BILL NUMBER: SB 168 CHAPTERED 09/29/00 CHAPTER 845 FILED WITH SECRETARY OF STATE SEPTEMBER 29, 2000 APPROVED BY GOVERNOR SEPTEMBER 28, 2000 PASSED THE SENATE AUGUST 31, 2000 PASSED THE ASSEMBLY AUGUST 31, 2000 AMENDED IN ASSEMBLY AUGUST 30, 2000 AMENDED IN ASSEMBLY JUNE 6, 2000 AMENDED IN ASSEMBLY JULY 12, 1999 AMENDED IN ASSEMBLY JUNE 24, 1999 AMENDED IN SENATE APRIL 21, 1999 INTRODUCED BY Senator Speier (Coauthors: Senators Rainey, Solis, and Vasconcellos) (Coauthors: Assembly Members Bock, Cunneen, Kuehl, Strom-Martin, and Zettel) JANUARY 11, 1999 An act to add Section 1367.36 to the Health and Safety Code, relating to health care service plans. LEGISLATIVE COUNSEL'S DIGEST SB 168, Speier. Health care service plans: immunizations for children: reimbursement of physicians. Existing law provides for the licensing and regulation of health care service plans by the Department of Managed Care. Existing law requires every health care service plan that covers hospital, medical, or surgical expenses on a group basis to provide certain preventative health care benefits for children, including immunizations. A willful violation of the provisions governing health care service plans is a crime. This bill would generally prohibit a risk-based contract between a health care service plan and a physician or physician group that is issued, amended, delivered, or renewed in this state on or after January 1, 2001, from including a provision that requires a physician or a physician group to assume financial risk for the acquisition costs of required immunizations for children as a condition of accepting the risk-based contract. This bill would provide that a physician or physician group shall not be required to assume financial risk for immunizations that are not part of the current contract. This bill would require plans to reimburse physicians or physician groups for immunizations that are not part of the current contract at not less than a specified amount, until the contract is renegotiated. This bill would prohibit a health care service plan from including the acquisition costs associated with required immunizations for children in the capitation rate of a physician who is individually capitated. This bill would enact other related provisions. Because a willful violation of the bill's requirements would be a crime, this bill would impose a state-mandated local program by creating a new 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 1367.36 is added to the Health and Safety Code, to read: 1367.36. (a) A risk-based contract between a health care service plan and a physician or physician group that is issued, amended, delivered, or renewed in this state on or after January 1, 2001, shall not include a provision that requires a physician or a physician group to assume financial risk for the acquisition costs of required immunizations for children as a condition of accepting the risk-based contract. A physician or physician group shall not be required to assume financial risk for immunizations that are not part of the current contract. (b) Beginning January 1, 2001, with respect to immunizations for children that are not part of the current contract between a health care service plan and a physician or physician group, the health care service plan shall reimburse a physician or physician group at the lowest of the following, until the contract is renegotiated: (1) the physician's actual acquisition cost, (2) the "average wholesale price" as published in the Drug Topics Red Book, or (3) the lowest acquisition cost through sources made available to the physician by the health care service plan. Reimbursements shall be made within 45 days of receipt by the plan of documents from the physician demonstrating that the immunizations were performed, consistent with Section 1371 or through an alternative funding mechanism mutually agreed to by the health care service plan and the physician or physician group. The alternative funding mechanism shall be based on reimbursements consistent with this subdivision. (c) Physicians and physician groups may assume financial risk for providing required immunizations, if the immunizations have experiential data that has been negotiated and agreed upon by the health care service plan and the physician risk-bearing organization. However, a health care service plan shall not require a physician risk-bearing organization to accept financial risk or impose additional risk on a physician risk-bearing organization in violation of subdivision (a). (d) A health care service plan shall not include the acquisition costs associated with required immunizations for children in the capitation rate of a physician who is individually capitated. SEC. 2. 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.