BILL NUMBER: AB 2533 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Fuentes
FEBRUARY 19, 2010
An act to amend Section 1367.02 of the Health and Safety Code, and
to amend Section 10123.36 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2533, as introduced, Fuentes. Health care coverage: quality
rating.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure regulation of health care service plans
by the Department of Managed Health Care. Existing law makes a
willful violation of the act's requirements a crime. Existing law
provides for the regulation of health insurers by the Department of
Insurance.
Existing law requires every health care service plan and certain
health insurers, on or before July 1, 1999, to file with the
respective departments a description of policies and procedures
related to economic profiling, as defined, utilized by the plan or
insurer and its medical groups and individual practice associations
and requires the director of the department and the Insurance
Commissioner to make these filings available to the public upon
request with certain exceptions. Existing law requires each plan or
health insurer using economic profiling to provide, upon request, a
copy of economic profiling information to the profiled individual,
group, or association. Existing law also requires each plan or
insurer, as a contract condition, to require its contracting medical
groups and individual practice associations that maintain economic
profiles of individual providers to provide, upon request, a copy to
the profiled individual providers.
This bill would require those filings to be made with the
respective departments on or before July 1, 2011. The bill would also
expand these provisions to apply to quality rating, as defined,
utilized by the plan or insurer with respect to individual or group
performance of physicians.
Because a willful violation of the bill's requirements with
respect to health care service plans would be a crime, it 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. Section 1367.02 of the Health and Safety Code is
amended to read:
1367.02. (a) On or before July 1, 1999
2011 , for purposes of public disclosure, every health care
service plan shall file with the department a description of any
policies and procedures related to economic profiling or quality
rating utilized by the plan and its medical groups and
individual practice associations. The filing shall describe how these
policies and procedures are used in utilization review, peer review,
incentive and penalty programs, network modification, and
patient steering, and in provider retention and termination
decisions. The filing shall also indicate in what manner ,
if any, the economic profiling or quality rating
system being used takes into consideration risk adjustments that
reflect case mix, accuracy and reliability of data relied upon,
type and severity of patient illness, age of patients,
patient compliance with a recommended procedure, and other
enrollee characteristics that may account for higher or lower than
expected quality, costs , or utilization of
services. The filing shall also indicate how the economic profiling
or quality rating activities avoid being in conflict with
subdivision (g) of Section 1367, which requires each plan to
demonstrate that medical decisions are rendered by qualified medical
providers, unhindered by fiscal and administrative management. Any
changes to the policies and procedures shall be filed with the
director pursuant to Section 1352. Nothing in this section shall be
construed to restrict or impair the department, in its discretion,
from utilizing the information filed pursuant to this section for
purposes of ensuring compliance with this chapter.
(b) The director shall make each plan's filing available to the
public upon request. The director shall not publicly disclose any
information submitted pursuant to this section that is determined by
the director to be confidential pursuant to state law.
(c) Each plan that uses economic profiling or quality rating
shall, upon request, provide a copy of economic profiling
or quality rating information related to an individual
provider, contracting medical group, or individual practice
association to the profiled or rated individual, group, or
association. In addition, each plan shall require as a condition of
contract that its medical groups and individual practice associations
that maintain economic profiles or quality ratings of
individual providers shall, upon request, provide a copy of
individual economic profiling or quality rating
information to the individual providers who are profiled or
rated . The economic profiling or quality rating
information provided pursuant to this section shall be provided upon
request until 60 days after the date upon which the contract between
the plan and the individual provider, medical group, or individual
practice association terminates, or until 60 days after the date the
contract between the medical group or individual practice association
and the individual provider terminates, whichever is applicable.
(d) For the purposes of this article
section , "economic profiling" shall mean any evaluation of a
particular physician, provider, medical group, or individual practice
association based in whole or in part on the economic costs or
utilization of services associated with medical care provided or
authorized by the physician, provider, medical group, or individual
practice association.
(e) For the purposes of this section, "quality rating" shall mean
any efforts by a health care service plan or by an entity contracted
by a health care service plan to develop, evaluate, rate, or
designate individual or group performance of physicians based on
quality measurements and claims data.
SEC. 2. Section 10123.36 of the Insurance Code is amended to read:
10123.36. (a) On or before July 1, 1999
2011 , for purposes of public disclosure, every
disability insurer that covers hospital, medical, or surgical
expenses, and health insurer that authorizes
insureds to select providers who have contracted with the insurer for
alternative rates of payment as described in Section 10133, and the
disability insurer or any of its contracting providers or provider
groups utilize economic profiling or quality rating
related to services provided to insureds, shall file with the
department a description of any policies and procedures related to
economic profiling or quality rating utilized by the
insurer and any of its contracting providers and provider groups. The
filing shall describe how these policies and procedures are used in
utilization review, peer review, incentive and penalty programs,
network modification, and patient steering, and in provider
retention and termination decisions. The filing shall also indicate
in what manner , if any, the economic profiling
or qualit y rating system being used takes into
consideration risk adjustments that reflect case mix, accuracy
and reliability of data relied upon, type and severity of
patient illness, age of patients, patient compliance with a
recommended procedure, and other policyholder characteristics
that may account for higher or lower than expected quality,
costs , or utilization of services. Any changes to
the policies and procedures shall be filed expeditiously with the
commissioner. Nothing in this section shall be construed to restrict
or impair the department, in its discretion, from utilizing the
information filed pursuant to this section for purposes of ensuring
compliance with this chapter.
(b) The commissioner shall make each disability insurer filing
available to the public upon request. The commissioner shall not
publicly disclose any information submitted pursuant to this section
that is determined by the commissioner to be confidential pursuant to
state law.
(c) Each disability insurer that uses economic profiling or
quality rating shall, upon request, provide a copy
of economic profiling or quality rating information
related to a contracting provider or provider group to the profiled
or rated provider or group. In addition, each disability
insurer shall require as a condition of contract that its contracting
provider groups that maintain economic profiles or quality
ratings of individual providers who may be selected by insureds
shall, upon request, provide a copy of individual economic profiling
or quality rating information to individual providers who
are profiled. The economic profiling or quality rating
information provided pursuant to this section shall be provided upon
request until 60 days after the date upon which the contract between
the insurer and the individual provider or provider group terminates,
or until 60 days after the date the contract between the provider
group and the individual provider terminates, whichever is
applicable.
(d) For the purposes of this section, "economic profiling" shall
mean any evaluation of a particular physician, provider, or provider
group based in whole or in part on the economic costs or utilization
of services associated with medical care provided or authorized by
the physician, provider, or provider group.
(e) For the purposes of this section, "quality rating" shall mean
any efforts by a health insurer or by an entity contracted by a
health insurer to develop, evaluate, rate, or designate individual or
group performance of physicians based on quality measurements and
claims data.
SEC. 3. 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.