to medical conditions, shall
contain clear and unambiguous questions designed to ascertain the
health condition or history of the applicant.
(2) The application questions designed to ascertain the health
condition or history of the applicant shall be based on medical
information that is reasonable and necessary for medical underwriting
purposes. The application shall include a prominently displayed
notice that states:
"California law prohibits an HIV test from being required or used
by health insurance companies as a condition of obtaining health
insurance coverage."
(d) Nothing in this section authorizes the commissioner to
establish or require a single or standard application form for
application questions.
(e) The commissioner may, from time to time as conditions warrant,
after notice and hearing, promulgate those reasonable rules and
regulations, and amendments and additions thereto, as are necessary
or convenient, to establish, in advance of the submission of
policies, the standard or standards conforming to subdivision (b), by
which he or she shall disapprove or withdraw approval of any
disability policy.
In promulgating a rule or regulation the commissioner shall give
consideration to the criteria herein established and to the
desirability of approving for use in policies in this state uniform
provisions, nationwide or otherwise, and is hereby granted the
authority to consult with insurance authorities of any other state
and their representatives individually or by way of convention or
committee, to seek agreement upon those provisions.
A rule or regulation shall be promulgated in accordance with the
procedure provided in Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code.
(f) The commissioner may withdraw approval of filing of any policy
or other document or matter required to be approved by the
commissioner, or filed with him or her, by this chapter when the
commissioner would be authorized to disapprove or refuse filing of
the same if originally submitted at the time of the action of
withdrawal.
The withdrawal shall be in writing and shall specify reasons. An
insurer adversely affected by the withdrawal may, within a period of
30 days following mailing or delivery of the writing containing the
withdrawal, by written request, secure a hearing to determine whether
the withdrawal should be annulled, modified, or confirmed. Unless,
at any time, it is mutually agreed to the contrary, a hearing shall
be granted and commenced within 30 days following filing of the
request and shall proceed with reasonable dispatch to determination.
Unless the commissioner in writing in the withdrawal, or subsequent
thereto, grants an extension, the withdrawal shall, in the absence of
the request, be effective, prospectively and not retroactively, on
the 91st day following the mailing or delivery of the withdrawal,
and, if request for the hearing is filed, on the 91st day following
mailing or delivery of written notice of the commissioner's
determination.
(g) No proceeding under this section is subject to Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code.
(h) Except as provided in subdivision (k), any action taken by the
commissioner under this section is subject to review by the courts
of this state and proceedings on review shall be in accordance with
the Code of Civil Procedure.
Notwithstanding any other provision of law to the contrary,
petition for review may be filed at any time before the effective
date of the action taken by the commissioner. No action of the
commissioner shall become effective before the expiration of 20 days
after written notice and a copy thereof are mailed or delivered to
the person adversely affected, and any action so submitted for review
shall not become effective for a further period of 15 days after the
filing of the petition in court. The court may stay the
effectiveness thereof for a longer period.
(i) This section shall be liberally construed to effectuate the
purpose and intentions herein stated; but shall not be construed to
grant the commissioner power to fix or regulate rates for disability
insurance or prescribe a standard form of disability policy, except
that the commissioner shall prescribe a standard supplementary
disclosure form for presentation with all disability insurance
policies, pursuant to Section 10603.
(j) This section shall be effective on and after July 1, 1950, as
to all policies thereafter submitted and on and after January 1,
1951, the commissioner may withdraw approval pursuant to subdivision
(d) of any policy thereafter issued or delivered in this state
irrespective of when its form may have been submitted or approved,
and prior to those dates the provisions of law in effect on January
1, 1949, shall apply to those policies.
(k) A policy issued by an insurer to an insured on a form
approved by the commissioner, and in accordance with the conditions,
if any, contained in the approval, at a time when that approval is
outstanding shall, as between the insurer and the insured, or any
person claiming under the policy, be conclusively presumed to comply
with, and conform to, this section.
SEC. 24. Section 10604 of the Insurance Code is amended to read:
10604. The disclosure form shall include the following
information, in concise and specific terms, relative to the
disability insurance policy:
(a) The applicable category or categories of coverage provided by
the policy, from among the following:
(1) Basic hospital expense coverage.
(2) Basic medical-surgical expense coverage.
(3) Hospital confinement indemnity coverage.
(4) Major medical expense coverage.
(5) Disability income protection coverage.
(6) Accident only coverage.
(7) Specified disease or specified accident coverage.
(8) Any other categories as the commissioner may prescribe.
(b) (1) The principal benefits and coverage of the disability
insurance policy.
(2) For insurers issuing group or individual policies of
disability insurance that covers hospital, medical, or surgical
expenses, the benefits and coverage of comprehensive reproductive
health services, as defined in subdivision (c) of Section 1345 of the
Health and Safety Code.
(c) (1) The exceptions, reductions, and limitations that apply to
the policy.
(2) For insurers issuing group or individual policies of
disability insurance that covers hospital, medical, surgical
expenses, the exceptions, reductions, and limitations that apply to
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code.
(d) A summary, including a citation of the relevant contractual
provisions, of the process used to authorize or deny payments for
services under the coverage provided by the policy including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. This subdivision shall only apply to
policies of disability insurance that cover hospital, medical, or
surgical expenses.
(e) The full premium cost of the policy.
(f) Any copayment, coinsurance, or deductible requirements that
may be incurred by the insured or his or her family in obtaining
coverage under the policy.
(g) The terms under which the policy may be renewed by the
insured, including any reservation by the insurer of any right to
change premiums.
(h) A statement that the disclosure form is a summary only, and
that the policy itself should be consulted to determine governing
contractual provisions.
SEC. 25.
SEC. 21. Section 10604.1 is added to the Insurance Code, to read:
10604.1. (a) On and after July 1, 2000, where a disability
insurer that covers hospital, medical, or surgical expenses provides
a list of providers to prospective insureds, plan enrollees, or
contracting providers, the disability insurer shall list all licensed
facilities with which the disability insurer is contracting. This
listing shall be updated at least annually and shall include a
membership services telephone number for purposes of complying with
the consumer notice in subdivision (c).
(b) The listing described in subdivision (a) shall indicate with
an asterisk (*) those licensed hospitals and ambulatory surgical
centers that do not provide sterilizations, emergency contraception
for rape victims, or abortions.
(c) The provider listing described in subdivisions (a) and (b)
shall include a statement on each page where a facility is identified
with an asterisk (*), as required in subdivision (b), in no less
than 12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
SEC. 22. Section 10702.2 is added to the Insurance Code, to
read:
10702.2. Notwithstanding any other provision of law, no person or
entity described in Section 10702 shall offer or provide different
terms, conditions, or benefits, or place a limitation on coverage,
under health benefit plans on the basis of race, color, religion,
national origin, ancestry, sex, or sexual orientation.
SEC. 26. Section 10705 of the Insurance Code is amended to read:
10705. Upon the effective date of this act:
(a) No group or individual policy or contract or certificate of
group insurance or statement of group coverage providing benefits to
employees of small employers as defined in this chapter shall be
issued or delivered by a carrier subject to the jurisdiction of the
commissioner regardless of the situs of the contract or master
policyholder or of the domicile of the carrier nor, except as
otherwise provided in Sections 10270.91 and 10270.92, shall a carrier
provide coverage subject to this chapter until a copy of the form of
the policy, contract, certificate, or statement of coverage is filed
with and approved by the commissioner in accordance with Sections
10290 and 10291, and the carrier has complied with the requirements
of Section 10717.
(b) Each carrier, except a self-funded employer, shall fairly and
affirmatively offer, market, and sell all of the carrier's benefit
plan designs that are sold to, offered through, or sponsored by,
small employers or associations that include small employers to all
small employers in each geographic region in which the carrier makes
coverage available or provides benefits. A carrier contracting to
participate in the Voluntary Alliance Uniting Employers Purchasing
Program shall be deemed to be in compliance with this requirement for
a benefit plan design offered through the program in those
geographic regions in which the carrier participates in the program
and the benefit plan design is offered exclusively through the
program.
(1) Nothing in this section shall be construed to require an
association, or a trust established and maintained by an association
to receive a master insurance policy issued by an admitted insurer
and to administer the benefits thereof solely for association
members, to offer, market or sell a benefit plan design to those who
are not members of the association. However, if the association
markets, offers or sells a benefit plan design to those who are not
members of the association it is subject to the requirements of this
section. This shall apply to an association that otherwise meets the
requirements of paragraph (5) formed by merger of two or more
associations after January 1, 1992, if the predecessor organizations
had been in active existence on January 1, 1992, and for at least
five years prior to that date and met the requirements of paragraph
(5).
(2) A carrier which (A) effective January 1, 1992, and at least 20
years prior to that date, markets, offers, or sells benefit plan
designs only to all members of one association and (B) does not
market, offer or sell any other individual, selected group, or group
policy or contract providing medical, hospital and surgical benefits
shall not be required to market, offer, or sell to those who are not
members of the association. However, if the carrier markets, offers
or sells any benefit plan design or any other individual, selected
group, or group policy or contract providing medical, hospital and
surgical benefits to those who are not members of the association it
is subject to the requirements of this section.
(3) Each carrier that sells health benefit plans to members of one
association pursuant to paragraph (2) shall submit an annual
statement to the commissioner which states that the carrier is
selling health benefit plans pursuant to paragraph (2) and which, for
the one association, lists all the information required by paragraph
(4).
(4) Each carrier that sells health benefit plans to members of any
association shall submit an annual statement to the commissioner
which lists each association to which the carrier sells health
benefit plans, the industry or profession that is served by the
association, the association's membership criteria, a list of
officers, the state in which the association is organized, and the
site of its principal office.
(5) For purposes of paragraphs (1) and (2), an association is a
nonprofit organization comprised of a group of individuals or
employers who associate based solely on participation in a specified
profession or industry, accepting for membership any individual or
small employer meeting its membership criteria, which do not
condition membership directly or indirectly on the health or claims
history of any person, which uses membership dues solely for and in
consideration of the membership and membership benefits, except that
the amount of the dues shall not depend on whether the member applies
for or purchases insurance offered by the association, which is
organized and maintained in good faith for purposes unrelated to
insurance, which has been in active existence on January 1, 1992, and
at least five years prior to that date, which has a constitution and
bylaws, or other analogous governing documents which provide for
election of the governing board of the association by its members,
which has contracted with one or more carriers to offer one or more
health benefit plans to all individual members and small employer
members in this state.
(c) Each carrier shall make available to each small employer all
benefit plan designs that the carrier offers or sells to small
employers or to associations that include small employers.
Notwithstanding subdivision (d) of Section 10700, for purposes of
this subdivision, companies that are affiliated companies or that are
eligible to file a consolidated income tax return shall be treated
as one carrier.
(d) Each carrier shall do all of the following:
(1) Prepare a brochure that summarizes all of its benefit plan
designs and make this summary available to small employers, agents
and brokers upon request. The summary shall include for each benefit
plan design information on benefits provided, including
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code, a generic
description of the manner in which services are provided, such as how
access to providers is limited, benefit limitations, including
limits on comprehensive reproductive health services, as defined in
subdivision (c) of Section 1345 of the Health and Safety Code,
required copayments and deductibles, standard employee risk rates, an
explanation of how creditable coverage is calculated if a
preexisting condition or affiliation period is imposed, and a
telephone number that can be called for more detailed benefit
information. Carriers are required to keep the information contained
in the brochure accurate and up to date, and, upon updating the
brochure, send copies to agents and brokers representing the carrier.
Any entity that provides administrative services only with regard
to a benefit plan design written or issued by another carrier shall
not be required to prepare a summary brochure which includes that
benefit plan design.
(2) For each benefit plan design, prepare a more detailed evidence
of coverage and make it available to small employers, agents and
brokers upon request. The evidence of coverage shall contain all
information, including information about comprehensive reproductive
health services, as defined in subdivision (c) of Section 1345 of the
Health and Safety Code, that a prudent buyer would need to be aware
of in making selections of benefit plan designs. An entity that
provides administrative services only with regard to a benefit plan
design written or issued by another carrier shall not be required to
prepare an evidence of coverage for that benefit plan design.
(3) Provide to small employers, agents, and brokers, upon request,
for any given small employer the sum of the standard employee risk
rates and the sum of the risk adjusted standard employee risk rates.
When requesting this information, small employers, agents and
brokers shall provide the carrier with the information the carrier
needs to determine the small employer's risk adjusted employee risk
rate.
(4) Provide copies of the current summary brochure to all agents
or brokers who represent the carrier and, upon updating the brochure,
send copies of the updated brochure to agents and brokers
representing the carrier for the purpose of selling health benefit
plans.
(5) Notwithstanding subdivision (d) of Section 10700, for purposes
of this subdivision, companies that are affiliated companies or that
are eligible to file a consolidated income tax return shall be
treated as one carrier.
(e) Every agent or broker representing one or more carriers for
the purpose of selling health benefit plans to small employers shall
do all of the following:
(1) When providing information on a health benefit plan to a small
employer but making no specific recommendations on particular
benefit plan designs:
(A) Advise the small employer of the carrier's obligation to sell
to any small employer any of the benefit plan designs it offers to
small employers and provide them, upon request, with the actual rates
that would be charged to that employer for a given benefit plan
design.
(B) Notify the small employer that the agent or broker will
procure rate and benefit information for the small employer on any
benefit plan design offered by a carrier for whom the agent or broker
sells health benefit plans.
(C) Notify the small employer that, upon request, the agent or
broker will provide the small employer with the summary brochure
required in paragraph (1) of subdivision (d) for any benefit plan
design offered by a carrier whom the agent or broker represents.
(2) When recommending a particular benefit plan design or designs,
advise the small employer that, upon request, the agent will provide
the small employer with the brochure required by paragraph (1) of
subdivision (d) containing the benefit plan design or designs being
recommended by the agent or
broker.
(3) Prior to filing an application for a small employer for a
particular health benefit plan:
(A) For each of the benefit plan designs offered by the carrier
whose benefit plan design the agent or broker is presenting, provide
the small employer with the benefit summary required in paragraph (1)
of subdivision (d) and the sum of the standard employee risk rates
for that particular employer.
(B) Notify the small employer that, upon request, the agent or
broker will provide the small employer with an evidence of coverage
brochure for each benefit plan design the carrier offers.
(C) Notify the small employer that, from July 1, 1993 to July 1,
1996, actual rates may be 20 percent higher or lower than the sum of
the standard employee risk rates, and from July 1, 1996, and
thereafter, actual rates may be 10 percent higher or lower than the
sum of the standard employee risk rates depending on how the carrier
assesses the risk of the small employer's group.
(D) Notify the small employer that, upon request, the agent or
broker will submit information to the carrier to ascertain the small
employer's sum of the risk adjusted standard employee risk rate for
any benefit plan design the carrier offers.
(E) Obtain a signed statement from the small employer
acknowledging that the small employer has received the disclosures
required by paragraph (3) of subdivision (e) and by Section 10716.
(f) No carrier, agent, or broker shall induce or otherwise
encourage a small employer to separate or otherwise exclude an
eligible employee from a health benefit plan which, in the case of an
eligible employee meeting the definition in paragraph (1) of
subdivision (f) of Section 10700, is provided in connection with the
employee's employment or which, in the case of an eligible employee
as defined in paragraph (2) of subdivision (f) of Section 17000, is
provided in connection with a guaranteed association.
(g) No carrier shall reject an application from a small employer
for a benefit plan design provided:
(1) The small employer as defined by paragraph (1) of subdivision
(w) of Section 10700 offers health benefits to 100 percent of its
eligible employees as defined in paragraph (1) of subdivision (f) of
Section 10700. Employees who waive coverage on the grounds that they
have other group coverage shall not be counted as eligible
employees.
(2) The small employer agrees to make the required premium
payments.
(h) No carrier or agent or broker shall, directly or indirectly,
engage in the following activities:
(1) Encourage or direct small employers to refrain from filing an
application for coverage with a carrier because of the health status,
claims experience, industry, occupation, or geographic location
within the carrier's approved service area of the small employer or
the small employer's employees.
(2) Encourage or direct small employers to seek coverage from
another carrier or the program because of the health status, claims
experience, industry, occupation, or geographic location within the
carrier's approved service area of the small employer or the small
employer's employees.
(i) No carrier shall, directly or indirectly, enter into any
contract, agreement, or arrangement with an agent or broker that
provides for or results in the compensation paid to an agent or
broker for a health benefit plan to be varied because of the health
status, claims experience, industry, occupation, or geographic
location of the small employer or the small employer's employees.
This subdivision shall not apply with respect to a compensation
arrangement that provides compensation to an agent or broker on the
basis of percentage of premium, provided that the percentage shall
not vary because of the health status, claims experience, industry,
occupation, or geographic area of the small employer.
(j) Except in the case of a late insured, or for satisfaction of a
preexisting condition clause in the case of initial coverage of an
eligible employee, a disability insurer may not exclude any eligible
employee or dependent who would otherwise be entitled to health care
services on the basis of any of the following: the health status,
the medical condition, including both physical and mental illnesses,
the claims experience, the medical history, the genetic information,
or the disability or evidence of insurability, including conditions
arising out of acts of domestic violence of that employee or
dependent. No health benefit plan may limit or exclude coverage for
a specific eligible employee or dependent by type of illness,
treatment, medical condition, or accident, except for preexisting
conditions as permitted by Section 10198.7 or 10708.
(k) If a carrier enters into a contract, agreement, or other
arrangement with a third-party administrator or other entity to
provide administrative, marketing, or other services related to the
offering of health benefit plans to small employers in this state,
the third-party administrator shall be subject to this chapter.
(l) (1) With respect to the obligation to provide coverage newly
issued under subdivision (d), the carrier may cease enrolling new
small employer groups and new eligible employees as defined by
paragraph (2) of subdivision (f) of Section 10700 if it certifies to
the commissioner that the number of eligible employees and
dependents, of the employers newly enrolled or insured during the
current calendar year by the carrier equals or exceeds: (A) in the
case of a carrier that administers any self-funded health benefits
arrangement in California, 10 percent of the total number of eligible
employees, or eligible employees and dependents, respectively,
enrolled or insured in California by that carrier as of December 31
of the preceding year, or (B) in the case of a carrier that does not
administer any self-funded health benefit arrangements in California,
8 percent of the total number of eligible employees, or eligible
employees and dependents, respectively, enrolled or insured by the
carrier in California as of December 31 of the preceding year.
(2) Certification shall be deemed approved if not disapproved
within 45 days after submission to the commissioner. If that
certification is approved, the small employer carrier shall not offer
coverage to any small employers under any health benefit plans
during the remainder of the current year. If the certification is
not approved, the carrier shall continue to issue coverage as
required by subdivision (d) and be subject to administrative
penalties as established in Section 10718.
SEC. 27.
SEC. 23. Section 10705.1 is added to the Insurance Code, to read:
10705.1. (a) On and after July 1, 2000, where a carrier subject
to this chapter, except self-funded employers, provides a list of
providers to small employers, employees, agents, brokers, or
contracting providers, the carrier shall list all licensed facilities
with which the carrier is contracting. This listing shall be
updated at least annually and shall include a membership services
telephone number for purposes of complying with the consumer notice
in subdivision (c).
(b) The listing described in subdivision (a) shall indicate with
an asterisk (*) those licensed hospitals and ambulatory surgical
centers that do not provide sterilizations, emergency contraception
for rape victims, or abortions.
(c) The provider listing described in subdivisions (a) and (b)
shall include a statement on each page where a facility is identified
with an asterisk (*), as required in subdivision (b), in no less
than 12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
SEC. 24. Section 14016.5 of the Welfare and Institutions
Code is amended to read:
14016.5. (a) (1) At the time of determining or
redetermining the eligibility of a Medi-Cal or aid to families with
dependent children (AFDC) applicant or beneficiary who resides in an
area served by a managed health care plan or pilot program in which
beneficiaries may enroll, each applicant or beneficiary shall
personally attend a presentation at which the applicant or
beneficiary is informed of the managed care and fee-for-service
options available regarding methods of receiving Medi-Cal benefits.
The county shall ensure that each beneficiary or applicant attends
this presentation.
(2) At the time of the presentation and at least 30 days prior to
enrollment, the following information shall be provided in writing in
readily understood language and in a clearly organized format to
each applicant or beneficiary:
(A) The principal benefits and coverage of the plan, including
coverage for comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code, and
how to access out-of-plan family planning services.
(B) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other principal primary, ancillary, or specialty health care
facilities available in the health plan network.
(C) The exceptions, reductions, and limitations that apply to the
plan, including exceptions, reductions, and limitations on
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code.
(D) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other primary, ancillary, or specialty health care facilities that do
not provide comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code.
(b) The health care options presentation described in subdivision
(a) shall include all of the following elements:
(1) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in the fee-for-service sector.
(2) (A) Each beneficiary or eligible applicant shall be
provided with the name, address, telephone number, and specialty, if
any, of each primary care provider, and each clinic and other
licensed facility participating in each prepaid managed health
care plan, pilot project, or fee-for-service case management provider
option. This information shall be provided under geographic area
designations, in alphabetical order by the name of the primary care
provider and clinic , clinic, and other
licensed facility . The name, address, and telephone number of
each specialist participating in each prepaid managed care health
plan, pilot project, or fee-for-service case management provider
option shall be made available by either contacting the health care
options contractor or the prepaid managed care health plan, pilot
project, or fee-for-service case management provider.
Information described in subparagraph (C) shall also be made
available by contacting each prepaid managed care health plan, pilot
project, or fee-for-service case management provider.
(B) Materials with the information described in subparagraph (A)
shall indicate with an asterisk (*) those licensed hospitals and
ambulatory surgical centers that do not provide sterilizations,
emergency contraception for rape victims, or abortions.
(C) Materials described in subparagraphs (A) and (B) shall include
a statement on each page where a facility is identified with an
asterisk (*), as required by subparagraph (B), in no less than
12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
(3) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating
provider is a primary care provider or clinic contracting with any of
the prepaid managed health care plans, pilot projects, or
fee-for-service case management provider options available, has
available capacity, and agrees to continue to treat that beneficiary
or applicant.
(4) In areas specified by the director, each beneficiary or
eligible applicant shall be informed that if he or she fails to make
a choice, or does not certify that he or she has an established
relationship with a primary care provider or clinic, he or she shall
be assigned to, and enrolled in, a prepaid managed health care plan,
pilot projects, or fee-for-service case management provider.
(c) No later than 30 days following the date a Medi-Cal or AFDC
beneficiary or applicant is determined eligible, the beneficiary or
applicant shall indicate his or her choice in writing, as a condition
of coverage for Medi-Cal benefits, of either of the following health
care options:
(1) To obtain benefits by receiving a Medi-Cal card, which may be
used to obtain services from individual providers, that the
beneficiary would locate, who choose to provide services to Medi-Cal
beneficiaries.
The department may require each beneficiary or eligible applicant,
as a condition for electing this option, to sign a statement
certifying that he or she has an established patient-provider
relationship, or in the case of a dependent, the parent or guardian
shall make that certification. This certification shall not require
the acknowledgment or guarantee of acceptance, by any indicated
Medi-Cal provider or health facility, of any beneficiary making a
certification under this section.
(2) (A) To obtain benefits by enrolling in a prepaid managed
health care plan, pilot program, or fee-for-service case management
provider that has agreed to make Medi-Cal services readily available
to enrolled Medi-Cal beneficiaries.
(B) At the time the beneficiary or eligible applicant selects a
prepaid managed health care plan, pilot project, or fee-for-service
case management provider, the department shall, when applicable,
encourage the beneficiary or eligible applicant to also indicate, in
writing, his or her choice of primary care provider or clinic
contracting with the selected prepaid managed health care plan, pilot
project, or fee-for-service case management provider.
(d) (1) In areas specified by the director, a Medi-Cal or AFDC
beneficiary or eligible applicant who does not make a choice, or who
does not certify that he or she has an established relationship with
a primary care provider or clinic shall be assigned to and enrolled
in an appropriate Medi-Cal managed care plan, pilot project, or
fee-for-service case management provider providing service within the
area in which the beneficiary resides.
(2) If it is not possible to enroll the beneficiary under a
Medi-Cal managed care plan or pilot project or a fee-for-service case
management provider because of a lack of capacity or availability of
participating contractors, the beneficiary shall be provided with a
Medi-Cal card and informed about fee-for-service primary care
providers who do all of the following:
(A) The providers agree to accept Medi-Cal patients.
(B) The providers provide information about the provider's
willingness to accept Medi-Cal patients as described in Section
14016.6.
(C) The providers provide services within the area in which the
beneficiary resides.
(e) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic or does not select any primary care
provider who is available, the managed health care plan, pilot
project, or fee-for-service case management provider that was
selected by or assigned to the beneficiary shall ensure that the
beneficiary selects a primary care provider or clinic within 30 days
after enrollment or is assigned to a primary care provider within 40
days after enrollment.
(f) (1) The managed care plan shall have a valid Medi-Cal
contract, adequate capacity, and appropriate staffing to provide
health care services to the beneficiary.
(2) The department shall establish standards for all of the
following:
(A) The maximum distances a beneficiary is required to travel to
obtain primary care services from the managed care plan,
fee-for-service managed care provider, or pilot project in which the
beneficiary is enrolled.
(B) The conditions under which a primary care service site shall
be accessible by public transportation.
(C) The conditions under which a managed care plan,
fee-for-service managed care provider, or pilot project shall provide
nonmedical transportation to a primary care service site.
(3) In developing the standards required by paragraph (2), the
department shall take into account, on a geographic basis, the means
of transportation used and distances typically traveled by Medi-Cal
beneficiaries to obtain fee-for-service primary care services and the
experience of managed care plans in delivering services to Medi-Cal
enrollees. The department shall also consider the provider's ability
to render culturally and linguistically appropriate services.
(g) To the extent possible, the arrangements for carrying out
subdivision (d) shall provide for the equitable distribution of
Medi-Cal beneficiaries among participating managed care plans,
fee-for-service case management providers, and pilot projects.
(h) If, under the provisions of subdivision (d), a Medi-Cal
beneficiary or applicant does not make a choice or does not certify
that he or she has an established relationship with a primary care
provider or clinic, the person may, at the option of the department,
be provided with a Medi-Cal card or be assigned to and enrolled in a
managed care plan providing service within the area in which the
beneficiary resides.
(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with the
provider or managed care plan, pilot project, or fee-for-service case
management provider shall be allowed to select or be assigned to
another provider or managed care plan, pilot project, or
fee-for-service case management provider.
(j) The department or its contractor shall notify a managed care
plan, pilot project, or fee-for-service case management provider when
it has been selected by or assigned to a beneficiary. The managed
care plan, pilot project, or fee-for-service case management provider
that has been selected by, or assigned to, a beneficiary, shall
notify the primary care provider or clinic than it has been selected
or assigned. The managed care plan, pilot project, or
fee-for-service case management provider shall also notify the
beneficiary of the managed care plan, pilot project, or
fee-for-service case management provider or clinic selected or
assigned.
(k) (1) The department shall ensure that Medi-Cal beneficiaries
eligible under Title XVI of the Social Security Act are provided with
information about options available regarding methods of receiving
Medi-Cal benefits as described in subdivision (c).
(2) (A) The director may waive the requirements of subdivisions
(c) and (d) until a means is established to directly provide the
presentation described in subdivision (a) to beneficiaries who are
eligible for the federal Supplemental Security Income for the Aged,
Blind, and Disabled Program (Subchapter 16 (commencing with Section
1381) of Chapter 7 of Title 42 of the United States Code).
(B) The director may elect not to apply the requirements of
subdivisions (c) and (d) to beneficiaries whose eligibility under the
Supplemental Security Income program is established before January
1, 1994.
(l) In areas where there is no prepaid managed health care plan or
pilot program which has contracted with the department to provide
services to Medi-Cal beneficiaries, and where no other enrollment
requirements have been established by the department, no explicit
choice need be made, and the beneficiary or eligible applicant shall
receive a Medi-Cal card.
(m) The following definitions contained in this subdivision shall
control the construction of this section, unless the context requires
otherwise:
(1) "Applicant," "beneficiary," or "eligible applicant," in the
case of a family group, means any person with legal authority to make
a choice on behalf of dependent family members.
(2) "Fee-for-service case management provider" means a provider
enrolled and certified to participate in the Medi-Cal fee-for-service
case management program the department may elect to develop in
selected areas of the state with the assistance of and in cooperation
with California physician providers and other interested provider
groups.
(3) "Managed health care plan" or "managed care plan" means a
person or entity operating under a Medi-Cal contract with the
department under this chapter or Chapter 8 (commencing with Section
14200) to provide, or arrange for, health care services for Medi-Cal
beneficiaries as an alternative to the Medi-Cal fee-for-service
program that has a contractual responsibility to manage health care
provided to Medi-Cal beneficiaries covered by the contract.
(n) (1) Whenever a county welfare department notifies a public
assistance recipient or Medi-Cal beneficiary that the recipient or
beneficiary is losing Medi-Cal eligibility, the county shall include,
in the notice to the recipient or beneficiary, notification that the
loss of eligibility shall also result in the recipient's or
beneficiary's disenrollment from Medi-Cal managed care health or
dental plans, if enrolled.
(2) (A) Whenever the department or the county welfare department
processes a change in a public assistance recipient's or Medi-Cal
beneficiary's residence or aid code that will result in the recipient'
s or beneficiary's disenrollment from the managed care health or
dental plan in which they are currently enrolled, a written notice
shall be given to the recipient or beneficiary.
(B) This paragraph shall become operative and the department shall
commence sending the notices required under this paragraph on or
before the expiration of 12 months after the effective date of this
section.
(o) This section shall be implemented in a manner consistent with
any federal waiver required to be obtained by the department in order
to implement this section.
SEC. 28.
SEC. 25. Section 14016.71 is added to the Welfare and
Institutions Code, to read:
14016.71. (a) On and after July 1, 2000, notwithstanding any
other provision of law, whenever a Medi-Cal managed health care plan
contracts with a hospital, clinic, ambulatory surgical
center, independent physician association, medical group, pharmacy,
or other primary, ancillary, or specialty health care facility that
licensed facility that excludes, limits, or
restricts the provision of reproductive health services enumerated in
subdivision (c) of Section 1345 of the Health and Safety Code, it
shall also contract with and make available and accessible to its
enrollees, a similar provider or licensed
facility that does not exclude, limit, or restrict the service.
These services shall be available and accessible within reasonable
proximity to the residence or place of business of the enrollee,
except when no such facility exists, in which case, the plan shall
provide transportation. Nothing in this section shall be construed to
permit any plan to apply a higher deductible or copayment for
services provided under this section.
(b) On and after July 1, 2000, each Medi-Cal managed health care
plan shall ensure that voluntary tubal ligations are available at the
time of labor and delivery, including by providing transportation if
necessary to access services. Nothing in this section shall be
construed to permit a Medi-Cal managed health care plan to apply any
deductible or copayment for services provided under this section.
(c)
(b) For the purposes of this section, "managed health care
plans" mean a person or entity including, but not limited to, county
organized health systems, pilot projects, primary care case
management plans, fee-for-service managed care plans, prepaid health
plans, and prepaid health plans that are contracting with, or
governed, owned, or operated by, either a county board of supervisors
or a county special commission, or a county health authority,
operating under a Medi-Cal contract under this chapter or Chapter 8
(commencing with Section 14200), or Chapter 3 (commencing with
Section 101675) of Part 4 of Division 101 of the Health and Safety
Code, to provide, arrange, or reimburse for, health services for
Medi-Cal beneficiaries as an alternative to the Medi-Cal
fee-for-service program that has a
contractual responsibility to manage health care
provided to Medi-Cal beneficiaries covered by the contract.
(d) A Medi-Cal managed health care plan shall provide to all
enrollees and subscribers written notice in readily understood
language and in a clearly organized format on how to access
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code. This written
notice shall be provided, commencing March 1, 2000, upon the enrollee'
s enrollment, and annually thereafter. In addition, the plan shall
provide this written notice to all pregnant enrollees during the
course of prenatal care if the plan received notice, whether by
receipt of a claim, a request for preauthorization for
pregnancy-related services, or other actual notice that the enrollee
is pregnant.
SEC. 29.
SEC. 26. Section 14016.8 is added to the Welfare and
Institutions Code, to read:
14016.8. (a) Notwithstanding any other provision of law, a
managed health care plan shall not discriminate against Medi-Cal
beneficiaries and enrollees in the terms, conditions, or benefits and
shall prohibit any limitation on coverage or the provision of
services on the basis of race, color, religion, national origin,
ancestry, sex, or sexual orientation.
(b) For the purposes of this section, "managed health care plans"
mean a person or entity including, but not limited to, county
organized health systems, pilot projects, primary care case
management plans, fee-for-service managed care plans, prepaid health
plans, and prepaid health plans that are contracting with, or
governed, owned, or operated by, either a county board of supervisors
or a county special commission, or a county health authority,
operating under a Medi-Cal contract under this chapter or Chapter 8
(commencing with Section 14200), or Chapter 3 (commencing with
Section 101675) of Part 4 of Division 101 of the Health and Safety
Code, to provide, arrange, or reimburse for, health services for
Medi-Cal beneficiaries as an alternative to the Medi-Cal
fee-for-service program that has a contractual responsibility to
manage health care provided to Medi-Cal beneficiaries covered by the
contract.
SEC. 30.
SEC. 27. Section 14016.9 is added to the Welfare and
Institutions Code, to read:
14016.9. (a) All On and after July 1,
2000, all county organized health systems shall provide in
writing in readily understood language and in a clearly organized
format to each Medi-Cal beneficiary the following information.
(1) The principal benefits and coverage of the managed care plan,
including coverage for comprehensive reproductive health services, as
defined in subdivision (c) of Section 1345 of the Health and Safety
Code, and how to access out-of-plan family planning services.
(2) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other principal primary, ancillary, or specialty health care
facilities available in the health plan network.
(3) The exceptions, reductions, and limitations that apply to the
plan, including exceptions, reductions, and limitations on
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code.
(4) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other primary, ancillary, or specialty health care facilities that do
not provide comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code.
(1) The name, address, telephone number, and specialty, if any, of
each primary care provider, each licensed clinic, and any other
licensed facility participating in the county organized health
system. This information shall be provided under geographic area
designations, in alphabetical order by the name of each primary care
provider, clinic, and licensed facility. The name, address, and
telephone number of each specialist participating in the county
organized health system shall be made available by contacting the
county organized health system. Information described in paragraph
(3) shall also be made available by contacting the county organized
health system.
(2) Materials with the information described in paragraph (1)
shall indicate with an asterisk (*) those licensed hospitals and
ambulatory surgical centers that do not provide sterilizations,
emergency contraception for rape victims, or abortions.
(3) The information described in paragraphs (1) and (2) shall
include a statement on each page where a facility is identified with
an asterisk (*), as required under paragraph (2), in no less than
12-point type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
(b) This information shall be provided within seven days after a
beneficiary has been determined eligible for Medi-Cal to
allow beneficiaries to be fully informed prior to making their choice
of providers within the county organized health system
and annually thereafter . Each beneficiary shall have 30
days from the time the information is provided to choose a primary
care provider. The written information described in subdivision
(a) shall be updated periodically, but no less often than annually.
(c) For purposes of this section, "county organized health systems"
mean a person or entity that is contracting with, or governed,
owned, or operated by, either a county board of supervisors or a
county special commission, or a county health authority, operating
under Article 2.8 (commencing with Section 14087.51) of this chapter
or Article 7 (commencing with Section 14490) of Chapter 8, or Chapter
3 (commencing with Section 101675) of Part 4 of Division 101 of the
Health and Safety Code, to provide, arrange, or reimburse for, health
services for Medi-Cal beneficiaries as an alternative to the
Medi-Cal fee-for-service program that has a contractual
responsibility to manage health care provided to Medi-Cal
beneficiaries covered by the contract.
SEC. 31.
SEC. 28. Section 14087.305 of the Welfare and Institutions
Code is amended to read:
14087.305. (a) In areas specified by the director for expansion
of the Medi-Cal managed care program under Section 14087.3 and where
the department is contracting with a prepaid health plan that is
contracting with, governed, owned or operated by a county board of
supervisors, a county special commission or county health authority
authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96, a Medi-Cal or Aid to Families with Dependent
Children (AFDC) applicant or beneficiary shall be informed of the
managed care options available regarding methods of receiving
Medi-Cal benefits. The county shall ensure that each beneficiary is
informed of these options and informed that a health care options
presentation is available.
(b) The managed care options information described in subdivision
(a) shall be provided in writing in readily understood language and
in a clearly organized format to each applicant or beneficiary and
shall include the following elements:
(1) Each beneficiary or eligible applicant shall be provided with
the name, address, telephone number, and specialty, if any, of each
primary care provider, by specialty, or clinic, participating in each
prepaid health plan option. This information shall be presented
under geographic area designations, in alphabetical order by the name
of the primary care provider and clinic. The name, address, and
telephone number of each specialist participating in each prepaid
health plan shall be made available by contacting the health care
options contractor or the prepaid health plan.
(2) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating
provider is a primary care provider or clinic contracting with any of
the prepaid health plan options available and has available capacity
and agrees to continue to treat that beneficiary or applicant.
(3) Each beneficiary or eligible applicant shall be informed that
if he or she fails to make a choice, he or she shall be assigned to,
and enrolled in, a prepaid health plan.
(4) (A) The principal benefits and coverage of the plan, including
coverage for comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code, and
how to access out-of-plan family planning services.
(B) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other principal primary, ancillary, or specialty health care
facilities available in the health plan network.
(C) The exceptions, reductions, and limitations that apply to the
plan, including exceptions, reductions, and limitations on
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code.
(D) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other primary, ancillary, or specialty health care facilities that do
not provide comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code.
(4) The information described in paragraph (2) of subdivision (b)
of Section 14016.5.
(c) No later than 30 days following the date a Medi-Cal or AFDC
beneficiary or applicant is determined eligible for Medi-Cal, the
beneficiary shall indicate his or her choice, in writing, from among
the available prepaid health plans in the region and his or her
choice of primary care provider or clinic contracting with the
selected prepaid health plan.
(d) At the time the beneficiary or eligible applicant selects a
prepaid health plan, the department shall, when applicable, encourage
the beneficiary or eligible applicant to also indicate, in writing,
his or her choice of primary care provider or clinic contracting with
the selected prepaid health plan.
(e) In areas specified by the director for expansion of the
Medi-Cal managed care program under Section 14087.3, and where the
department is contracting with a prepaid health plan that is
contracting with, governed, owned or operated by a county board of
supervisors, a county special commission or county health authority
authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96, a Medi-Cal or AFDC beneficiary who does not
make a choice of managed care plans, shall be assigned to and
enrolled in an appropriate Medi-Cal prepaid health plan providing
service within the area in which the beneficiary resides.
(f) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select any primary care
provider who is available, the prepaid health plan that was selected
by or assigned to the beneficiary shall ensure that the beneficiary
selects a primary care provider or clinic within 30 days after
enrollment or is assigned to a primary care provider within 40 days
after enrollment.
(g) Any Medi-Cal or AFDC beneficiary dissatisfied with the primary
care provider or prepaid health plan shall be allowed to select or
be assigned to another primary care provider within the same prepaid
health plan. In addition, the beneficiary shall be allowed to select
or be assigned to another prepaid health plan contracted for
pursuant to this article that is in effect for the geographic area in
which he or she resides, in accordance with Section 1903 (m) (2) (F)
(ii) of the Social Security Act.
(h) The department or its contractor shall notify a prepaid health
plan when it has been selected by or assigned to a beneficiary. The
prepaid health plan that has been selected by or assigned to a
beneficiary shall notify the primary care provider that has been
selected or assigned. The prepaid health plan shall also notify the
beneficiary of the prepaid health plan and primary care provider or
clinic selected or assigned.
(i) (1) The managed health care plan shall have a valid Medi-Cal
contract, adequate capacity, and appropriate staffing to provide
health care services to the beneficiary.
(2) The department shall establish standards for all of the
following:
(A) The maximum distances a beneficiary is required to travel to
obtain primary care services from the managed care plan, in which the
beneficiary is enrolled.
(B) The conditions under which a primary care service site shall
be accessible by public transportation.
(C) The conditions under which a managed care plan shall provide
nonmedical transportation to a primary care service site.
(3) In developing the standards required by paragraph (2) the
department shall take into account, on a geographic basis, the means
of transportation used and distances typically traveled by Medi-Cal
beneficiaries to obtain fee-for-service primary care services and the
experience of managed care plans in delivering services to Medi-Cal
enrollees. The department shall also consider the provider's ability
to render culturally and linguistically appropriate services.
(j) To the extent possible, the arrangements for carrying out
subdivision (e) shall provide for the equitable distribution of
Medi-Cal beneficiaries among participating prepaid health plans, or
managed care plans.
(k) This section shall be implemented in a manner consistent with
any federal waiver required to be obtained by the department in order
to implement this section.
SEC. 32.
SEC. 29. Section 14089 of the Welfare and Institutions Code
is amended to read:
14089. (a) The purpose of this article is to provide a
comprehensive program of managed health care plan services to
Medi-Cal recipients residing in clearly defined geographical areas.
It is, further, the purpose of this article to create maximum
accessibility to health care services by permitting Medi-Cal
recipients the option of choosing from among two or more managed
health care plans or fee-for-service managed case arrangements,
including, but not limited to, health maintenance organizations,
prepaid health plans, primary care case management plans.
Independent practice associations, health insurance carriers, private
foundations, and university medical centers systems, not-for-profit
clinics, and other primary care providers, may be offered as choices
to Medi-Cal recipients under this article if they are organized and
operated as managed care plans, for the provision of preventive
managed health care plan services.
(b) The negotiator may seek proposals and then shall contract
based on relative costs, extent of coverage offered, quality of
health services to be provided, financial stability of the health
care plan or carrier, recipient access to services, cost-containment
strategies, peer and community participation in quality control,
emphasis on preventive and managed health care services and the
ability of the health plan to meet all requirements for both of the
following:
(1) Certification, where legally required, by the Commissioner of
Corporations and the Insurance Commissioner.
(2) Compliance with all of the following:
(A) The health plan shall satisfy all applicable state and federal
legal requirements for participation as a Medi-Cal managed care
contractor.
(B) The health plan shall meet any standards established by the
department for the implementation of this article.
(C) The health plan receives the approval of the department to
participate in the pilot project under this article.
(c) (1) (A) The proposals shall be for the provision of preventive
and managed health care services to specified eligible populations
on a capitated, prepaid or postpayment basis.
(B) Enrollment in a Medi-Cal managed health care plan under this
article shall be voluntary for beneficiaries eligible for the federal
Supplemental Security Income for the Aged, Blind, and Disabled
Program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of
Title 42 of the United States Code).
(2) The cost of each program established under this section shall
not exceed the total amount which the department estimates it would
pay for all services and requirements within the same geographic area
under the fee-for-service Medi-Cal program.
(d) The department shall enter into contracts pursuant to this
article, and shall be bound by the rates, terms, and conditions
negotiated by the negotiator.
(e) (1) An eligible beneficiary shall be entitled to enroll in any
health care plan contracted for pursuant to this article that is in
effect for the geographic area in which he or she resides.
Enrollment shall be for a minimum of six months. Contracts entered
into pursuant to this article shall be for at least one but no more
than three years. The director shall make available to recipients
information summarizing the benefits and limitations of each health
care plan available pursuant to this section in the geographic area
in which the recipient resides.
(2) No later than 30 days following the date a Medi-Cal or AFDC
recipient is informed of the health care options described in
paragraph (1) of subdivision (e), the recipient shall indicate his or
her choice in writing of one of the available health care plans and
his or her choice of primary care provider or clinic contracting with
the selected health care plan.
(3) The health care options information described in paragraph (1)
of subdivision (e) shall be provided in writing in readily
understood language and in a clearly organized format to each
applicant or beneficiary and shall include the following elements:
(A) Each beneficiary or eligible applicant shall be provided with
the name, address, telephone number, and specialty, if any, of each
primary care provider, and each clinic each
clinic, and each licensed facility participating in each health
care plan. This information shall be presented under geographic
area designations in alphabetical order by the name of the primary
care provider and clinic. The name, address, and telephone number of
each specialist participating in each health care plan shall be made
available by contacting the health care options contractor or the
health care plan. Information described in subparagraph (C)
shall also be made available by contacting each prepaid managed care
health plan, pilot project, or fee-for-service case management
provider.
(B) Materials with the information described in subparagraph (A)
shall indicate with an asterisk (*) those licensed hospitals and
ambulatory surgical centers that do not provide sterilizations,
emergency contraception for rape victims, or abortion.
(C) Materials described in subparagraphs (A) and (B) shall include
a statement on each page where a facility is identified with an
asterisk (*), as required in paragraph (B), in no less than 12-point
type and shall read as follows:
* This hospital or ambulatory surgical center does not provide one
or more of the following services: emergency contraception for rape
victims, sterilizations, or abortions. If you need these services,
you should talk with your doctor about how you can get them. You
also can call your health plan at (insert membership services
telephone number).
(B)
(D) Each beneficiary or eligible applicant shall be informed
that he or she may choose to continue an established
patient-provider relationship in a managed care option, if his or her
treating provider is a primary care provider or clinic contracting
with any of the health plans available and has the available capacity
and agrees to continue to treat that beneficiary or eligible
applicant.
(C)
(E) Each beneficiary or eligible applicant shall be informed
that if he or she fails to make a choice, he or she shall be
assigned to, and enrolled in, a health care plan.
(D) (i) The principal benefits and coverage of the plan, including
coverage for comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code, and
how to access out-of-plan family planning services.
(ii) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other principal primary, ancillary, or specialty health care
facilities available in the health plan network.
(iii) The exceptions, reductions, and limitations that apply to
the plan, including exceptions, reductions, and limitations on
comprehensive reproductive health services, as defined in subdivision
(c) of Section 1345 of the Health and Safety Code.
(iv) The hospitals, clinics, ambulatory surgical centers,
independent physician associations, medical groups, pharmacies, and
other primary, ancillary, or specialty health care facilities that do
not provide comprehensive reproductive health services, as defined
in subdivision (c) of Section 1345 of the Health and Safety Code.
(4) At the time the beneficiary or eligible applicant selects a
health care plan, the department shall, when applicable, encourage
the beneficiary or eligible applicant to also indicate, in writing,
his or her choice of primary care provider or clinic contracting with
the selected health care plan.
(5) Commencing with the implementation of a geographic managed
care project in a designated county, a Medi-Cal or AFDC beneficiary
who does not make a choice of health care plans in accordance with
paragraph (2), shall be assigned to and enrolled in an appropriate
health care plan providing service within the area in which the
beneficiary resides.
(6) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select any primary care
provider who is available, the health care plan selected by or
assigned to the beneficiary shall ensure that the beneficiary selects
a primary care provider or clinic within 30 days after enrollment or
is assigned to a primary care provider within 40 days after
enrollment.
(7) Any Medi-Cal or AFDC beneficiary dissatisfied with the primary
care provider or health care plan shall be allowed to select or be
assigned to another primary care provider within the same health care
plan. In addition, the beneficiary shall be allowed to select or be
assigned to another health care plan contracted for pursuant to this
article that is in effect for the geographic area in which he or she
resides in accordance with Section 1903(m)(2)(F)(ii) of the Social
Security Act.
(8) The department or its contractor shall notify a health care
plan when it has been selected by or assigned to a beneficiary. The
health care plan that has been selected or assigned by a beneficiary
shall notify the primary care provider that has been selected or
assigned. The health care plan shall also notify the beneficiary of
the health care plan and primary care provider selected or assigned.
(9) This section shall be implemented in a manner consistent with
any federal waiver that is required to be obtained by the department
to implement this section.
(f) A participating county may include within the plan or plans
providing coverage pursuant to this section, employees of county
government, and others who reside in the geographic area and who
depend upon county funds for all or part of their health care costs.
(g) The negotiator and the department shall establish pilot
projects to test the cost effectiveness of delivering benefits as
defined in subdivisions (a) to (f), inclusive.
(h) The California Medical Assistance Commission shall evaluate
the cost effectiveness of these pilot projects after one year of
implementation. Pursuant to this evaluation the commission may either
terminate or retain the existing pilot projects.
(i) Funds may be provided to prospective contractors to assist in
the design, development, and installation of appropriate programs.
The award of these funds shall be based on criteria established by
the department.
(j) In implementing this article, the department may enter into
contracts for the provision of essential administrative and other
services. Contracts entered into under this subdivision may be on a
noncompetitive bid basis and shall be exempt from Chapter 2
(commencing with Section 10290) of Part 2 of Division 2 of the Public
Contract Code.
SEC. 33.
SEC. 30. Section 14165.6 of the Welfare and Institutions
Code is amended to read:
14165.6. The commission shall direct the planning, development
and negotiation of contract services which provide for:
(a) The provision of services through a capitation methodology,
including, but not limited to, health maintenance organizations,
organized county health systems, insurance companies, and independent
practice associations.
(b) Hospital inpatient or hospital outpatient services.
(c) Pilot projects meeting the provisions of Section 14491.5.
(d) Health care projects meeting the provisions of Article 2.91
(commencing with Section 14089).
(e) Notwithstanding any other provision of law, all contracts
negotiated by the commission shall prohibit both of the following:
(1)
Discrimination against Medi-Cal beneficiaries and enrollees in the
terms, conditions, or benefits.
(2) Any limitation on coverage or the provision of services on the
basis of race, color, religion, national origin, ancestry, sex, or
sexual orientation.
SEC. 34.
SEC. 31. The provisions of this act are severable. If any
provision of this act or its application is held invalid, that
invalidity shall not affect other provisions or applications that can
be given effect without the invalid provision or application.
SEC. 32. No reimbursement is required by this act pursuant
to Section 6 of Article XIIIB of the California Constitution for
certain costs that may be incurred by a local agency or school
district because in that regard 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.
However, notwithstanding Section 17610 of the Government Code, if
the Commission on State Mandates determines that this act contains
other costs mandated by the state, reimbursement to local agencies
and school districts for those costs shall be made pursuant to Part 7
(commencing with Section 17500) of Division 4 of Title 2 of the
Government Code. If the statewide cost of the claim for
reimbursement does not exceed one million dollars ($1,000,000),
reimbursement shall be made from the State Mandates Claims Fund.