California Legislature—2013–14 Regular Session

Assembly Bill No. 2533

Introduced by Assembly Member Ammiano

February 21, 2014

An act to amend Section 1262.8 of the Health and Safety Code, relating to health facilities.

LEGISLATIVE COUNSEL’S DIGEST

AB 2533, as introduced, Ammiano. Noncontracting hospitals.

Existing law prohibits a noncontracting hospital, as defined, from billing a patient who is an enrollee of a health care service plan for poststabilization care, except for applicable copayments, coinsurance, and deductible, unless certain conditions are met.

This bill would make technical, nonsubstantive changes to these 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 1.  

Section 1262.8 of the Health and Safety Code is
amended to read:

1262.8.  

(a) A noncontracting hospital shall not bill a patient
who is an enrollee of a health care service plan for poststabilization
care, except for applicable copayments, coinsurance, and
deductibles, unless one of the following conditions are met:

(1) The patient or the patient’s spouse or legal guardian refuses
to consent, pursuant to subdivision (f), for the patient to be
transferred to the contracting hospital as requested and arranged
for by the patient’s health care service plan.

(2) The hospital is unable to obtain the name and contact
information of the patient’s health care service plan as provided
in subdivision (c).

(b) If a patient with an emergency medical condition, as defined
by Section 1317.1, is covered by a health care service plan that
requires prior authorization for poststabilization care, a
noncontracting hospital, except as provided in subdivision (n),
shall, prior to providing poststabilization care, do all of the
following once the emergency medical condition has been
stabilized, as defined by Section 1317.1:

(1) Seek to obtain the name and contact information of the
patient’s health care service plan. The hospital shall document its
attempt to ascertain this information in the patient’s medical record,
which shall include requesting the patient’s health care service
plan member card or asking the patient, or a family member or
other person accompanying the patient, if he or she can identify
the patient’s health care service plan, or any other means known
to the hospital for accurately identifying the patient’s health care
service plan.

(2) Contact the patient’s health care service plan, or the health
plan’s contracting medical provider, for authorization to provide
poststabilization care, if identification of the plan was obtained
pursuant to paragraph (1).

(A) The hospital shall make the contact described in this
subparagraph by either following the instructions on the patient’s
health care service plan member card or using the contact
information provided by the patient’s health care service plan
pursuant to subdivision (j) or (k).

(B) A representative of the hospital shall not be required to
make more than one telephone call to the health care service plan,
or its contracting medical provider, provided that in all cases the
health care service plan, or its contracting medical provider, shall
be able to reach a representative of the hospital upon returning the
call, should the plan, or its contracting medical provider, need to
call back. The representative of the hospital who makes the
telephone call may be, but is not required to be, a physician and
surgeon.

(3) Upon request of the patient’s health care service plan, or the
health plan’s contracting medical provider, provide to the plan, or
its contracting medical provider, the treating physician and
surgeon’s diagnosis and any other relevant information reasonably
necessary for the health care service plan or the plan’s contracting
medical provider to make a decision to authorize poststabilization
care or to assume management of the patient’s care by prompt
transfer.

(c) A noncontracting hospital that is not able to obtain the name
and contact information of the patient’s health care service plan
pursuant to subdivision (b) is not subject to the requirements of
this section.

(d) (1) A health care service plan, or its contracting medical
provider, that is contacted by a noncontracting hospital pursuant
to paragraph (2) of subdivision (b), shall, within 30 minutes from
the time the noncontracting hospital makes the initial contact, do
either of the following:

(A) Authorize poststabilization care.

(B) Inform the noncontracting hospital that it will arrange for
the prompt transfer of the enrollee to another hospital.

(2) If the health care service plan, or its contracting medical
provider, does not notify the noncontracting hospital of its decision
pursuant to paragraph (1) within 30 minutes, the poststabilization
care shall be deemed authorized, and the health care service plan,
or its contracting medical provider, shall pay charges for the care,
in accordance with the Knox-Keene Health Care Service Plan Act
of 1975 (Chapter 2.2 (commencing with Section 1340) of Division
2) and any regulation adopted thereunder.

(3) If the health care service plan, or its contracting medical
provider, notified the noncontracting hospital that it would assume
management of the patient’s care by prompt transfer, but either
the health care service plan or its contracting medical provider
fails to transfer the patient within a reasonable time, the
poststabilization care shall be deemed authorized, and the health
care service plan, or its contracting medical provider, shall pay
charges, in accordance with the Knox-Keene Health Care Service
Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340)
of Division 2 of the Health and Safety Code) and any regulation
adopted thereunder, for the care until the enrollee is transferred.

(4) If the health care service plan, or its contracting medical
provider, provides authorization to the noncontracting hospital for
specified poststabilization care and services, the health care service
plan, or its contracting medical provider, shall be responsible to
pay for that authorized care.

(e) If a health care service plan, or its contracting medical
provider, decides to assume management of the patient’s care by
prompt transfer, the health care service plan, or its contracting
medical provider, shall do all of the following:

(1) Arrange and pay the reasonable charges associated with the
transfer of the patient.

(2) Pay for all of the immediately required medically necessary
care rendered to the patient prior to the transfer in order to maintain
the patient’s clinical stability.

(3) Be responsible for making all arrangements for the patient’s
transfer, including, but not limited to, finding a contracted facility
available for the transfer of the patient.

(f) (1) If the patient, or the patient’s spouse or legal guardian
refuses to consent to the patient’s transfer under subdivision (e),
the noncontracting hospital shall promptly provide a written notice
to the patient or the patient’s spouse or legal guardian indicating
that the patient will be financially responsible for any further
poststabilization care provided by the hospital.

(2) For patients whose primary language is one of the Medi-Cal
threshold languages, the notice shall be delivered to them in their
primary language.

(3) The Department of Managed Health Care shall translate the
notice required by this subdivision in all Medi-Cal threshold
languages and make the translations available to the hospitals
subject to this section.

(4) The written notice provided pursuant to this subdivision
shall include the following statement:

THIS NOTICE MUST BE PROVIDED TO YOU UNDER
CALIFORNIA LAW

“You have received emergency care at a hospital that is not a
part of your health plan’s provider network. Under state law,
emergency care must be paid by your health plan no matter where
you get that care. The doctor who is caring for you has decided
that you may be safely moved to another hospital for the additional
care you need. Because you no longer need emergency care, your
health plan has not authorized further care at this hospital. Your
health plan has arranged for you to be moved to a hospital that is
in your health plan’s provider network.

If you agree to be moved, your health plan will pay for your care
at that hospital. You will only have to pay for your deductible,
copayments, or coinsurance for care. You will not have to pay for
your deductible, copayments, or coinsurance for transportation
costs to another hospital that is covered by your health plan.

IF YOU CHOOSE TO STAY AT THIS HOSPITAL FOR YOUR
ADDITIONAL CARE, YOU WILL HAVE TO PAY THE FULL
COST OF CARE NOW THAT YOU NO LONGER NEED
EMERGENCY CARE. This cost may include the cost of the doctor
or doctors, the hospital, and any laboratory, radiology, or other
services that you receive.

If you do not think you can be safely moved, talk to the doctor
about your concerns. If you would like additional help, you may
contact:

Your health plan member services department. Look on your
health plan member card for that phone number. You can file a
grievance with your plan.

The HMO Helpline at 888-HMO-2219. The HMO Helpline is
available 24 hours a day, 7 days a week. The HMO Helpline can
work with your health plan to address your concerns, but you may
still have to pay the full cost of care at this hospital if you stay.”

(5) The hospital shall give one copy of the written notice
required by this subdivision to the patient, or the patient’s spouse
or legal guardian, for signature and may retain a copy in the
patient’s medical record.

(6) The hospital shall ensure prompt delivery of the notice to
the patient or his or her spouse or legal guardian. The hospital shall
obtain signed acceptance of the written notice required by this
subdivision, and signed acceptance of any other documents the
hospital requires for any further poststabilization care, from the
patient or the patient’s spouse or legal guardian, and shall provide
the health care service plan, or its contracting medical provider,
with confirmation of the patient’s, or his or her spouse or legal
guardian’s, receipt of the written notice.

(7) If the noncontracting hospital fails to meet the requirements
of this subdivision, the hospital shall not bill the patient or the
patient’s health care service plan, or its contracting medical
provider, for poststabilization care provided to the patient.

(8) If the patient, or the patient’s spouse or legal guardian,
refuses to sign the notice, the noncontracting hospital shall
document in the patient’s medical record that the notice was
provided and signature was refused. Upon the patient’s refusal to
sign, the patient shall assume financial responsibility for any further
poststabilization care provided by the hospital.

(9) The Department of Managed Health Care may, by regulation,
modify the wording of the notice required under this subdivision
for clarity, readability, and accuracy of the information provided.

(10) The Department of Managed Health Care may, in
conjunction with consumer groups, health care service plans, and
hospitals, modify the wording of the notice to include language
regarding Medicare beneficiaries, if appropriate under Medicare
rules. The initial modification shall not be subject to the
Administrative Procedure Act (Chapter 3.5 (commencing with
Section 11340, et. seq.) of Part 1 of Division 3 of Title 2 of the
Government Code).

(g) If poststabilization care has been authorized by the health
care service plan, the noncontracting hospital shall request the
patient’s medical record from the patient’s health care service plan
or its contracting medical provider.

(h) The health care service plan, or its contracting medical
provider, shall, upon conferring with the noncontracting hospital,
transmit any appropriate portion of the patient’s medical record,
if the records are in the plan’s possession, via facsimile
transmission or electronic mail, whichever method is requested
by the noncontracting hospital’s representative or the
noncontracting physician and surgeon. The health care service
plan, or its contracting medical provider, shall transmit the patient’s
medical record in a manner that complies with all legal
requirements to protect the patient’s privacy.

(i) A health care service plan, or its contracting medical provider,
that requires prior authorization for poststabilization care shall
provide 24-hour access for patients and providers, including
noncontracting hospitals, to obtain timely authorization for
medically necessary poststabilization care.

(j) A health care service plan shall provide all noncontracting
hospitals in the state with specific contact information needed to
make the contact required by this section. The contact information
provided to hospitals shall be updated as necessary, but no less
than once a year.

(k) In addition to meeting the requirements of subdivision (j),
a health care service plan shall provide the contact information
described in subdivision (j) to the Department of Managed Health
Care. The contact information provided pursuant to this subdivision
shall be updated as necessary, but no less than once a year. The
receiving department shall post this contact information on its
Internet Web site no later than January 1 of each calendar year.

(l) This section shall only apply to a noncontracting hospital.

(m) For purposes of this section, the following definitions shall
apply:

(1) “Health care service plan” means a health care service plan
licensed pursuant to Chapter 2.2 (commencing with Section 1340)
of Division 2 that covers hospital, medical, or surgical expenses.

(2) “Noncontracting hospital” means a general acute care
hospital, as defined in subdivision (a) of Section 1250 or an acute
psychiatric hospital, as defined in subdivision (b) of Section 1250,
that does not have a written contract with the patient’s health care
service plan to provide health care services to the patient.

(3) “Poststabilization care” means medically necessary care
provided after an emergency medical condition has been stabilized,
as defined by subdivision (j) of Section 1317.1.

(4) “Contracting medical provider” means a medical group,
independent practice association, or any other similar organization
that, pursuant to a signed written contract, has agreed to accept
responsibility for provision or reimbursement of a noncontracting
hospital for emergency and poststabilization services provided to
a health plan’s enrollees.

(n) Subdivisions (b) to (h), inclusive, shall not apply to minor
treatment procedures, if all of the following apply:

(1) The procedure is provided in the treatment area of the
emergency department.

(2) The procedure concludes the treatment of the presenting
emergency medical condition of a patient and is related to that
condition, even though the treatment may not resolve the
underlying medical condition.

(3) The procedure is performed according to accepted standards
of practice.

(4) The procedure would result in the direct discharge or release
of the patient from the emergency department following this care.

(o)  begin delete Nothing in this section is intended to end delete begin insert This section shall not end insert
prevent a health care service plan or its contracting medical
provider from assuming management of the patient’s care at any
time after the initial provision of poststabilization care by the
noncontracting hospital before the patient has been discharged.
Upon the request of the health care service plan or its contracting
medical provider, the noncontracting hospital shall provide the
health care service plan or its contracting medical provider with
any information specified in paragraph (3) of subdivision (b).

(p)  begin delete Nothing in this section shall end delete begin insert This section shall not end insert authorize
a provider of health care services to bill a Medi-Cal beneficiary
enrolled in a Medi-Cal managed care plan or otherwise alter the
provisions of subdivision (a) of Section 14019.3 of the Welfare
and Institutions Code.