AB 533 — Health care coverage: out-of-network coverage.

Summary

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, 2016, 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. 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 overpaid by, and 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 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. 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. The bill would require a noncontracting individual health professional who 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. 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.

Bill Text

• Amended 09/04/15 - Amended Senate Current pdf September 04, 2015
• Amended 08/18/15 - Amended Senate pdf August 18, 2015
• Amended 07/07/15 - Amended Senate pdf July 07, 2015
• Amended 04/23/15 - Amended Assembly pdf April 23, 2015
• Amended 04/15/15 - Amended Assembly pdf April 15, 2015
• Introduced 02/23/15 - Introduced pdf February 23, 2015
• AB533 View text html

Action History

1. August 31, 2016

   Ordered to inactive file at the request of Assembly Member Bonta.

2. August 31, 2016

   Reconsideration granted. (Page 6544.)

3. September 12, 2015

   Motion to reconsider made by Assembly Member Bonta.

4. September 12, 2015

   Assembly refused to concur in Senate amendments. (Ayes 38. Noes 10. Page 3214.)

5. September 10, 2015

   In Assembly. Concurrence in Senate amendments pending.

6. September 10, 2015

   Read third time. Passed. Ordered to the Assembly. (Ayes 25. Noes 10. Page 2706.).

7. September 09, 2015

   From committee: Return to Senate floor for consideration. (Ayes 7. Noes 1.) (September 9).

8. September 08, 2015

   From committee: Be re-referred to Com. on HEALTH pursuant to Senate Rule 29.10(b). (Ayes 5. Noes 0.) Re-referred to Com. on HEALTH.

9. September 08, 2015

   Re-referred to Com. on RLS. pursuant to Senate Rule 29.10(b).

10. September 08, 2015

    Read second time. Ordered to third reading.

11. September 04, 2015

    Read third time and amended. Ordered to second reading.

12. August 31, 2015

    Read second time. Ordered to third reading.

13. August 27, 2015

    From committee: Do pass. (Ayes 5. Noes 2.) (August 27).

14. August 24, 2015

    In committee: Referred to APPR. suspense file.

15. August 18, 2015

    Read second time and amended. Re-referred to Com. on APPR.

16. August 17, 2015

    From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 6. Noes 2.) (July 15).

17. July 07, 2015

    From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on HEALTH.

18. June 25, 2015

    In committee: Set, first hearing. Hearing canceled at the request of author.

19. June 11, 2015

    Referred to Com. on HEALTH.

20. June 02, 2015

    In Senate. Read first time. To Com. on RLS. for assignment.

21. June 02, 2015

    Read third time. Passed. Ordered to the Senate. (Ayes 74. Noes 1. Page 1770.)

22. May 28, 2015

    Read second time. Ordered to third reading.

23. May 28, 2015

    From committee: Do pass. (Ayes 17. Noes 0.) (May 28).

24. May 06, 2015

    In committee: Set, first hearing. Referred to APPR. suspense file.

25. April 27, 2015

    Re-referred to Com. on APPR.

26. April 23, 2015

    Read second time and amended.

27. April 22, 2015

    From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 17. Noes 0.) (April 21).

28. April 16, 2015

    Re-referred to Com. on HEALTH.

29. April 15, 2015

    From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended.

30. April 14, 2015

    In committee: Set, first hearing. Hearing canceled at the request of author.

31. March 05, 2015

    Referred to Com. on HEALTH.

32. February 24, 2015

    From printer. May be heard in committee March 26.

33. February 23, 2015

    Read first time. To print.

Sponsors

• Mia Bonta · Primary

Votes

Subjects