Bill Text: CA AB2372 | 2015-2016 | Regular Session | Amended
Bill Title: Health care coverage: HIV specialists.
Spectrum: Slight Partisan Bill (Democrat 2-1)
Status: (Failed) 2016-11-30 - From committee without further action. [AB2372 Detail]
Download: California-2015-AB2372-Amended.html
BILL NUMBER: AB 2372 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 25, 2016
AMENDED IN ASSEMBLY APRIL 13, 2016
INTRODUCED BY Assembly Member Burke
(Principal coauthor: Assembly Member Waldron)
(Principal coauthor: Senator Hertzberg)
FEBRUARY 18, 2016
An act to amend Section 1367.03 of, and to add
Section 1367.693 to, to the Health and
Safety Code, and to amend Section 10133.5 of, and to
add Section 10123.833 to, to
the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 2372, as amended, Burke. Health care coverage: HIV specialists.
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. A willful violation
of the act is 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. Existing law requires the Department of Managed Health Care
to develop indicators of timeliness of access to care, including
waiting times for appointments with physicians, including primary
care and speciality physicians. Existing law requires health c
are service plans to report annually to the
Department of Managed Health Care on compliance with the standards
developed pursuant to these provisions. Existing law requires
the Insurance Commissioner to adopt regulations that ensure, among
other things, the adequacy of the number of professional providers in
relationship to the projected demands for services covered under the
group policy.
This bill would define for these purposes "specialty
physician" and "professional provider," respectively, to include a
physician who meets the criteria for an HIV specialist, as specified.
require access to HIV specialists to be subject to
the regulations, standards, and reporting requirements developed
pursuant to the above specified provisions. The bill would
require a health care service plan contract or health insurance
policy that is issued, amended, or renewed on or after January 1,
2017, to include an HIV specialist, as defined, as an eligible
primary care provider, as defined, if the provider requests primary
care provider status and meets the plan's or health insurer's
eligibility criteria for all specialists seeking primary care
provider status. Because a willful violation of these requirements by
a health care service plan 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 1367.03 of the Health and
Safety Code is amended to read:
1367.03. (a) The department shall develop and adopt regulations
to ensure that enrollees have access to needed health care services
in a timely manner. In developing these regulations, the department
shall develop indicators of timeliness of access to care and, in so
doing, shall consider the following as indicators of timeliness of
access to care:
(1) Waiting times for appointments with physicians, including
primary care and specialty physicians.
(2) Timeliness of care in an episode of illness, including the
timeliness of referrals and obtaining other services, if needed.
(3) Waiting time to speak to a physician, registered nurse, or
other qualified health professional acting within his or her scope of
practice who is trained to screen or triage an enrollee who may need
care.
(b) In developing these standards for timeliness of access, the
department shall consider the following:
(1) Clinical appropriateness.
(2) The nature of the specialty.
(3) The urgency of care.
(4) The requirements of other provisions of law, including Section
1367.01 governing utilization review, that may affect timeliness of
access.
(c) The department may adopt standards other than the time elapsed
between the time an enrollee seeks health care and obtains care. If
the department chooses a standard other than the time elapsed between
the time an enrollee first seeks health care and obtains it, the
department shall demonstrate why that standard is more appropriate.
In developing these standards, the department shall consider the
nature of the plan network.
(d) The department shall review and adopt standards, as needed,
concerning the availability of primary care physicians, specialty
physicians, hospital care, and other health care, so that consumers
have timely access to care. In so doing, the department shall
consider the nature of physician practices, including individual and
group practices as well as the nature of the plan network. The
department shall also consider various circumstances affecting the
delivery of care, including urgent care, care provided on the same
day, and requests for specific providers. If the department finds
that health care service plans and health care providers have
difficulty meeting these standards, the department may make
recommendations to the Assembly Committee on Health and the Senate
Committee on Insurance of the Legislature pursuant to subdivision
(i).
(e) In developing standards under subdivision (a), the department
shall consider requirements under federal law, requirements under
other state programs, standards adopted by other states, nationally
recognized accrediting organizations, and professional associations.
The department shall further consider the needs of rural areas,
specifically those in which health facilities are more than 30 miles
apart and any requirements imposed by the State Department of Health
Care Services on health care service plans that contract with the
State Department of Health Care Services to provide Medi-Cal managed
care.
(f) (1) Contracts between health care service plans and health
care providers shall ensure compliance with the standards developed
under this section. These contracts shall require reporting by health
care providers to health care service plans and by health care
service plans to the department to ensure compliance with the
standards.
(2) Health care service plans shall report annually to the
department on compliance with the standards in a manner specified by
the department. The reported information shall allow consumers to
compare the performance of plans and their contracting providers in
complying with the standards, as well as changes in the compliance of
plans with these standards.
(3) The department may develop standardized methodologies for
reporting that shall be used by health care service plans to
demonstrate compliance with this section and any regulations adopted
pursuant to it. The methodologies shall be sufficient to determine
compliance with the standards developed under this section for
different networks of providers if a health care service plan uses a
different network for Medi-Cal managed care products than for other
products or if a health care service plan uses a different network
for individual market products than for small group market products.
The development and adoption of these methodologies shall not be
subject to the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code) until January 1, 2020. The department shall consult
with stakeholders in developing standardized methodologies under this
paragraph.
(g) (1) When evaluating compliance with the standards, the
department shall focus more upon patterns of noncompliance rather
than isolated episodes of noncompliance.
(2) The director may investigate and take enforcement action
against plans regarding noncompliance with the requirements of this
section. Where substantial harm to an enrollee has occurred as a
result of plan noncompliance, the director may, by order, assess
administrative penalties subject to appropriate notice of, and the
opportunity for, a hearing in accordance with Section 1397. The plan
may provide to the director, and the director may consider,
information regarding the plan's overall compliance with the
requirements of this section. The administrative penalties shall not
be deemed an exclusive remedy available to the director. These
penalties shall be paid to the Managed Care Administrative Fines and
Penalties Fund and shall be used for the purposes specified in
Section 1341.45. The director shall periodically evaluate grievances
to determine if any audit, investigative, or enforcement actions
should be undertaken by the department.
(3) The director may, after appropriate notice and opportunity for
hearing in accordance with Section 1397, by order, assess
administrative penalties if the director determines that a health
care service plan has knowingly committed, or has performed with a
frequency that indicates a general business practice, either of the
following:
(A) Repeated failure to act promptly and reasonably to assure
timely access to care consistent with this chapter.
(B) Repeated failure to act promptly and reasonably to require
contracting providers to assure timely access that the plan is
required to perform under this chapter and that have been delegated
by the plan to the contracting provider when the obligation of the
plan to the enrollee or subscriber is reasonably clear.
(C) The administrative penalties available to the director
pursuant to this section are not exclusive, and may be sought and
employed in any combination with civil, criminal, and other
administrative remedies deemed warranted by the director to enforce
this chapter.
(4) The administrative penalties shall be paid to the Managed Care
Administrative Fines and Penalties Fund and shall be used for the
purposes specified in Section 1341.45.
(h) The department shall work with the patient advocate to assure
that the quality of care report card incorporates information
provided pursuant to subdivision (f) regarding the degree to which
health care service plans and health care providers comply with the
requirements for timely access to care.
(i) The department shall annually review information regarding
compliance with the standards developed under this section and shall
make recommendations for changes that further protect enrollees.
Commencing no later than December 1, 2015, and annually thereafter,
the department shall post its final findings from the review on its
Internet Web site.
(j) The department shall post on its Internet Web site any waivers
or alternative standards that the department approves under this
section on or after January 1, 2015.
(k) For purposes of this section, "specialty physician" includes a
physician who meets the criteria for an HIV specialist as published
by the American Academy of HIV Medicine or the HIV Medicine
Association, or who is contracted to provide outpatient medical care
under the federal Ryan White Comprehensive AIDS Resources Emergency
(CARE) Act of 1990 (Public Law 101-381).
SEC. 2. SECTION 1. Section 1367.693
is added to the Health and Safety Code, immediately following Section
1367.69, to read:
1367.693. (a) Every health care service plan contract that is
issued, amended, or renewed on or after January 1, 2017, that
provides hospital, medical, or surgical coverage
coverage, excluding specialized health care service plan
contracts, shall include an HIV specialist as an eligible
primary care provider, if the provider requests primary care provider
status and meets the health care service plan's eligibility criteria
for all specialists seeking primary care provider status.
(b) For purposes of this section, "primary care provider" means a
physician or a nonphysician medical practitioner, as each term is
defined in Section 14254 of the Welfare and Institutions Code, who
has the responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and for
initiating referral for specialist care. This means providing care
for the majority of health care problems, including, but not limited
to, preventive services, acute and chronic conditions, and
psychosocial issues.
(c) Access to HIV specialists shall be subject to the regulations
developed pursuant to Section 1367.03 and shall be included in the
reports and other information required under Section 1367.035,
consistent with the specialty designation.
(c)
(d) For purposes of this section, "HIV specialist"
means a physician physician, physician
assistant, or a nurse practitioner who meets the criteria for
an HIV specialist as published by the American Academy of HIV
Medicine or the HIV Medicine Association, or who is contracted to
provide outpatient medical care under the federal Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law
101-381).
SEC. 3. SEC. 2. Section 10123.833 is
added to the Insurance Code, immediately following Section 10123.83,
to read:
10123.833. (a) Every health insurance policy that is issued,
amended, or renewed on or after January 1, 2017, that provides
hospital, medical, or surgical coverage
coverage, excluding specialized health insurance policies,
shall include an HIV specialist as an eligible primary care provider,
if the provider requests primary care provider status and meets the
health insurer's eligibility criteria for all specialists seeking
primary care provider status.
(b) For purposes of this section, "primary care provider" means a
physician or a nonphysician medical practitioner, as each term is
defined in Section 14254 of the Welfare and Institutions Code, who
has the responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and for
initiating referral for specialist care. This means providing care
for the majority of health care problems, including, but not limited
to, preventive services, acute and chronic conditions, and
psychosocial issues.
(c) Access to HIV specialists shall be subject to the regulations
developed pursuant to Section 10133.5, consistent with the specialty
designation.
(c)
(d) For purposes of this section, "HIV specialist" means
a physician physician, physician assistant,
or a nurse practitioner who meets the criteria for an HIV
specialist as published by the American Academy of HIV Medicine or
the HIV Medicine Association, or who is contracted to provide
outpatient medical care under the federal Ryan White Comprehensive
AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).
SEC. 4. Section 10133.5 of the Insurance Code
is amended to read:
10133.5. (a) The commissioner shall promulgate regulations
applicable to health insurers that contract with providers for
alternative rates pursuant to Section 10133 to ensure that insureds
have the opportunity to access needed health care services in a
timely manner.
(b) These regulations shall be designed to ensure accessibility of
provider services in a timely manner to individuals comprising the
insured or contracted group, pursuant to benefits covered under the
policy or contract. The regulations shall ensure:
(1) Adequacy of number and locations of institutional facilities
and professional providers, and consultants in relationship to the
size and location of the insured group and that the services offered
are available at reasonable times.
(2) Adequacy of number of professional providers, and license
classifications of such providers, in relationship to the projected
demands for services covered under the group policy or plan. The
department shall consider the nature of the specialty in determining
the adequacy of professional providers.
(3) The policy or contract is not inconsistent with standards of
good health care and clinically appropriate care.
(4) All contracts, including contracts with providers, and other
persons furnishing services or facilities, shall be fair and
reasonable.
(c) In developing standards under subdivision (a), the department
shall also consider requirements under federal law; requirements
under other state programs and law, including utilization review; and
standards adopted by other states, national accrediting
organizations, and professional associations. The department shall
further consider the accessability to provider services in rural
areas.
(d) In designing the regulations, the commissioner shall consider
the regulations in Title 28 of the California Code of Regulations,
commencing with Section 1300.67.2, which are applicable to Knox-Keene
plans, and all other relevant guidelines in an effort to accomplish
maximum accessibility within a cost-efficient system of
indemnification. The department shall consult with the Department of
Managed Health Care concerning regulations developed by that
department pursuant to Section 1367.03 of the Health and Safety Code
and shall seek public input from a wide range of interested parties.
(e) Health insurers that contract for alternative rates of payment
with providers shall report annually on complaints received by the
insurer regarding timely access to care. The department shall review
these complaints and any complaints received by the department
regarding timeliness of care and shall make public this information.
(f) The department shall report to the Assembly Committee on
Health and the Senate Committee on Insurance of the Legislature on
March 1, 2003, and on March 1, 2004, regarding the progress towards
the implementation of this section.
(g) Every three years, the commissioner shall review the latest
version of the regulations adopted pursuant to subdivision (a) and
shall determine if the regulations should be updated to further the
intent of this section.
(h) For purposes of this section, "professional provider" includes
a physician who meets the criteria for an HIV specialist as
published by the American Academy of HIV Medicine or the HIV Medicine
Association, or who is contracted to provide outpatient medical care
under the federal Ryan White Comprehensive AIDS Resources Emergency
(CARE) Act of 1990 (Public Law 101-381).
SEC. 5. 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.
