BILL ANALYSIS
AB 2093
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 2093 (V. Manuel Perez)
As Amended August 20, 2010
Majority vote
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|ASSEMBLY: |73-1 |(June 2, 2010) |SENATE: |24-9 |(August 24, |
| | | | | |2010) |
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Original Committee Reference: HEALTH
SUMMARY : Requires a health care service plan or health insurer
(collectively carriers) that provides coverage for childhood and
adolescent immunizations to reimburse a physician or physician
group the entire cost of acquiring and administering the
vaccine.
The Senate amendments :
1)Delete the definition of actual cost of acquiring a vaccine as
the vaccine's private sector cost per dose, as published on
the most current pediatric Vaccine Price List of the federal
Centers for Disease Control and Prevention, plus reasonable
costs associated with shipping and handling.
2)Delete the requirement that carriers reimburse a physician or
physician group, for immunizations that are not part of the
current contract between a carrier and a physician or
physician group including, but not limited to, immunizations
in the most current version of the Recommended Childhood and
Adolescent Immunization Schedules jointly approved by the
federal Advisory Committee on Immunization Practices, the
American Academy of Pediatrics, and the American Academy of
Family Physicians.
3)Require, to the extent required by federal law, a carrier plan
or contract issued, amended, renewed, or delivered on or after
September 23, 2010, to comply with the federal Public Health
Service (PHS) Act and any rules or regulations issued in
accordance with the PHS.
4)Require carriers to reimburse a physician or physician group,
for immunizations that are not part of the current contract
between a carrier and a physician or physician group, at the
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lowest of the following, until the contract is renegotiated:
a) The physician's actual acquisition cost;
b) The "average wholesale price" as published in the Drug
Topics Red Book; or,
c) The lowest acquisition cost through sources made
available to the physician by the carrier.
5)Require reimbursement to be made 45 days of receipt by the
carrier of documents from the physician or physician group
demonstrating that the immunizations were performed,
consistent with existing law or through an alternative funding
mechanism mutually agreed to by the carrier and the physician
or physician group. Require the alternative funding mechanism
to be based on reimbursement consistent with the provisions of
this bill.
6)Clarify that physician groups are permitted to assume
financial risk for the acquisition costs and administration
costs as defined in this bill of providing immunizations if
the immunizations have experiential data that has been
negotiated and agreed upon by carriers and the physician
group.
7)Permit physician groups to assume financial risk for
acquisition costs and administration costs as defined in this
bill of providing immunizations 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.
8)Delete the requirement that a carrier plan or contract issued,
amended, or renewed on or after January 1, 2011, that provides
coverage for childhood and adolescent immunizations pursuant
to existing law, to do either of the following:
a) 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; or,
b) Contain a dollar limit provision for the administration
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of childhood and adolescent immunizations to include the
cost of those immunizations in a dollar limit provision of
the contract
9)Delete the exemption for contracts entered into between health
care service plans with Board of Administration of the Public
Employees' Retirement System pursuant to the Public Employees'
Medical and Hospital Care Act from provisions of this bill, as
specified.
10)Delete the exemption for contracts entered into between
health care service plans and the State Department of Health
Care Services for enrolled Medi-Cal beneficiaries are exempt
from the provisions of this bill.
11)Delete the exemption for contracts entered into between
health care service plans and the Manages Risk Medical
Insurance Board for enrolled Healthy Families beneficiaries
are exempt from the provisions of this bill.
12)Make other technical and clarifying changes.
EXISTING LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care and health insurers by the California
Department of Insurance (CDI).
2)Requires health plans licensed under the Knox-Keene Health
Care Service Plan Act of 1975 to cover all medically necessary
basic health care services, as defined. Defines basic health
care services to include: physician services; hospital
inpatient and outpatient services; including outpatient
physical, occupational, and speech therapy; diagnostic
laboratory and X-ray services; preventive and routine care,
such as vaccinations and routine checkups; emergency and
urgent care services, including ambulance and out-of-area
emergency services; and, medically appropriate home health
services. There is no requirement for health insurers subject
to regulation by CDI to cover medically necessary basic
services or any specific minimum basic benefits.
3)Prohibits a risk-based contract between a physician or
physician group and a health plan from requiring a physician
or physician group to assume financial risk for the cost of
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acquiring required immunizations for children as a condition
of accepting the contract. Prohibits a health plan from
requiring a physician to assume financial risk for
immunizations that are not part of the contract.
4)Requires a health plan to reimburse a physician for
immunizations within 45 days of receiving from the physician
documentation that the immunizations were administered.
AS PASSED BY THE ASSEMBLY , this bill was substantially similar
to the version passed by the Senate.
FISCAL EFFECT : According to the Senate Appropriations
Committee, $60,000 in ongoing absorbable Special Managed Care
Fund costs.
COMMENTS : According to the author, pediatric immunizations have
proven to be one of the most successful, safe, and
cost-effective public health interventions of the 20th Century.
While the author maintains that existing law prohibits carriers
from requiring physicians or physician groups to assume
financial risk for the costs of acquiring required immunizations
for children, the author argues that the cost of administering a
vaccine is not included in the prohibition. The author
specifies administration costs associated with giving
immunizations to include refrigeration and storage, clinical
staff time, and medical supplies such as gloves and syringes.
The author contends that health plans and insurers often do not
reimburse for the entire cost of providing vaccines, which
forces physicians to absorb these costs. The author states that
as small businesses, physicians face severe financial strain
when they absorb the costs associated with vaccine
administration. According to the author, some physicians may be
forced to discontinue or delay offering the most costly
vaccinations, or require parents to pay up front, which could
shift the burden of vaccine financing to parents' out-of-pocket
expenses or to public programs. The author further argues that
as costlier new vaccines are approved and recommended, the
problem will only get worse. The author states this bill is
intended 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 patients from immunizing
their children.
AB 2093
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Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
FN: 0006212