Bill Text: CA AB1742 | 2011-2012 | Regular Session | Amended
Bill Title: Health care coverage: payment for benefits.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-04-24 - In committee: Set second hearing. Failed passage. Reconsideration granted. [AB1742 Detail]
Download: California-2011-AB1742-Amended.html
BILL NUMBER: AB 1742 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MARCH 19, 2012
INTRODUCED BY Assembly Member Pan
FEBRUARY 17, 2012
An act to amend Section 1371.3 of the Health and Safety Code, and
to add Section 10133.75 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1742, as amended, Pan. Health care coverage: payment for
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 requires a health care
service plan to reimburse providers for emergency services and care
provided to its enrollees until the care results in stabilization of
the enrollee, except as specified, and to reimburse providers for
poststabilization care in specified 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.
This bill would impose that assignment requirement on a group or
individual health care service plan , except a plan
providing benefits under a specialized health care service plan
contract, as defined, and would also require those plans to
authorize and permit assignment of an enrollee's or subscriber's
right to reimbursement for covered services to the provider
furnishing those services, except as specified. The bill would
require the provider to provide the plan with certain information in
order to receive reimbursement.
Because a willful violation of those provisions would be a crime,
the bill would impose a state-mandated local program.
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
or, in the case of a Medi-Cal beneficiary, to the State Department of
Health Care Services, as specified. Existing law requires that the
amount of the reimbursement not exceed the amount of the benefit
provided by the policy or the amount of expenses incurred on account
of the hospitalization or medical or surgical aid.
This bill would provide for the direct payment of individual
insurance medical benefits by a health insurer , except an
insurer providing benefits under a specialized health insurance
policy, as defined, to the person who provided the
hospitalization or medical or surgical aid where that person has
submitted certain information to the insurer for reimbursement. The
bill would limit the amount of the reimbursement to the amount of the
benefit covered by the policy.
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 1371.3 of the Health and Safety Code is amended
to read:
1371.3. (a) A health care service plan that provides hospital,
medical, or surgical expense benefits for plan members and their
dependents shall authorize and permit assignment of the enrollee's or
subscriber's right to any reimbursement for health care services
covered under the plan contract to the provider who furnished the
health care services or, when the services are provided to a Medi-Cal
beneficiary, to the State Department of Health Care Services. This
section, however, shall not apply to a Medi-Cal beneficiary for
health care services provided pursuant to a contract with the State
Department of Health Care Services under Chapter 7 (commencing with
Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3
of Division 9 of the Welfare and Institutions Code.
(b) When seeking payment from a health care service plan pursuant
to subdivision (a), a provider shall provide the plan with the
provider's itemized bill for service, the name and address of the
person to be reimbursed, and the name and contract number of the
enrollee.
(c) Subdivisions (a) and (b) shall not apply to a plan providing
benefits pursuant to a specialized health care service plan contract,
as defined in subdivision (o) of Section 1345.
SEC. 2. Section 10133.75 is added to the Insurance Code, to read:
10133.75. (a) On and after January 1, 2013, a disability insurer
shall pay individual insurance benefits contingent upon, or for
expenses incurred on account of, hospitalization or medical or
surgical aid to the person or persons having provided the
hospitalization or medical or surgical aid where that person has
qualified for reimbursement by submitting the items and information
specified in subdivision (b). The amount of that payment shall not
exceed the amount of the benefit covered by the policy. Payment so
made shall discharge the insurer's obligation with respect to the
amount so paid.
(b) When seeking payment from a disability insurer pursuant to
subdivision (a), a person shall provide the insurer with the provider'
s itemized bill for service, the name and address of the person to be
reimbursed, and the name and policy number of the insured.
(c) Subdivisions (a) and (b) shall not apply to an insurer
providing benefits pursuant to a specialized health insurance policy,
as defined in subdivision (c) of Section 106.
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.
