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 abegin delete physicianend deletebegin insert contracted physician or a contracted qualified nonphysician health care providerend insert. 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 reimbursedbegin delete on a capitated or prepaid basis or using an episode-based payment methodologyend deletebegin insert in a specified mannerend 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 abegin delete physicianend deletebegin insert contracted
6physician or a contracted qualified nonphysician health care
7providerend insert.
8(b) This section shall not be construed to authorize a health care
9service plan to require the use of telephone visits when the
10physicianbegin insert or nonphysician health care providerend insert
has determined
11that providing services by telephone is not medically appropriate.
12(c) This section shall not be construed to alter the scope of
13practice of a health care provider or authorize the delivery of health
14care services in a setting, or in a manner, that is not otherwise
15authorized by law.
16(d) All laws regarding the confidentiality of health information
17and a patient’s rights to his or her medical information shall apply
18to telephone visits.
P3 1(e) This section shall not apply to a patient under the jurisdiction
2of the Department of Corrections and Rehabilitation or any other
3correctional facility.
4(f) Notwithstanding subdivision
(a), a health care service plan
5shall not be required to reimburse separately for any of the
6following:
7(1) A telephone visit that is related to a service or procedure
8provided to an established patient within a reasonable period of
9time prior to the telephone visit, as recognized by the American
10Medical Association, Current Procedural Terminology codes.
11(2) A telephone visit that leads to a related service or procedure
12provided to an established patient within a reasonable period of
13time, or within an applicable postoperative period, as recognized
14by the American Medical Association, Current Procedural
15Terminology codes.
16(3) A telephone visit provided as part of a bundle of services
17for which reimbursement is provided for
on a capitated or prepaid
18basis or for which reimbursement is provided for using an
19episode-based payment methodology.
20(4) A telephone visit that is not initiated by the patient.
21(g) Nothing in this section shall be construed to prohibit a health
22care service plan from requiring reasonable documentation specific
23to telephone visits.
24(h) For purposes of this section, the following definitions apply:
25(1) “Established patient” means a patient who, within the three
26years immediately preceding the telephone visit, has received
27professional services from the provider or another provider of the
28exact same specialty and subspecialty who belongs to the same
29group
practice.
30(2) “Nonphysician health care provider” means a provider,
31other than a physician, who is licensed pursuant to Division 2
32(commencing with Section 500) of the Business and Professions
33Code.
34(2)
end delete
35begin insert(3)end insert “Telephone visit” means evaluation and management
36services that meets all of the following criteria:
37(A) Do not require a face-to-face visit with the physicianbegin insert
or
38nonphysician health care providerend insert.
P4 1(B) Are provided remotely through live voice communication
2to an established patient, or parents or guardians of a minor who
3is an established patient.
4(C) Are initiated by the patient, or the parents or guardians of
5a minor who is a patient. For purposes of this section, “initiated
6by the patient” excludes a visit for which a provider or staff
7contacts a patient to initiate a service.
8(D) Are recognized by the American Medical Association,
9Current Procedural Terminology codes.
Section 10123.855 is added to the Insurance Code, to
11read:
(a) A health insurer shall, with respect to policies
13of health insurance issued, amended, or renewed on or after January
141, 2016, cover telephone visits provided by abegin insert contractedend insert physician
15begin insert or a contracted qualified nonphysician health care providerend insert.
16(b) This section shall not be construed to authorize a health
17insurer to require the use of telephone visits when the physician
18begin insert or nonphysician health care provider end inserthas
determined that providing
19services by telephone is not medically appropriate.
20(c) This section shall not be construed to alter the scope of
21practice of a health care provider or authorize the delivery of health
22care services in a setting, or in a manner, that is not otherwise
23authorized by law.
24(d) All laws regarding the confidentiality of health information
25and a patient’s rights to his or her medical information shall apply
26to telephone visits.
27(e) This section shall not apply to a patient under the jurisdiction
28of the Department of Corrections and Rehabilitation or any other
29correctional facility.
30(f) Notwithstanding subdivision (a), a health insurer shall
not
31be required to reimburse separately for any of the following:
32(1) A telephone visit that is related to a service or procedure
33provided to an established patient within a reasonable period of
34time prior to the telephone visit, as recognized by the American
35Medical Association, Current Procedural Terminology codes.
36(2) A telephone visit that leads to a related service or procedure
37provided to an established patient within a reasonable period of
38time, or within an applicable postoperative period, as recognized
39by the American Medical Association, Current Procedural
40Terminology codes.
P5 1(3) A telephone visit provided as part of a bundle of services
2for whichbegin delete reimbursement is provided for on a capitated or prepaid begin insert
separate reimbursement is
3basis or for which reimbursement is provided for using an
4episode-based payment methodologyend delete
5not consistent with the American Medical Association, Current
6Procedural Terminology codesend insert.
7(4) A telephone visit that is not initiated by the patient.
8(g) Nothing in this section shall be construed to prohibit a health
9insurer from requiring reasonable documentation specific to
10telephone visits.
11(h) For purposes of this section, the following definitions apply:
12(1) “Established patient” means a patient who, within the three
13years immediately preceding the telephone visit, has received
14professional services from the provider or another provider of the
15exact same specialty and subspecialty who belongs to the
same
16group practice.
17(2) “Nonphysician health care provider” means a provider,
18other than a physician, who is licensed pursuant to Division 2
19(commencing with Section 500) of the Business and Professions
20Code.
21(2)
end delete
22begin insert(3)end insert “Telephone visit” means evaluation and management
23services that meets all of the following criteria:
24(A) Do not require a face-to-face visit with the physicianbegin insert
or
25nonphysician health care providerend insert.
26(B) Are provided remotely through live voice communication
27to an established patient, or parents or guardians of a minor who
28is an established patient.
29(C) Are initiated by the patient, or the parents or guardians of
30a minor who is a patient. For purposes of this section, “initiated
31by the patient” excludes a visit for which a provider or staff
32contacts a patient to initiate a service.
33(D) Are recognized by the American Medical Association,
34Current Procedural Terminology codes.
No reimbursement is required by this act pursuant to
36Section 6 of Article XIII B of the California Constitution because
37the only costs that may be incurred by a local agency or school
38district will be incurred because this act creates a new crime or
39infraction, eliminates a crime or infraction, or changes the penalty
40for a crime or infraction, within the meaning of Section 17556 of
P6 1the Government Code, or changes the definition of a crime within
2the meaning of Section 6 of Article XIII B of the California
3Constitution.
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