Amended IN Assembly May 17, 2019 Amended IN Assembly March 26, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 577Introduced by Assembly Member Eggman(Principal coauthor: Senator Portantino)(Coauthor: Assembly Member Burke)February 14, 2019 An act to amend Section 1373.96 of the Health and Safety Code, to amend Section 10133.56 of the Insurance Code, and to amend Section 14005.18 of the Welfare and Institutions Code, relating to Medi-Cal. maternal health.LEGISLATIVE COUNSEL'S DIGESTAB 577, as amended, Eggman. Medi-Cal: maternal mental health. Health care coverage: postpartum period.Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under Existing law establishes the Medi-Cal Access Program, which provides health care services to a woman who is pregnant or in her postpartum period and whose household income is within specified thresholds of the federal poverty level, and to a child under 2 years of age who is delivered by a mother enrolled in the program, as specified.Under existing law, an individual is eligible for Medi-Cal benefits, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy. This bill would extend Medi-Cal eligibility for a pregnant individual who is receiving health care coverage under the Medi-Cal program, or another specified program, and who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individuals pregnancy if the individual complies with certain requirements. The bill would define maternal mental health condition for purposes of the bill.Under this bill, if the above-described individual has a household income below 138% of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual would remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.This bill would, for the above-described individual, or an individual under the Medi-Cal Access Program, who is disenrolling from coverage after the 60-day period, require the department to assist the individual in applying for and purchasing a qualified health plan in the California Health Benefit Exchange, also known as Covered California, if the individual is eligible for that coverage.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.Existing law requires a health care service plan and a health insurer, at the request of an enrollee or insured, to provide for the completion of services by a terminated or nonparticipating provider if the enrollee or insured is undergoing a course of treatment for one of specified conditions, including a serious chronic condition, at the time of the contract or policy termination or the time the coverage became effective.This bill would, for purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition, as defined, from the individuals treating health care provider, require completion of covered services for that condition, not exceeding 12 months, as specified. By expanding the duties of health care service plans, the bill would expand the scope of an existing crime, thereby imposing 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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NOYES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1373.96 of the Health and Safety Code is amended to read:1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.SEC. 2. Section 10133.56 of the Insurance Code is amended to read:10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.SECTION 1.Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18.(a)(1)An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.(2)For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b)(1)Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program for a period of one year following the last day of the individuals pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.(2)For purposes of this section, maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and, includes, but is not limited to, postpartum depression.(c)(1)An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to this section shall submit to a county eligibility worker a note from that individuals treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individuals pregnancy.(2)Notwithstanding paragraph (1), an individual who has had Medi-Cal program coverage terminated within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy, may seek redetermination of eligibility pursuant to subdivision (i) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individuals treating health care provider within the time frame described in that subdivision and after the 60-day period beginning the last day of pregnancy.(d)For purposes of this section, Medi-Cal program refers to any of the following programs:(1)The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.(2)The Medi-Cal program, as described in this article.(3)The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).(e)This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.SEC. 3. Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
Amended IN Assembly May 17, 2019 Amended IN Assembly March 26, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 577Introduced by Assembly Member Eggman(Principal coauthor: Senator Portantino)(Coauthor: Assembly Member Burke)February 14, 2019 An act to amend Section 1373.96 of the Health and Safety Code, to amend Section 10133.56 of the Insurance Code, and to amend Section 14005.18 of the Welfare and Institutions Code, relating to Medi-Cal. maternal health.LEGISLATIVE COUNSEL'S DIGESTAB 577, as amended, Eggman. Medi-Cal: maternal mental health. Health care coverage: postpartum period.Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under Existing law establishes the Medi-Cal Access Program, which provides health care services to a woman who is pregnant or in her postpartum period and whose household income is within specified thresholds of the federal poverty level, and to a child under 2 years of age who is delivered by a mother enrolled in the program, as specified.Under existing law, an individual is eligible for Medi-Cal benefits, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy. This bill would extend Medi-Cal eligibility for a pregnant individual who is receiving health care coverage under the Medi-Cal program, or another specified program, and who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individuals pregnancy if the individual complies with certain requirements. The bill would define maternal mental health condition for purposes of the bill.Under this bill, if the above-described individual has a household income below 138% of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual would remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.This bill would, for the above-described individual, or an individual under the Medi-Cal Access Program, who is disenrolling from coverage after the 60-day period, require the department to assist the individual in applying for and purchasing a qualified health plan in the California Health Benefit Exchange, also known as Covered California, if the individual is eligible for that coverage.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.Existing law requires a health care service plan and a health insurer, at the request of an enrollee or insured, to provide for the completion of services by a terminated or nonparticipating provider if the enrollee or insured is undergoing a course of treatment for one of specified conditions, including a serious chronic condition, at the time of the contract or policy termination or the time the coverage became effective.This bill would, for purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition, as defined, from the individuals treating health care provider, require completion of covered services for that condition, not exceeding 12 months, as specified. By expanding the duties of health care service plans, the bill would expand the scope of an existing crime, thereby imposing 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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NOYES
Amended IN Assembly May 17, 2019 Amended IN Assembly March 26, 2019
Amended IN Assembly May 17, 2019
Amended IN Assembly March 26, 2019
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION
Assembly Bill No. 577
Introduced by Assembly Member Eggman(Principal coauthor: Senator Portantino)(Coauthor: Assembly Member Burke)February 14, 2019
Introduced by Assembly Member Eggman(Principal coauthor: Senator Portantino)(Coauthor: Assembly Member Burke)
February 14, 2019
An act to amend Section 1373.96 of the Health and Safety Code, to amend Section 10133.56 of the Insurance Code, and to amend Section 14005.18 of the Welfare and Institutions Code, relating to Medi-Cal. maternal health.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 577, as amended, Eggman. Medi-Cal: maternal mental health. Health care coverage: postpartum period.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under Existing law establishes the Medi-Cal Access Program, which provides health care services to a woman who is pregnant or in her postpartum period and whose household income is within specified thresholds of the federal poverty level, and to a child under 2 years of age who is delivered by a mother enrolled in the program, as specified.Under existing law, an individual is eligible for Medi-Cal benefits, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy. This bill would extend Medi-Cal eligibility for a pregnant individual who is receiving health care coverage under the Medi-Cal program, or another specified program, and who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individuals pregnancy if the individual complies with certain requirements. The bill would define maternal mental health condition for purposes of the bill.Under this bill, if the above-described individual has a household income below 138% of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual would remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.This bill would, for the above-described individual, or an individual under the Medi-Cal Access Program, who is disenrolling from coverage after the 60-day period, require the department to assist the individual in applying for and purchasing a qualified health plan in the California Health Benefit Exchange, also known as Covered California, if the individual is eligible for that coverage.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.Existing law requires a health care service plan and a health insurer, at the request of an enrollee or insured, to provide for the completion of services by a terminated or nonparticipating provider if the enrollee or insured is undergoing a course of treatment for one of specified conditions, including a serious chronic condition, at the time of the contract or policy termination or the time the coverage became effective.This bill would, for purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition, as defined, from the individuals treating health care provider, require completion of covered services for that condition, not exceeding 12 months, as specified. By expanding the duties of health care service plans, the bill would expand the scope of an existing crime, thereby imposing 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.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under Existing law establishes the Medi-Cal Access Program, which provides health care services to a woman who is pregnant or in her postpartum period and whose household income is within specified thresholds of the federal poverty level, and to a child under 2 years of age who is delivered by a mother enrolled in the program, as specified.
Under existing law, an individual is eligible for Medi-Cal benefits, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
This bill would extend Medi-Cal eligibility for a pregnant individual who is receiving health care coverage under the Medi-Cal program, or another specified program, and who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individuals pregnancy if the individual complies with certain requirements. The bill would define maternal mental health condition for purposes of the bill.
Under this bill, if the above-described individual has a household income below 138% of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual would remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
This bill would, for the above-described individual, or an individual under the Medi-Cal Access Program, who is disenrolling from coverage after the 60-day period, require the department to assist the individual in applying for and purchasing a qualified health plan in the California Health Benefit Exchange, also known as Covered California, if the individual is eligible for that coverage.
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.
Existing law requires a health care service plan and a health insurer, at the request of an enrollee or insured, to provide for the completion of services by a terminated or nonparticipating provider if the enrollee or insured is undergoing a course of treatment for one of specified conditions, including a serious chronic condition, at the time of the contract or policy termination or the time the coverage became effective.
This bill would, for purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition, as defined, from the individuals treating health care provider, require completion of covered services for that condition, not exceeding 12 months, as specified. By expanding the duties of health care service plans, the bill would expand the scope of an existing crime, thereby imposing 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.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1373.96 of the Health and Safety Code is amended to read:1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.SEC. 2. Section 10133.56 of the Insurance Code is amended to read:10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.SECTION 1.Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18.(a)(1)An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.(2)For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b)(1)Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program for a period of one year following the last day of the individuals pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.(2)For purposes of this section, maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and, includes, but is not limited to, postpartum depression.(c)(1)An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to this section shall submit to a county eligibility worker a note from that individuals treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individuals pregnancy.(2)Notwithstanding paragraph (1), an individual who has had Medi-Cal program coverage terminated within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy, may seek redetermination of eligibility pursuant to subdivision (i) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individuals treating health care provider within the time frame described in that subdivision and after the 60-day period beginning the last day of pregnancy.(d)For purposes of this section, Medi-Cal program refers to any of the following programs:(1)The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.(2)The Medi-Cal program, as described in this article.(3)The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).(e)This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.SEC. 3. Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1373.96 of the Health and Safety Code is amended to read:1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.
SECTION 1. Section 1373.96 of the Health and Safety Code is amended to read:
### SECTION 1.
1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.
1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.
1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).(c) The health care service plan shall provide for the completion of covered services for the following conditions:(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.(3) A violation of this subdivision does not constitute a crime under Section 1390.(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).(n) The following definitions apply for the purposes of this section:(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(2)(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.(3)(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.(4)(5) Provider group means a medical group, independent practice association, or any other similar organization.
1373.96. (a) A health care service plan shall, at the request of an enrollee, provide for the completion of covered services as set forth in this section by a terminated provider or by a nonparticipating provider.
(b) (1) The completion of covered services shall be provided by a terminated provider to an enrollee who, at the time of the contracts termination, was receiving services from that provider for one of the conditions described in subdivision (c).
(2) The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time his or her the enrollees coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c).
(c) The health care service plan shall provide for the completion of covered services for the following conditions:
(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.
(2) (A) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health care service plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practice. Completion
(B) Completion of covered services under this paragraph subparagraph (A) of this paragraph and subparagraph (B) of paragraph (3) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.
(3) (A) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.
(B) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in subparagraph (B) of paragraph (2).
(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new enrollee.
(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.
(6) Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered enrollee.
(d) (1) The plan may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider before termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services beyond the contract termination date.
(2) Unless otherwise agreed upon by the terminated provider and the plan or by the individual provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the terminated provider. Neither the plan nor the provider group is required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this paragraph.
(e) (1) The plan may require a nonparticipating provider whose services are continued pursuant to this section for a newly covered enrollee to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the providers services.
(2) Unless otherwise agreed upon by the nonparticipating provider and the plan or by the nonparticipating provider and the provider group, the services rendered pursuant to this section shall be compensated at rates and methods of payment similar to those used by the plan or the provider group for currently contracting providers providing similar services who are not capitated and who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the plan nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph.
(f) The amount of, and the requirement for payment of, copayments, deductibles, or other cost-sharing components during the period of completion of covered services with a terminated provider or a nonparticipating provider are the same as would be paid by the enrollee if receiving care from a provider currently contracting with or employed by the plan.
(g) If a plan delegates the responsibility of complying with this section to a provider group, the plan shall ensure that the requirements of this section are met.
(h) This section does not require a plan to provide for completion of covered services by a provider whose contract with the plan or provider group has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.
(i) This section does not require a plan to cover services or provide benefits that are not otherwise covered under the terms and conditions of the plan contract. Except as provided in subdivision (l), this section does not apply to a newly covered enrollee covered under an individual subscriber agreement who is undergoing a course of treatment on the effective date of his or her their coverage for a condition described in subdivision (c).
(j) Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with his or her their previous health plan or provider and instead voluntarily chose to change health plans.
(k) The provisions contained in this section are in addition to any other responsibilities of a health care service plan to provide continuity of care pursuant to this chapter. This section does not preclude a plan from providing continuity of care beyond the requirements of this section.
(l) (1) A health care service plan shall, at the request of a newly covered enrollee under an individual health care service plan contract, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (c) if the newly covered enrollee meets both of the following:
(A) The newly covered enrollees prior coverage was terminated under paragraph (5) or (6) of subdivision (a) of Section 1365 or subdivision (d) or (e) of Section 10273.6 of the Insurance Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.
(B) At the time his or her the enrollees coverage became effective, the newly covered enrollee was receiving services from that provider for one of the conditions described in subdivision (c).
(2) The completion of covered services required to be provided under this subdivision apply to services rendered to the newly covered enrollee on and after the effective date of his or her their new coverage.
(3) A violation of this subdivision does not constitute a crime under Section 1390.
(m) Notice as to the process by which an enrollee may request completion of covered services pursuant to this section shall be provided in every disclosure form as required under Section 1363 and in any evidence of coverage issued after January 1, 2018. A plan shall provide a written copy of this information to its contracting providers and provider groups. A plan shall also provide a copy to its enrollees upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (l).
(n) The following definitions apply for the purposes of this section:
(1) Individual provider means a person who is a licentiate, as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.
(2) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(2)
(3) Nonparticipating provider means a provider who is not contracted with the enrollees health care service plan to provide services under the enrollees plan contract.
(3)
(4) Provider shall have the same meaning as set forth in subdivision (i) of Section 1345.
(4)
(5) Provider group means a medical group, independent practice association, or any other similar organization.
SEC. 2. Section 10133.56 of the Insurance Code is amended to read:10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.
SEC. 2. Section 10133.56 of the Insurance Code is amended to read:
### SEC. 2.
10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.
10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.
10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.(e) For the purposes of this section, the following terms have the following meanings:(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.(2) Provider group includes a medical group, independent practice association, or any other similar organization.(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.
10133.56. (a) (1) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:
(A) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.
(B) (i) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion
(ii) Completion of covered services under this paragraph clause (i) of this subparagraph and clause (ii) of subparagraph (C) shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.
(C) (i) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.
(ii) For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individuals treating health care provider, completion of covered services for the maternal mental health condition shall be subject to the timeframe described in clause (ii) of subparagraph (B).
(D) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a new insured.
(E) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered insured.
(F) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contracts termination date or within 180 days of the effective date of coverage for a newly covered insured.
(2) The insurer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subdivision, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services beyond the contract termination date.
(3) Unless otherwise agreed upon between the terminated provider and the insurer or between the terminated provider and the provider group, the agreement shall be construed to require a rate and method of payment to the terminated provider, for the services rendered pursuant to this subdivision, that are the same as the rate and method of payment for the same services while under contract with the insurer and at the time of termination. The provider shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).
(b) Notice as to the process by which an insured may request completion of covered services pursuant to this section shall be provided in any insurer evidence of coverage and disclosure form issued after March 31, 2004. An insurer shall provide a written copy of this information to its contracting providers and provider groups. An insurer shall also provide a copy to its insureds upon request. Notice as to the availability of the right to request completion of covered services shall be part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described in subdivision (i).
(c) The payment of copayments, deductibles, or other cost-sharing components by the insured during the period of completion of covered services with a terminated provider pursuant to subdivision (a) or a nonparticipating provider pursuant to subdivision (i) shall be the same copayments, deductibles, or other cost-sharing components that would be paid by the insured when receiving care from a provider currently contracting with the insurer.
(d) If an insurer delegates the responsibility of complying with this section to its contracting entities, the insurer shall ensure that the requirements of this section are met.
(e) For the purposes of this section, the following terms have the following meanings:
(1) Provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code.
(2) Provider group includes a medical group, independent practice association, or any other similar organization.
(3) Nonparticipating provider means a provider who is not contracted with the insureds health insurer to provide services under the insureds policy. A nonparticipating provider does not include a terminated provider.
(4) Terminated provider means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurers contracting provider groups. A terminated provider is not a provider who voluntarily leaves the insurer or contracting provider group.
(5) Maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(f) This section does not require an insurer or provider group to provide for the completion of covered services by a provider whose contract with the insurer or provider group has been terminated or not renewed for reasons relating to medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Professions Code, or fraud or other criminal activity.
(g) This section does not require an insurer to cover services or provide benefits that are not otherwise covered under the terms and conditions of the insurer contract.
(h) The provisions contained in this section are in addition to any other responsibilities of insurers to provide continuity of care pursuant to this chapter. Nothing in this section shall preclude an insurer from providing continuity of care beyond the requirements of this section.
(i) (1) A health insurer shall, at the request of a newly covered insured under an individual insurance policy, arrange for the completion of covered services as set forth in this section by a nonparticipating provider for one of the conditions described in subdivision (a) if the newly covered insured meets both of the following:
(A) The newly covered insureds prior coverage was terminated under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or (6) of subdivision (a) of Section 1365 of the Health and Safety Code, which includes circumstances when a health benefit plan is withdrawn from any portion of a market.
(B) At the time his or her the insureds coverage became effective, the newly covered insured was receiving services from that provider for one of the conditions described in subdivision (a).
(2) The completion of covered services required to be provided under this subdivision shall apply to services rendered to the newly covered insured on and after the effective date of his or her their new coverage.
(3) (A) The insurer may require a nonparticipating provider whose services are continued pursuant to this subdivision for a newly covered insured to agree in writing to be subject to the same contractual terms and conditions that are imposed upon currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider, including, but not limited to, credentialing, hospital privileging, utilization review, peer review, and quality assurance requirements. If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer is not required to continue the providers services.
(B) Unless otherwise agreed upon by the nonparticipating provider and the insurer, the services rendered pursuant to this subdivision shall be compensated at rates and methods of payment similar to those used by the insurer for currently participating providers providing similar services who are practicing in the same or a similar geographic area as the nonparticipating provider. Neither the insurer nor the provider group is required to continue the services of a nonparticipating provider if the provider does not accept the payment rates provided for in this paragraph. The provider who agrees to provide services pursuant to this subdivision shall accept the reimbursement as payment in full and shall not bill the insured for any amount in excess of the reimbursement rate, with the exception of copayments and deductibles pursuant to subdivision (c).
(C) A providers agreement to contractual terms and conditions and acceptance of payment rates to provide the completion of covered services to an insured pursuant to this subdivision shall not be construed as an agreement to contractual terms and conditions or acceptance of payment rates for any other insureds or for any services other than covered services pursuant to this subdivision, nor shall it be construed as agreement to any other contract.
(a)(1)An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
(2)For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.
(b)(1)Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program for a period of one year following the last day of the individuals pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.
(2)For purposes of this section, maternal mental health condition means a mental health condition that occurs during pregnancy or during the postpartum period and, includes, but is not limited to, postpartum depression.
(c)(1)An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to this section shall submit to a county eligibility worker a note from that individuals treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individuals pregnancy.
(2)Notwithstanding paragraph (1), an individual who has had Medi-Cal program coverage terminated within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy, may seek redetermination of eligibility pursuant to subdivision (i) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individuals treating health care provider within the time frame described in that subdivision and after the 60-day period beginning the last day of pregnancy.
(d)For purposes of this section, Medi-Cal program refers to any of the following programs:
(1)The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.
(2)The Medi-Cal program, as described in this article.
(3)The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).
(e)This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.
SEC. 3. Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
SEC. 3. Section 14005.18 of the Welfare and Institutions Code is amended to read:
### SEC. 3.
14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.For purposes of this section,(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
14005.18. A woman (a) (1) An individual is eligible, to the extent required by federal law, as though she were the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
For purposes of this section,
(2) For purposes of paragraph (1), postpartum services means those services provided after childbirth, child delivery, or miscarriage.
(b) For an individual described in subdivision (a), or subdivision (a) of Section 15840, who is disenrolling from coverage after the 60-day period, the department shall, for purposes of the transition, assist the individual in applying for and purchasing a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of the Government Code if the individual is eligible for coverage pursuant to that title.
(c) Notwithstanding subdivision (a), subdivision (a) of Section 15840, the income eligibility requirements specified in Section 15832, the annual redetermination requirements described in Section 14005.37, or any other law, but subject to Section 14011.10, if an individual described in subdivision (a) has a household income below 138 percent of the federal poverty level, continues to reside in the state, and would otherwise not be eligible for full-scope Medi-Cal coverage, the individual shall remain eligible for coverage under the Medi-Cal program for up to one year beginning on the last day of the pregnancy.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
### SEC. 4.