BILL NUMBER: SB 1200 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 28, 2010
INTRODUCED BY Senator Leno
FEBRUARY 18, 2010
An act to amend Section 1367.03 of the Health and Safety Code, and
to amend Section 10133.5 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1200, as amended, Leno. Health care coverage:
school-based health timeliness of care.
Existing law provides for the licensing and regulation
of health care service plans by the Department of Managed Health
Care. Existing law provides for the regulation of health
insurers by the Insurance Commissioner. Existing law requires the
department and the commissioner to develop and adopt regulations to
ensure that enrollees or insureds of health care service plans and
certain health insurers have access to needed health care services in
a timely manner pursuant to specified indicators of timeliness.
This bill would add timeliness of care for schoolage children who
must receive medically necessary services during school hours as one
of the indicators of timeliness.
Existing law requires the department to review and adopt
standards, as needed, concerning the availability of primary care
physicians, specialty physicians, hospital care, and other health
care so that consumers have timely access to care. In adopting
those standards, the department is required to consider the nature of
physician practices and circumstances affecting the delivery of
care. If the department finds that health care service plans and
health care providers have difficulty meeting those standards,
existing law authorizes the department to make recommendations to the
Assembly Committee on Health and the Senate Committee on Insurance
on specified dates regarding implementation.
This bill would add availability of school-based health care to
the timely access to care provisions for which the department may
adopt standards. The bill would instead authorize the department
to report and make recommendations to the Assembly Committee on
Health and the Senate Committee on Health regarding those standards.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.03 of the Health and Safety Code is
amended to read:
1367.03. (a) The department shall develop and adopt regulations
to ensure that enrollees have access to needed health care services
in a timely manner. In developing these regulations, the department
shall develop indicators of timeliness of access to care and, in so
doing, shall consider the following as indicators of timeliness of
access to care:
(1) Waiting times for appointments with physicians, including
primary care and specialty physicians.
(2) Timeliness of care in an episode of illness, including the
timeliness of referrals and obtaining other services, if needed.
(3) Waiting time to speak to a physician, registered nurse, or
other qualified health professional acting within his or her scope of
practice who is trained to screen or triage an enrollee who may need
care.
(4) Timeliness of care for schoolage children who must receive
medically necessary services during school hours.
(b) In developing these standards for timeliness of access, the
department shall consider the following:
(1) Clinical appropriateness.
(2) The nature of the specialty.
(3) The urgency of care.
(4) The requirements of other provisions of law, including Section
1367.01 governing utilization review, that may affect timeliness of
access.
(c) The department may adopt standards other than the time elapsed
between the time an enrollee seeks health care and obtains care. If
the department chooses a standard other than the time elapsed between
the time an enrollee first seeks health care and obtains it, the
department shall demonstrate why that standard is more appropriate.
In developing these standards, the department shall consider the
nature of the plan network.
(d) The department shall review and adopt standards, as needed,
concerning the availability of primary care physicians, specialty
physicians, hospital care, school-based health care, and other health
care, so that consumers have timely access to care. In so doing, the
department shall consider the nature of physician practices,
including individual and group practices as well as the nature of the
plan network. The department shall also consider various
circumstances affecting the delivery of care, including urgent care,
care provided on the same day, and requests for specific providers.
If the department finds that health care service plans and health
care providers have difficulty meeting these standards, the
department may report and make recommendations to the Assembly
Committee on Health and the Senate Committee on Insurance
Health of the Legislature.
(e) In developing standards under subdivision (a), the department
shall consider requirements under federal law, requirements under
other state programs, standards adopted by other states, nationally
recognized accrediting organizations, and professional associations.
The department shall further consider the needs of rural areas,
specifically those in which health facilities are more than 30 miles
apart and any requirements imposed by the State Department of Health
Care Services on health care service plans that contract with the
State Department of Health Care Services to provide Medi-Cal managed
care.
(f) (1) Contracts between health care service plans and health
care providers shall assure ensure
compliance with the standards developed under this section. These
contracts shall require reporting by health care providers to health
care service plans and by health care service plans to the department
to ensure compliance with the standards.
(2) Health care service plans shall report annually to the
department on compliance with the standards in a manner specified by
the department. The reported information shall allow consumers to
compare the performance of plans and their contracting providers in
complying with the standards, as well as changes in the compliance of
plans with these standards.
(g) (1) When evaluating compliance with the standards, the
department shall focus more upon patterns of noncompliance rather
than isolated episodes of noncompliance.
(2) The director may investigate and take enforcement action
against plans regarding noncompliance with the requirements of this
section. Where substantial harm to an enrollee has occurred as a
result of plan noncompliance, the director may, by order, assess
administrative penalties subject to appropriate notice of, and the
opportunity for, a hearing in accordance with Section 1397. The plan
may provide to the director, and the director may consider,
information regarding the plan's overall compliance with the
requirements of this section. The administrative penalties shall not
be deemed an exclusive remedy available to the director. These
penalties shall be paid to the Managed Care Administrative Fines and
Penalties Fund and shall be used for the purposes specified in
Section 1341.45. The director shall periodically evaluate grievances
to determine if any audit, investigative, or enforcement actions
should be undertaken by the department.
(3) The director may, after appropriate notice and opportunity for
hearing in accordance with Section 1397, by order, assess
administrative penalties if the director determines that a health
care service plan has knowingly committed, or has performed with a
frequency that indicates a general business practice, either of the
following:
(A) Repeated failure to act promptly and reasonably to
assure ensure timely access to care consistent
with this chapter.
(B) Repeated failure to act promptly and reasonably to require
contracting providers to assure ensure
timely access that the plan is required to perform under this chapter
and that have been delegated by the plan to the contracting provider
when the obligation of the plan to the enrollee or subscriber is
reasonably clear.
(C) The administrative penalties available to the director
pursuant to this section are not exclusive, and may be sought and
employed in any combination with civil, criminal, and other
administrative remedies deemed warranted by the director to enforce
this chapter.
(4) The administrative penalties shall be paid to the Managed Care
Administrative Fines and Penalties Fund and shall be used for the
purposes specified in Section 1341.45.
(h) The department shall work with the patient advocate to
assure ensure that the quality of care
report card incorporates information provided pursuant to subdivision
(f) regarding the degree to which health care service plans and
health care providers comply with the requirements for timely access
to care.
(i) Every three years, the department shall review information
regarding compliance with the standards developed under this section
and shall make recommendations for changes that further protect
enrollees.
SEC. 2. Section 10133.5 of the Insurance Code
is amended to read:
10133.5. (a) The commissioner shall promulgate regulations
applicable to health insurers that contract with providers for
alternative rates pursuant to Section 10133 to ensure that insureds
have the opportunity to access needed health care services in a
timely manner.
(b) These regulations shall be designed to assure accessibility of
provider services in a timely manner to individuals comprising the
insured or contracted group, pursuant to benefits covered under the
policy or contract. The regulations shall insure:
1. Adequacy of number and locations of institutional facilities
and professional providers, and consultants in relationship to the
size and location of the insured group and that the services offered
are available at reasonable times.
2. Adequacy of number of professional providers, and license
classifications of such providers, in relationship to the projected
demands for services covered under the group policy or plan. The
department shall consider the nature of the specialty in determining
the adequacy of professional providers.
3. The policy or contract is not inconsistent with standards of
good health care and clinically appropriate care.
4. All contracts including contracts with providers, and other
persons furnishing services, or facilities shall be fair and
reasonable.
5. Timeliness of care for schoolage children who must receive
medically necessary services during school hours.
(c) In developing standards under subdivision (a), the department
shall also consider requirements under federal law; requirements
under other state programs and law, including utilization review; and
standards adopted by other states, national accrediting
organizations and professional associations. The department shall
further consider the accessability to provider services in rural
areas.
(d) In designing the regulations the commissioner shall consider
the regulations in Title 28, of the California Administrative Code of
Regulations, commencing with Section 1300.67.2, which are applicable
to health care service plans, and all other relevant guidelines in
an effort to accomplish maximum accessibility within a cost efficient
system of indemnification. The department shall consult with the
Department of Managed Health Care concerning regulations developed by
that department pursuant to Section 1367.03 of the Health and Safety
Code and shall seek public input from a wide range of interested
parties.
(e) Health insurers that contract for alternative rates of payment
with providers shall report annually on complaints received by the
insurer regarding timely access to care. The department shall review
these complaints and any complaints received by the department
regarding timeliness of care and shall make public this information.
(f) Every three years, the commissioner shall review the latest
version of the regulations adopted pursuant to subdivision (a) and
shall determine if the regulations should be updated to further the
intent of this section.
SEC. 2. Section 10133.5 of the
Insurance Code is amended to read:
10133.5. (a) The commissioner shall , on or before
January 1, 2004, promulgate regulations applicable to
health insurers which that contract
with providers for alternative rates pursuant to Section 10133 to
ensure that insureds have the opportunity to access needed health
care services in a timely manner.
(b) These regulations shall be designed to assure
ensure accessibility of provider services in a
timely manner to individuals comprising the insured or contracted
group, pursuant to benefits covered under the policy or contract. The
regulations shall insure ensure all of the
following :
1.
(1) Adequacy of number and locations of
institutional facilities and professional providers, and consultants
in relationship to the size and location of the insured group and
that the services offered are available at reasonable times.
2.
(2) Adequacy of number of professional
providers, and license classifications of such providers, in
relationship to the projected demands for services covered under the
group policy or plan. The department shall consider the nature of the
specialty in determining the adequacy of professional providers.
3.
(3) The policy or contract is not
inconsistent with standards of good health care and clinically
appropriate care.
4.
(4) All contracts including contracts with
providers, and other persons furnishing services, or facilities shall
be fair and reasonable.
(5) Timeliness of care for schoolage children who must receive
medically necessary services during school hours.
(c) In developing standards under subdivision (a), the department
shall also consider requirements under federal law; requirements
under other state programs and law, including utilization review; and
standards adopted by other states, national accrediting
organizations and professional associations. The department shall
further consider the accessability
accessibility to provider services in rural areas.
(d) In designing the regulations the commissioner shall consider
the regulations in Title 28, of the California Administrative Code of
Regulations, commencing with Section 1300.67.2, which are applicable
to Knox-Keene health care service
plans, and all other relevant guidelines in an effort to accomplish
maximum accessibility within a cost efficient
cost-efficient system of indemnification. The department shall
consult with the Department of Managed Health Care concerning
regulations developed by that department pursuant to Section 1367.03
of the Health and Safety Code and shall seek public input from a wide
range of interested parties.
(e) Health insurers that contract for alternative rates of payment
with providers shall report annually on complaints received by the
insurer regarding timely access to care. The department shall review
these complaints and any complaints received by the department
regarding timeliness of care and shall make public this information.
(f) The department shall report to the Assembly Committee on
Health and the Senate Committee on Insurance of the Legislature on
March 1, 2003, and on March 1, 2004, regarding the progress towards
the implementation of this section.
(g)
(f) Every three years, the commissioner
shall review the latest version of the regulations adopted pursuant
to subdivision (a) and shall determine if the regulations should be
updated to further the intent of this section.