BILL NUMBER: AB 2533 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 6, 2010
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 amended, Fuentes. Health care coverage: quality
rating.
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. 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 Director of
the department Department of Managed Health
Care 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
annua lly . 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 a particular physician,
provider, medical group, or individual practice association .
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, 2011, for
For purposes of public disclosure, every health care
service plan shall annually 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
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 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. designate a
particular physician, provider, medical group, or individual practice
association based in whole or in part on quality measures and claims
data.
SEC. 2. Section 10123.36 of the Insurance Code is amended to read:
10123.36. (a) On or before July 1, 2011, for
For purposes of public disclosure, every 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 health
insurer or any of its contracting providers or provider groups
utilize economic profiling or quality rating related to services
provided to insureds, shall annually 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
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 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
health 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 health 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
health 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. a particular physician,
provider, medical group, or individual practice association based in
whole or in part on quality measures 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.