Bill Text: CA SB931 | 2015-2016 | Regular Session | Introduced
Bill Title: Health care service plans.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2016-11-30 - From committee without further action. [SB931 Detail]
Download: California-2015-SB931-Introduced.html
BILL NUMBER: SB 931 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Nguyen
FEBRUARY 1, 2016
An act to amend Section 1367 of the Health and Safety Code,
relating to health care service plans.
LEGISLATIVE COUNSEL'S DIGEST
SB 931, as introduced, Nguyen. Health care service plans.
Under existing law, the Knox-Keene Health Care Service Plan Act of
1975, the Department of Managed Health Care licenses and regulates
health care service plans. Existing law requires a health care
service plan to meet certain requirements, including, but not limited
to, having the organizational and administrative capacity to provide
services to subscribers and enrollees and providing basic health
care services, as defined, to those subscribers and enrollees, and
having facilities licensed, as specified.
This bill would make technical, nonsubstantive changes to those
provisions.
Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367 of the Health and Safety Code is amended
to read:
1367. A health care service plan and, if applicable, a
specialized health care service plan shall meet all of the
following requirements:
(a) Facilities A facility located in
this state including, but not limited to, clinics, hospitals, and
skilled nursing facilities to be utilized by the plan shall be
licensed by the State Department of Public Health, where
if licensure is required by law.
Facilities A facility not located in this state
shall conform to all licensing and other requirements of the
jurisdiction in which they are it is
located.
(b) Personnel employed by or under contract to the plan shall be
licensed or certified by their respective board or agency,
where if licensure or certification is required
by law.
(c) Equipment required to be licensed or registered by law shall
be so licensed or registered, and the operating
personnel for that equipment shall be licensed or certified as
required by law.
(d) The plan shall furnish services in a manner providing
continuity of care and ready referral of patients to other providers
at times as may be appropriate consistent with good professional
practice.
(e) (1) All services shall be readily available at reasonable
times to each enrollee consistent with good professional practice. To
the extent feasible, the plan shall make all services readily
accessible to all enrollees consistent with Section 1367.03.
(2) To the extent that telehealth services are appropriately
provided through telehealth, as defined in subdivision (a) of Section
2290.5 of the Business and Professions Code, these services shall be
considered in determining compliance with Section 1300.67.2 of Title
28 of the California Code of Regulations.
(3) The plan shall make all services accessible and appropriate
consistent with Section 1367.04.
(f) The plan shall employ and utilize allied health manpower
for the furnishing of to furnish
services to the extent permitted by law and consistent with good
medical practice.
(g) The plan shall have the organizational and administrative
capacity to provide services to subscribers and enrollees. The plan
shall be able to demonstrate to the department that medical decisions
are rendered by qualified medical providers, unhindered by fiscal
and administrative management.
(h) (1) Contracts with subscribers and enrollees, including group
contracts, and contracts with providers, and other persons furnishing
services, equipment, or facilities to or in connection with the
plan, shall be fair, reasonable, and consistent with the objectives
of this chapter. All contracts with providers shall contain
provisions requiring a fast, fair, and cost-effective dispute
resolution mechanism under which providers may submit disputes to the
plan, and requiring the plan to inform its providers upon
contracting with the plan, or upon change to these provisions, of the
procedures for processing and resolving disputes, including the
location and telephone number where information regarding disputes
may be submitted.
(2) A health care service plan shall ensure that a dispute
resolution mechanism is accessible to noncontracting providers for
the purpose of resolving billing and claims disputes.
(3) On and after January 1, 2002, a A
health care service plan shall annually submit a report to the
department regarding its dispute resolution mechanism. The report
shall include information on the number of providers who utilized the
dispute resolution mechanism and a summary of the disposition of
those disputes.
(i) A health care service plan contract shall provide to
subscribers and enrollees all of the basic health care services
included in subdivision (b) of Section 1345, except that the director
may, for good cause, by rule or order exempt a plan contract or any
class of plan contracts from that requirement. The director shall by
rule define the scope of each basic health care service that health
care service plans are required to provide as a minimum for licensure
under this chapter. Nothing in this chapter shall
This chapter does not prohibit a health care service plan
from charging subscribers or enrollees a copayment or a deductible
for a basic health care service consistent with Section 1367.006 or
1367.007, provided that the copayments, deductibles, or other cost
sharing are reported to the director and set forth to the subscriber
or enrollee pursuant to the disclosure provisions of Section 1363.
Nothing in this chapter shall This chapter
does not prohibit a health care service plan from setting
forth, by contract, limitations on maximum coverage of basic health
care services, provided that the limitations are reported to, and
held unobjectionable by, the director and set forth to the subscriber
or enrollee pursuant to the disclosure provisions of Section 1363.
(j) A health care service plan shall not require registration
under the federal Controlled Substances Act (21 U.S.C. Sec. 801 et
seq.) as a condition for participation by an optometrist certified to
use therapeutic pharmaceutical agents pursuant to Section 3041.3 of
the Business and Professions Code.
Nothing in this
(k) This section shall not
be construed to permit the director to establish the rates
charged subscribers and enrollees for contractual health care
services.
The
(l) The director's enforcement of
Article 3.1 (commencing with Section 1357) shall not be
deemed to does not establish the rates charged
to subscribers and enrollees for contractual health care
services.
The
(m) The obligation of the plan to
comply with this chapter shall not be waived when the plan delegates
any services that it is required to perform to its medical groups,
independent practice associations, or other contracting entities.
