AB 2301, as introduced, Mansoor. Health care service plans.
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. Existing law requires health care service plans to meet certain requirements, including, but not limited to, having the organizational and administrative capacity to provide services to subscribers and enrollees and providing basic health care services, as defined, to those subscribers and enrollees, and having facilities licensed, as specified.
This bill would make technical, nonsubstantive changes to those provisions.
Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 1367 of the Health and Safety Code is
2amended to read:
A health care service plan and, if applicable, a specialized
4health care service plan shall meetbegin insert all ofend insert the following
5requirements:
P2 1(a) Facilities located in this state including, but not limited to,
2clinics, hospitals, and skilled nursing facilities to be utilized by
3the plan shall be licensed by the State Department of Public Health,
4where licensure is required by law. Facilities not located in this
5state shall conform to all licensing and other requirements of the
6jurisdiction in which they are located.
7(b) Personnel employed by or under contract to the plan shall
8be licensed or certified by their respective board
or agency, where
9licensure or certification is required by law.
10(c) Equipment required to be licensed or registered by law shall
11be so licensed or registered, and the operating personnel for that
12equipment shall be licensed or certified as required by law.
13(d) The plan shall furnish services in a manner providing
14continuity of care and ready referral of patients to other providers
15at times as may be appropriate consistent with good professional
16practice.
17(e) (1) All services shall be readily available at reasonable times
18to each enrollee consistent with good professional practice. To the
19extent feasible, the plan shall make all services readily accessible
20to all enrollees consistent with Section 1367.03.
21(2) To the extent that
telehealth services are appropriately
22provided through telehealth, as defined in subdivision (a) of Section
232290.5 of the Business and Professions Code, these services shall
24be considered in determining compliance with Section 1300.67.2
25of Title 28 of the California Code of Regulations.
26(3) The plan shall make all services accessible and appropriate
27consistent with Section 1367.04.
28(f) The plan shall employ and utilize allied health manpower
29for the furnishing of services to the extent permitted by law and
30consistent with good medical practice.
31(g) The plan shall have the organizational and administrative
32capacity to provide services to subscribers and enrollees. The plan
33shall be able to demonstrate to the department that medical
34decisions are rendered by qualified medical providers, unhindered
35by fiscal and
administrative management.
36(h) (1) Contracts with subscribers and enrollees, including
37group contracts, and contracts with providers, and other persons
38furnishing services, equipment, or facilities to or in connection
39with the plan, shall be fair, reasonable, and consistent with the
40objectives of this chapter. All contracts with providers shall contain
P3 1provisions requiring a fast, fair, and cost-effective dispute
2resolution mechanism under which providers may submit disputes
3to the plan, and requiring the plan to inform its providers upon
4contracting with the plan, or upon change to these provisions, of
5the procedures for processing and resolving disputes, including
6the location and telephone number where information regarding
7disputes may be submitted.
8(2) A health care service plan shall ensure that a dispute
9resolution mechanism is accessible to
noncontracting providers
10for the purpose of resolving billing and claims disputes.
11(3) On and after January 1, 2002, a health care service plan shall
12annually submit a report to the department regarding its dispute
13resolution mechanism. The report shall include information on the
14number of providers who utilized the dispute resolution mechanism
15and a summary of the disposition of those disputes.
16(i) A health care service plan contract shall provide to
17subscribers and enrollees all of the basic health care services
18included in subdivision (b) of Section 1345, except that the director
19may, for good cause, by rule or order exempt a plan contract or
20any class of plan contracts from that requirement. The director
21shall by rule define the scope of each basic health care service that
22health care service plans are required to provide as a minimum for
23licensure under this chapter.begin delete Nothing in this chapter shallend deletebegin insert
This
24chapter does notend insert prohibit a health care service plan from charging
25subscribers or enrollees a copayment or a deductible for a basic
26health care service consistent with Section 1367.006 or 1367.007,
27provided that the copayments, deductibles, or other cost sharing
28are reported to the director and set forth to the subscriber or
29enrollee pursuant to the disclosure provisions of Section 1363.
30begin delete Nothing in this chapter shallend deletebegin insert This chapter does notend insert prohibit a health
31care service plan from setting forth, by contract, limitations on
32maximum coverage of basic health care services, provided that
33the limitations are reported to, and held unobjectionable by, the
34director and set forth to the subscriber or enrollee pursuant to the
35disclosure provisions of Section 1363.
36(j) A health care service plan shall not require registration under
37the federal Controlled Substances Act (21 U.S.C. Sec. 801 et seq.)
38as a condition for participation by an optometrist certified to use
39therapeutic pharmaceutical agents pursuant to Section 3041.3 of
40the Business and Professions Code.
P4 1Nothing in this
end delete
2begin insertThis end insertsection shallbegin insert notend insert be construed to permit the director to
3establish the rates charged subscribers and enrollees for contractual
4health care services.
5The director’s enforcement of Article 3.1 (commencing
with
6Section 1357)begin delete shall not be deemed toend deletebegin insert does notend insert establish the rates
7chargedbegin insert toend insert subscribers and enrollees for contractual health care
8services.
9The obligation of the plan to comply with this chapter shall not
10be waived when the plan delegates any services that it is required
11to perform to its medical groups, independent practice associations,
12or other contracting entities.
O
99