| 1 | | - | Amended IN Senate March 23, 2017 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Senate Bill No. 647Introduced by Senator PanFebruary 17, 2017 An act to amend Section 511.3 of the Business and Professions Code, to amend Section 1375.7 of the Health and Safety Code, to amend Section 10178.4 of the Insurance Code, and to amend Section 4611 of the Labor Code, relating to health care providers. add Section 1348.97 to the Health and Safety Code, and to add Section 10191.7 to the Insurance Code, relating to health care coverage.LEGISLATIVE COUNSEL'S DIGESTSB 647, as amended, Pan. Health care providers: contracts. Health care coverage: consumer complaints: reporting.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 (DMHC) and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law, the Health Care Providers Bill of Rights, prescribes restrictions on the types of contractual provisions that may be included in agreements between health care service plans and health care providers and agreements between health insurers and health care providers. Existing law provides that when a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the health care provider shall be governed by the underlying contract between the health care provider and the contracting agent. Insurance (DOI). Existing law requires the Director of Managed Health Care to establish and maintain a toll-free telephone number for the purpose of receiving complaints regarding health care service plans regulated by the director, and requires the DMHC and its contractors to respond to complaints concerning health care coverage available in California. Existing law requires the commissioner to notify health insurance consumers of the method by which a consumer may register a complaint relating to health insurance issues with the DOI, and specifies the manner and timing of processing and resolution of complaints.This bill would make technical, nonsubstantive changes to those provisions. require the DMHC and the DOI, no later than July 1, 2018, and annually on July 1 thereafter, to submit to the Legislature, and post on each departments Internet Web site, a record of all complaints received by each department regarding employee welfare benefit plans as defined under the federal Employee Retirement Income Security Act of 1974.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NOYES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1348.97 is added to the Health and Safety Code, to read:1348.97. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA).SEC. 2. Section 10191.7 is added to the Insurance Code, to read:10191.7. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 1 | + | CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Senate Bill No. 647Introduced by Senator PanFebruary 17, 2017 An act to amend Section 511.3 of the Business and Professions Code, to amend Section 1375.7 of the Health and Safety Code, to amend Section 10178.4 of the Insurance Code, and to amend Section 4611 of the Labor Code, relating to health care providers. LEGISLATIVE COUNSEL'S DIGESTSB 647, as introduced, Pan. Health care providers: contracts.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 Department of Insurance. Existing law, the Health Care Providers Bill of Rights, prescribes restrictions on the types of contractual provisions that may be included in agreements between health care service plans and health care providers and agreements between health insurers and health care providers. Existing law provides that when a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.This bill would make technical, nonsubstantive changes to those provisions.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NO Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 511.3 of the Business and Professions Code is amended to read:511.3. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 511.1.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 511.1.SEC. 2. Section 1375.7 of the Health and Safety Code is amended to read:1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision.SEC. 3. Section 10178.4 of the Insurance Code is amended to read:10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3.SEC. 4. Section 4611 of the Labor Code is amended to read:4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 36 | | - | The people of the State of California do enact as follows:SECTION 1. Section 1348.97 is added to the Health and Safety Code, to read:1348.97. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA).SEC. 2. Section 10191.7 is added to the Insurance Code, to read:10191.7. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 36 | + | The people of the State of California do enact as follows:SECTION 1. Section 511.3 of the Business and Professions Code is amended to read:511.3. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 511.1.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 511.1.SEC. 2. Section 1375.7 of the Health and Safety Code is amended to read:1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision.SEC. 3. Section 10178.4 of the Insurance Code is amended to read:10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3.SEC. 4. Section 4611 of the Labor Code is amended to read:4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 64 | | - | SEC. 2. Section 10191.7 is added to the Insurance Code, to read: |
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| 64 | + | SEC. 2. Section 1375.7 of the Health and Safety Code is amended to read:1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. |
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| 65 | + | |
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| 66 | + | SEC. 2. Section 1375.7 of the Health and Safety Code is amended to read: |
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| 68 | | - | 10191.7. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 70 | + | 1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. |
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| 70 | | - | 10191.7. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 72 | + | 1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. |
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| 72 | | - | 10191.7. (a) No later than July 1, 2018, and annually on July 1 thereafter, the department shall submit to the Legislature, and post on the departments Internet Web site, a record of all complaints it receives from consumers regarding employee welfare benefit plans, as defined in the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001, et seq.).(b) The reported records shall be submitted in compliance with Section 9795 of the Government Code.(c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 74 | + | 1375.7. (a) This section shall be known and may be cited as the Health Care Providers Bill of Rights.(b) No contract issued, amended, or renewed on or after January 1, 2003, between a plan and a health care provider for the provision of health care services to a plan enrollee or subscriber shall contain any of the following terms:(1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change.(B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change.(C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met:(i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract.(ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i).(iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii).(iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii).(2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care.(3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1).(4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter.(5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information.(c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply:(1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b).(2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers.(3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed.(4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan.(d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(2) For purposes of this subdivision, the following terms shall have the following meanings:(A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6.(B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6.(e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable.(f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year.(g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers.(h) For purposes of this section the following definitions apply:(1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services.(2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. |
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| 80 | | - | (c) Records posted and submitted pursuant to subdivision (a) shall not disclose the personal identifying information of any individual and shall comply with the privacy standards of the Confidentiality of Medical Information Act (Chapter 1 (commencing with Section 56) of Part 2.6 of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191)(HIPAA). |
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| 82 | + | (1) (A) Authority for the plan to change a material term of the contract, unless the change has first been negotiated and agreed to by the provider and the plan or the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. If a change is made by amending a manual, policy, or procedure document referenced in the contract, the plan shall provide 45 business days notice to the provider, and the provider has the right to negotiate and agree to the change. If the plan and the provider cannot agree to the change to a manual, policy, or procedure document, the provider has the right to terminate the contract prior to the implementation of the change. In any event, the plan shall provide at least 45 business days notice of its intent to change a material term, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. However, if the parties mutually agree, the 45-business day notice requirement may be waived. Nothing in this subparagraph limits the ability of the parties to mutually agree to the proposed change at any time after the provider has received notice of the proposed change. |
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| 83 | + | |
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| 84 | + | (B) If a contract between a provider and a plan provides benefits to enrollees or subscribers through a preferred provider arrangement, the contract may contain provisions permitting a material change to the contract by the plan if the plan provides at least 45 business days notice to the provider of the change and the provider has the right to terminate the contract prior to the implementation of the change. |
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| 85 | + | |
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| 86 | + | (C) If a contract between a noninstitutional provider and a plan provides benefits to enrollees or subscribers covered under the Medi-Cal or Healthy Families Program and compensates the provider on a fee-for-service basis, the contract may contain provisions permitting a material change to the contract by the plan, if the following requirements are met: |
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| 87 | + | |
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| 88 | + | (i) The plan gives the provider a minimum of 90 business days notice of its intent to change a material term of the contract. |
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| 89 | + | |
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| 90 | + | (ii) The plan clearly gives the provider the right to exercise his or her intent to negotiate and agree to the change within 30 business days of the providers receipt of the notice described in clause (i). |
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| 91 | + | |
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| 92 | + | (iii) The plan clearly gives the provider the right to terminate the contract within 90 business days from the date of the providers receipt of the notice described in clause (i) if the provider does not exercise the right to negotiate the change or no agreement is reached, as described in clause (ii). |
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| 93 | + | |
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| 94 | + | (iv) The material change becomes effective 90 business days from the date of the notice described in clause (i) if the provider does not exercise his or her right to negotiate the change, as described in clause (ii), or to terminate the contract, as described in clause (iii). |
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| 95 | + | |
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| 96 | + | (2) A provision that requires a health care provider to accept additional patients beyond the contracted number or in the absence of a number if, in the reasonable professional judgment of the provider, accepting additional patients would endanger patients access to, or continuity of, care. |
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| 97 | + | |
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| 98 | + | (3) A requirement to comply with quality improvement or utilization management programs or procedures of a plan, unless the requirement is fully disclosed to the health care provider at least 15 business days prior to the provider executing the contract. However, the plan may make a change to the quality improvement or utilization management programs or procedures at any time if the change is necessary to comply with state or federal law or regulations or any accreditation requirements of a private sector accreditation organization. A change to the quality improvement or utilization management programs or procedures shall be made pursuant to paragraph (1). |
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| 99 | + | |
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| 100 | + | (4) A provision that waives or conflicts with any provision of this chapter. A provision in the contract that allows the plan to provide professional liability or other coverage or to assume the cost of defending the provider in an action relating to professional liability or other action is not in conflict with, or in violation of, this chapter. |
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| 101 | + | |
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| 102 | + | (5) A requirement to permit access to patient information in violation of federal or state laws concerning the confidentiality of patient information. |
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| 103 | + | |
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| 104 | + | (c) With respect to a health care service plan contract covering dental services or a specialized health care service plan contract covering dental services, all of the following shall apply: |
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| 105 | + | |
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| 106 | + | (1) If a material change is made to the health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services, the plan shall provide at least 45 business days written notice to the dentists contracting with the health care service plan to provide services under the plans individual or group plan contracts, including specialized health care service plan contracts, unless a change in state or federal law or regulations or any accreditation requirements of a private sector accreditation organization requires a shorter timeframe for compliance. For purposes of this paragraph, written notice shall include notice by electronic mail or facsimile transmission. This paragraph shall apply in addition to the other applicable requirements imposed under this section, except that it shall not apply where notice of the proposed change is required to be provided pursuant to subparagraph (C) of paragraph (1) of subdivision (b). |
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| 107 | + | |
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| 108 | + | (2) For purposes of paragraph (1), a material change made to a health care service plans rules, guidelines, policies, or procedures concerning dental provider contracting or coverage of or payment for dental services is a change to the system by which the plan adjudicates and pays claims for treatment that would reasonably be expected to cause delays or disruptions in processing claims or making eligibility determinations, or a change to the general coverage or general policies of the plan that affect rates and fees paid to providers. |
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| 109 | + | |
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| 110 | + | (3) A plan that automatically renews a contract with a dental provider shall annually make available to the provider, within 60 days following a request by the provider, either online, via email, or in paper form, a copy of its current contract and a summary of the changes described in paragraph (1) of subdivision (b) that have been made since the contract was issued or last renewed. |
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| 111 | + | |
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| 112 | + | (4) This subdivision shall not apply to a health care service plan that exclusively contracts with no more than two medical groups in the state to provide or arrange for the provision of professional medical services to the enrollees of the plan. |
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| 113 | + | |
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| 114 | + | (d) (1) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent. |
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| 115 | + | |
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| 116 | + | (2) For purposes of this subdivision, the following terms shall have the following meanings: |
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| 117 | + | |
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| 118 | + | (A) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 1395.6. |
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| 119 | + | |
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| 120 | + | (B) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 1395.6. |
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| 121 | + | |
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| 122 | + | (e) Any contract provision that violates subdivision (b), (c), or (d) shall be void, unlawful, and unenforceable. |
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| 123 | + | |
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| 124 | + | (f) The department shall compile the information submitted by plans pursuant to subdivision (h) of Section 1367 into a report and submit the report to the Governor and the Legislature by March 15 of each calendar year. |
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| 125 | + | |
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| 126 | + | (g) Nothing in this section shall be construed or applied as setting the rate of payment to be included in contracts between plans and health care providers. |
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| 127 | + | |
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| 128 | + | (h) For purposes of this section the following definitions apply: |
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| 129 | + | |
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| 130 | + | (1) Health care provider means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by the state to deliver or furnish health services. |
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| 131 | + | |
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| 132 | + | (2) Material means a provision in a contract to which a reasonable person would attach importance in determining the action to be taken upon the provision. |
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| 133 | + | |
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| 134 | + | SEC. 3. Section 10178.4 of the Insurance Code is amended to read:10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3. |
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| 135 | + | |
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| 136 | + | SEC. 3. Section 10178.4 of the Insurance Code is amended to read: |
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| 137 | + | |
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| 138 | + | ### SEC. 3. |
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| 139 | + | |
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| 140 | + | 10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3. |
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| 141 | + | |
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| 142 | + | 10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3. |
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| 143 | + | |
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| 144 | + | 10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms shall have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3. |
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| 145 | + | |
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| 146 | + | |
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| 147 | + | |
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| 148 | + | 10178.4. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent. |
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| 149 | + | |
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| 150 | + | (b) For purposes of this section, the following terms shall have the following meanings: |
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| 151 | + | |
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| 152 | + | (1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 10178.3. |
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| 153 | + | |
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| 154 | + | (2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 10178.3. |
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| 155 | + | |
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| 156 | + | SEC. 4. Section 4611 of the Labor Code is amended to read:4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 157 | + | |
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| 158 | + | SEC. 4. Section 4611 of the Labor Code is amended to read: |
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| 159 | + | |
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| 160 | + | ### SEC. 4. |
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| 161 | + | |
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| 162 | + | 4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 163 | + | |
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| 164 | + | 4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 165 | + | |
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| 166 | + | 4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent.(b) For purposes of this section, the following terms have the following meanings:(1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609.(2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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| 167 | + | |
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| 168 | + | |
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| 169 | + | |
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| 170 | + | 4611. (a) When a contracting agent sells, leases, or transfers a health care providers contract to a payor, the rights and obligations of the that health care provider shall be governed by the underlying contract between the health care provider and the contracting agent. |
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| 171 | + | |
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| 172 | + | (b) For purposes of this section, the following terms have the following meanings: |
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| 173 | + | |
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| 174 | + | (1) Contracting agent has the meaning set forth in paragraph (2) of subdivision (d) of Section 4609. |
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| 175 | + | |
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| 176 | + | (2) Payor has the meaning set forth in paragraph (3) of subdivision (d) of Section 4609. |
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