Rob Bonta
- Democratic
Author
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. A willful violation of the act is a crime. Existing law requires a health care service plan to reimburse providers for emergency services and care provided to its enrollees, until the care results in stabilization of the enrollee. Existing law prohibits a health care service plan from requiring a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee's emergency medical care, as specified. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health insurance policy issued, amended, or renewed on or after January 1, 2014, that provides or covers benefits with respect to services in an emergency department of a hospital to cover emergency services without the need for prior authorization, regardless of whether the provider is a participating provider, and subject to the same cost sharing required if the services were provided by a participating provider, as specified. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2017, to provide that if an enrollee or insured receives covered services from a contracting health facility, as defined, at which, or as a result of which, the enrollee or insured receives covered services provided by a noncontracting individual health professional, as defined, the enrollee or insured would be required to pay the noncontracting individual health professional only the same cost sharing required if the services were provided by a contracting individual health professional, which would be referred to as the "in-network cost-sharing amount." The bill would prohibit an enrollee or insured from owing the noncontracting individual health professional at the contracting health facility more than the in-network cost-sharing amount if the noncontracting individual health professional receives reimbursement for services provided to the enrollee or insured at a contracting health facility from the health care service plan or health insurer. However, the bill would make an exception from this prohibition if the enrollee or insured provides written consent that satisfies specified criteria. The bill would require a noncontracting individual health professional who collects more than the in-network cost-sharing amount from the enrollee or insured to refund any overpayment to the enrollee or insured, as specified, and would provide that interest on any amount not refunded to the enrollee or insured shall accrue at 15% per annum, as specified. Existing law requires a contract between a health care service plan and a provider, or a contract between an insurer and a provider, to contain provisions requiring a fast, fair, and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan or insurer. Existing law requires that dispute resolution mechanism also be made accessible to a noncontracting provider for the purpose of resolving billing and claims disputes. This bill would require the department and the commissioner to each establish, by September 1, 2017, an independent dispute resolution process that would allow a noncontracting individual health professional who rendered services at a contracting health facility, or a plan or insurer, to appeal a claim payment dispute, as specified. The bill would authorize the department and the commissioner to contract with one or more independent dispute resolution organizations to conduct the independent dispute resolution process, as specified. Contracts entered into pursuant to these provisions would be exempt from specified statutory provisions and related state agency review and approval requirements. The bill would provide that the decision of the organization would be binding on the parties. The bill would require a plan or insurer to base reimbursement for covered services on the amount the individual health professional would have been reimbursed by Medicare for the same or similar services in the general geographic area in which the services were rendered pursuant to a specified methodology and would specify, among other responsibilities, the duties of health care service plans, their delegated entities, and health insurers in identifying and calculating the applicable reimbursement rates, as well as various related duties of the department and the commissioner. The bill would require the department and the commissioner to report on the data and information provided in the independent dispute resolution process to the Governor and other specified recipients by January 1, 2019. The bill would require a noncontracting individual health professional, health care service plan or delegated entity, or health insurer that disputes that claim reimbursement to utilize the independent dispute resolution process. The bill would provide that these provisions do not apply to emergency services and care, as defined. Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest. This bill would make legislative findings to that effect. Because a willful violation of the bill's provisions relative to 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.
Chaptered by Secretary of State - Chapter 492, Statutes of 2016.
Approved by the Governor.
Enrolled and presented to the Governor at 2:30 p.m.
Senate amendments concurred in. To Engrossing and Enrolling. (Ayes 79. Noes 0. Page 6534.).
In Assembly. Concurrence in Senate amendments pending.
From committee: That the Senate amendments be concurred in. (Ayes 15. Noes 0.) (August 30).
Joint Rule 62(a), file notice suspended. (Page 6474.)
Re-referred to Com. on HEALTH. pursuant to Assembly Rule 77.2.
Read third time. Passed. Ordered to the Assembly. (Ayes 35. Noes 1. Page 5488.).
(Ayes 38. Noes 0. Page 5451.)
Ordered to third reading.
Withdrawn from committee.
From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on RLS.
Senate Rule 29.3(b) suspended. (Page 5433.)
Read second time. Ordered to third reading.
Read third time and amended. Ordered to second reading.
Read second time. Ordered to third reading.
From committee: Do pass. (Ayes 5. Noes 0.) (August 11).
From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on APPR.
Read second time and amended. Re-referred to Com. on APPR.
From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 7. Noes 1.) (June 29).
Re-referred to Com. on RLS. pursuant to Senate Rule 29.10(c).
Read second time. Ordered to third reading.
From inactive file.
Ordered to second reading.
Read second time and amended. Ordered returned to second reading.
Ordered to inactive file at the request of Senator Hancock.
Read second time. Ordered to third reading.
From committee: Do pass. (Ayes 4. Noes 3.) (September 10).
Joint Rule 61(a) suspended. (Ayes 27. Noes 6. Page 2645.)
From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on GOV. & F.
Joint Rule 62(a) suspended. (Ayes 27. Noes 6. Page 2646.)
Re-referred to Com. on RLS. pursuant to Senate Rule 29.10(c).
Read second time. Ordered to third reading.
Read third time and amended. Ordered to second reading.
Read second time. Ordered to third reading.
Ordered to second reading.
From inactive file.
Ordered to inactive file at the request of Senator Hernandez.
Read second time. Ordered to third reading.
From committee: Do pass. (Ayes 6. Noes 0.) (August 17).
From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 9. Noes 0.) (July 15). Re-referred to Com. on APPR.
In committee: Hearing postponed by committee.
In Senate. Read first time. To Com. on RLS. for assignment.
Read third time. Urgency clause adopted. Passed. Ordered to the Senate. (Ayes 78. Noes 0. Page 1107.).
Read second time. Ordered to Consent Calendar.
From committee: Do pass. To Consent Calendar. (Ayes 16. Noes 0.) (April 15).
From committee: Do pass and re-refer to Com. on APPR. (Ayes 18. Noes 0.) (April 7). Re-referred to Com. on APPR.
Read first time.
From printer. May be heard in committee January 18.
Introduced. To print.
| Bill Text Versions | Format |
|---|---|
| AB72 | HTML |
| 12/18/14 - Introduced | |
| 09/04/15 - Amended Senate | |
| 09/09/15 - Amended Senate | |
| 06/15/16 - Amended Senate | |
| 08/01/16 - Amended Senate | |
| 08/04/16 - Amended Senate | |
| 08/19/16 - Amended Senate | |
| 08/25/16 - Amended Senate | |
| 09/02/16 - Enrolled | |
| 09/23/16 - Chaptered |
| Document | Format |
|---|---|
| No related documents. |
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