Immunizations for children: reimbursement of physicians.

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 that act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires every health care service plan or health insurer that covers hospital, medical, or surgical expenses on a group basis to provide certain preventive health care benefits for children, including immunizations. Existing law specifies the reimbursement rate with respect to immunizations that are not part of the current contract between a health care service plan or physician group. This bill would require a health care service plan or health insurer that provides coverage for childhood and adolescent immunizations to reimburse a physician or physician group in an amount not less than the actual cost of acquiring the vaccine plus the cost of administration of the vaccine, as specified. The bill would prohibit a health care service plan contract or health insurance policy providing coverage for childhood or adolescent immunizations from imposing a deductible, copayment, coinsurance, or other cost-sharing mechanism for the administration of a childhood or adolescent immunization or for related procedures. The bill would also prohibit those contracts or policies from containing a dollar limit provision for the administration of childhood and adolescent immunizations or including the cost of those immunizations in a dollar limit provision. Existing law prohibits a risk-based contract between a health care service plan and a physician or physician group from including a provision requiring the physician or physician group to assume financial risk for the acquisition costs of required immunizations for children. Existing law prohibits a plan from requiring a physician or physician group to assume financial risk for immunizations that are not part of the current contract. This bill would make those provisions apply to all contracts between plans and physicians or physician groups rather than just risk-based contracts. The bill would prohibit a plan from requiring a physician or physician group to assume financial risk for immunizations, whether or not those immunizations are part of the current contract. The bill would make other related changes. Existing law prohibits a health care service plan from including the acquisition costs associated with required immunizations for children in the capitation rate of a physician who is individually captitated. This bill would additionally prohibit a plan from including in that capitation rate the administration costs of those immunizations. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program. Existing law creates the Healthy Families Program, administered by the Managed Risk Medical Insurance Board, to arrange for the provision of health, dental, and vision benefits to eligible children pursuant to a federal program, the State Children's Health Insurance Program. This bill would require a health plan participating in that program to reimburse a physician or physician group for immunizations administered to program subscribers in an amount not less than the actual cost of acquiring the vaccine plus the cost of administration of the vaccine, as specified. 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.