1375.7
. (a) This section shall be known and may be cited as the
Health Care Providers' Bill of Rights.
(b) No contract issued, amended, or renewed on or after January 1,
2003, between a plan and a health care provider for the provision of
health care services to a plan enrollee or subscriber shall contain
any of the following terms:
(1) (A) Authority for the plan to change a material term of the
contract, unless the change has first been negotiated and agreed to
by the provider and the plan or the change is necessary to comply
with state or federal law or regulations or any accreditation
requirements of a private sector accreditation organization. If a
change is made by amending a manual, policy, or procedure document
referenced in the contract, the plan shall provide 45 business days'
notice to the provider, and the provider has the right to negotiate
and agree to the change. If the plan and the provider cannot agree to
the change to a manual, policy, or procedure document, the provider
has the right to terminate the contract prior to the implementation
of the change. In any event, the plan shall provide at least 45
business days' notice of its intent to change a material term, unless
a change in state or federal law or regulations or any accreditation
requirements of a private sector accreditation organization requires
a shorter timeframe for compliance. However, if the parties mutually
agree, the 45-business day notice requirement may be waived. Nothing
in this subparagraph limits the ability of the parties to mutually
agree to the proposed change at any time after the provider has
received notice of the proposed change.
(B) If a contract between a provider and a plan provides benefits
to enrollees or subscribers through a preferred provider arrangement,
the contract may contain provisions permitting a material change to
the contract by the plan if the plan provides at least 45 business
days' notice to the provider of the change and the provider has the
right to terminate the contract prior to the implementation of the
change.
(C) If a contract between a noninstitutional provider and a plan
provides benefits to enrollees or subscribers covered under the
Medi-Cal or Healthy Families Program and compensates the provider on
a fee-for-service basis, the contract may contain provisions
permitting a material change to the contract by the plan, if the
following requirements are met:
(i) The plan gives the provider a minimum of 90 business days'
notice of its intent to change a material term of the contract.
(ii) The plan clearly gives the provider the right to exercise his
or her intent to negotiate and agree to the change within 30
business days of the provider's receipt of the notice described in
clause (i).
(iii) The plan clearly gives the provider the right to terminate
the contract within 90 business days from the date of the provider's
receipt of the notice described in clause (i) if the provider does
not exercise the right to negotiate the change or no agreement is
reached, as described in clause (ii).
(iv) The material change becomes effective 90 business days from
the date of the notice described in clause (i) if the provider does
not exercise his or her right to negotiate the change, as described
in clause (ii), or to terminate the contract, as described in clause
(iii).
(2) A provision that requires a health care provider to accept
additional patients beyond the contracted number or in the absence of
a number if, in the reasonable professional judgment of the
provider, accepting additional patients would endanger patients'
access to, or continuity of, care.
(3) A requirement to comply with quality improvement or
utilization management programs or procedures of a plan, unless the
requirement is fully disclosed to the health care provider at least
15 business days prior to the provider executing the contract.
However, the plan may make a change to the quality improvement or
utilization management programs or procedures at any time if the
change is necessary to comply with state or federal law or
regulations or any accreditation requirements of a private sector
accreditation organization. A change to the quality improvement or
utilization management programs or procedures shall be made pursuant
to paragraph (1).
(4) A provision that waives or conflicts with any provision of
this chapter. A provision in the contract that allows the plan to
provide professional liability or other coverage or to assume the
cost of defending the provider in an action relating to professional
liability or other action is not in conflict with, or in violation
of, this chapter.
(5) A requirement to permit access to patient information in
violation of federal or state laws concerning the confidentiality of
patient information.
(c) With respect to a health care service plan contract covering
dental services or a specialized health care service plan contract
covering dental services, all of the following shall apply:
(1) If a material change is made to the health care service plan's
rules, guidelines, policies, or procedures concerning dental
provider contracting or coverage of or payment for dental services,
the plan shall provide at least 45 business days' written notice to
the dentists contracting with the health care service plan to provide
services under the plan's individual or group plan contracts,
including specialized health care service plan contracts, unless a
change in state or federal law or regulations or any accreditation
requirements of a private sector accreditation organization requires
a shorter timeframe for compliance. For purposes of this paragraph,
written notice shall include notice by electronic mail or facsimile
transmission. This paragraph shall apply in addition to the other
applicable requirements imposed under this section, except that it
shall not apply where notice of the proposed change is required to be
provided pursuant to subparagraph (C) of paragraph (1) of
subdivision (b).
(2) For purposes of paragraph (1), a material change made to a
health care service plan's rules, guidelines, policies, or procedures
concerning dental provider contracting or coverage of or payment for
dental services is a change to the system by which the plan
adjudicates and pays claims for treatment that would reasonably be
expected to cause delays or disruptions in processing claims or
making eligibility determinations, or a change to the general
coverage or general policies of the plan that affect rates and fees
paid to providers.
(3) A plan that automatically renews a contract with a dental
provider shall annually make available to the provider, within 60
days following a request by the provider, either online, via email,
or in paper form, a copy of its current contract and a summary of the
changes described in paragraph (1) of subdivision (b) that have been
made since the contract was issued or last renewed.
(4) This subdivision shall not apply to a health care service plan
that exclusively contracts with no more than two medical groups in
the state to provide or arrange for the provision of professional
medical services to the enrollees of the plan.
(d) (1) When a contracting agent sells, leases, or transfers a
health provider's contract to a payor, the rights and obligations of
the provider shall be governed by the underlying contract between the
health care provider and the contracting agent.
(2) For purposes of this subdivision, the following terms shall
have the following meanings:
(A) "Contracting agent" has the meaning set forth in paragraph (2)
of subdivision (d) of Section 1395.6.
(B) "Payor" has the meaning set forth in paragraph (3) of
subdivision (d) of Section 1395.6.
(e) Any contract provision that violates subdivision (b), (c), or
(d) shall be void, unlawful, and unenforceable.
(f) The department shall compile the information submitted by
plans pursuant to subdivision (h) of Section 1367 into a report and
submit the report to the Governor and the Legislature by March 15 of
each calendar year.
(g) Nothing in this section shall be construed or applied as
setting the rate of payment to be included in contracts between plans
and health care providers.
(h) For purposes of this section the following definitions apply:
(1) "Health care provider" means any professional person, medical
group, independent practice association, organization, health care
facility, or other person or institution licensed or authorized by
the state to deliver or furnish health services.
(2) "Material" means a provision in a contract to which a
reasonable person would attach importance in determining the action
to be taken upon the provision.