BILL NUMBER: AB 2168 ENROLLED
BILL TEXT
PASSED THE ASSEMBLY AUGUST 28, 2000
PASSED THE SENATE AUGUST 25, 2000
AMENDED IN SENATE AUGUST 22, 2000
AMENDED IN ASSEMBLY MAY 15, 2000
AMENDED IN ASSEMBLY MAY 4, 2000
INTRODUCED BY Assembly Member Gallegos
(Coauthor: Assembly Member Shelley)
FEBRUARY 23, 2000
An act to amend, add, and repeal Section 1374.16 of the Health and
Safety Code, relating to health care.
LEGISLATIVE COUNSEL'S DIGEST
AB 2168, Gallegos. Health care coverage.
Existing law provides for regulation and licensing of health care
service plans by the Department of Managed Care, effective no later
than July 1, 2000, or earlier pursuant to an Executive Order of the
Governor. A willful violation of the provisions governing health
care service plans is a crime. Existing law requires every health
care service plan, except a specialized health care service plan, to
establish and implement procedures by which an enrollee could receive
a standing referral, as defined, to a specialist and by which an
enrollee with a condition or disease that requires specialized care
over a prolonged period of time and is life-threatening,
degenerative, or disabling could receive a referral to a specialist
who, or a specialty care center, as defined, that, has expertise in
treating the condition or disease for the purpose of having the
specialist, or the specialty care center, coordinate the enrollee's
health care.
This bill would require, until January 1, 2004, or an earlier
determined date, that human immunodeficiency virus (HIV) or acquired
immune deficiency syndrome (AIDS) be interpreted broadly as a
"condition or disease that requires specialized medical care over a
prolonged period of time and is life-threatening, degenerative, or
disabling" so as to maximize the access of an enrollee with HIV or
AIDS to a provider with demonstrated expertise in treating a
condition or disease involving a complicated treatment regimen that
requires ongoing monitoring of the patient's adherence to the
regimen.
Because a violation of this bill's requirements with respect to a
health care service plan would be a crime, this bill would impose a
state-mandated local program by expanding the definition of an
existing crime.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1374.16 of the Health and Safety Code is
amended to read:
1374.16. (a) Every health care service plan, except a specialized
health care service plan, shall establish and implement a procedure
by which an enrollee may receive a standing referral to a specialist.
The procedure shall provide for a standing referral to a specialist
if the primary care physician determines in consultation with the
specialist, if any, and the plan medical director or his or her
designee, that an enrollee needs continuing care from a specialist.
The referral shall be made pursuant to a treatment plan approved by
the health care service plan in consultation with the primary care
physician, the specialist, and the enrollee, if a treatment plan is
deemed necessary to describe the course of the care. A treatment
plan may be deemed to be not necessary provided that a current
standing referral to a specialist is approved by the plan or its
contracting provider, medical group, or independent practice
association. The treatment plan may limit the number of visits to
the specialist, limit the period of time that the visits are
authorized, or require that the specialist provide the primary care
physician with regular reports on the health care provided to the
enrollee.
(b) Every health care service plan, except a specialized health
care service plan, shall establish and implement a procedure by which
an enrollee with a condition or disease that requires specialized
medical care over a prolonged period of time and is life-threatening,
degenerative, or disabling may receive a referral to a specialist or
specialty care center that has expertise in treating the condition
or disease for the purpose of having the specialist coordinate the
enrollee's health care. The referral shall be made if the primary
care physician, in consultation with the specialist or specialty care
center if any, and the plan medical director or his or her designee
determines that this specialized medical care is medically necessary
for the enrollee. The referral shall be made pursuant to a treatment
plan approved by the health care service plan in consultation with
the primary care physician, specialist or specialty care center, and
enrollee, if a treatment plan is deemed necessary to describe the
course of care. A treatment plan may be deemed to be not necessary
provided that the appropriate referral to a specialist or specialty
care center is approved by the plan or its contracting provider,
medical group, or independent practice association. After the
referral is made, the specialist shall be authorized to provide
health care services that are within the specialist's area of
expertise and training to the enrollee in the same manner as the
enrollee's primary care physician, subject to the terms of the
treatment plan.
(c) The determinations described in subdivisions (a) and (b) shall
be made within three business days of the date the request for the
determination is made by the enrollee or the enrollee's primary care
physician and all appropriate medical records and other items of
information necessary to make the determination are provided. Once a
determination is made, the referral shall be made within four
business days of the date the proposed treatment plan, if any, is
submitted to the plan medical director or his or her designee.
(d) Subdivisions (a) and (b) do not require a health care service
plan to refer to a specialist who, or to a specialty care center
that, is not employed by or under contract with the health care
service plan to provide health care services to its enrollees, unless
there is no specialist within the plan network that is appropriate
to provide treatment to the enrollee, as determined by the primary
care physician in consultation with the plan medical director as
documented in the treatment plan developed pursuant to subdivision
(a) or (b).
(e) For the purposes of this section, "specialty care center"
means a center that is accredited or designated by an agency of the
state or federal government or by a voluntary national health
organization as having special expertise in treating the
life-threatening disease or condition or degenerative and disabling
disease or condition for which it is accredited or designated.
(f) As used in this section, a "standing referral" means a
referral by a primary care physician to a specialist for more than
one visit to the specialist, as indicated in the treatment plan, if
any, without the primary care physician having to provide a specific
referral for each visit.
(g) As used in this section, with regard to an enrollee with human
immunodeficiency virus (HIV) or acquired immune deficiency syndrome
(AIDS), "a condition or disease that requires specialized medical
care over a prolonged period of time and is life-threatening,
degenerative, or disabling" shall be interpreted broadly so as to
maximize the enrollee's access to provider with demonstrated
expertise in treating a condition or disease involving a complicated
treatment regimen that requires ongoing monitoring of the patient's
adherence to the regimen.
(h) This section shall become inoperative on (1) January 1, 2004,
or (2) the date of adoption of an accreditation or designation by an
agency of the state or federal government or by a voluntary national
health organization of an HIV or AIDS specialist, whichever date is
earlier, and, as of January 1, 2004, or of the January 1 following
the inoperative date whichever date is earlier, is repealed, unless a
later enacted statute that is enacted before those dates deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 2. Section 1374.16 is added to the Health and Safety Code, to
read:
1374.16. (a) Every health care service plan, except a specialized
health care service plan, shall establish and implement a procedure
by which an enrollee may receive a standing referral to a specialist.
The procedure shall provide for a standing referral to a specialist
if the primary care physician determines in consultation with the
specialist, if any, and the plan medical director or his or her
designee, that an enrollee needs continuing care from a specialist.
The referral shall be made pursuant to a treatment plan approved by
the health care service plan in consultation with the primary care
physician, the specialist, and the enrollee, if a treatment plan is
deemed necessary to describe the course of the care. A treatment
plan may be deemed to be not necessary provided that a current
standing referral to a specialist is approved by the plan or its
contracting provider, medical group, or independent practice
association. The treatment plan may limit the number of visits to
the specialist, limit the period of time that the visits are
authorized, or require that the specialist provide the primary care
physician with regular reports on the health care provided to the
enrollee.
(b) Every health care service plan, except a specialized health
care service plan, shall establish and implement a procedure by which
an enrollee with a condition or disease that requires specialized
medical care over a prolonged period of time and is life-threatening,
degenerative, or disabling may receive a referral to a specialist or
specialty care center that has expertise in treating the condition
or disease for the purpose of having the specialist coordinate the
enrollee's health care. The referral shall be made if the primary
care physician, in consultation with the specialist or specialty care
center if any, and the plan medical director or his or her designee
determines that this specialized medical care is medically necessary
for the enrollee. The referral shall be made pursuant to a treatment
plan approved by the health care service plan in consultation with
the primary care physician, specialist or specialty care center, and
enrollee, if a treatment plan is deemed necessary to describe the
course of care. A treatment plan may be deemed to be not necessary
provided that the appropriate referral to a specialist or specialty
care center is approved by the plan or its contracting provider,
medical group, or independent practice association. After the
referral is made, the specialist shall be authorized to provide
health care services that are within the specialist's area of
expertise and training to the enrollee in the same manner as the
enrollee's primary care physician, subject to the terms of the
treatment plan.
(c) The determinations described in subdivisions (a) and (b) shall
be made within three business days of the date the request for the
determination is made by the enrollee or the enrollee's primary care
physician and all appropriate medical records and other items of
information necessary to make the determination are provided. Once a
determination is made, the referral shall be made within four
business days of the date the proposed treatment plan, if any, is
submitted to the plan medical director or his or her designee.
(d) Subdivisions (a) and (b) do not require a health care service
plan to refer to a specialist who, or to a specialty care center
that, is not employed by or under contract with the health care
service plan to provide health care services to its enrollees, unless
there is no specialist within the plan network that is appropriate
to provide treatment to the enrollee, as determined by the primary
care physician in consultation with the plan medical director as
documented in the treatment plan developed pursuant to subdivision
(a) or (b).
(e) For the purposes of this section, "specialty care center"
means a center that is accredited or designated by an agency of the
state or federal government or by a voluntary national health
organization as having special expertise in treating the
life-threatening disease or condition or degenerative and disabling
disease or condition for which it is accredited or designated.
(f) As used in this section, a "standing referral" means a
referral by a primary care physician to a specialist for more than
one visit to the specialist, as indicated in the treatment plan, if
any, without the primary care physician having to provide a specific
referral for each visit.
(g) This section shall become operative on (1) January 1, 2004, or
(2) the date of adoption of an accreditation or designation by an
agency of the state or federal government or by a voluntary national
health organization of an HIV or AIDS specialist, whichever date is
earlier.
SEC. 3. No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution because the
only costs that may be incurred by a local agency or school district
will be incurred because this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIIIB of the California Constitution.