BILL NUMBER: AB 2093	ENROLLED
	BILL TEXT

	PASSED THE SENATE  AUGUST 24, 2010
	PASSED THE ASSEMBLY  AUGUST 25, 2010
	AMENDED IN SENATE  AUGUST 20, 2010
	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 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, 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 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.
   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.


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 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, or if the physician
group contracts with a health care service plan that has an
exclusive contract with that physician group to serve a specific
geographic area to provide or arrange for professional medical
services for the enrollees of the plan. 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.
  SEC. 3.  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 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) This section shall not apply to services provided pursuant to
any of the following:
   (1) 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).
   (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 insurers for
enrolled Medi-Cal beneficiaries.
   (3) 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.  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.