Bill Text: CA AB931 | 2023-2024 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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-Amended.html
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-Amended.html
|
Amended
IN
Senate
June 15, 2023 |
CALIFORNIA LEGISLATURE—
2023–2024 REGULAR SESSION
Assembly Bill
No. 931
| Introduced by Assembly Member Irwin |
February 14, 2023 |
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 amended, 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. The bill would require a
physical therapy provider to verify an enrollee’s or an insured’s coverage and disclose their share of the cost of care, as specified. The bill would require a physical therapy provider to disclose if the provider is not in the network of the enrollee’s plan or the insured’s policy, and if so, to obtain the enrollee’s or the insured’s consent in writing to receive services from the noncontracting provider prior to initiating care. 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: YESBill 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.
(c) Prior to treatment, a physical
therapy provider shall verify the enrollee’s coverage and disclose the enrollee’s cost sharing, including the maximum out-of-pocket expense the enrollee may be charged per visit if the health care service plan denies coverage for services rendered. The physical therapy provider shall disclose if the physical therapy provider is not in the network of the enrollee’s health care service plan. If an enrollee has a health care service plan with out-of-network benefits or does not have a plan with out-of-network benefits but chooses to seek care knowing the provider is out-of-network, the physical therapy provider shall obtain the enrollee’s consent in writing to receive services from the identified noncontracting physical therapy provider prior to initiating care.
(1) The consent shall be obtained by the noncontracting physical therapy provider in a document that is separate from the document used to obtain the consent for any other part of the care
or procedure.
(2) At the time consent is provided, the noncontracting physical therapy provider shall give the enrollee a written estimate of the enrollee’s per visit out-of-pocket cost of care. The noncontracting physical therapy provider shall not attempt to collect more than the estimated amount without receiving separate written consent from the enrollee or the enrollee’s authorized representative, unless circumstances arise during delivery of services that were unforeseeable at the time the estimate was given that would require the provider to change the estimate.
(3) The consent document shall advise the enrollee that the enrollee may elect to seek care from a contracted physical therapy provider.
(4) The consent document and cost estimate shall be provided to the enrollee in the language spoken by the enrollee
if the language is a Medi-Cal threshold language as defined in Section 128552.
(5) The consent document shall advise the enrollee that any costs incurred as a result of the enrollee’s use of the out-of-network benefit shall be in addition to in-network cost-sharing amounts and may not count toward the annual out-of-pocket maximum on in-network benefits or a deductible, if any, for in-network benefits.
(d) This section does not exempt a noncontracting individual health professional providing services at a contracting health facility from the requirements of Section 1371.9.
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.
(c) Prior to treatment, a physical therapy provider
shall verify the insured’s coverage and disclose the insured’s cost sharing, including the maximum out-of-pocket expense the insured may be charged per visit if the health insurer denies coverage for services rendered. The physical therapy provider shall disclose if the physical therapy provider is not in the network of the insured’s health insurance policy. The physical therapy provider shall obtain the insured’s consent in writing to receive services from the identified out-of-network physical therapy provider prior to initiating care.
(1) The consent shall be obtained by the noncontracting physical therapy provider in a document that is separate from the document used to obtain the consent for any other part of the care or procedure.
(2) At the time consent is provided, the noncontracting physical therapy provider shall give the insured a written estimate of the insured’s per
visit out-of-pocket cost of care. The noncontracting physical therapy provider shall not attempt to collect more than the estimated amount without receiving separate written consent from the insured or the insured’s authorized representative, unless circumstances arise during delivery of services that were unforeseeable at the time the estimate was given that would require the provider to change the estimate.
(3) The consent document shall advise the insured that the insured may elect to seek care from a contracted physical therapy provider.
(4) The consent document and cost estimate shall be provided to the insured in the language spoken by the insured if the language is a Medi-Cal threshold language as defined in Section 128552 of the Health and Safety Code.
(5) The consent document shall advise the insured that
any costs incurred as a result of the insured’s use of the out-of-network provider may not count toward the annual out-of-pocket maximum on in-network benefits or a deductible, if any, for in-network benefits.
(d) This section does not exempt a noncontracting individual health professional providing services at a contracting health facility from the requirements of Section 10112.8.
