BILL NUMBER: AB 2093 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 9, 2010
AMENDED IN SENATE JULY 15, 2010
AMENDED IN ASSEMBLY MAY 28, 2010
INTRODUCED BY Assembly Member V. Manuel Perez
(Coauthors: Assembly Members Blumenfield, Fletcher, and Jones)
FEBRUARY 18, 2010
An act to amend Section 1367.36 of , and to add Section
1367.37 to, the Health and Safety Code, and to add Section
10123.56 to the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2093, as amended, V. Manuel Perez. Immunizations for children:
reimbursement of physicians.
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 Department of Managed Health Care and makes a willful
violation of that act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires every health care service plan or health
insurer that covers hospital, medical, or surgical expenses on a
group basis to provide certain preventive health care benefits for
children, including immunizations. Existing law prohibits a
risk-based contract between a health care service plan and a
physician or physician group from including a provision requiring the
physician or physician group to assume financial risk for the
acquisition costs of required immunizations for children and
specifies the reimbursement rate with respect to immunizations that
are not part of the current contract between a health care service
plan and a physician or physician group.
This bill would prohibit a plan from requiring a physician or
physician group to assume financial risk for the acquisition or
administration costs of required immunizations and would require a
health care service plan or health insurer that provides coverage for
childhood and adolescent immunizations to include in its
reimbursement of a physician or physician group a reimbursement for
the cost of administration of the vaccine, as specified. The bill
would specify that this requirement these
requirements would not apply to services provided pursuant to
contracts or policies with the Board of Administration of the Public
Employees' Retirement System or to services provided pursuant to
Medi-Cal or the Healthy Families Program. The bill would make other
related changes.
The bill would prohibit a health care service plan contract or
health insurance policy providing coverage for childhood or
adolescent immunizations from imposing a deductible, copayment,
coinsurance, or other cost-sharing mechanism for the administration
of a childhood or adolescent immunization or for related procedures.
The bill would also prohibit those contracts or policies from
containing a dollar limit provision for the administration of
childhood and adolescent immunizations or including the cost of those
immunizations in a dollar limit provision. The bill would specify
that these prohibitions do not apply to services provided pursuant to
Medi-Cal or the Healthy Families Program.
Because a willful violation of the bill's requirements relative to
health care service plans would be a crime, the bill would impose a
state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
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. The Legislature finds and declares all of the
following:
(a) Pediatric immunizations proved to be one of the most
successful, safe, and cost-effective public health interventions of
the 20th century. Worldwide, millions of childhood deaths are
prevented by vaccinations every year. Vaccine-preventable disease
levels are at or near record lows.
(b) Vaccines are among the most cost-effective components of
preventive medical care. In 2003, the federal Centers for Disease
Control and Prevention estimated a direct cost savings of six dollars
and thirty cents ($6.30) for every dollar spent on vaccinations. If
societal costs are factored in, the savings increase to eighteen
dollars and forty cents ($18.40) per dollar spent.
(c) Due to increasing numbers of approved and recommended
life-saving vaccines, as well as increasing prices, pediatric vaccine
acquisition costs have increased dramatically in recent years and
could triple by the year 2020.
(d) Physicians typically face higher vaccine prices than large
public purchasers and usually lose money when they provide
immunizations due to under-reimbursement, which may discourage
physicians from purchasing adequate doses to meet the demand in their
practices. This trend could shift the burden of vaccine financing to
parents' out-of-pocket expenses or to local public health clinics or
other public programs.
(e) As small businesses, physicians face severe financial strain
when they continue to absorb the unreimbursed costs associated with
vaccine acquisition and administration. The purchase of vaccines is
the single most expensive part of a pediatric or family practice.
When providers are not adequately reimbursed to cover the direct and
indirect costs of providing immunizations, the viability of their
practice is threatened.
(f) Insured children and their families can face financial
barriers to immunization such as deductibles, copayments, and other
out-of-pocket expenses.
(g) Unvaccinated children can contract a dangerous or
life-threatening disease at any time in their lives. In order to
effectively protect the public health, it is imperative that we
ensure continued access to disease-preventing vaccines in order to
achieve maximum immunization for infants, children, and adolescents.
(h) Therefore, in order to maximize immunization rates to protect
individual children and the general population from existing and
emerging communicable diseases, it is the intent of the Legislature
to ensure that physicians are fully reimbursed for the costs to
acquire and administer recommended vaccines and that out-of-pocket
expenses do not deter parents from immunizing their children.
(i) The Legislature further recognizes the importance of the
California Immunization Registry in maximizing immunization rates and
supports and encourages physicians and their specialty societies in
efforts to increase physician participation in the registry.
SEC. 2. Section 1367.36 of the Health and Safety Code is amended
to read:
1367.36. (a) A 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, 2011, shall not include
a provision that requires a physician or a physician group to assume
financial risk for the acquisition costs or administration costs, as
defined in subdivision (b), of required immunizations for children as
a condition of accepting the contract. A physician or physician
group shall not be required to assume financial risk for
immunizations, regardless of whether those immunizations are part of
the current contract.
(b) A health care service plan that provides coverage for
childhood and adolescent immunizations pursuant to Section 1367.3 or
1367.35 shall include in its reimbursement of a physician or
physician group a reimbursement for the administration cost of the
vaccine. For purposes of this section, the administration cost of the
vaccine, which includes physician time, clinical staff time, and
office staff time, as well as other practice expenses associated with
providing the immunization such as storage, insurance, supplies, and
medical equipment, shall be an amount not less than that specified
in the most current annual Medicare physician fee schedule published
pursuant to Section 1395w-4(b)(1) of Title 42 of the United States
Code.
(c) 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 pursuant to this subdivision shall
be made within 45 days of receipt by the plan of documents from the
physician or physician group 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.
(d) Physician groups may assume financial risk for the acquisition
costs and administration costs, as defined in subdivision (b), of
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 group. However, a health
care service plan shall not require a physician group to accept
financial risk or impose additional risk on a physician group in
violation of subdivision (a) or (b).
(e) A health care service plan shall not include the acquisition
costs or administration costs, as defined in subdivision (b),
associated with required immunizations for children in the capitation
rate of a physician who is individually capitated.
(f) The amendments to this section by the act adding this
subdivision shall not apply to services provided pursuant to any of
the following:
(1) Health care service plan contracts entered into with the Board
of Administration of the Public Employees' Retirement System
pursuant to the Public Employees' Medical and Hospital Care Act (Part
5 (commencing with Section 22750) of Division 5 of Title 2 of the
Government Code).
(2) Contracts entered into pursuant to Chapter 7 (commencing with
Section 14000) of, or Chapter 8 (commencing with Section 14200) of,
Part 3 of Division 9 of the Welfare and Institutions Code between the
State Department of Health Care Services and health care service
plans for enrolled Medi-Cal beneficiaries.
(3) Contracts entered into pursuant to Part 6.2 (commencing with
Section 12693) of Division 2 of the Insurance Code between the
Managed Risk Medical Insurance Board and health care service plans
for enrolled Healthy Families beneficiaries.
(f) A health care service plan contract issued, amended, or
SEC. 3. Section 1367.37 is added to the Health and
Safety Code, to read:
1367.37. (a) A health care
service plan contract issued, amended, or renewed on or after
January 1, 2011, that provides coverage for childhood and adolescent
immunizations pursuant to Section 1367.3 or 1367.35 shall not do
either of the following:
(1) Impose a deductible, copayment, coinsurance, or other
cost-sharing mechanism for the administration of a childhood or
adolescent immunization or for procedures related to that
administration. Nothing in this paragraph prohibits charging a
deductible, copayment, coinsurance, or other cost-sharing mechanism
for procedures, services, or treatment unrelated to an immunization.
(2) Contain a dollar limit provision for the administration of
childhood and adolescent immunizations or include the cost of those
immunizations in a dollar limit provision of the contract.
(g) Subdivision (b) shall not apply to services provided pursuant
to health care service plan contracts entered into with the Board of
Administration of the Public Employees' Retirement System pursuant to
the Public Employees' Medical and Hospital Care Act (Part 5
(commencing with Section 22750) of Division 5 of Title 2 of the
Government Code).
(h) Subdivisions (b) and (f) shall not apply to
(b) This section shall not apply to
services provided pursuant to either of the following:
(1) Contracts entered into pursuant to Chapter 7 (commencing with
Section 14000) of, or Chapter 8 (commencing with Section 14200) of,
Part 3 of Division 9 of the Welfare and Institutions Code between the
State Department of Health Care Services and health care service
plans for enrolled Medi-Cal beneficiaries.
(2) Contracts entered into pursuant to Part 6.2 (commencing with
Section 12693) of Division 2 of the Insurance Code between the
Managed Risk Medical Insurance Board and health care service plans
for enrolled Healthy Families beneficiaries.
SEC. 3. SEC. 4. Section 10123.56 is
added to the Insurance Code, to read:
10123.56. (a) A health insurer that provides coverage for
childhood and adolescent immunizations pursuant to Section 10123.5 or
10123.55 shall include in its reimbursement of a physician or
physician group a reimbursement for the cost of administration of the
vaccine. For purposes of this section, the cost of administration of
the vaccine, which includes physician time, clinical staff time, and
office staff time, as well as other practice expenses associated
with providing the immunization such as storage, insurance, supplies,
and medical equipment, shall be an amount not less than that
specified in the most current annual Medicare physician fee schedule
published pursuant to Section 1395w-4(b)(1) of Title 42 of the United
States Code.
(b) A health insurance policy issued, amended, or renewed on or
after January 1, 2011, that provides coverage for childhood and
adolescent immunizations pursuant to Section 10123.5 or 10123.55
shall not do either of the following:
(1) Impose a deductible, copayment, coinsurance, or other
cost-sharing mechanism for the administration of a childhood or
adolescent immunization or for procedures related to that
administration. Nothing in this paragraph prohibits charging a
deductible, copayment, coinsurance, or other cost-sharing mechanism
for procedures, services, or treatment unrelated to an immunization.
(2) Contain a dollar limit provision for the administration of
childhood and adolescent immunizations or include the cost of those
immunizations in a dollar limit provision of the contract.
(c) Subdivision (a) shall not apply to services provided pursuant
to health insurance policies entered into with the Board of
Administration of the Public Employees' Retirement System pursuant to
the Public Employees' Medical and Hospital Care Act (Part 5
(commencing with Section 22750) of Division 5 of Title 2 of the
Government Code).
(d) This section shall not apply to services provided pursuant to
either of the following:
(1) Contracts entered into pursuant to Chapter 7 (commencing with
Section 14000) of, or Chapter 8 (commencing with Section 14200) of,
Part 3 of Division 9 of the Welfare and Institutions Code between the
State Department of Health Care Services and health insurers for
enrolled Medi-Cal beneficiaries.
(2) Contracts entered into pursuant to Part 6.2 (commencing with
Section 12693) between the Managed Risk Medical Insurance Board and
health insurers for enrolled Healthy Families beneficiaries.
SEC. 4. SEC. 5. No reimbursement is
required by this act pursuant to Section 6 of Article XIII B 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 XIII
B of the California Constitution.