Health care service plans: provider network transitions.

Plain English Breakdown

The official source material does not specify whether the bill mandates clear notice requirements for consumers, only stating legislative intent.

Health Care Service Plans: Provider Network Transitions

This law requires health insurance companies to automatically return patients to their original doctors if a change in the doctor's network is delayed, canceled, or fails within four months of changing the patient's assigned provider.

What This Bill Does

• Requires health care service plans to automatically reinstate enrollees to their previously assigned primary care providers or groups if a transition delay happens and the original provider remains contracted with the plan for up to 120 days after reassignment.
• If the original provider is no longer part of the network, the plan must offer continuity of care or arrange out-of-network care at in-network costs.

Who It Names or Affects

• Health insurance companies and their enrollees
• Primary care providers and provider groups

Terms To Know

Provider Network Transition

A change in the network of doctors or hospitals that a health plan covers.

Enrollee

A person who is covered by a health care service plan.

Limits and Unknowns

• Does not specify what happens if the original provider leaves the network after 120 days.
• The bill does not provide details on how continuity of care or out-of-network arrangements will be managed beyond the initial period.

Official Summary Text

AB 2613, as amended, Sharp-Collins.
Health care service plans:
notice.
provider network transitions.
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 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.
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 to meet specified requirements, including notice requirements, and requires a health care service plan contract to provide to subscribers and enrollees specified basic health care services.
This bill would state the intent of the Legislature to enact legislation to require health care service plans to provide clear notice to consumers about their health care coverage.

Current Bill Text

Download Bill PDF