Bill Text: CA AB931 | 2023-2024 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Prior authorization: physical therapy.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Vetoed) 2024-01-25 - Consideration of Governor's veto stricken from file. [AB931 Detail]

Download: California-2023-AB931-Introduced.html

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CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill

No. 931

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Introduced by Assembly Member Irwin

February 14, 2023

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An act to add Section 1367.26 to the Health and Safety Code, and to add Section 10123.75 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

AB 931, as introduced, Irwin. Prior authorization: physical therapy.

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 provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth specified prior authorization limitations for health care service plans and health insurers.

This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, that provides coverage for physical therapy from imposing prior authorization for the initial 12 treatment visits for a new episode of care for physical therapy. Because a willful violation of this provision 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.

Digest Key

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

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Bill Text

The people of the State of California do enact as follows:

SECTION 1.

 The Legislature finds and declares all of the following:

(a) The Legislature remains committed to ensuring that health care service plans and health insurers provide patients with the right care at the right time, without requiring patients or the clinicians who provide that care to have to navigate arduous, opaque, or clinically inappropriate authorization processes that delay access to care.

(b) Recent practices by various health care service plans, health insurers, and their agents to limit the availability of physical therapy, including the use of computer-generated denials or modifications of treatment plans recommended by the patient’s treating clinician, are interfering in this ongoing goal of timely, appropriate care.

(c) The practice to create barriers to physical therapy at levels significantly below the number of visits recognized in research literature as medically necessary to treat various conditions and consistent with visit limits specified in patients’ “Evidence of Coverage” disclosures creates confusion for patients’ reasonable expectations of coverage and puts patients at risk for poor outcomes, which affects their long-term health.

SEC. 2.

 Section 1367.26 is added to the Health and Safety Code, to read:

1367.26.

 (a) A health care service plan contract issued, amended, or renewed on or after January 1, 2025, that provides coverage for physical therapy shall not, for a new episode of care, require prior authorization for the initial 12 treatment visits for physical therapy.

(b) For purposes of this section, “new episode of care” means treatment for a new or recurring condition for which the enrollee has not been treated by the provider within the previous 90 days and is not currently undergoing active treatment.

SEC. 3.

 Section 10123.75 is added to the Insurance Code, to read:

10123.75.

 (a) A health insurance policy issued, amended, or renewed on or after January 1, 2025, that provides coverage for physical therapy shall not, for a new episode of care, require prior authorization for the initial 12 treatment visits for physical therapy.

(b) For purposes of this section, “new episode of care” means treatment for a new or recurring condition for which the insured has not been treated by the provider within the previous 90 days and is not currently undergoing active treatment.

SEC. 4.

 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.