Bill Text: CA AB1579 | 2011-2012 | Regular Session | Amended

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Bill Title: Dental coverage: noncontracting providers: assignment of

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Engrossed - Dead) 2012-06-13 - In committee: Set, first hearing. Hearing canceled at the request of author. [AB1579 Detail]

Download: California-2011-AB1579-Amended.html

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BILL NUMBER: AB 1579	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 23, 2012
	AMENDED IN ASSEMBLY  MARCH 20, 2012

INTRODUCED BY   Assembly Member Campos

                        FEBRUARY 2, 2012

   An act to add Section 1374.196 to the Health and Safety Code, and
to add Section 10120.4 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 1579, as amended, Campos. Dental coverage: noncontracting
providers: assignment of benefits.
   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 authorizes licensed nonphysician providers that contract
with a medical group, physician, or independent practice association
to provide services to health care service plan enrollees to
directly bill the plan for services rendered under certain
circumstances. Existing law requires group health care service plans
to authorize and permit assignment of a Medi-Cal beneficiary's right
to reimbursement for covered services to the State Department of
Health Care Services, except as specified. Existing law provides for
the direct payment of group insurance medical benefits by a health
insurer to the person or persons furnishing or paying for
hospitalization or medical or surgical aid, as specified.
   This bill would require a health care service plan or health
insurer that pays a contracting dental provider directly for covered
services rendered to an enrollee or insured to also pay a
noncontracting dental provider directly for covered services rendered
to an enrollee or insured where the provider submits a written
assignment of benefits signed by the enrollee or insured or the legal
representative thereof, as specified. The bill would specify that
 an   a plan or  insurer's payment pursuant
to this provision discharges the  plan or  insurer's
obligation with respect to the amount paid. The bill would also
require a noncontracting dental provider to disclose to the enrollee
or insured or the legal representative thereof that the provider is a
noncontracting provider prior to accepting an assignment of benefits
 , and to provide additional specified written notices to the
enrollee or insured or the legal representative thereof, including a
written notice of the estimated full cost of the planned treatment
and the estimated amount of those costs payable by the enrollee or
insured. The bill would also prohibit a provider from collecting from
an enrollee or insured any amount over the enrollee's or insured's
estimated cost, and would require the provider to refund any
overpayment to the enrollee or insured .
   Because a willful violation of the bill's 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 1374.196 is added to the Health and Safety
Code, to read:
   1374.196.  (a) For purposes of this section, "assignment of
benefits" means the transfer of reimbursement or other rights
provided for under a health care service plan contract to a treating
provider for services or items rendered to an enrollee.
   (b) If a health care service plan pays a contracting dental
provider directly for covered services rendered to an enrollee, the
plan shall pay a noncontracting dental provider directly for covered
services rendered to an enrollee where the noncontracting provider
submits to the plan a written assignment of benefits signed by the
enrollee or, if the enrollee is a minor or is incompetent or
incapacitated, the legal representative thereof. When payment is made
directly to a noncontracting dental provider pursuant to this
section, the plan shall give written notice of the payment to the
enrollee who received the services or, if the enrollee is a minor or
is incompetent or incapacitated, the legal representative thereof.

   (c) (1) A noncontracting dental provider accepting assignment of
benefits pursuant to this section shall give, prior to treatment, a
written notice to the enrollee or, if the enrollee is a minor or is
incompetent or incapacitated, the legal representative thereof, that
contains the following:  
   (A) Notification that the provider is not in the network of the
enrollee's plan.  
   (B) The estimated full cost of the planned treatment and the
estimated amount for which the enrollee is responsible.  
   (C) The estimate of the treatment cost covered by the health care
service plan, pursuant to paragraph (2), if available prior to
treatment. Nothing in this section shall be construed to require a
delay in treatment to the enrollee.  
   (2) For purposes of the notice required pursuant to paragraph (1),
a health care service plan shall, upon inquiry from the provider,
provide an estimate of the treatment cost to be covered by the plan
as soon as possible, but no later than three business days from the
date of the request.  
   (3) The notice required pursuant to paragraph (1) shall be made
available by the provider in the primary language of the two largest
populations seen by the provider who either do not speak English or
who are unable to effectively communicate in English because English
is not their native language, and who comprise 5 percent or more of
the patients served by the provider.  
   (4) In addition to the notice required pursuant to paragraph (1),
a noncontracting dental provider accepting an assignment of benefits
shall provide, prior to providing treatment, the enrollee or, if the
enrollee is a minor or is incompetent or incapacitated, the enrollee'
s legal representative, the following notification, in 12-point type,
on a single page without any additional information, and obtain the
signature of the enrollee or the enrollee's legal representative
indicating receipt and review thereof: 

   Assignment of Benefits  
   Your signature below acknowledges that you have chosen to have
your dental services provided by provider's name] at business name
and location] and that you are aware that this provider is not
participating in your plan's network. You also acknowledge that when
you obtain care from a nonparticipating or out-of-network provider
you understand the following:  
   Your plan's benefits and policies may not apply to the treatment
you will receive. The provider is not subject to contract
requirements or oversight by your health plan as required by state
law for participating and network providers. Contact 1-800-HMO-HELP
for more information.  
   Your out-of-pocket costs may be higher when visiting a dentist who
is not in your plan's network due to higher cost-sharing
requirements under your health plan and because you may be
responsible for any difference between the dentist's usual fee and
your plan's payment.  
   You have the right to confirm your dental benefit or insurance
information from your plan, insurer, or employer before beginning
treatment. 

   (c) 
    (d)     (1)  The amount of the payment
made pursuant to this section shall not exceed the  amount
of the benefit covered by the plan contract with respect to the
service or the billing of the provider of the service. Payment made
pursuant to this section shall discharge the plan's obligation with
respect to that amount paid.   following:  
    (A) The amount of the benefit covered by the plan contract with
respect to the service or the billing of the provider of the service.
 
   (B) The amount of expenses incurred on account of the dental care
or treatment provided.  
   (2) Payment made pursuant to this section shall discharge the plan'
s obligation with respect to that amount paid.  
   (d) Prior to accepting an assignment of benefits, a noncontracting
dental provider shall disclose to the enrollee or, if the enrollee
is a minor or is incompetent or incapacitated, the legal
representative thereof, that the provider is a noncontracting dental
provider.  
   (e) A provider accepting an assignment of benefits may only
collect from the enrollee the enrollee's estimated cost according to
the written treatment plan pursuant to subparagraph (B) of paragraph
(1) of subdivision (c). A provider shall refund any overpayment to
the enrollee within 30 business days after receiving the direct
payment from the enrollee's plan if the actual payment is more than
the estimated payment.  
   (e) 
    (f)  This section shall only apply to a health care
service plan contract covering dental services or a specialized
health care service plan contract covering dental services pursuant
to this chapter  that is a preferred provider organization plan
contract, a point-of-service plan contract, or any other plan
contract that provides coverage for out-of-network services  .

   (g) Nothing in this section shall be construed to exempt a health
care service plan from the requirements of Section 1373.96 or 1371.4.

  SEC. 2.  Section 10120.4 is added to the Insurance Code, to read:
   10120.4.  (a) For purposes of this section, "assignment of
benefits" means the transfer of reimbursement or other rights
provided for under a health insurance policy to a treating provider
for services or items rendered to an insured.
   (b) If a health insurer pays a contracting dental provider
directly for covered services rendered to an insured, the insurer
shall pay a noncontracting dental provider directly for covered
services rendered to an insured where the noncontracting provider
submits to the insurer a written assignment of benefits signed by the
insured or, if the insured is a minor or is incompetent or
incapacitated, the legal representative thereof. When payment is made
directly to a noncontracting dental provider pursuant to this
section, the insurer shall give written notice of the payment to the
insured who received the services or, if the insured is a minor or is
incompetent or incapacitated, the legal representative thereof. 

   (c) (1) A noncontracting dental provider accepting assignment of
benefits pursuant to this section shall give, prior to treatment, a
written notice to the insured or, if the insured is a minor or is
incompetent or incapacitated, the legal representative thereof, that
contains the following:  
   (A) Notification that the provider is not in the network covered
by the insured's policy.  
   (B) The estimated full cost of the planned treatment and the
estimated amount for which the insured is responsible.  
   (C) The estimated treatment cost covered by the policy, pursuant
to paragraph (2), if available prior to treatment. Nothing in this
section shall be construed to require a delay in treatment to the
insured.  
   (2) For purposes of the notice required pursuant to paragraph (1),
a health insurer shall, upon inquiry from the provider, the insured,
or both, provide an estimate of the treatment cost covered by the
policy as soon as possible, but no later than three business days
from the date of the request.  
   (3) The notice required pursuant to paragraph (1) shall be made
available by the provider in the primary language of the two largest
populations seen by the provider who either do not speak English or
who are unable to effectively communicate in English because English
is not their native language, and who comprise 5 percent or more of
the patients served by the provider.  
   (4) In addition to the notice required pursuant to paragraph (1),
a noncontracting dental provider accepting an assignment of benefits
shall provide, prior to providing treatment, the insured or, if the
insured is a minor or is incompetent or incapacitated, the insured's
legal representative, the following notification, in 12-point type,
on a single page without any additional information, and obtain the
signature of the insured or the insured's legal representative
indicating receipt and review thereof:  
   Assignment of Benefits  
   Your signature below acknowledges that you have chosen to have
your dental services provided by provider's name] at business name
and location] and that you are aware that this provider is not
participating in your insurer's network. You also acknowledge that
when you obtain care from a nonparticipating or out-of-network
provider you understand the following:  
   Your insurance policy's benefits may not apply to the treatment
you will receive. The provider is not subject to contract
requirements or oversight by a dental insurer as required by state
law for participating and network providers. Contact 1-800-927-HELP
for more information.  
   Your out-of-pocket costs may be higher when visiting a dentist who
is not in your insurer's network due to higher cost-sharing
requirements under your policy and because you may be responsible for
any difference between the dentist's usual fee and your policy's
payment.  
   You have the right to confirm your dental benefit or insurance
information from your plan, insurer, or employer before beginning
treatment.  
   (c) 
    (d)     (1)  The amount of the payment
made pursuant to this section shall not exceed the  amount
of the benefit covered by the policy with respect to the service or
the billing of the provider of the service. Payment made pursuant to
this section shall discharge the insurer's obligation with respect to
that amount paid.   following:  
   (A) The amount of the benefit covered by the policy with respect
to the service or the billing of the provider of the service. 

   (B) The amount of expenses incurred on account of the dental care
or treatment provided.  
   (2) Payment made pursuant to this section shall discharge the
insurer's obligation with respect to that amount paid.  

   (d) Prior to accepting an assignment of benefits, a noncontracting
dental provider shall disclose to the insured or, if the insured is
a minor or is incompetent or incapacitated, the legal representative
thereof, that the provider is a noncontracting dental provider.
 
   (e) A provider accepting an assignment of benefits may only
collect from the insured the insured's estimated cost according to
the written treatment plan pursuant to subparagraph (B) of paragraph
(1) of subdivision (c). A provider shall refund any overpayment to
the insured within 30 business days after receiving the direct
payment from the insurer if the actual payment is more than the
estimated payment.  
   (e) 
    (f)  This section shall only apply to a health insurance
policy covering dental services or a specialized health insurance
policy covering dental services pursuant to this part  that
provides services at alternative rates of payment pursuant to Section
10133  . 
   (g) Nothing in this section shall be construed to exempt a health
insurer from the requirements of Section 10133.56. 
  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.