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AB-1036 Health care coverage: emergency medical transport.(2023-2024)



Current Version: 02/15/23 - Introduced

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AB1036:v99#DOCUMENT


CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 1036

Introduced by Assembly Member Bryan

February 15, 2023

An act to amend Section 1371.5 of the Health and Safety Code, to amend Section 10126.6 of the Insurance Code, and to add Section 14132.04 to the Welfare and Institutions Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 1036, as introduced, Bryan. Health care coverage: emergency medical transport.
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 generally requires a health care service plan contract or large group health insurance policy to provide an enrollee or insured with basic health care services, which include emergency health care services. Existing law prohibits a health care service plan that provides basic health care services from requiring prior authorization or refusing to pay for an ambulance or ambulance transport services if the request was made for an emergency medical condition and the services were required or if an enrollee reasonably believed the medical condition was an emergency that required ambulance transport services. Existing law requires a policy of disability insurance issued, amended, delivered, or renewed in this state on or after January 1, 1999, that provides hospital, medical, or surgical coverage with coverage for emergency health care services to include coverage for emergency medical transportation services without regard to whether or not the emergency provider contracts with the insurer or to prior authorization.
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 establishes a schedule of benefits under the Medi-Cal program, including various emergency medical services.
This bill would require a physician, upon an individual’s arrival to an emergency department of a hospital, to certify in the treatment record whether an emergency medical condition existed, or was reasonably believed to have existed, and required emergency medical transportation services, as specified. This bill would, if a physician has certified that emergency medical transportation services according to these provisions, require a health care service plan, disability insurance policy, and Medi-Cal managed care plan, to provide coverage for emergency medical transport, consistent with an individual’s plan or policy. The bill would specify that the indication by a physician pursuant to these provisions is limited to an assessment of the medical necessity of the emergency medical transport services, and does not apply or otherwise impact provisions regarding coverage for care provided following completion of the emergency medical transport. The bill would specify for Medi-Cal benefits, these provisions do not apply to various specified provisions relating to nonemergency transport services or any other law or regulation related to reimbursement or authorization requirements for services provided for emergency services and care.
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 1371.5 of the Health and Safety Code is amended to read:

1371.5.
 (a)  No health care service plan that provides basic health care services shall require prior authorization or refuse to pay for any ambulance or ambulance transport services, referred to in paragraph (6) of subdivision (b) of Section 1345, provided to an enrollee as a result of a “911” emergency response system request for assistance if either of the following conditions apply:
(1)  The request was made for an emergency medical condition and ambulance transport services were required.
(2)  An enrollee reasonably believed that the medical condition was an emergency medical condition and reasonably believed that the condition required ambulance transport services.
(b) (1) Upon arrival to an emergency department of a hospital through the use of an ambulance or ambulance transport service as a result of a “911” emergency response system request for assistance, a physician shall certify in the treatment record, in a manner determined by the department, whether an emergency medical condition existed, or was reasonably believed to have existed, and required ambulance or ambulance transport services.
(2) The certification by a physician pursuant to this subdivision is limited to whether an ambulance or ambulance transport service was required solely for the purposes of evaluating coverage for the ambulance or ambulance transport service. This section shall not be construed as an evaluation or determination of the medical necessity of care otherwise provided following the completion of the ambulance or ambulance transport service.

(b)

(c) As used in this section, “emergency medical condition” has the same meaning as in Section 1317.1.

(c)

(d) The determination as to whether an enrollee reasonably believed that the medical condition was an emergency medical condition that required an emergency response shall not be based solely upon a retrospective analysis of the level of care eventually provided to, or a final discharge of, the person who received emergency assistance.

(d)

(e) (1) A health care service plan shall not be required to pay for any ambulance or ambulance transport services if the health care service plan determines that the ambulance or ambulance transport services were never performed, an emergency condition did not exist, or upon findings of fraud, incorrect billings, the provision of services that were not covered under the member’s current benefit plan, or membership that was invalid at the time services were delivered for the pending emergency claim.
(2) If a physician certifies in the treatment record that an emergency medical condition existed, or was reasonably believed to have existed pursuant to subdivision (b), a health care service plan shall pay for the ambulance or ambulance transport services in accordance with the member’s benefit plan.

SEC. 2.

 Section 10126.6 of the Insurance Code is amended to read:

10126.6.
 (a) Every policy of disability insurance that provides hospital, medical, or surgical coverage under a health benefit plan, defined in subdivision (a) of Section 10198.6, that provides coverage for emergency health care services, that is issued, amended, delivered, or renewed in this state on or after January 1, 1999, shall include coverage for emergency medical transportation services, as defined in subdivision (b). This coverage shall be provided without regard to whether the emergency provider has a contractual arrangement with the insurer or whether there was prior authorization, subject to the terms and conditions of the policy.
(b) (1) Upon arrival to an emergency department of a hospital through the use of emergency medical transportation services, a physician shall certify in the treatment record, in a manner determined by the department, whether an emergency medical condition existed, or was reasonably believed to have existed, and required emergency medical transportation services.
(2) The certification by a physician pursuant to this subdivision is limited to whether emergency medical transportation services were required solely for the purposes of evaluating coverage for the emergency medical transportation services. This section shall not be construed as an evaluation or determination of the medical necessity of care otherwise provided following the completion of emergency medical transportation services.
(c) If a physician certifies in the treatment record that an emergency medical condition existed, or was reasonably believed to have existed pursuant to subdivision (b), a policy subject to this section shall pay for the emergency medical transportation services in accordance with the insured’s policy.

(b)

(d) For purposes of this section, “emergency medical transportation services” means ambulance services provided through the “911” emergency response system. the following definitions apply:
(1) “Emergency medical condition” has the same meaning as in Section 1371.1 of the Health and Safety Code.
(2) “Emergency medical transportation service” means ambulance services provided through the “911” emergency response system.

SEC. 3.

 Section 14132.04 is added to the Welfare and Institutions Code, to read:

14132.04.
 (a) Upon arrival to an emergency department of a hospital through the use of emergency medical transport provided through the “911” emergency response system request for assistance, a physician shall indicate in the treatment record, in a manner determined by the department, whether an emergency medical condition existed, or was reasonably believed to have existed, and required emergency medical transport.
(b) (1) The physician certification pursuant to this section is limited to whether emergency medical transport was required solely for the purposes of evaluating coverage for the emergency medical transport. This section shall not be construed as an evaluation or determination of the medical necessity of care pursuant to Section 14059.5 that is otherwise provided following the completion of an emergency medical transport service.
(2)  The physician certification pursuant to this section shall not be construed to change an obligation to render care consistent with the federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. 1395dd).
(c) If a physician certifies in the treatment record that an emergency medical condition existed, or was reasonably believed to have existed pursuant to subdivision (a), the emergency transport services are covered, subject to utilization controls.
(d) This section shall not apply to, or change coverage obligations related to, the provision of emergency services and care, consistent with subdivision (b) of Section 14132, services completed at a noncontract hospital pursuant to Section 14103.5, or otherwise alter existing state law or regulations related to reimbursement or authorization requirements for services provided for emergency services and care.
(e) This section shall not apply to or in any way limit coverage for nonemergency medical transport services pursuant to any other law or regulation related to reimbursement for services provided, including, but not limited to, paragraph (3) of subdivision (s) of Section 14132 and Sections 14136 and 14136.3.
(f) For the purposes of this section the following definitions apply:
(1) “Emergency medical transport” has the same meaning as in Section 14105.945.
(2) “Emergency services and care” and “emergency medical condition” have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(g) This section shall only be implemented to the extent permitted by federal law.

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.