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AB-2593 Air ambulance services.(2017-2018)

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Date Published: 07/03/2018 09:00 PM
AB2593:v96#DOCUMENT

Amended  IN  Senate  July 03, 2018
Amended  IN  Senate  June 18, 2018
Amended  IN  Assembly  May 25, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 2593


Introduced by Assembly Member Grayson
(Principal coauthor: Assembly Member Wood)
(Coauthor: Senator Dodd)

February 15, 2018


An act to add Section 1371.6 to the Health and Safety Code, to add Section 10126.65 to the Insurance Code, and to add Section 14124.14 14124.15 to the Welfare and Institutions Code, relating to air ambulance services.


LEGISLATIVE COUNSEL'S DIGEST


AB 2593, as amended, Grayson. Air ambulance services.
(1) 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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires that health care service plans and health insurance policies, as specified, provide coverage for certain services and treatments, including emergency medical transportation services.
This bill would provide that an enrollee, subscriber, or insured shall not be liable for the cost of emergency transportation by an air ambulance service, except for applicable cost-sharing amounts, including, but not limited to, a copayment, coinsurance, or a deductible. The bill would require a health care service plan contract or health insurer to reimburse providers for air ambulance services either a reasonable and customary value, as defined, or an amount otherwise negotiated, among other things. require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2019, to provide that if an enrollee, insured, or subscriber, as applicable, receives covered services from a noncontracting air ambulance provider, the insured or subscriber shall pay no more than the same cost sharing that the insured or subscriber would pay for the same covered services received from a contracting air ambulance provider, referred to as the in-network cost-sharing amount. The bill would specify that an enrollee, subscriber, or insured would not owe the noncontracting provider more than the in-network cost-sharing amount for services subject to the bill, as specified. The bill would allow a noncontracting provider to advance to collections only the in-network cost-sharing amount as determined by the health care service plan or insurer. The bill would authorize a health care service plan, health insurer, or provider to seek relief in any court for the purpose of resolving a payment dispute. The bill would make these provisions severable. dispute, and would not prohibit a provider from using a health care service plan’s or health insurer’s existing dispute resolution processes. 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.
(2) Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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. Existing law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
This bill would require the department to establish the Medi-Cal fee rate for air ambulance services provided either by fixed or rotary wing aircraft at a level equal to a percentage of the rural Medicare rates for those services, as described and effective July 1, 2019, and to the extent federal financial participation is available and any necessary federal approvals have been obtained. The bill would specify that, commencing July 1, 2019, the amounts a noncontract emergency medical transport provider could collect if the beneficiary received medical assistance other than through enrollment in a Medi-Cal managed care health plan pursuant to a specified federal law would be the resulting fee-for-service payment schedule amounts after the application of the rate established pursuant to the bill.
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.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1371.6 is added to the Health and Safety Code, to read:
1371.6.

(a)A subscriber or enrollee receiving emergency transportation by an air ambulance services provider covered consistent with paragraph (6) of subdivision (b) of Section 1345 shall not be held liable for the cost of that service, except for applicable cost-sharing amounts, including, but not limited to, a copayment, coinsurance, or a deductible.

(b)(1)A health care service plan shall reimburse providers for services subject to this section in accordance with this chapter, including Section 1371 or 1371.35, as applicable, and the health care service plan shall provide an explanation of benefits or similar claim processing information to the enrollee and provider.

(2)Notwithstanding any other law, reimbursement shall be based on either the reasonable and customary value for the service as described in subparagraph (B) of paragraph (3) of subdivision (a) of Section 1300.71 of Title 28 of the California Code of Regulations or an amount otherwise negotiated between the health care service plan and the provider.

1371.6.
 (a) (1) Notwithstanding Section 1367.11, a health care service plan contract issued, amended, or renewed on or after January 1, 2019, shall provide that if an enrollee receives covered services from a noncontracting air ambulance provider, the enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from a contracting air ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.”
(2) An enrollee shall not owe the noncontracting provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee.
(b) The following shall apply for purposes of this section:
(1) Any cost sharing paid by the enrollee for the services subject to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.
(2) Cost sharing arising from services subject to this section shall be counted toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.
(3) The cost sharing paid by the enrollee pursuant to this section shall satisfy the enrollee’s obligation to pay cost sharing for the health service.
(c) A noncontracting provider may advance to collections only the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee has failed to pay.

(3)

(d) A health care service plan or a provider may seek relief in any court for the purpose of resolving a payment dispute. A provider is not prohibited from using a health care service plan’s existing dispute resolution processes.

(c)The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

(e) Air ambulance services providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.

SEC. 2.

 Section 10126.65 is added to the Insurance Code, to read:
10126.65.

(a)An insured receiving emergency transportation by an air ambulance services provider covered consistent with paragraph (6) of subdivision (b) of Section 1345 shall not be held liable for the cost of that service, except for applicable cost-sharing amounts, including, but not limited to, a copayment, coinsurance, or a deductible.

(b)Notwithstanding any other law, a health insurer shall provide an explanation of benefits to the insured or an explanation of benefits or remittance advice to the provider concerning air ambulance services.

(c)(1)A health insurer shall provide reimbursement, in accordance with this chapter, to a provider for a claim submitted for air ambulance services.

(2)Reimbursement to a provider shall be based on either the reasonable and customary value for the service as described in subparagraph (B) of paragraph (3) of subdivision (a) of Section 1300.71 of Title 28 of the California Code of Regulations or an amount otherwise negotiated between the health insurer and the provider.

10126.65.
 (a) (1) Notwithstanding Section 10352, a health insurance policy issued, amended, or renewed on or after January 1, 2019, shall provide that if an insured or subscriber receives covered services from a noncontracting air ambulance provider, the insured or subscriber shall pay no more than the same cost sharing that the insured or subscriber would pay for the same covered services received from a contracting air ambulance provider. This amount shall be referred to as the “in-network cost-sharing amount.”
(2) A subscriber or insured shall not owe the noncontracting provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the insurer shall inform the insured or subscriber and the noncontracting provider of the in-network cost-sharing amount owed by the insured or subscriber.
(b) The following shall apply for purposes of this section:
(1) Any cost sharing paid by the insured or subscriber for the services subject to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.
(2) Cost sharing arising from services subject to this section shall be counted toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.
(3) The cost sharing paid by the insured or subscriber pursuant to this section shall satisfy the insured or subscriber’s obligation to pay cost sharing for the health service.
(c) A noncontracting provider may advance to collections only the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured or subscriber has failed to pay.

(3)

(d) A health insurer or a provider may seek relief in any court for the purpose of resolving a payment dispute. A health insurer is not prohibited from using a health insurer’s existing dispute resolution processes.

(d)The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

SEC. 3.

 Section 14124.14 14124.15 is added to the Welfare and Institutions Code, to read:

14124.14.14124.15.
 (a) The department shall set and maintain the Medi-Cal fee rate for air ambulance services provided either by fixed or rotary wing aircraft that is equal to a percentage, as specified in subdivision (b), of the rural Medicare rates for those services.
(b) The final rate shall either meet or exceed the sum of the air ambulance service rate as provided in the Medi-Cal program on December 31, 2017, and the supplemental payment offered in the year 2017 pursuant to Section 76000.10 of the Government Code.
(c) Each applicable Medi-Cal managed care health plan shall satisfy its obligation under Section 438.114(c) of Title 42 of the Code of Federal Regulations for emergency medical transports and shall provide payment to noncontract emergency medical transport providers consistent with Section 1396u-2(b)(2)(D) of Title 42 of the United States Code. Effective July 1, 2019, and for each state fiscal year thereafter for which this chapter is operative, the amounts a noncontract emergency medical transport provider could collect if the beneficiary received medical assistance other than through enrollment in a Medi-Cal managed care health plan pursuant to Section 1396u-2(b)(2)(D) of Title 42 of the United States Code shall be the resulting fee-for-service payment schedule amounts after the application of this section.

(c)

(d) This section shall be effective July 1, 2019, and the section shall be implemented only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.

SEC. 4.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B 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 XIII B of the California Constitution.