Bill Text: CA AB2533 | 2013-2014 | Regular Session | Amended
Bill Title: Health care coverage: noncontracting providers.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2014-08-19 - Read second time and amended. Ordered to third reading. [AB2533 Detail]
Download: California-2013-AB2533-Amended.html
BILL NUMBER: AB 2533 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 19, 2014
AMENDED IN ASSEMBLY MAY 6, 2014
AMENDED IN ASSEMBLY APRIL 22, 2014
AMENDED IN ASSEMBLY MARCH 28, 2014
INTRODUCED BY Assembly Member Ammiano
FEBRUARY 21, 2014
An act to add Section 1367.031 to the Health and Safety Code, and
to add Section 10133.51 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2533, as amended, Ammiano. Health care coverage: noncontracting
providers.
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 and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires the Department of Managed Health
Care and the Insurance Commissioner to adopt regulations to ensure
that enrollees and insureds have access to needed health care
services in a timely manner, as specified. Existing law authorizes
the Department of Managed Health Care to assess
administrative penalties for noncompliance with the requirements,
which are paid into the Managed Care Administrative Fines and
Penalties Fund.
This bill would require a health care service plan or health
insurer that contracts for alternative rates of payment to arrange
for, or assist in arranging for, an enrollee or insured who is unable
to obtain a medically necessary covered service to receive the care
or service from a noncontracting provider in an accessible and timely
manner. The bill would prohibit the health care service plan or
health insurer from imposing copayments, coinsurance, or deductibles
on an enrollee or insured that exceed what the enrollee or insured
would pay for services from a contracting provider. The bill
would also prohibit a noncontracting provider that agrees to provide
services under these provisions from billing an enrollee or insured
for any amount in excess of the in-network reimbursement
rate, except as specified. The bill would require a
health care service plan or health insurer to report annually to the
respective department on the occurrences of denial of care and
complaints received by the plan or insurer regarding accessible and
timely access to care. The bill would require each department to
review those complaints and any complaints received by the department
regarding accessibility or timeliness of care and annually prepare
and post on its Internet Web site a report of the information
received.
This bill would authorize the Insurance Commissioner to
investigate and take enforcement action against insurers regarding
noncompliance with these provisions and would authorize the
commissioner to assess administrative penalties for violations, as
specified. The bill would require the commissioner, on or before
January 1, 2016, to promulgate related regulations and review the
regulations every 3 years to determine if the regulations should be
updated.
Because a willful violation of these requirements with respect to
health care service plans would be a crime, the bill 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 1367.031 is added to the Health and Safety
Code, immediately following Section 1367.03, to read:
1367.031. (a) If an enrollee is unable to obtain a medically
necessary covered service in an accessible and timely manner, as
required under Section 1367.03, from a contracted provider, the
health care service plan shall 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 noncontracting provider, and
shall not impose copayments, coinsurance, or deductibles on the
enrollee that exceed what the enrollee would pay for services from a
contracting provider.
(b) A noncontracting provider that agrees to provide services
pursuant to this section shall not bill the enrollee for any amount
in excess of the in-network reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (a).
(b)
( c) In addition to any reporting
requirements in subdivision (f) of Section 1367.03, a health care
service plan shall report annually to the department on any and all
occurrences of denial of care and on complaints received by the
health care service plan regarding accessible and timely access to
care. The department shall review these complaints and any complaints
received by the department regarding accessibility or timeliness of
care and annually prepare and post on the department's Internet Web
site a report on the information received.
SEC. 2. Section 10133.51 is added to the Insurance Code, to read:
10133.51. (a) This section shall apply to insurers that contract
for alternative rates of payment pursuant to Section 10133.
(b) If an insured is unable to obtain a medically necessary
covered service in an accessible and timely manner, as required under
Section 10133.5, from a contracted provider, the health insurer
shall arrange for, or assist the insured in arranging for, the
insured to receive the care or service in an accessible and timely
manner from a noncontracting provider, and shall not impose
copayments, coinsurance, or deductibles on the insured that exceed
what an insured would pay for services from a contracting provider.
(c) A noncontracting provider that agrees to provide services
pursuant to this section shall not bill the insured for any amount in
excess of the in-network reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (b).
(c)
( d) In addition to the reporting
requirements in Section 10133.5, health insurers shall report
annually to the department on any and all occurrences of denial of
care and on complaints received by the insurer regarding accessible
and timely access to care. The department shall review these
complaints and any complaints received by the department regarding
accessibility or timeliness of care and annually prepare and post on
the department's Internet Web site a report on the information
received.
(d)
( e) The commissioner shall, on or before
January 1, 2016, promulgate regulations pursuant to this section and
Section 10133.5 to ensure that insureds have the opportunity to
access medically necessary health care services in an accessible and
timely manner. Every three years, the commissioner shall review the
latest version of the regulations adopted pursuant to this section
and determine if the regulations should be updated to further the
intent of this section.
(e)
( f) The commissioner may investigate and
take enforcement action against insurers regarding noncompliance with
the requirements of this section and Section 10133.5. The
commissioner may, by order, assess administrative penalties for
violations of this section and Section 10133.5, subject to
appropriate notice of, and the opportunity for, a hearing in
accordance with Chapter 5 (commencing with Section 11500) of Part 1
of Division 3 of Title 2 of the Government Code. The insurer may
provide to the commissioner, and the commissioner may consider,
information regarding the insurer's overall compliance with the
requirements of this section. The administrative penalties available
to the commissioner pursuant to this section are not exclusive and
may be sought and employed in any combination with civil, criminal,
and other administrative remedies as determined by the commissioner.
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.
