Bill Text: CA AB1287 | 2009-2010 | Regular Session | Introduced
Bill Title: Health care coverage: utilization review.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-02-02 - Died at Desk. [AB1287 Detail]
Download: California-2009-AB1287-Introduced.html
BILL NUMBER: AB 1287 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Torrico
FEBRUARY 27, 2009
An act to amend Section 1363.5 of the Health and Safety Code, and
to amend Section 10123.135 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1287, as introduced, Torrico. Health care coverage: utilization
review.
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 also
provides for the regulation of health insurers by the Department of
Insurance. Existing law requires health care service plans and health
insurers to disclose to specified persons the process the plan or
insurer uses to authorize, modify, or deny health care services and
requires the criteria plans or insurers use to make that
determination to meet specified requirements.
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 1. Section 1363.5 of the Health and Safety Code is amended
to read:
1363.5. (a) A plan shall disclose or provide for the disclosure
to the director and to network providers the process the plan, its
contracting provider groups, or any entity with which the plan
contracts for services that include utilization review or utilization
management functions, uses to authorize, modify, or deny health care
services under the benefits provided by the plan, including coverage
for subacute care, transitional inpatient care, or care provided in
skilled nursing facilities. A plan shall also disclose those
processes to enrollees or persons designated by an enrollee, or to
any other person or organization, upon request. The disclosure to the
director shall include the policies, procedures, and the description
of the process that are filed with the director pursuant to
subdivision (b) of Section 1367.01.
(b) The criteria or guidelines used by plans, or any entities with
which plans contract for services that include utilization review or
utilization management functions, to determine whether to authorize,
modify, or deny health care services shall comply with all of
the following requirements :
(1) Be developed with involvement from actively practicing health
care providers.
(2) Be consistent with sound clinical principles and processes.
(3) Be evaluated, and updated if necessary, at least annually.
(4) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the enrollee in that specified case.
(5) Be available to the public upon request. A plan shall only be
required to disclose the criteria or guidelines for the specific
procedures or conditions requested. A plan may charge reasonable fees
to cover administrative expenses related to disclosing criteria or
guidelines pursuant to this paragraph, limited to copying and postage
costs. The plan may also make the criteria or guidelines available
through electronic communication means.
(c) The disclosure required by paragraph (5) of subdivision (b)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this plan to authorize, modify, or
deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and the
benefits covered under your contract."
SEC. 2. Section 10123.135 of the Insurance Code is amended to
read:
10123.135. (a) Every disability A health
insurer, or an entity with which it contracts for services that
include utilization review or utilization management functions,
that covers hospital, medical, or surgical expenses and
that prospectively, retrospectively, or concurrently
reviews and approves, modifies, delays, or denies, based in whole or
in part on medical necessity, requests by providers prior to,
retrospectively, or concurrent with the provision of health care
services to insureds, or that delegates these functions to medical
groups or independent practice associations or to other contracting
providers, shall comply with this section.
(b) A disability health insurer that
is subject to this section, or any entity with which an
a health insurer contracts for services that
include utilization review or utilization management functions, shall
have written policies and procedures establishing the process by
which the insurer prospectively, retrospectively, or concurrently
reviews and approves, modifies, delays, or denies, based in whole or
in part on medical necessity, requests by providers of health care
services for insureds. These policies and procedures shall ensure
that decisions based on the medical necessity of proposed health care
services are consistent with criteria or guidelines that are
supported by clinical principles and processes. These criteria and
guidelines shall be developed pursuant to subdivision (f). These
policies and procedures, and a description of the process by which
an a health insurer, or an entity with
which an a health insurer contracts for
services that include utilization review or utilization management
functions, reviews and approves, modifies, delays, or denies requests
by providers prior to, retrospectively, or concurrent with the
provision of health care services to insureds, shall be filed with
the commissioner, and shall be disclosed by the insurer to insureds
and providers upon request, and by the insurer to the public upon
request.
(c) If the number of insureds covered under health benefit plans
in this state that are issued by an insurer subject to this section
constitute at least 50 percent of the number of insureds covered
under health benefit plans issued nationwide by that insurer, the
insurer shall employ or designate a medical director who holds an
unrestricted license to practice medicine in this state issued
pursuant to Section 2050 of the Business and Professions Code or the
Osteopathic Initiative Act, or the insurer may employ a clinical
director licensed in California whose scope of practice under
California law includes the right to independently perform all those
services covered by the insurer. The medical director or clinical
director shall ensure that the process by which the insurer reviews
and approves, modifies, delays, or denies, based in whole or in part
on medical necessity, requests by providers prior to,
retrospectively, or concurrent with the provision of health care
services to insureds, complies with the requirements of this section.
Nothing in this subdivision shall be construed as restricting the
existing authority of the Medical Board of California.
(d) If an insurer subject to this section, or individuals under
contract to the insurer to review requests by providers, approve the
provider's request pursuant to subdivision (b), the decision shall be
communicated to the provider pursuant to subdivision (h).
(e) An individual, other than a licensed physician or a licensed
health care professional who is competent to evaluate the specific
clinical issues involved in the health care services requested by the
provider, may not deny or modify requests for authorization of
health care services for an insured for reasons of medical necessity.
The decision of the physician or other health care provider shall be
communicated to the provider and the insured pursuant to subdivision
(h).
(f) (1) An A health insurer shall
disclose, or provide for the disclosure, to the commissioner and to
network providers, the process the insurer, its contracting provider
groups, or any entity with which it contracts for services that
include utilization review or utilization management functions, uses
to authorize, delay, modify, or deny health care services under the
benefits provided by the insurance contract
policy , including coverage for subacute care, transitional
inpatient care, or care provided in skilled nursing facilities.
An A health insurer shall also disclose
those processes to policyholders or persons designated by a
policyholder, or to any other person or organization, upon request.
(2) The criteria or guidelines used by an insurer, or an entity
with which an insurer contracts for utilization review or utilization
management functions, to determine whether to authorize, modify,
delay, or deny health care services, shall comply with all of the
following requirements :
(A) Be developed with involvement from actively practicing health
care providers.
(B) Be consistent with sound clinical principles and processes.
(C) Be evaluated, and updated if necessary, at least annually.
(D) If used as the basis of a decision to modify, delay, or deny
services in a specified case under review, be disclosed to the
provider and the policyholder in that specified case.
(E) Be available to the public upon request. An insurer shall only
be required to disclose the criteria or guidelines for the specific
procedures or conditions requested. An insurer may charge reasonable
fees to cover administrative expenses related to disclosing criteria
or guidelines pursuant to this paragraph that are limited to copying
and postage costs. The insurer may also make the criteria or
guidelines available through electronic communication means.
(3) The disclosure required by subparagraph (E) of paragraph (2)
shall be accompanied by the following notice: "The materials provided
to you are guidelines used by this insurer to authorize, modify, or
deny health care benefits for persons with similar illnesses or
conditions. Specific care and treatment may vary depending on
individual need and the benefits covered under your insurance
contract."
(g) If an insurer subject to this section requests medical
information from providers in order to determine whether to approve,
modify, or deny requests for authorization, the insurer shall request
only the information reasonably necessary to make the determination.
(h) In determining whether to approve, modify, or deny requests by
providers prior to, retrospectively, or concurrent with the
provision of health care services to insureds, based in whole or in
part on medical necessity, every insurer subject to this section
shall meet the following requirements:
(1) Decisions to approve, modify, or deny, based on medical
necessity, requests by providers prior to, or concurrent with, the
provision of health care services to insureds that do not meet the
requirements for the 72-hour review required by paragraph (2), shall
be made in a timely fashion appropriate for the nature of the insured'
s condition, not to exceed five business days from the insurer's
receipt of the information reasonably necessary and requested by the
insurer to make the determination. In cases where the review is
retrospective, the decision shall be communicated to the individual
who received services, or to the individual's designee, within 30
days of the receipt of information that is reasonably necessary to
make this determination, and shall be communicated to the provider in
a manner that is consistent with current law. For purposes of this
section, retrospective reviews shall be for care rendered on or after
January 1, 2000.
(2) When the insured's condition is such that the insured faces an
imminent and serious threat to his or her health, including, but not
limited to, the potential loss of life, limb, or other major bodily
function, or the normal timeframe for the decisionmaking process, as
described in paragraph (1), would be detrimental to the insured's
life or health or could jeopardize the insured's ability to regain
maximum function, decisions to approve, modify, or deny requests by
providers prior to, or concurrent with, the provision of health care
services to insureds shall be made in a timely fashion, appropriate
for the nature of the insured's condition, but not to exceed 72 hours
after the insurer's receipt of the information reasonably necessary
and requested by the insurer to make the determination.
(3) Decisions to approve, modify, or deny requests by providers
for authorization prior to, or concurrent with, the provision of
health care services to insureds shall be communicated to the
requesting provider within 24 hours of the decision. Except for
concurrent review decisions pertaining to care that is underway,
which shall be communicated to the insured's treating provider within
24 hours, decisions resulting in denial, delay, or modification of
all or part of the requested health care service shall be
communicated to the insured in writing within two business days of
the decision. In the case of concurrent review, care shall not be
discontinued until the insured's treating provider has been notified
of the insurer's decision and a care plan has been agreed upon by the
treating provider that is appropriate for the medical needs of that
patient.
(4) Communications regarding decisions to approve requests by
providers prior to, retrospectively, or concurrent with the provision
of health care services to insureds shall specify the specific
health care service approved. Responses regarding decisions to deny,
delay, or modify health care services requested by providers prior
to, retrospectively, or concurrent with the provision of health care
services to insureds shall be communicated to insureds in writing,
and to providers initially by telephone or facsimile, except with
regard to decisions rendered retrospectively, and then in writing,
and shall include a clear and concise explanation of the reasons for
the insurer's decision, a description of the criteria or guidelines
used, and the clinical reasons for the decisions regarding medical
necessity. Any written communication to a physician or other health
care provider of a denial, delay, or modification or a request shall
include the name and telephone number of the health care professional
responsible for the denial, delay, or modification. The telephone
number provided shall be a direct number or an extension, to allow
the physician or health care provider easily to contact the
professional responsible for the denial, delay, or modification.
Responses shall also include information as to how the provider or
the insured may file an appeal with the insurer or seek department
review under the unfair practices provisions of Article 6.5
(commencing with Section 790) of Chapter 1 of Part 2 of Division 1
and the regulations adopted thereunder.
(5) If the insurer cannot make a decision to approve, modify, or
deny the request for authorization within the timeframes specified in
paragraph (1) or (2) because the insurer is not in receipt of all of
the information reasonably necessary and requested, or because the
insurer requires consultation by an expert reviewer, or because the
insurer has asked that an additional examination or test be performed
upon the insured, provided that the examination or test is
reasonable and consistent with good medical practice, the insurer
shall, immediately upon the expiration of the timeframe specified in
paragraph (1) or (2), or as soon as the insurer becomes aware that it
will not meet the timeframe, whichever occurs first, notify the
provider and the insured, in writing, that the insurer cannot make a
decision to approve, modify, or deny the request for authorization
within the required timeframe, and specify the information requested
but not received, or the expert reviewer to be consulted, or the
additional examinations or tests required. The insurer shall also
notify the provider and enrollee of the anticipated date on which a
decision may be rendered. Upon receipt of all information reasonably
necessary and requested by the insurer, the insurer shall approve,
modify, or deny the request for authorization within the timeframes
specified in paragraph (1) or (2), whichever applies.
(6) If the commissioner determines that an insurer has failed to
meet any of the timeframes in this section, or has failed to meet any
other requirement of this section, the commissioner may assess, by
order, administrative penalties for each failure. A proceeding for
the issuance of an order assessing administrative penalties shall be
subject to appropriate notice to, and an opportunity for a hearing
with regard to, the person affected. The administrative penalties
shall not be deemed an exclusive remedy for the commissioner. These
penalties shall be paid to the Insurance Fund.
(i) Every insurer subject to this section shall maintain telephone
access for providers to request authorization for health care
services.
(j) Nothing in this section shall cause a disability
health insurer to be defined as a health care
provider for purposes of any provision of law, including, but not
limited to, Section 6146 of the Business and Professions Code,
Sections 3333.1 and 3333.2 of the Civil Code, and Sections 340.5,
364, 425.13, 667.7, and 1295 of the Code of Civil Procedure.
