BILL NUMBER: AB 1327	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Portantino

                        FEBRUARY 18, 2011

   An act to amend Section 1374.16 of, and to add Section 1374.18 to,
the Health and Safety Code, and to add Section 14087.309 to the
Welfare and Institutions Code, relating to health care.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 1327, as introduced, Portantino. Health care: specialists.
   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 and makes a violation
of its provisions a crime. Under the act, a plan is required to
provide a standing referral to a specialist if the enrollee's primary
care physician, in consultation with designated persons, determines
that the enrollee requires continuing care from the specialist.
   This bill would expand the duty of a health care service plan to
provide a standing referral to a specialist, requiring such a
referral upon the enrollee's request, and would require the plan to
ensure the availability, as specified, of HIV specialists to its
enrollees. Because the bill would specify additional requirements
under the act, the violation of which would be a crime, it would
impose a state-mandated local program.
   Existing law establishes the Medi-Cal program to provide
qualifying individuals with health care services. Under existing law,
the director of the State Department of Health Care Services is
authorized to contract with any qualified individual, organization,
or entity to provide services to Medi-Cal beneficiaries.
   This bill would require the State Department of Health Care
Services to determine a per capita payment rate for services provided
to Medi-Cal beneficiaries with HIV or AIDS and would specify its
calculation method.
   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 1374.16 of the Health and Safety Code is
amended to read:
   1374.16.  (a) Every health care service plan, except a specialized
health care service plan, shall establish and implement a procedure
by which an enrollee may receive a standing referral to a specialist.
The procedure shall provide for a standing referral to a specialist
if the  enrollee requests a referral or his or her  primary
care physician determines in consultation with the specialist, if
any, and the plan medical director or his or her designee, that an
enrollee needs continuing care from a specialist. The referral shall
be made pursuant to a treatment plan approved by the health care
service plan in consultation with the primary care physician, the
specialist, and the enrollee, if a treatment plan is deemed necessary
to describe the course of the care. A treatment plan may be deemed
to be not necessary  provided that   if  a
current standing referral to a specialist is approved by the plan or
its contracting provider, medical group, or independent practice
association. The treatment plan may limit the number of visits to the
specialist, limit the period of time that the visits are authorized,
or require that the specialist provide the primary care physician
with regular reports on the health care provided to the enrollee.
   (b) Every health care service plan, except a specialized health
care service plan, shall establish and implement a procedure by which
an enrollee with a condition or disease that requires specialized
medical care over a prolonged period of time and is life-threatening,
degenerative, or disabling may receive a referral to a specialist or
specialty care center that has expertise in treating the condition
or disease for the purpose of having the specialist coordinate the
enrollee's health care. The referral shall be made if the primary
care physician, in consultation with the specialist or specialty care
center if any, and the plan medical director or his or her designee
determines that this specialized medical care is medically necessary
for the enrollee. The referral shall be made pursuant to a treatment
plan approved by the health care service plan in consultation with
the primary care physician, specialist or specialty care center, and
enrollee, if a treatment plan is deemed necessary to describe the
course of care. A treatment plan may be deemed to be not necessary
 provided that   if  the appropriate
referral to a specialist or specialty care center is approved by the
plan or its contracting provider, medical group, or independent
practice association. After the referral is made, the specialist
shall be authorized to provide health care services that are within
the specialist's area of expertise and training to the enrollee in
the same manner as the enrollee's primary care physician, subject to
the terms of the treatment plan.
   (c) The determinations described in subdivisions (a) and (b) shall
be made within three business days of the date the request for the
determination is made by the enrollee or the enrollee's primary care
physician and all appropriate medical records and other items of
information necessary to make the determination are provided. Once a
determination is made, the referral shall be made within four
business days of the date the proposed treatment plan, if any, is
submitted to the plan medical director or his or her designee.
   (d) Subdivisions (a) and (b) do not require a health care service
plan to refer to a specialist who, or to a specialty care center
that, is not employed by or under contract with the health care
service plan to provide health care services to its enrollees, unless
there is no specialist within the plan network that is appropriate
to provide treatment to the enrollee  or, with respect to HIV
specialists   ,   no specialist is available within
the distance parameters described in Section 1374.18  , as
determined by the primary care physician in consultation with the
plan medical director as documented in the treatment plan developed
pursuant to subdivision (a) or (b).
   (e) For the purposes of this section, "specialty care center"
means a center that is accredited or designated by an agency of the
state or federal government or by a voluntary national health
organization as having special expertise in treating the
life-threatening disease or condition or degenerative and disabling
disease or condition for which it is accredited or designated.
   (f) As used in this section, a "standing referral" means a
referral by a primary care physician to a specialist for more than
one visit to the specialist, as indicated in the treatment plan, if
any, without the primary care physician having to provide a specific
referral  or authorization  for each visit.
   (g) This section shall become operative on (1) January 1, 2004, or
(2) the date of adoption of an accreditation or designation by an
agency of the state or federal government or by a voluntary national
health organization of an HIV or AIDS specialist, whichever date is
earlier.
  SEC. 2.  Section 1374.18 is added to the Health and Safety Code, to
read:
   1374.18.  (a) A group health care service plan that provides
hospital, medical, or surgical expense benefits shall ensure that one
HIV specialist per 500 of the plan's enrollees, as of January 1 of
each year, is available on a full-time basis to treat enrollees
referred pursuant to Section 1374.16. The plan shall ensure for its
enrollees residing in an urban area that the HIV specialist's
practice is within 15 miles of the enrollee's residential or business
address or within one hour traveling time by motor vehicle from the
enrollee's residential or business address. "Urban area" for this
purpose means ______.
   (b) An HIV specialist is a licensed physician and surgeon who
meets the criteria of a medical expert as described by the HIV
Academy of Medicine or by the HIV Medical Association of the
Infectious Disease Society of America.
  SEC. 3.  Section 14087.309 is added to the Welfare and Institutions
Code, to read:
   14087.309.  The department shall determine a per capita rate of
payment to a managed care plan for services provided to Medi-Cal
beneficiaries with HIV or AIDS. In developing the rate, the
department shall use all of the coding elements of the definition of
AIDS issued by the United States Centers for Disease Prevention and
Control and by the National Drug Code for antiretroviral medications.
The rate shall be an average of medical treatment costs for the
Medi-Cal beneficiary population with HIV and the Medi-Cal beneficiary
population with AIDS. A managed care plan shall be reimbursed at
this rate for a Medi-Cal beneficiary with HIV or AIDS.
  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.