AB 1771, as amended, V. Manuel Pérez. Telephone visits.
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 willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law prohibits a health care service plan or health insurer from requiring in-person contact between a health care provider and a patient before payment is made for covered services appropriately provided through telehealth, which is defined to mean the mode of delivering health care services via information and communication technologies, as specified.
This bill would require a health care service plan or a health insurer, with respect to contracts and policies issued, amended, or renewed on or after January 1, 2016, to cover telephone visits, as defined, provided by a physician. The bill would provide that a health care service plan or a health insurer is not required to reimburse separately for specified telephone visits, including a telephone visit provided as part of a bundle of services reimbursed on a capitatedbegin insert or prepaidend insert basisbegin insert or using an episode-based payment methodologyend insert. Because a willful violation of the bill’s requirements by a health care service plan would be a crime, the 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 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 1374.14 is added to the Health and Safety
2Code, to read:
(a) A health care service plan shall, with respect to
4plan contracts issued, amended, or renewed on or after January 1,
52016, cover telephone visits provided by a physician.
6(b) This section shall not be construed to authorize a health care
7service plan to require the use of telephone visits when the
8physician has determined that providing services by telephone is
9not medically appropriate.
10(c) This section shall not be construed to alter the scope of
11practice of a health care provider or authorize the delivery of health
12care services in a setting, or in a manner, that is not otherwise
13authorized by law.
14(d) All laws regarding the confidentiality of health information
15and a patient’s rights to his or her medical information shall apply
16to telephone visits.
17(e) This section shall not apply to a patient under the jurisdiction
18of the Department of Corrections and Rehabilitation or any other
19correctional facility.
P3 1(f) Notwithstanding subdivision (a), a health care service plan
2shall not be required to reimburse separately for any of the
3following:
4(1) A telephone visit that is related to a service or procedure
5provided to an established patient within a reasonable period of
6time prior to the telephone visit, as recognized by the American
7Medical
Association, Current Procedural Terminology codes.
8(2) A telephone visit that leads to a related service or procedure
9provided to an established patient within a reasonable period of
10time, or within an applicable postoperative period, as recognized
11by the American Medical Association, Current Procedural
12Terminology codes.
13(3) A telephone visit provided as part of a bundle of services
14for which reimbursement is provided for on a capitated or prepaid
15basisbegin insert or for which reimbursement is provided for using an
16episode-based payment methodologyend insert.
17(4) A telephone visit that is not initiated by the patient.
18(g) Nothing in this section shall be construed to prohibit a health
19care service plan from requiring reasonable documentation specific
20to telephone visits.
21(h) For purposes of this section, the following definitions apply:
22(1) “Established patient” means a patient who, within the three
23years immediately preceding the telephone visit, has received
24professional services from the provider or another provider of the
25exact same specialty and subspecialty who belongs to the same
26group practice.
27(2) “Telephone visit” means evaluation and management
28services that meets all of the following criteria:
29(A) Do not require a face-to-face visit with the physician.
30(B) Are provided remotely through live voice communication
31to an established patient, or parents or guardians of a minor who
32is an established patient.
33(C) Are initiated by the patient, or the parents or guardians of
34a minor who is a patient. For purposes of this section, “initiated
35by the patient” excludes a visit for which a provider or staff
36contacts a patient to initiate a service.
37(D) Are recognized by the American Medical Association,
38Current Procedural Terminology codes.
Section 10123.855 is added to the Insurance Code, to
40read:
(a) A health insurer shall, with respect to policies
2of health insurance issued, amended, or renewed on or after January
31, 2016, cover telephone visits provided by a physician.
4(b) This section shall not be construed to authorize a health
5insurer to require the use of telephone visits when the physician
6has determined that providing services by telephone is not
7medically appropriate.
8(c) This section shall not be construed to alter the scope of
9practice of a health care provider or authorize the delivery of health
10care services in a setting, or in a manner, that is not otherwise
11authorized by law.
12(d) All laws regarding the confidentiality of health information
13and a patient’s rights to his or her medical information shall apply
14to telephone visits.
15(e) This section shall not apply to a patient under the jurisdiction
16of the Department of Corrections and Rehabilitation or any other
17correctional facility.
18(f) Notwithstanding subdivision (a), a health insurer shall not
19be required to reimburse separately for any of the following:
20(1) A telephone visit that is related to a service or procedure
21provided to an established patient within a reasonable period of
22time prior to the telephone visit, as recognized by the American
23Medical Association, Current
Procedural Terminology codes.
24(2) A telephone visit that leads to a related service or procedure
25provided to an established patient within a reasonable period of
26time, or within an applicable postoperative period, as recognized
27by the American Medical Association, Current Procedural
28Terminology codes.
29(3) A telephone visit provided as part of a bundle of services
30for which reimbursement is provided for on a capitated or prepaid
31basisbegin insert or for which reimbursement is provided for using an
32episode-based payment methodologyend insert.
33(4) A telephone visit that is not initiated by the patient.
34(g) Nothing in this section shall be construed to prohibit a health
35insurer from requiring reasonable documentation specific to
36telephone visits.
37(h) For purposes of this section, the following definitions apply:
38(1) “Established patient” means a patient who, within the three
39years immediately preceding the telephone visit, has received
40professional services from the provider or another provider of the
P5 1exact same specialty and subspecialty who belongs to the same
2group practice.
3(2) “Telephone visit” means evaluation and management
4services that meets all of the following criteria:
5(A) Do not require a face-to-face visit with the physician.
6(B) Are provided remotely through live voice communication
7to an established patient, or parents or guardians of a minor who
8is an established patient.
9(C) Are initiated by the patient, or the parents or guardians of
10a minor who is a patient. For purposes of this section, “initiated
11by the patient” excludes a visit for which a provider or staff
12contacts a patient to initiate a service.
13(D) Are recognized by the American Medical Association,
14Current Procedural Terminology codes.
No reimbursement is required by this act pursuant to
16Section 6 of Article XIII B of the California Constitution because
17the only costs that may be incurred by a local agency or school
18district will be incurred because this act creates a new crime or
19infraction, eliminates a crime or infraction, or changes the penalty
20for a crime or infraction, within the meaning of Section 17556 of
21the Government Code, or changes the definition of a crime within
22the meaning of Section 6 of Article XIII B of the California
23Constitution.
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