Health care service plans: provider contract termination: notice.

Plain English Breakdown

The official source material does not provide specific details on penalties for violations, nor does it specify how this will affect plans that do not currently use email or text message notifications.

Health Care Service Plans: Provider Contract Termination Notice

AB-2613 requires health care service plans to notify enrollees by email or text message about provider contract terminations and automatically reinstates enrollees to their previous providers if a transition fails within 120 days.

What This Bill Does

• Requires health care service plans to send notice of provider contract termination by email or text message at least 60 days before the termination date.
• If a terminated provider is rehired, the plan must notify enrollees about this change within 60 days via mail and electronic means.
• Automatically reinstates an enrollee to their previous primary care provider if a network transition fails within 120 days after reassignment.

Who It Names or Affects

• Health care service plan enrollees
• Health care service plans and their providers

Terms To Know

Provider network transition

A change in the group of healthcare providers that a health insurance plan covers.

Enrollee

A person who is covered by a health care service plan and receives medical benefits from it.

Limits and Unknowns

• The bill does not specify the exact penalties for violating these requirements.
• It is unclear how this will affect plans that do not currently use email or text message notifications.

Official Summary Text

AB 2613, as amended, Sharp-Collins.
Health care service plans:
provider network transitions.
provider contract termination: notice.
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 requires a health care service plan to notify an enrollee
by United States mail
at least 60 days before the termination date of a contract between a health care service plan and a provider group or a general acute care hospital to which the enrollee is assigned. If the plan reaches an agreement with a terminated provider after sending that notice, existing law requires the plan to offer each affected enrollee the option to return to that provider and to reassign the enrollee to another provider if the enrollee does not exercise
that option.
This bill would require a health care service plan to automatically
reinstate the enrollee to the enrollee’s previously assigned primary care provider or provider group if a provider network transition is materially delayed, terminated, rescinded, or otherwise fails within 120 days of an enrollee reassignment and that provider or provider group remains contracted with the plan. If, after that failure, the previously assigned provider is no longer contracted with the plan, the bill would require the plan to offer continuity of care or arrange for out-of-network care at in-network cost sharing, as specified. Because a willful violation of these provisions would be a crime, this bill would impose a state-mandated local program.
This bill would additionally require a health care service plan to notify an enrollee by email or text message, as specified, at least 60 days before the termination date of a contract between a health care
service plan and a provider group or a general acute care hospital to which the enrollee is assigned. If the plan reaches an agreement with a terminated provider after sending the notice of termination, the bill would require the health care service plan to send written notice by United States mail and by email or text message, as specified, to affected enrollees within 60 days of reaching the agreement. Because a willful violation of these provisions 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.

Current Bill Text

Download Bill PDF