Health care coverage: out-of-network coverage.

Existing law provides for the licensure and regulation of health facilities, including hospitals, by the State Department of Public Health and makes a violation of those provisions a misdemeanor. Existing law, the Payers' Bill of Rights, requires a hospital that uses a charge description master to make a written or electronic copy available in accordance with specified provisions and requires the hospital to post a notice that informs patients that the charge description master is available pursuant to specified provisions. 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 requires plans to reimburse noncontracting providers for emergency services and care rendered to enrollees of the plan, as specified. Existing law requires plans to, upon request, provide a list of specified contracting providers within the enrollee's or prospective enrollee's general geographic area. Existing law provides for the regulation of health insurers by the Department of Insurance and authorizes health insurers to contract for alternative rates of payment with providers. Existing law requires insurers to provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates under their group policy and to make that list available for inspection during regular business hours at the insurer's principal office. Under this bill, when a patient seeks services at a hospital for an elective or scheduled procedure and the patient is covered by a specified type of health care service plan contract or health insurance policy that provides out-of-network coverage, the hospital would be required to provide the patient with a notice stating, among other things, that certain hospital-based providers may not be within the network of the patient's plan or insurer. The bill would require that the hospital receive the signature of the patient, or his or her legal representative, on this notice prior to rendering services to the patient. The bill would also require that a health care service plan or health insurer that receives a request from a subscriber, enrollee, policyholder, or insured for a referral to a noncontracting provider based on this hospital notice either authorize the enrollee or subscriber or policyholder or insured to obtain covered services from the noncontracting provider or refer the enrollee to a contracting provider with similar clinical expertise providing similar services in the same geographic region. The bill would also prohibit a hospital or a provider group from holding itself out as being within a plan or provider network unless all of the individual providers providing services at the hospital or with the provider group are within the plan or provider network or the hospital or provider group acknowledges that individual providers within the hospital or provider group may be outside the plan or provider network. Because a violation of certain of the bill's requirements would be a crime, this bill would impose a state-mandated local program by creating a new crime. 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.