BILL NUMBER: SB 289 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 6, 2015
INTRODUCED BY Senator Mitchell
FEBRUARY 23, 2015
An act to add Section 1374.14 to the Health and Safety Code, and
to add Section 10123.855 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 289, as amended, Mitchell. Telephonic and electronic patient
management services.
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 also provides for the
regulation of health insurers by the Insurance Commissioner. Existing
law prohibits a health care service plan or health insurer from
requiring in-person contact between a health care provider and a
patient before payment is made for covered services appropriately
provided through telehealth, which is defined to mean the mode of
delivering health care services via information and communication
technologies, as specified.
This bill would require a health care service plan or a health
insurer, with respect to plan contracts and policies issued, amended,
or renewed on or after January 1, 2016, to cover telephonic and
electronic patient management services, as defined, provided by a
physician or nonphysician health care provider and reimburse those
services based on their complexity and time expenditure. The bill
would provide that a health care service plan or a health insurer is
not required to reimburse separately for specified telephonic or
electronic visits, including a telephonic or electronic visit
provided as part of a bundle of services reimbursed in a specified
manner. Because a willful violation of the bill's requirements by a
health care service plan 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 1374.14 is added to the Health and Safety Code,
to read:
1374.14. (a) A health care service plan shall, with respect to
plan contracts issued, amended, or renewed on or after January 1,
2016, cover telephonic and electronic patient management services
provided by a physician or nonphysician health care provider and
reimburse those services based on their complexity and time
expenditure.
(b) This section shall not be construed to authorize a health care
service plan to require the use of telephonic and electronic patient
management services when the physician or nonphysician health care
provider has determined that those services are not medically
appropriate.
(c) This section shall not be construed to alter the scope of
practice of a health care provider or authorize the delivery of
health care services in a setting, or in a manner, that is not
otherwise authorized by law.
(d) All laws regarding the confidentiality of health information
and a patient's rights to his or her medical information shall apply
to telephonic and electronic patient management services.
(e) This section shall not apply to a patient under the
jurisdiction of the Department of Corrections and Rehabilitation or
any other correctional facility.
(f) Notwithstanding subdivision (a), a health care service plan
shall not be required to reimburse separately for any of the
following:
(1) A telephonic or electronic visit that is related to a service
or procedure provided to an established patient within a reasonable
period of time prior to the telephonic or electronic visit, as
recognized by the American Medical Association, Current Procedural
Terminology codes.
(2) A telephonic or electronic visit that leads to a related
service or procedure provided to an established patient within a
reasonable period of time, or within an applicable postoperative
period, as recognized by the American Medical Association, Current
Procedural Terminology codes.
(3) A telephonic or electronic visit provided as part of a bundle
of services for which reimbursement is provided for on a prepaid
basis, including capitation, or for which reimbursement is provided
for using an episode-based payment methodology.
(4) A telephonic or electronic visit that is not initiated by the
established patient, or the parents or guardians of a minor who is an
established patient, or an established patient's legally recognized
health care decisionmaker.
(g) Nothing in this section shall be construed to prohibit a
health care service plan from requiring documentation reasonably
relevant to a telephonic or electronic visit, as recognized by the
American Medical Association, Current Procedural Terminology codes.
(h) For purposes of this section, the following definitions apply:
(1) "Established patient" means a patient who, within three years
immediately preceding the telephonic or electronic visit, has
received professional services from the provider or another provider
of the exact same specialty and subspecialty who belongs to the same
group practice.
(2) "Nonphysician health care provider" means a provider, other
than a physician, who is licensed pursuant to Division 2 (commencing
with Section 500) of the Business and Professions Code.
(3) "Telephonic and electronic patient management services" means
the use of electronic communication tools to enable treating
physicians to evaluate and manage established patients in a manner
that meets all of the following criteria:
(A) Do Does not require
a face-to-face an in-person visit with
the physician or nonphysician health care provider.
(B) Are initiated by the established patient, the parents or
guardians of a minor who is an established patient, or an established
patient's legally recognized health care decisionmaker. For purposes
of this section, "initiated by the established patient" excludes a
visit for which a provider or staff contacts a patient to initiate a
service.
(C) Are recognized by the American Medical Association, Current
Procedural Terminology codes.
SEC. 2. Section 10123.855 is added to the Insurance Code, to read:
10123.855. (a) A health insurer shall, with respect to health
insurance policies issued, amended, or renewed on or after January 1,
2016, cover telephonic and electronic patient management services
provided by a physician or nonphysician health care provider and
reimburse those services based on their complexity and time
expenditure.
(b) This section shall not be construed to authorize a health
insurer to require the use of telephonic and electronic patient
management services when the physician or nonphysician health care
provider has determined that those services are not medically
appropriate.
(c) This section shall not be construed to alter the scope of
practice of a health care provider or authorize the delivery of
health care services in a setting, or in a manner, that is not
otherwise authorized by law.
(d) All laws regarding the confidentiality of health information
and a patient's rights to his or her medical information shall apply
to telephonic and electronic patient management services.
(e) This section shall not apply to a patient under the
jurisdiction of the Department of Corrections and Rehabilitation or
any other correctional facility.
(f) Notwithstanding subdivision (a), a health insurer shall not be
required to reimburse separately for any of the following:
(1) A telephonic or electronic visit that is related to a service
or procedure provided to an established patient within a reasonable
period of time prior to the telephonic or electronic visit, as
recognized by the American Medical Association, Current Procedural
Terminology codes.
(2) A telephonic or electronic visit that leads to a related
service or procedure provided to an established patient within a
reasonable period of time, or within an applicable postoperative
period, as recognized by the American Medical Association, Current
Procedural Terminology codes.
(3) A telephonic or electronic visit provided as part of a bundle
of services for which separate reimbursement is not consistent with
the American Medical Association, Current Procedural Terminology
codes.
(4) A telephonic or electronic visit that is not initiated by the
established patient, the parents or guardians of a minor who is an
established patient, or an established patient's legally recognized
health care decisionmaker.
(g) Nothing in this section shall be construed to prohibit a
health insurer from requiring documentation reasonably relevant to a
telephonic or electronic visit, as recognized by the American Medical
Association, Current Procedural Terminology codes.
(h) For purposes of this section, the following definitions apply:
(1) "Established patient" means a patient who, within the three
years immediately preceding the telephonic or electronic visit, has
received professional services from the provider, or another provider
of the exact same specialty and subspecialty who belongs to the same
group practice.
(2) "Nonphysician health care provider" means a provider, other
than a physician, who is licensed pursuant to Division 2 (commencing
with Section 500) of the Business and Professions Code.
(3) "Telephonic and electronic patient management services" means
the use of electronic communication tools to enable treating
physicians to evaluate and manage established patients in a manner
that meets all of the following criteria:
(A) Do Does not require
a face-to-face an in-person visit with
the physician or nonphysician health care provider.
(B) Are initiated by the established patient, the parents or
guardians of a minor who is an established patient, or an established
patient's legally recognized health care decisionmaker. For purposes
of this section, "initiated by the established patient" excludes a
visit for which a provider or staff contacts a patient to initiate a
service.
(C) Are recognized by the American Medical Association, Current
Procedural Terminology codes.
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.