Section 1367.36 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.36
. (a) A risk-based contract between a health care service
plan and a physician or physician group that is issued, amended,
delivered, or renewed in this state on or after January 1, 2001,
shall not include a provision that requires a physician or a
physician group to assume financial risk for the acquisition costs of
required immunizations for children as a condition of accepting the
risk-based contract. A physician or physician group shall not be
required to assume financial risk for immunizations that are not part
of the current contract.
(b) Beginning January 1, 2001, with respect to immunizations for
children that are not part of the current contract between a health
care service plan and a physician or physician group, the health care
service plan shall reimburse a physician or physician group at the
lowest of the following, until the contract is renegotiated: (1) the
physician's actual acquisition cost, (2) the "average wholesale price"
as published in the Drug Topics Red Book, or (3) the lowest
acquisition cost through sources made available to the physician by
the health care service plan. Reimbursements shall be made within 45
days of receipt by the plan of documents from the physician
demonstrating that the immunizations were performed, consistent with
Section 1371 or through an alternative funding mechanism mutually
agreed to by the health care service plan and the physician or
physician group. The alternative funding mechanism shall be based on
reimbursements consistent with this subdivision.
(c) Physicians and physician groups may assume financial risk for
providing required immunizations, if the immunizations have
experiential data that has been negotiated and agreed upon by the
health care service plan and the physician risk-bearing organization.
However, a health care service plan shall not require a physician
risk-bearing organization to accept financial risk or impose
additional risk on a physician risk-bearing organization in violation
of subdivision (a).
(d) A health care service plan shall not include the acquisition
costs associated with required immunizations for children in the
capitation rate of a physician who is individually capitated.