BILL NUMBER: AB 1954INTRODUCED BILL TEXT INTRODUCED BY Assembly Member Burke FEBRUARY 12, 2016 An act to add Section 1367.31 to the Health and Safety Code, and to add Section 10123.202 to the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGEST AB 1954, as introduced, Burke. Health care coverage: reproductive health care 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 provides for the regulation of health insurers by the Department of Insurance. This bill would require every health care service plan contract or health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, to provide coverage for reproductive and sexual health care services, as defined, through out-of-network providers under specified circumstances. The bill would prohibit those plan contracts or insurance policies from requiring an enrollee or insured to receive a referral in order to receive reproductive or sexual health care services. Because a willful violation of these provisions by 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. 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. This act shall be known and may be cited as the Direct Access to Reproductive Health Care Act. SEC. 2. (a) The Legislature hereby finds and declares all of the following: (1) For many women, reproductive health care is primary health care. (2) According to the Guttmacher Institute, one-half of all pregnancies in the United States each year, more than three million pregnancies, are unintended. By 45 years of age, more than one-half of all women in the United States will have experienced an unintended pregnancy, and three in 10 will have had an abortion. (3) The inability to access comprehensive reproductive health care in a timely manner can lead to negative health outcomes including increased risk for unintended pregnancy, sexually transmitted diseases, and delayed care for critical and time-sensitive reproductive health services. (4) Providing timely access to comprehensive reproductive health services is cost effective. (5) California has a long history of, and commitment to, expanding access to services that aim to reduce the risk of unintended pregnancies, improve reproductive and sexual health outcomes, and reduce costs. (6) Recognizing the importance of timely access to comprehensive reproductive health services, the Legislature and the United States Congress passed measures to allow Medi-Cal enrollees to go out-of-network for sensitive services and enable women to access care provided by an obstetrician/gynecologist (OB/GYN) without a referral. (7) The Legislature has also passed measures to help health plan enrollees and insureds access timely health care by setting standards and policies regarding wait times for an appointment. (8) Despite these advances, there are wide variances in network adequacy and health care service plan contracts and health insurance policies regarding referral requirements for reproductive and sexual health care services. (b) It is hereby the intent of the Legislature in enacting this act to build on current state and federal law to increase timely, equal, and direct access to time-sensitive and comprehensive reproductive and sexual health care services for enrollees in health care service plans or insureds under health insurance policies by doing both of the following: (1) Allowing enrollees or insureds to seek care from an out-of-network provider if access to an appropriate reproductive and sexual health provider is unavailable in-network in a timely manner. (2) Prohibiting health care service plans or insurers from requiring an enrollee or insured to secure a referral from a primary care provider prior to receiving reproductive and sexual health care services. SEC. 3. Section 1367.31 is added to the Health and Safety Code, to read: 1367.31. (a) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2017, shall provide coverage for reproductive and sexual health care services provided by an out-of-network provider in an enrollee's service region under either of the following circumstances: (1) Access to an appropriate provider is unavailable in-network in the enrollee's service region within 10 days after the enrollee's initial request for reproductive and sexual health care services, or sooner if a medical provider indicates an earlier appointment is medically necessary. (2) An in-network provider is not available within a reasonable distance of the enrollee's work or home address. (b) Every health care service plan contract issued, amended, renewed, or delivered on or after January 1, 2017, shall be prohibited from requiring an enrollee to receive a referral prior to receiving coverage or services for reproductive and sexual health care. (c) For the purposes of this section: (1) "Appropriate provider" means either of the following: (A) A provider with the training and licensure necessary to ably provide the covered time-sensitive reproductive and sexual health care services, treatment, and devices requested by the enrollee in the clinical setting in which he or she practices. (B) A provider that meets the standards set forth in subparagraph (A), and is selected by an enrollee based on the provider's gender and the enrollee's preference to be treated by a provider of that gender. (2) "Reasonable distance" is the distance defined by the Department of Managed Health Care. (3) "Reproductive and sexual health care services" are all reproductive and sexual health services described in Sections 6924, 6925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified in that section. (d) This section shall not apply to any health care service plan that is governed by Section 14131 of the Welfare and Institutions Code. SEC. 4. Section 10123.202 is added to the Insurance Code, to read: 10123.202. (a) Every health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, shall provide coverage for reproductive and sexual health care services provided by an out-of-network provider in an insured's service region under either of the following circumstances: (1) Access to an appropriate provider is unavailable in-network in the insured's service region within 10 days after the insured's initial request for reproductive and sexual health care services, or sooner if a medical provider indicates an earlier appointment is medically necessary. (2) An in-network provider is not available within a reasonable distance of the insured's work or home address. (b) Every health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, shall be prohibited from requiring an insured to receive a referral prior to receiving coverage or services for reproductive and sexual health care. (c) For the purposes of this section: (1) "Appropriate provider" means either of the following: (A) A provider with the training and licensure necessary to ably provide the covered time-sensitive reproductive and sexual health care services, treatment, and devices requested by the insured in the clinical setting in which he or she practices. (B) A provider that meets the standards set forth in subparagraph (A), and is selected by an insured based on the provider's gender and the insured's preference to be treated by a provider of that gender. (2) "Reasonable distance" is the distance defined by the Department of Insurance. (3) "Reproductive and sexual health care services" are all reproductive and sexual health services described in Sections 6924, 6925, 6926, 6927, 6928, and 6929 of the Family Code, or Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified in that section. SEC. 5. 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.