BILL NUMBER: AB 1059 AMENDED
BILL TEXT
AMENDED IN SENATE SEPTEMBER 7, 2011
AMENDED IN SENATE AUGUST 30, 2011
AMENDED IN SENATE JULY 12, 2011
AMENDED IN ASSEMBLY MAY 27, 2011
INTRODUCED BY Assembly Member Huffman
FEBRUARY 18, 2011
An act to amend and repeal Section 1371.37 of the Health
and Safety Code, relating to health care service plans.
An act to amend Section 1797.98b of the Health and Safety Code,
relating to emergency medical care.
LEGISLATIVE COUNSEL'S DIGEST
AB 1059, as amended, Huffman. Health care service plans.
Emergency medical care.
Existing law authorizes a county to establish an emergency medical
services fund for reimbursement of emergency medical services (EMS)
related costs, and requires an annual report to the Legislature on
the implementation and status of the fund, including the fund balance
and the amount of moneys disbursed to physicians and surgeons, for
hospitals, and for other emergency medical services purposes.
This bill would require the report to provide additional
information regarding the moneys collected and disbursed, including,
but not limited to, a description of the other medical services
purposes, and the total amount of allowable claims, if the moneys are
disbursed to hospitals on a claims basis, and the names and contact
information of the entity responsible for the collection and
disbursement of prescribed funds. By increasing the duties of local
officials, this bill 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, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the regulation of health care service plans by the
Department of Managed Health Care. Existing law requires a health
care service plan to pay claims for provided health care services
within a specified period of time and prohibits a health care service
plan from engaging in an unfair payment pattern, as defined.
This bill would require the director, upon a final determination
that a health care service plan has underpaid or failed to pay a
provider, as specified, to require the plan to pay the provider the
amount owed plus interest, as specified. The bill would also specify
that a provider shall not be required to resubmit a claim to a plan
unless the director makes a determination that an extraordinary
circumstance exists and requires the plan to reimburse the provider
for the cost of resubmission, as specified.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no yes .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1797.98b of the
Health and Safety Code is amended to read:
1797.98b. (a) Each county establishing a fund, on January 1,
1989, and on each April 15 thereafter, shall report to the
Legislature on the implementation and status of the Emergency Medical
Services Fund. The report shall cover the preceding fiscal year, and
shall include, but not be limited to, all of the following:
(1) The total amount of fines and forfeitures collected, the
total amount of penalty assessments collected, and the total amount
of penalty assessments deposited into the Emergency Medical Services
Fund. Fund, or, if no moneys were deposited
into the fund, the reason or reasons for the lack of deposits. The
total amounts of penalty assessments shall be listed on the basis of
each statute that provides the authority for th e penalty
assessment, including Sections 76000, 76000.5, and 76104 of the
Government Code, and Section 42007 of the Vehicle Code.
(2) The amount of penalty assessment funds collected under Section
76000.5 of the Government Code that are used for the purposes of
subdivision (e) of Section 1797.98a.
(2)
(3) The fund balance and the amount of moneys disbursed
under the program to physicians and surgeons, for hospitals, and for
other emergency medical services purposes.
purposes, and the amount of money disbursed for actual administrative
costs. If funds were disbursed for other emergency medical services,
the report shall provide a description of each of those services.
(3)
(4) The number of claims paid to physicians and
surgeons, and the percentage of claims paid, based on the uniform fee
schedule, as adopted by the county.
(4)
(5) The amount of moneys available to be disbursed to
physicians and surgeons, descriptions of the physician and surgeon
and hospital claims payment methodologies, the
dollar amount of the total allowable claims submitted, and the
percentage at which those claims were reimbursed.
(5)
(6) A statement of the policies, procedures, and
regulatory action taken to implement and run the program under this
chapter.
(6)
(7) The name of the physician and surgeon and hospital
administrator organization, or names of specific physicians and
surgeons and hospital administrators, contracted
contacted to review claims payment methodologies.
(8) A description of the process used to solicit input from
physicians and surgeons and hospitals to review payment distribution
methodology as described in subdivision (a) of Section 1797.98e.
(9) An identification of the fee schedule used by the county
pursuant to subdivision (e) of Section 1797.98c.
(10) (A) A description of the methodology used to disburse moneys
to hospitals pursuant to subparagraph (B) of paragraph (5) of
subdivision (b) of Section 1797.98a.
(B) The amount of moneys available to be disbursed to hospitals.
(C) If moneys are disbursed to hospitals on a claims basis, the
dollar amount of the total allowable claims submitted and the
percentage at which those claims were reimbursed to hospitals.
(11) The name and contact information of the entity responsible
for each of the following:
(A) Collection of fines, forfeitures, and penalties.
(B) Distribution of penalty assessments into the Emergency Medical
Services Fund.
(C) Distribution of moneys to physicians and surgeons.
(b) (1) Each county, upon request, shall make available to any
member of the public the report required under subdivision (a).
(2) Each county, upon request, shall make available to any member
of the public a listing of physicians and surgeons and hospitals that
have received reimbursement from the Emergency Medical Services Fund
and the amount of the reimbursement they have received. This listing
shall be compiled on a semiannual basis.
SEC. 2. If the Commission on State Mandates
determines that this act contains costs mandated by the state,
reimbursement to local agencies and school districts for those costs
shall be made pursuant to Part 7 (commencing with Section 17500) of
Division 4 of Title 2 of the Government Code.
SECTION 1. Section 1371.37 of the Health and
Safety Code, as added by Section 6 of Chapter 827 of the Statutes of
2000, is amended to read:
1371.37. (a) A health care service plan is prohibited from
engaging in an unfair payment pattern, as defined in this section.
(b) Consistent with subdivision (a) of Section 1371.39, the
director may investigate a health care service plan to determine
whether it has engaged in an unfair payment pattern.
(c) An "unfair payment pattern," as used in this section, means
any of the following:
(1) Engaging in a demonstrable and unjust pattern, as defined by
the department, of reviewing or processing complete and accurate
claims that results in payment delays.
(2) Engaging in a demonstrable and unjust pattern, as defined by
the department, of reducing the amount of payment or denying complete
and accurate claims.
(3) Failing on a repeated basis to pay the uncontested portions of
a claim within the timeframes specified in Section 1371, 1371.1, or
1371.35.
(4) Failing on a repeated basis to automatically include the
interest due on claims pursuant to Section 1371.
(d) (1) Upon a final determination by the director that a health
care service plan has engaged in an unfair payment pattern, the
director may:
(A) Impose monetary penalties as permitted under this chapter.
(B) Require the health care service plan for a period of three
years from the date of the director's determination, or for a shorter
period prescribed by the director, to pay complete and accurate
claims from the provider within a shorter period of time than that
required by Section 1371. The provisions of this subparagraph shall
not become operative until January 1, 2002.
(C) Include a claim for costs incurred by the department in any
administrative or judicial action, including investigative expenses
and the cost to monitor compliance by the plan.
(2) For any overpayment made by a health care service plan while
subject to the provisions of paragraph (1), the provider shall remain
liable to the plan for repayment pursuant to Section 1371.1.
(e) Upon a final determination by the director that a health care
service plan has engaged in an unfair payment pattern, the director
shall require the plan to pay the provider an amount that includes
the amount owed plus interest pursuant to subdivisions (b) and (e) of
Section 1371.35.
(f) Except as provided in subdivision (g), a provider shall not be
required to resubmit a claim to a health care service plan in order
to receive payment pursuant to this section.
(g) If the director makes a determination that an extraordinary
circumstance exists, the director may require a provider to resubmit
a claim to a health care service plan in order to receive payment
pursuant to this section, provided that the director also requires
the plan to add to the amount owed to the provider a reasonable
amount necessary to reimburse the provider for the cost of
resubmission.
(h) The enforcement remedies provided in this section are not
exclusive and shall not limit or preclude the use of any otherwise
available criminal, civil, or administrative remedy.
(i) The penalties set forth in this section shall not preclude,
suspend, affect, or impact any other duty, right, responsibility, or
obligation under a statute or under a contract between a health care
service plan and a provider.
(j) A health care service plan may not delegate any statutory
liability under this section.
(k) For the purposes of this section, "complete and accurate claim"
has the same meaning as that provided in the regulations adopted by
the department pursuant to subdivision (a) of Section 1371.38.
(l) On or before December 31, 2001, the department shall report to
the Legislature and the Governor information regarding the
development of the definition of "unjust pattern" as used in this
section. This report shall include, but not be limited to, a
description of the process used and a list of the parties involved in
the department's development of this definition as well as
recommendations for statutory adoption.
(m) The department shall make available upon request and on its
website, information regarding actions taken pursuant to this
section, including a description of the activities that were the
basis for the action.
SEC. 2. Section 1371.37 of the Health and
Safety Code, as added by Section 6 of Chapter 825 of the Statutes of
2000, is repealed.