BILL NUMBER: AB 72 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Eng
DECEMBER 21, 2010
An act to amend Section 1373.10 of the Health and Safety Code, and
to amend Sections 10127.3 and 10176 of the Insurance Code, relating
to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 72, as introduced, Eng. Health care coverage: acupuncture.
Existing law requires a health care service plan, that is not a
health care maintenance organization or is not a plan that enters
exclusively into specialized health care service plan contracts, and
a disability insurer issuing policies on a groupwide basis, to offer
acupuncture coverage under those terms and conditions as may be
agreed upon by the parties, with specified exceptions. A willful
violation of the laws regulating health care service plans is a
crime.
This bill would instead require every health care service plan,
except a plan that enters exclusively into specialized health care
service plan contracts, and every disability insurer issuing policies
on a groupwide basis, to provide acupuncture coverage under those
terms and conditions as may be agreed upon by the parties.
Because a violation of this bill's requirements with respect to a
health care service plan would be a crime, this bill would impose a
state-mandated local program by creating a new crime.
Existing law authorizing a disability insurance policy to provide
payment for acupuncture services requires that the disability
insurance policy or contract expressly include acupuncture as a
benefit in order for a licensed or certified acupuncturist to be paid
or reimbursed under the policy for his or her services.
This bill would delete the requirement conditioning the payment
and reimbursement of a certified or licensed acupuncturist, for his
or her services, on the express inclusion of acupuncture as a benefit
in a disability insurance policy or contract. This bill would also
make technical and conforming changes.
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 1373.10 of the Health and Safety Code is
amended to read:
1373.10. (a) On and after January 1, 1985, every health care
service plan, that is not a health maintenance organization or is not
a plan that enters exclusively into specialized health care service
plan contracts, as defined by subdivision (n)
(o) of Section 1345, which that
provides coverage for hospital, medical, or surgical expenses, shall
offer coverage to group contract holders for expenses incurred as a
result of treatment by holders of certificates under Section 4938 of
the Business and Professions Code, under such
terms and conditions as may be agreed upon between the health care
service plan and the group contract holder.
A health care service plan is not required to offer the coverage
provided by this section as part of any contract covering employees
of a public entity.
(b) For the purposes of this section, "health maintenance
organization" or "HMO" means a public or private organization,
organized under the laws of this state, which does all of the
following:
(1) Provides or otherwise makes available to enrolled
participants health care services, including at least the following
basic health care services: usual physician services,
hospitalization, laboratory, X-ray, emergency and preventive
services, and out-of-area coverage.
(2) Is compensated, except for copayments, for the provision of
basic health care services listed in paragraph (1) to enrolled
participants on a predetermined periodic rate basis.
(3) Provides physician services primarily directly through
physicians who are either employees or partners of the organization,
or through arrangements with individual physicians or one or more
groups of physicians, organized on a group practice or individual
practice basis.
(b) On and after January 1, 2012, every health care service plan,
that is not a plan that enters exclusively into specialized health
care service plan contracts, as defined by subdivision (o) of Section
1345, that provides coverage for hospital, medical, or surgical
expenses, shall provide coverage to group contract holders for
expenses incurred as a result of treatment by holders of certificates
under Section 4938 of the Business and Professions Code, under terms
and conditions as may be agreed upon between the health care service
plan and the group contract holder.
SEC. 2. Section 10127.3 of the Insurance Code is amended to read:
10127.3. (a) On and after January 1, 1985,
every insurer issuing group disability insurance which
that covers hospital, medical, or surgical
expenses shall offer coverage for expenses incurred as a result of
treatment by holders of certificates under Section 4938 of the
Business and Professions Code, under such terms
and conditions as may be agreed upon between the group policyholder
and the insurer.
An insurer is not required to offer the coverage provided by this
section as part of any policy covering employees of a public entity.
(b) On and after January 1, 2012, every insurer issuing group
disability insurance that covers hospital, medical, or surgical
expenses shall provide coverage for expenses incurred as a result of
treatment by holders of certificates under Section 4938 of the
Business and Professions Code, under terms and conditions as may be
agreed upon between the group policyholder and the insurer.
SEC. 3. Section 10176 of the Insurance Code is amended to read:
10176. In disability insurance, the policy may provide for
payment of medical, surgical, chiropractic, physical therapy, speech
pathology, audiology, acupuncture, professional mental health,
dental, hospital, or optometric expenses upon a reimbursement basis,
or for the exclusion of any of those services, and provision may be
made therein for payment of all or a portion of the amount of charge
for these services without requiring that the insured first pay the
expenses. The policy shall not prohibit the insured from selecting
any psychologist or other person who is the holder of a certificate
or license under Section 1000, 1634, 2050, 2472, 2553, 2630, 2948,
3055, or 4938 of the Business and Professions Code, to perform the
particular services covered under the terms of the policy, the
certificate holder or licensee being expressly authorized by law to
perform those services.
If the insured selects any person who is a holder of a certificate
under Section 4938 of the Business and Professions Code, a
disability insurer or nonprofit hospital service plan shall pay the
bona fide claim of an acupuncturist holding a certificate pursuant to
Section 4938 of the Business and Professions Code for the treatment
of an insured person only if the insured's policy or contract
expressly includes acupuncture as a benefit and includes coverage for
the injury or illness treated. Unless the policy or contract
expressly includes acupuncture as a benefit, no person who is the
holder of any license or certificate set forth in this section shall
be paid or reimbursed under the policy for acupuncture.
Nor shall the policy prohibit the insured, upon referral by a
physician and surgeon licensed under Section 2050 of the Business and
Professions Code, from selecting any licensed clinical social worker
who is the holder of a license issued under Section 4996 of the
Business and Professions Code or any occupational therapist as
specified in Section 2570.2 of the Business and Professions Code, or
any marriage and family therapist who is the holder of a license
under Section 4980.50 of the Business and Professions Code, to
perform the particular services covered under the terms of the
policy, or from selecting any speech-language pathologist or
audiologist licensed under Section 2532 of the Business and
Professions Code or any registered nurse licensed pursuant to Chapter
6 (commencing with Section 2700) of Division 2 of the Business and
Professions Code, who possesses a master's degree in
psychiatric-mental health nursing and is listed as a
psychiatric-mental health nurse by the Board of Registered Nursing or
any advanced practice registered nurse certified as a clinical nurse
specialist pursuant to Article 9 (commencing with Section 2838) of
Chapter 6 of Division 2 of the Business and Professions Code who
participates in expert clinical practice in the specialty of
psychiatric-mental health nursing, or any respiratory care
practitioner certified pursuant to Chapter 8.3 (commencing with
Section 3700) of Division 2 of the Business and Professions Code to
perform services deemed necessary by the referring physician, that
certificate holder, licensee or otherwise regulated person, being
expressly authorized by law to perform the services.
Nothing in this section shall be construed to allow any
certificate holder or licensee enumerated in this section to perform
professional mental health services beyond his or her field or fields
of competence as established by his or her education, training, and
experience. For the purposes of this section, "marriage and family
therapist" means a licensed marriage and family therapist who has
received specific instruction in assessment, diagnosis, prognosis,
and counseling, and psychotherapeutic treatment of premarital,
marriage, family, and child relationship dysfunctions that is
equivalent to the instruction required for licensure on January 1,
1981.
An individual disability insurance policy, which is issued,
renewed, or amended on or after January 1, 1988, and which
includes mental health services coverage may not include a lifetime
waiver for that coverage with respect to any applicant. The lifetime
waiver of coverage provision shall be deemed unenforceable.
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.