Important Healthcare Legislation passed in California in 1997-98


A summary of 16 of the 40 or so relevant bills passed.
Unless otherwise noted, they are effective January 1, 1999.
Most of these bills cover: The laws apply to:
Disclosure of Benefits
Health & Safety Code 1363 (AB 607, Scott) -
Requires health plan disclosure forms to contain specific information concerning: principle benefits and coverage, limitations and exclusions, full premium cost of the plan, copay and deductible requirements, renewal terms, termination of benefits, and other enrollee rights and responsibilities. Also requires plans to provide a Health Plan Benefits and Coverage Matrix with specified information to compare plan contracts. Medi-Cal and Medicare plans are excluded from the matrix requirement.
Disclosure of choices and financial incentives
Health & Safety Code 1367.10 (SB 750 , Rosenthal) -
Requires health plans to include within Evidence of Coverage (EOC) a clear description of how participation in the plan may affect the choice of physician, hospital, or other health care providers, the basic method of reimbursement, including the scope and general methods of payment to providers, and whether financial bonuses or other incentives are used. Requires release of information, upon request, describing any bonus or incentive arrangements and how they are related to a provider's use of referral services. Excludes trade secrets or financial information that is privileged or confidential.
Disclosure of 'economic profiling' criteria
Health & Safety Code 1367.02
Insurance Code 10123.36 (SB 984, Rosenthal) -
Requires Health Plans to disclose the financial criteria used to select and fire plan physicians.
Written Decisions in Arbitration cases
Health & Safety Code 1373.21 (SB 1702, Rosenthal) -
An arbitration award must be accompanied by a written decision to the parties that contains the reasons for the award. A copy shall be provided to the Department of Corporations.
Direct access to obstetricians and gynecologists
Health & Safety Code 1367.695,
Insurance Code 10123.84 (AB 12, Davis, Granlund) -
Enrollee cannot be required to obtain prior approval from another provider to obtain access to an OBGYN.
Continuity of services rendered by terminated providers
Health & Safety Code 1363, 1373.96,
Insurance Code 10133.56 (SB 1129, Sher) -
Health plans and health insurers must provide continuity of covered services rendered by a terminated provider to an enrollee currently being treated for an acute or serious chronic condition, a high-risk pregnancy, or second or third trimester pregnancy.
Standing referrals to specialists for coordination of care
Health & Safety Code 1374.16,
Welfare & Institutions Code 14450.5 (AB 1181, Escutia) -
Requires health plans to establish procedures for an enrollee with a condition or disease that requires specialized medical care over a prolonged period of time and is life- threatening, degenerative, or disabling to receive a standing referral to a specialist or specialty care center for the purpose of coordinating the enrollee's health care.
Post-mastectomy hospital stays must be determined by physicians;
Post-mastectomy prostheses, reconstruction, and complications must be covered by plans that cover mastectomies;
Health & Safety Code 1367.635,
Insurance Code 10123.86 (AB 7, Brown) -
Requires every health plan and health insurance policy that covers mastectomies and lymph node dissections to allow associated hospital stays to be determined by attending physician and surgeon in consultation with patient and consistent with sound medical practices, to cover prosthetic devices or reconstructive surgery, and to cover all complications resulting from a mastectomy. (Note: this does not mandate coverage of mastectomies and lymph node dissections.)
Screening and diagnosis of prostate cancer must be covered
Health & Safety Code 1367.64,
Insurance Code 10123.83 (SB 2020, Karnette) -
Requires coverage for the screening and diagnosis of prostate cancer, including, but not limited to, prostate-specific antigen testing and digital rectal exams, when medically necessary and consistent with professional practice. Does not prevent use of deductibles or copayments. Exempts specialized health care service plan contracts.
Reconstructive surgery must be covered, and can only be denied by licensed physician competent to evaluate the clinical issues
Health & Safety Code 1367.63,
Insurance Code 10123.88,
Welfare & Institutions Code 14132.62 (AB 1621, Figueroa & Leach), effective 7/1/99 -
Requires health plans and health insurers to cover reconstructive surgeries, but excludes cosmetic surgery. Requests cannot be denied by anyone other than a licensed physician competent to evaluate the specific clinical issues involved, and if another more appropriate surgery will be approved, the surgery offers only minimal improvement, or there was no prior authorization. Exempts specialized health care service plans.
Emergency "911" Ambulance services must be covered by plans that provide emergency health services;
Health & Safety Code 1345, 1363.2, 1371.5, 1797.114;
Insurance Code 10126.6 (AB 984, Davis), effective, in part, 7/1/99 -
Prohibits health plans from requiring prior authorization or refusing to pay for "911" ambulance services if the request was made for an emergency medical condition and ambulance transport was required, or an enrollee reasonably believed that such was the case.
Previously approved drugs cannot be excluded from coverage under certain circumstances;
information about formularies required to be provided in EOC and disclosure form, and to members of public;
Health & Safety Code 1363.01, 1367.20, 1367.22 (AB 974, Gallegos), effective, in part, 7/1/99 -
Prohibits health plans from limiting or excluding coverage for a drug if the drug previously had been approved and the plan's prescribing provider continues to prescribe it appropriately, and it is considered safe and effective for the enrollee's medical condition by the FDA. Requires every plan to disclose whether it uses a formulary and how it works, and to make it available to the public.
Expedited process for obtaining non-formulary prescription drugs Information about formularies must be made available to public
Health & Safety Code 1367.20, 1367.24 (SB 625, Rosenthal), effective, in part, 7/1/99 -
Requires health plans that include prescription drug benefits to maintain an expedited process by which prescribing providers may obtain authorization for a medically necessary non- formulary prescription drug. Requires that plans make copy of the formulary available to the public, upon request, with an indication if any drugs are preferred over others.
Pain management medications for terminally ill patients must be covered by plans that cover prescription drugs
Business & Professional Code 725, 2024;
Health & Safety Code 1367.215 (AB 2305, Runner) -
Requires health plans that cover prescription drug benefits to cover pain management medications for terminally ill patients when medically necessary, subject to authorization. The request must be approved or denied within 72 hours or will be deemed authorized. No physician in compliance with the California Intractable Pain Treatment Acts shall be subject to disciplinary action for lawfully prescribing or administering controlled substances in the course of treatment of a person for intractable pain.
Controlled substances for patients with terminal illness exempted from triplicate requirements;
Health & Safety Code 11159.2 (AB 2693, Migden & Thomson) -
Exempts prescriptions for Schedule II controlled substances for patients with a terminal illness from triplicate prescription form requirements in existing law.
Pain management education for physicians and hospitals required;
Business & Professional Code 2191, 2811.5, 2196.2 (SB 1140, Committee on Health and Human Services) -
Requires the California Medical Board Licensing Division to consider a course in pain management among its continuing education requirements for licensees, and requires Board to periodically develop and disseminate information and educational material on pain management techniques and procedures to licensees and general acute care hospitals.