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's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth requirements for a contract between a plan or insurer and a dentist and requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. This bill would require a dental plan or dental insurer to establish a dental portal accessible to a treating dental provider to provide information regarding an enrollee's contract or insured's policy, including the actual payment or reimbursement amounts for covered services. The bill would require the portal to provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format, provide specified information about a corresponding payment, accept attachments in an electronic format, and be made available at no cost to contracted and noncontracted dental providers, among other requirements. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
(1) Existing federal law requires the Secretary of Health and Human Services to designate health professional shortage areas and requires the secretary, in establishing criteria for the designation of those areas, to consider, among other things, the ratio of available health manpower to the number of individuals in an area or population group and indicators of a need for health services, as specified. Existing state law makes references to federally recognized or designated health professional shortage areas in various contexts, including, among others, the California Physician Corps Program, the California Reproductive Health Services Corps, the Oral Health Program, the Virtual Health Hub for Rural Communities Pilot Program, and health professions planning grants. This bill, until January 1, 2035, would define the term "health professional shortage area" to mean (1) an area determined by the Department of Health Care Access and Information to have a shortage of health professionals, (2) a health professional shortage area currently designated or recognized by the United States Department of Health and Human Services, or (3) an area designated or recognized as a health professional shortage area by the United States Department of Health and Human Services on January 1, 2025, regardless of whether that area remains designated or recognized by the United States Department of Health and Human Services as a health professional shortage area. The bill would authorize the Department of Health Care Access and Information to revoke designations, as specified. (2) Existing law requires specified boards, including the Board of Registered Nursing and the Respiratory Care Board of California, to collect certain workforce data from their respective licensees and registrants for future workforce planning at least biennially. Existing law requires other boards that regulate healing arts licensees or registrants to request workforce data from their respective licensees and registrants for future workforce planning at least biennially. Existing law requires the workforce data collected or requested to include specified information, including, among others, the type of employer or classification of primary practice site, as specified. Existing law prohibits a licensee or registrant from being required to provide the information as a condition for license or registration renewal and prohibits licensees or registrants from being subject to discipline for not providing the information. Existing law requires the boards and the Department of Health Care Access and Information to maintain the confidentiality of licensee and registrant information collected pursuant to these provisions and authorizes release of the information only in aggregate form. Existing law requires each board to provide individual licensee and registrant data to the Department of Health Care Access and Information on a quarterly basis, as specified. This bill would require the workforce data to be collected or requested by boards at the time a license or registration is issued, except as specified. The bill would require the information collected or requested by boards to also include, among other things, the hours worked in inpatient care, hours worked in outpatient care, and whether the licensee or registrant offers a formal sliding fee scale. The bill would instead require each board to provide licensee and registrant data on a monthly basis. (3) Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest. This bill would make legislative findings to that effect. (4) This bill would incorporate additional changes to Section 502 of the Business and Professions Code proposed by SB 1271 to be operative only if this bill and SB 1271 are enacted and this bill is enacted last.
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 contract or health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Existing law requires this treatment to be provided under a prescribed treatment plan that is reviewed no less than every 6 months by the qualified autism service provider. This bill would prohibit a health care service plan or health insurer from imposing restrictions on the utilization of authorized treatment hours within the treatment plan's 6-month authorization period. The bill would require authorized hours to remain available for use throughout the authorization period if the use of the hours is consistent with the treatment plan and clinical guidelines, and is documented in the treatment plan and progress reports. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
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 or health insurer to reimburse a complete claim or a portion thereof within 30 calendar days after receipt of the claim, or, if a claim or portion thereof does not meet the criteria for completeness, to notify the claimant no later than 30 calendar days after receipt that the claim or portion thereof is contested or denied. This bill would grant a claimant no less than 90 calendar days to submit a corrected claim after a health care service plan or health insurer denies a claim or portion thereof or sends a notice of overpayment for a claim based on a defect that may be remedied by submitting a corrected claim. The bill would prohibit a plan or insurer from denying a corrected claim on the grounds that the claim was not submitted within another applicable claim filing deadline. Under the bill, a dispute related to a corrected claim would be required to be eligible for submission to the plan's or insurer's fast, fair, and cost-effective dispute resolution mechanism. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law requires the State Department of Public Health to license and regulate various health facilities, including general acute care hospitals. Existing law requires the department to issue a special permit, in addition to a license, to a health facility to offer one or more special services, such as an emergency center, if specified requirements are met, including that the department finds that the standards of care and services are adequate and appropriate. Existing law requires the department to issue a special permit to allow a general acute care hospital to offer emergency stabilization services at a location that is neither inside nor contiguous to the applicant hospital if the hospital provides satisfactory evidence to the department that, among other things, the hospital has a written transfer agreement with the hospital closest to the location where emergency stabilization services will be provided and satisfactory evidence to the department that this location meets certain requirements, including that the location is in the town of Paradise within the County of Butte and serves the same area previously served by Feather River Hospital. This bill would require the department to issue a waiver, as specified, to a publicly owned and operated general acute care hospital, in collaboration with Del Puerto Health Care District, to operate one rural emergency stabilization care unit and waive designated general acute care hospital licensure requirements if specified conditions are met. The bill would limit the term of the waiver based on prescribed factors, including the completion of a hospital build within a 5-mile radius of the emergency stabilization care unit or within 10 years from the initial issuance of the waiver, except as specified. This bill would make legislative findings and declarations as to the necessity of a special statute for Del Puerto Health Care District.
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 or health insurer that provides prescription drug benefits and maintains one or more drug formularies to meet certain criteria for its formularies and the placement of drugs on formularies. This bill would prohibit a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies from making changes to a formulary during a plan or policy year, except in specified circumstances. If a plan or insurer implements a formulary change requiring an enrollee or insured to change to a different drug in the same drug class during the plan year, the bill would authorize the individual to remain on the previously covered drug for the rest of the plan year if the drug was previously approved for coverage for the individual's medical condition, is appropriately prescribed, and is considered safe and effective for treating that condition, and would require the plan or insurer to notify the individual and their provider no less than 90 days before the change is implemented. The bill would require a plan or insurer, or its pharmacy benefit manager, to report to the appropriate department any changes made to a formulary during a plan or policy year within 30 days of the change being made. The bill would authorize the departments to investigate and take enforcement action against a plan or insurer for noncompliance with the above-described requirements and to impose, after notice and the opportunity for a hearing, administrative penalties, as specified, for a violation of these provisions. The bill would authorize the departments to conduct audits related to these provisions. Because a willful violation of the bill's provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law requires a health care service plan that provides prescription drug benefits to maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary nonformulary prescription drug. This bill would define "expeditious process" for the above-described purpose to require a plan to approve authorization within 72 hours for nonurgent requests, or within 24 hours if exigent circumstances exist, of a request for approval of a drug prescription. If the plan fails to meet those requirements, the bill would authorize an enrollee to request, and would require the plan to provide, 90 days of transitional coverage to the enrollee for the previously covered drug. The bill would require the Department of Managed Health Care to utilize existing data and its existing authority to collect data from plans and annually publish on its internet website and submit to the Legislature an aggregated report on information related to requests for approval of a nonformulary drug as described above. 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, 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 violation of the act by a health care service plan a misdemeanor. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law defines "unreasonable rate increase," for these purposes, to have the same meaning as in the federal Patient Protection and Affordable Care Act, which is that an unreasonable rate increase exists when the federal Centers for Medicare and Medicaid Services makes a determination that a rate increase is excessive, unjustified, or unfairly discriminatory, among other things. This bill would instead define "unreasonable rate increase," for the above-described purposes, to mean a rate increase that the Director of the Department of Managed Health Care or the Insurance Commissioner, as applicable, determines is excessive, unjustified, unfairly discriminatory, or otherwise unreasonable. Existing law requires a health care service plan or health insurer to submit rates to their regulating entity for review and to demonstrate the impact of any changes in the rate of growth of health care costs resulting from health care cost targets. This bill would instead require a health care service plan or health insurer to demonstrate the impact of health care cost targets and to demonstrate whether a health care service plan's or health insurer's annual rate growth exceeds or will exceed the cost target for the rating period. The bill would require, if a health care service plan's or health insurer's rate growth is expected to exceed the cost target for a rating period, the health care service plan or health insurer to include specified information in its rate filing, including, among other things, a detailed list of any proactive steps it is taking, or plans to take, for annual rate growth to meet the cost targets. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law requires the director or the commissioner, as applicable, in determining if a rate is unreasonable or not justified for purposes of the above-described review, to consider the impact on changes in health care costs as a result of the health care cost targets described above. This bill would delete those provisions and instead require the Department of Managed Health Care and the Department of Insurance to report on if rates, by plan or policy and in aggregate, meet the affordability standard, as defined, for an individual, a couple, and a family of four. The bill would require the report to include the annual change in premiums and cost sharing for the prior 5 years. The bill would, as part of the existing rate submission process, require a health care service plan or health insurer to provide information on premiums, deductibles, cost sharing, and any other factors specified by the department as necessary to complete the reports. 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, 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. Existing law requires a health care service plan contract that includes terms requiring binding arbitration for dispute settlement to provide a specified disclosure to subscribers or enrollees. Existing law, the California Arbitration Act, provides a statutory framework for the enforcement of contractual arbitration under California law. Existing law establishes standards for arbitration, and requires a court to vacate an arbitration award if it makes certain findings. This bill would require the Attorney General to oversee compliance by health care service plans with specified provisions regulating the use of binding arbitration to settle disputes. The bill would authorize the Attorney General to require reports from health care service plans for this purpose. The bill would also require the Attorney General to notify the director of the department of any corrective action taken pursuant to these provisions.
Existing law, the Physical Therapy Practice Act, establishes the Physical Therapy Board of California to license and regulate physical therapists and the practice of physical therapy. A violation of the act is a crime. Existing law defines the terms "physical therapist," "physical therapist assistant," and "physical therapy" and sets forth the scope of practice of a physical therapist. Existing law authorizes only a licensed physical therapist to use the title "physical therapist" or the letters "P.T." or any other words, letters, or figures indicating that the person is a licensed physical therapist. Existing law requires the board to define those doctoral degrees that are in a related health science for specified provisions of the Physical Therapy Practice Act. Existing law authorizes a licensed physical therapist who has received a doctoral degree in physical therapy or, after the adoption of the above-described definition by the board, a doctoral degree in a related health science to, among other things, use the initials "DPT," "PhD," or "EdD", as applicable, in a written communication following the licensee's name. Existing regulations define a physical therapy related health science for the purpose of the above-described authorization to include, among other things, biology, biomechanics, and exercise physiology. This bill, among other changes to the act, would redefine "physical therapy," "physical therapist," and "physical therapist assistant" for purposes of the act, as specified. The bill would, among other things, prohibit the use of any words, abbreviation, or insignia implying that physical therapy is provided unless those services are provided by or under the direction of a licensed physical therapist. The bill would delete the requirement on the board to define the doctoral degrees that are in a related health science described above and would update those provisions to, instead, specify that the doctoral degrees in a related health science are those specified by the board in regulation. The bill would additionally authorize a licensed physical therapist who has received a doctoral degree in physical therapy or a related health science to use the initials "DSc", as applicable, following the licensee's name. This bill would delete existing requirements for the performance of tissue penetration by a physical therapist and instead would include within the practice of physical therapy the use of electrode needles to perform tissue penetration for the purpose of evaluating and interpreting performance of the neuromusculoskeletal system. Existing law prohibits a physical therapist from supervising more than 2 physical therapist assistants at one time and establishes conditions for the initiation of services by a physical therapist directly, including providing a specified notice, orally and in writing, to a patient that is signed by the patient. This bill would increase the number of physical therapist assistants a physical therapist is authorized to supervise from 2 to 3. The bill would require a physical therapist to refer a patient to a physician and surgeon or other appropriately licensed health care provider when the situation or condition of the patient is beyond the scope of the education and training of the physical therapist. The bill would repeal the notice and other requirements for the provision of direct physical therapy treatment services. Because the bill would expand the scope of a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law provides for the licensure and regulation of health facilities, including general acute care hospitals, by the State Department of Public Health. Existing law authorizes a general acute care hospital to be approved to offer special services, including, among others, cardiac surgery. Existing regulation requires, when a general acute care hospital is providing cardiovascular operative service, that a minimum of 3 surgeons constitute a surgical team if the procedure requires extracorporeal bypass. This bill would require the department, on or before January 1, 2030, to update that regulation to reflect current professional standards of care relating to extracorporeal bypass surgery.
