Bill Text: CA SB1200 | 2009-2010 | Regular Session | Introduced

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

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Bill Title: Health care coverage: timeliness of care.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Engrossed - Dead) 2010-08-13 - Set, second hearing. Held in committee and under submission. [SB1200 Detail]

Download: California-2009-SB1200-Introduced.html

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BILL NUMBER: SB 1200	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Leno

                        FEBRUARY 18, 2010

   An act to amend Section 1367.03 of the Health and Safety Code and
to amend Section 10133.5 of the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 1200, as introduced, Leno. Health care coverage: school-based
health care.
   Existing law provides for licensing and regulation of health care
service plans by the Department of Managed Health Care. Existing law
provides for regulation of health insurers by the Insurance
Commissioner. Existing law requires the department and the
commissioner to develop and adopt regulations to ensure that
enrollees or insureds of health care service plans and certain health
insurers have access to needed health care services in a timely
manner pursuant to specified indicators of timeliness.
   This bill would add timeliness of care for schoolage children who
must receive medically necessary services during school hours as one
of the indicators of timeliness.
   Existing law requires the department to 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.
   This bill would add availability of school-based health care to
the timely access to care provisions for which the department may
adopt standards.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.


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)  Not later than January 1, 2004, the
  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. 
   (4) Timeliness of care for schoolage children who must receive
medically necessary services during school hours. 
   (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,  school-based health 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  report and  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 assure 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.
   (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 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 toward
the implementation of this section.  
   (j) 
    (i)    Every three years, the department shall
review information regarding compliance with the standards developed
under this section and shall make recommendations for changes that
further protect enrollees.
  SEC. 2.  Section 10133.5 of the Insurance Code is amended to read:
   10133.5.  (a) The commissioner shall  , on or before
January 1, 2004,  promulgate regulations applicable to
health insurers  which   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 assure 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 insure:
   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. 
   5. Timeliness of care for schoolage children who must receive
medically necessary services during school hours. 
   (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 Administrative Code of
Regulations, commencing with Section 1300.67.2, which are applicable
to  Knox-Keene   health care service 
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. 
    (f)    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.