BILL ANALYSIS �
AB 2533
Page 1
ASSEMBLY THIRD READING
AB 2533 (Ammiano)
As Amended May 6, 2014
Majority vote
HEALTH 12-6 APPROPRIATIONS 12-5
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|Ayes:|Pan, Ammiano, Chau, |Ayes:|Gatto, Bocanegra, |
| |Bonta, Chesbro, Gomez, | |Bradford, |
| |Gonzalez, | |Ian Calderon, Campos, |
| |Roger Hern�ndez, | |Eggman, Gomez, Holden, |
| |Lowenthal, Nazarian, | |Pan, Quirk, |
| |Ridley-Thomas, Wieckowski | |Ridley-Thomas, Weber |
| | | | |
|-----+--------------------------+-----+--------------------------|
|Nays:|Maienschein, Ch�vez, |Nays:|Bigelow, Donnelly, Jones, |
| |Waldron, Nestande, | |Linder, Wagner |
| |Patterson, Wagner | | |
| | | | |
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SUMMARY : Requires health plans and insurers to arrange for, or
assist enrollees in arranging for, care or services from a
noncontracted provider if an enrollee is unable to obtain a
medically necessary covered service in an accessible or timely
manner from a contracted provider, as specified, and imposes
related reporting requirements on health plans and insurers.
Specifically, this bill :
1)In cases where an enrollee is unable to obtain a medically
necessary covered service from a contracted provider in an
accessible and timely manner, requires the health plan or
insurer to arrange for, or assist the enrollee in arranging
for, the enrollee to receive care and services from a
noncontracting provider.
2)Prohibits health plans and insurers from imposing any
copayments, coinsurance or deductibles on an enrollee
accessing care from a noncontracted provider under 1) above
that exceed what the enrollee would have paid for the services
from a contracted provider.
3)Requires health plans and insurers to report annually, to the
Department of Managed Health Care (DMHC) and California
AB 2533
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Department of Insurance (CDI), respectively, any and all
occurrences of denial of care and on complaints received
regarding accessible and timely access to care, and requires
DMHC and CDI to review the reported complaints, and any
complaints regarding accessibility of care the departments
receive, and annually prepare and post a report on the
departments' Internet Web site.
4)Requires the Commissioner of the CDI to promulgate regulations
implementing this bill for health insurers under CDI
jurisdiction and to review the regulation every three years to
determine if the regulations should be updated.
5)Authorizes CDI to investigate and take enforcement action
against insurers regarding noncompliance with the provisions
of this bill and to assess administrative penalties for
violations, subject to appropriate notice of, and the
opportunity for, a hearing under the Administrative Procedures
Act, and establishes that the administrative penalties are not
exclusive and may be sought and employed in any combination
with civil, criminal, and other administrative remedies, as
determined by the commissioner. Authorizes insurers to
provide to the commissioner, and the commissioner to consider,
the insurer's overall compliance with the requirements.
EXISTING LAW :
1)Establishes DMHC to regulate health plans under the Knox-Keene
Health Care Service Plan Act of 1975 (Knox-Keene) and CDI to
regulate health insurers under the Insurance Code.
2)Requires health plans and insurers to meet statutory and
regulatory standards related to arranging for contracted
network provider services and imposes similar but not
identical standards on the adequacy of the networks applicable
to health plans under DMHC and health insurers under CDI
including but not limited to:
a) Health plans under DMHC must ensure that subscribers and
enrollees receive available and accessible services in a
manner providing for continuity of care and ready referrals
to other providers consistent with good professional
practice, offer a complete network of contracting or
employed primary care and specialist physicians each of
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whom has staff privileges with at least one contracting
hospital, comply with minimum ratios for number of
physician providers for the number of enrollees in the
health plan (one physician for every 1,200 enrollees and
one primary care physician (PCP) for every 2,000
enrollees), ensure accessibility of providers within
prescribed geographic distances (for PCPs within 30 minutes
or 15 miles of an enrollee's residence or workplace), and
ensure that the contracted networks have adequate capacity
and availability of licensed providers to offer enrollees
appointments in a timely manner in compliance with
specified timeframes and appointment waiting times, and
maintain a system to monitor and report on timely access
compliance and access to care; and,
b) Health insurers offering contracted networks under CDI
must ensure accessibility of provider services in a timely
manner and ensure that providers are sufficient, in number
and size, to be capable of furnishing the health care
services covered by the insurance contract, taking into
account the characteristics and medical needs of insured
persons, ensure accessibility of providers within
prescribed geographic distances (for PCPs within 30 minutes
or 15 miles of each covered person's residence or
workplace), comply with minimum ratios for number of
physician providers based on the number of covered persons
(one physician for every 1,200 enrollees and one PCP for
every 2,000 enrollees) and monitor waiting times for
appointments as part of the overall system the insurer must
maintain to monitor access.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, this bill would result in the following:
1)Costs to 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
cases brought forth pursuant to the bill.
AB 2533
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2)Costs to 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 : According to the author, this bill is aimed at
protecting patients from long wait times and high out-of-pocket
costs when health plans and insurers fail to meet timely access
standards. By requiring health plans and insurers to help
enrollees who cannot get timely in-network care to get the
services from a noncontracted provider, with the same cost
sharing, enrollees are able to get timely care as promised in
the contract or policy and required by law. In addition, this
bill is intended to create parity between DMHC and CDI with
regard to timely access requirements and enforcement by giving
the CDI Commissioner the authority to promulgate regulations and
to assess administrative penalties, authorities that are already
granted to the Director of DMHC.
Health plans and insurers write in opposition to this bill.
DMHC-regulated plans argue the requirements in this bill are
duplicative and slightly broader than existing law governing the
provision of timely access to services in Knox-Keene, and that
this bill would require more administrative resources for
reporting. Health plans and insurers argue
that by increasing enrollee access to noncontracting providers
this bill may threaten their ability to control costs.
Analysis Prepared by : Deborah Kelch and Ben Russell / HEALTH
/ (916) 319-2097
FN: 0003812