Bill Text: CA SB196 | 2009-2010 | Regular Session | Amended

California Senate Bill 196 (Prior Session Legislation)

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

Bill Title: Emergency medical services.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Vetoed) 2010-01-19 - Stricken from Senate file. [SB196 Detail]

Download: California-2009-SB196-Amended.html

BILL NUMBER: SB 196	AMENDED
	BILL TEXT

	AMENDED IN SENATE  APRIL 14, 2009

INTRODUCED BY   Senator Corbett

                        FEBRUARY 23, 2009

   An act to add Section 1367.49 to the Health and Safety Code, and
to add Section 10117.6 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 196, as amended, Corbett. Health care coverage: provider
contracts.
   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.
   This bill would prohibit a contract between a health care provider
and a health care service plan or a health insurer from containing a
provision that restricts the ability of the plan or insurer to
furnish information on the cost of procedures, as  defined
  specified  , or information on health care
quality to subscribers, enrollees, policyholders, or insureds. If the
health care quality information is quality of care data compiled by
the plan or insurer, the bill would require plans and insurers to
involve health care providers in the development of the information
and to provide affected health care providers an opportunity to
review the information prior to furnishing it to subscribers,
enrollees, policyholders, or insureds, as specified, and would also
require that information to be based on specified guidelines and to
be updated at appropriate intervals. The bill would also prohibit a
health care service plan or health care provider from disclosing
negotiated capitation rates or other prepaid arrangements to
enrollees or subscribers.
   Because a willful violation of the bill's provisions relating to
health care service plans would be a crime, this 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 1367.49 is added to the Health and Safety Code,
to read:
   1367.49.  (a) A contract between a health care service plan and a
health care provider that is issued, amended, renewed, or delivered
on or after January 1, 2010, shall not contain any provision that
restricts the ability of the health care service plan to furnish
information on the cost of procedures or information about health
care quality to subscribers or enrollees of the plan.
   (b) If the health care quality information that the health care
service plan proposes to disclose pursuant to subdivision (a) is
quality of care data that the health care service plan has compiled,
all of the following requirements shall be satisfied:
   (1) The information shall be based on nationally recognized
evidence-based or consensus-based clinical recommendations or
guidelines. When available, a plan shall use measures endorsed by the
National Quality Forum or other entities whose work in the area of
quality performance is generally accepted in the health care
industry. A plan shall utilize risk adjustment factors, with
appropriate and transparent statistical techniques, to account for
differences in the use of health care resources among individual
health care providers.
   (2) The information shall be updated at appropriate intervals.
   (3) The health care service plan shall, prior to furnishing the
information to its enrollees or subscribers, do both of the
following:
   (A) Involve health care providers in the development of the
information.
   (B) Provide all of the following to any affected health care
provider:
   (i) At least 45 days written notice to review the information.
   (ii) The criteria used in the development and evaluation of
quality measurements. The criteria shall be sufficiently detailed and
reasonably understandable to allow the provider to verify the data
against his or her records.
   (iii) An explanation to the provider that he or she has the right
to correct errors and seek review of the data and that he or she may
submit any additional information for consideration. The health care
service plan shall provide a reasonable, prompt, and transparent
appeal process. If a provider makes a timely appeal, the plan shall
make no changes to its current information about the provider until
the appeal is completed.
   (c) A health care service plan or health care provider shall not
disclose negotiated capitation rates or other prepaid arrangements to
subscribers or enrollees of the plan.
   (d) Nothing in this section shall apply to specialized health care
service plans covering dental benefits.
   (e) Any contractual provision inconsistent with this section shall
be void and unenforceable.
   (f) For purposes of this section, the following definitions shall
apply:
   (1) "Information on the cost of procedures" means information that
an enrollee or subscriber of a health care service plan may use to
make comparisons among individual health care providers or health
care facilities concerning the cost to the enrollee or subscriber of
health care treatment options.  A health care service plan
shall, to the extent possible, display inpatient facility treatment
costs that are associated with a given episode of care, including,
but not limited to, diagnostic tests, prescription drugs, hospital
days, and physician fees.   Information on the cost of
procedures shall be displayed as an episode of care, unless an
episode of care is not applicable, and shall include, but not be
limited to, applicable diagnostic tests, prescription drugs, hospital
days, and physician fees that are associated with a typical
procedure or illness. 
   (2) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, other than a long-term health care facility as defined in
Section 1418, or other person or institution licensed or authorized
by the state to deliver or furnish health care services.
  SEC. 2.  Section 10117.6 is added to the Insurance Code, to read:
   10117.6.  (a) A contract between a health insurer and a health
care provider that is issued, amended, renewed, or delivered on or
after January 1, 2010, shall not contain any provision that restricts
the ability of the health insurer to furnish information on the cost
of procedures or information about health care quality to
policyholders or insureds of the insurer.
   (b) If the health care quality information that the health insurer
proposes to disclose pursuant to subdivision (a) is quality of care
data that the health insurer has compiled, all of the following
requirements shall be satisfied:
   (1) The information shall be based on nationally recognized
evidence-based or consensus-based clinical recommendations or
guidelines. When available, an insurer shall use measures endorsed by
the National Quality Forum or other entities whose work in the area
of quality performance is generally accepted in the health care
industry. An insurer shall utilize risk adjustment factors, with
appropriate and transparent statistical techniques, to account for
differences in the use of health care resources among individual
health care providers.
   (2) The information shall be updated at appropriate intervals.
   (3) The health insurer shall, prior to furnishing the information
to its policyholders or insureds, do both of the following:
   (A) Involve health care providers in the development of the
information.
   (B) Provide all of the following to any affected health care
provider:
   (i) At least 45 days written notice to review the information.
   (ii) The criteria used in the development and evaluation of
quality measurements. The criteria shall be sufficiently detailed and
reasonably understandable to allow the provider to verify the data
against his or her records.
   (iii) An explanation to the provider that he or she has the right
to correct errors and seek review of the data and that he or she may
submit any additional information for consideration. The health
insurer shall provide a reasonable, prompt, and transparent appeal
process. If a provider makes a timely appeal, the insurer shall make
no changes to its current information about the provider until the
appeal is completed.
   (c) Nothing in this section shall apply to dental insurers.
   (d) Any contractual provision inconsistent with this section shall
be void and unenforceable.
   (e) For purposes of this section, the following definitions shall
apply:
   (1) "Information on the cost of procedures" means information that
a policyholder or insured of a health insurer may use to make
comparisons among individual health care providers or health care
facilities concerning the cost to the policyholder or insured of
health care treatment options.  A health insurer shall, to
the extent possible, display inpatient facility treatment costs that
are associated with a given episode of care, including, but not
limited to, diagnostic tests, prescription drugs, hospital days, and
physician fees.   Information on the cost of procedures
shall be displayed as an episode of care, unless an episode of care
is not applicable, and shall include, but not be limited to,
applicable diagnostic tests, prescription drugs, hospital days, and
physician fees that are associated with a typical procedure or
illness. 
   (2) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, other than a long-term health care facility as defined in
Section 1418 of the Health and Safety Code, or other person or
institution licensed or authorized by the state to deliver or furnish
health care services.
  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.