BILL ANALYSIS �
AB 2533
Page 1
Date of Hearing: May 14, 2014
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
AB 2533 (Ammiano) - As Amended: May 6, 2014
Policy Committee: HealthVote:12-6
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill requires health plans and insurers, if an enrollee is
unable to obtain a medically necessary covered service in an
accessible and timely manner from a contracted provider, to
arrange for, or assist the enrollee in arranging for, the
enrollee to receive the care or service in an accessible and
timely manner from a non-contracting provider. It also:
1)Prohibits a plan or insurer from imposing cost-sharing for
services accessed under this provision from exceeding what an
enrollee would pay for services from a contracted provider.
2)Requires the Insurance Commissioner to promulgate implementing
regulations and update them every three years.
3)Authorizes the IC to investigate and take enforcement action
against insurers for violating these and current-law
provisions relating to timely access to care.
FISCAL EFFECT
1)Costs to the Department of Managed Health Care (DMHC) as
follows (Managed Care Fund):
a) One-time cost for workload related to issuance of
regulations estimated at $250,000.
b) Plan licensing and enforcement workload likely in the
range of $550,000 for the first year of implementation,
$250,000 ongoing. Actual costs will depend on the number of
AB 2533
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cases brought forth pursuant to the bill.
2)Costs to the California Department of Insurance (CDI) as
follows (Insurance Fund):
a) One-time cost for workload related to issuance of
regulations estimated at $280,000 and $25,000 ongoing for
revisions.
b) Enforcement workload potentially in the low hundreds of
thousands of dollars annually, depending on the number of
cases brought forth pursuant to the bill.
COMMENTS
1)Purpose . According to the author, this bill is aimed at
protecting patients from high out-of-pocket costs when health
plans and insurers fail to meet timely access standards. This
bill is sponsored by the California Nurses Association (CNA).
2)Background . AB 2179 (Cohn), Chapter 797, Statutes of 2002,
directed DMHC and CDI to adopt regulations to ensure enrollee
access to necessary health care services in a timely manner.
DMHC Timely Access to Non-Emergency Health Care Services
regulation became effective January 17, 2010. Each health
plan must show that its provider network is large and varied
enough to offer enrollees appointments that meet the certain
waiting time standards. DMHC regulations already include
requirements similar to this bill. For example, they require
health plans to assist enrollees in locating available and
accessible contracted providers if they have difficulty
finding a contracted provider, and arrange for specialty
services from specialists outside of the contracted network if
a specialist is not available in the network.
CDI adopted provider network access regulations to implement
AB 2179, imposing specific geographic time and distance
standards for contracted providers, full-time hours and
availability of providers and minimum provider-to-insured
ratios. CDI is in the process of reviewing and potentially
revising the network adequacy and access regulations,
consistent with the requirement that DMHC and CDI review the
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regulations every three years. Unlike DMHC-regulated plans,
however, there does not appear to be a current-law requirement
for CDI-regulated plans to arrange for insured persons to
receive services from a non-contracting provider if a
contracting provider is unavailable.
3)Opposition . Health plans and insurers write in opposition to
this bill. DMHC-regulated plans believe the Health and Safety
Code requirements are duplicative and slightly broader than
existing law governing the provision of timely access to
services, and that the bill would require more administrative
resources for reporting. Health plans and insurers believe
this bill may threaten the ability of health plans to control
costs by increasing enrollee access to non-contracting
providers.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081