Bill Text: CA AB2533 | 2009-2010 | Regular Session | Amended
Bill Title: Health care coverage: quality rating.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2010-08-05 - From Consent Calendar. Ordered to third reading. To inactive file on motion of Senator Padilla. [AB2533 Detail]
Download: California-2009-AB2533-Amended.html
BILL NUMBER: AB 2533 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 23, 2010
AMENDED IN ASSEMBLY MAY 6, 2010
INTRODUCED BY Assembly Member Fuentes
FEBRUARY 19, 2010
An act to amend Section 1367.02 of the Health and Safety Code, and
to amend Section 10123.36 of the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2533, as amended, Fuentes. Health care coverage: quality
rating.
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 makes a
willful violation of the act's requirements a crime. Existing law
provides for the regulation of health insurers by the Department of
Insurance.
Existing law requires every health care service plan and certain
health insurers, on or before July 1, 1999, to file with the
respective departments a description of policies and procedures
related to economic profiling, as defined, utilized by the plan or
insurer and its medical groups and individual practice associations
and requires the Director of the Department of Managed Health Care
and the Insurance Commissioner to make these filings available to the
public upon request with certain exceptions. Existing law requires
each plan or health insurer using economic profiling to provide, upon
request, a copy of economic profiling information to the profiled
individual, group, or association. Existing law also requires each
plan or insurer, as a contract condition, to require its contracting
medical groups and individual practice associations that maintain
economic profiles of individual providers to provide, upon request, a
copy to the profiled individual providers.
This bill would expand these provisions to apply to quality
rating, as defined, utilized by the plan or insurer with respect to a
particular physician, provider, medical group, or individual
practice association. The bill would also require
those the department filings to be made
with the respective departments annually immediately
upon adoption of the policies and procedures and within 30 days of
making any changes to the policies and procedures. The bill would
modify the required content of the filings, as specified, and would
require a plan or insurer that submitted a filing prior to January 1,
2011, to update the filing by March 31, 2011, to comply with the
bill's requirements and to reflect the plan's or insurer's current
policies and procedures . The bill would also expand
these provisions to apply to quality rating, as defined, utilized by
the plan or insurer with respect to a particular physician, provider,
medical group, or individual practice association.
Because a willful violation of the bill's requirements with
respect to health care service plans would be a crime, it would
impose a state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.02 of the Health and Safety Code is
amended to read:
1367.02. (a) (1) For purposes of public
disclosure, every health care service plan shall annually
file with the department a description of any policies and
procedures related to economic profiling or quality rating utilized
by the plan and its medical groups and individual practice
associations. The A plan shall file this
description immediately upon adoption of the policies and
procedures and within 30 days of adopting any changes to the policies
and procedures. A plan that filed a description pursuant to this
section prior to January 1, 2011, shall update that filing by March
31, 2011, in order to meet the requirements of this section and to
reflect its current policies and procedures.
(2) The filing shall describe how
these policies and procedures are used in utilization review, peer
review, incentive and penalty programs, network
modification, and patient steering, and in provider
retention and termination decisions , as well as how they are
used to designate or rate a particular physician, provider, medical
group, or individual practice association within the plan's existing
network and to encourage patients to see only designated or rated
physicians, providers, medical groups, or individual practice
associations within the plan's existing network. The filing shall
include a description of the manner and methodology used to share
results from economic profiling and quality rating with patients
. The filing shall also indicate in what manner the economic
profiling or quality rating system being used takes into
consideration risk adjustments that reflect case mix, accuracy and
reliability of data relied upon, type and severity of patient
illness, age of patients, patient compliance with a recommended
procedure, and other enrollee characteristics that may account for
higher or lower than expected quality, costs, or utilization of
services. The filing shall also indicate how the economic profiling
or quality rating activities avoid being in conflict with subdivision
(g) of Section 1367, which requires each plan to demonstrate that
medical decisions are rendered by qualified medical providers,
unhindered by fiscal and administrative management. Nothing in this
section shall be construed to restrict or impair the department, in
its discretion, from utilizing the information filed pursuant to this
section for purposes of ensuring compliance with this chapter.
(b) The director shall make each plan's filing available to the
public upon request. The director shall not publicly disclose any
information submitted pursuant to this section that is determined by
the director to be confidential pursuant to state law.
(c) Each plan that uses economic profiling or quality rating
shall, upon request, provide a copy of economic profiling or quality
rating information related to an individual provider, contracting
medical group, or individual practice association to the profiled or
rated individual, group, or association. In addition, each plan shall
require as a condition of contract that its medical groups and
individual practice associations that maintain economic profiles or
quality ratings of individual providers shall, upon request, provide
a copy of individual economic profiling or quality rating information
to the individual providers who are profiled or rated. The economic
profiling or quality rating information provided pursuant to this
section shall be provided upon request until 60 days after the date
upon which the contract between the plan and the individual provider,
medical group, or individual practice association terminates, or
until 60 days after the date the contract between the medical group
or individual practice association and the individual provider
terminates, whichever is applicable.
(d) For the purposes of this section, "economic profiling" shall
mean any evaluation of a particular physician, provider, medical
group, or individual practice association based in whole or in part
on the economic costs or utilization of services associated with
medical care provided or authorized by the physician, provider,
medical group, or individual practice association.
(e) For the purposes of this section, "quality rating" shall mean
any efforts by a health care service plan or by an entity contracted
by a health care service plan to develop, evaluate, rate, or
designate a particular physician, provider, medical group, or
individual practice association based in whole or in part on quality
measures and claims data.
SEC. 2. Section 10123.36 of the Insurance Code is amended to read:
10123.36. (a) (1) For purposes of public
disclosure, every health insurer that authorizes insureds to select
providers who have contracted with the insurer for alternative rates
of payment as described in Section 10133, and the health insurer or
any of its contracting providers or provider groups utilize economic
profiling or quality rating related to services provided to insureds,
shall annually file with the department a
description of any policies and procedures related to economic
profiling or quality rating utilized by the insurer and any of its
contracting providers and provider groups. The
A health insurer shall file this description immediately upon
adoption of the policies and procedures and within 30 days of
adopting any changes to the policies and procedures. A health insurer
that filed a description pursuant to this section prior to January
1, 2011, shall update that filing by March 31, 2011, in order to meet
the requirements of this section and to reflect its current policies
and procedures.
(2) The filing shall describe how
these policies and procedures are used in utilization review, peer
review, incentive and penalty programs, network
modification, and patient steering, and in provider
retention and termination decisions , as well as how they are
used to designate or rate a particular physician, provider, medical
group, or individual practice association within the insurer's
existing network and to encourage patients to see only designated or
rated physicians, providers, medical groups, or individual practice
associations within the insurer's existing networ k. The
filing shall include a description of the manner and methodology used
to share results from economic profiling and quality rating with
patients . The filing shall also indicate in what manner the
economic profiling or quality rating system being used takes into
consideration risk adjustments that reflect case mix, accuracy and
reliability of data relied upon, type and severity of patient
illness, age of patients, patient compliance with a recommended
procedure, and other policyholder characteristics that may account
for higher or lower than expected quality, costs, or utilization of
services. Nothing in this section shall be construed to restrict or
impair the department, in its discretion, from utilizing the
information filed pursuant to this section for purposes of ensuring
compliance with this chapter.
(b) The commissioner shall make each health insurer filing
available to the public upon request. The commissioner shall not
publicly disclose any information submitted pursuant to this section
that is determined by the commissioner to be confidential pursuant to
state law.
(c) Each health insurer that uses economic profiling or quality
rating shall, upon request, provide a copy of economic profiling or
quality rating information related to a contracting provider or
provider group to the profiled or rated provider or group. In
addition, each health insurer shall require as a condition of
contract that its contracting provider groups that maintain economic
profiles or quality ratings of individual providers who may be
selected by insureds shall, upon request, provide a copy of
individual economic profiling or quality rating information to
individual providers who are profiled. The economic profiling or
quality rating information provided pursuant to this section shall be
provided upon request until 60 days after the date upon which the
contract between the insurer and the individual provider or provider
group terminates, or until 60 days after the date the contract
between the provider group and the individual provider terminates,
whichever is applicable.
(d) For the purposes of this section, "economic profiling" shall
mean any evaluation of a particular physician, provider, or provider
group based in whole or in part on the economic costs or utilization
of services associated with medical care provided or authorized by
the physician, provider, or provider group.
(e) For the purposes of this section, "quality rating" shall mean
any efforts by a health insurer or by an entity contracted by a
health insurer to develop, evaluate, rate, or designate a particular
physician, provider, medical group, or individual practice
association based in whole or in part on quality measures and claims
data.
SEC. 3. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
