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. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would define for these purposes specialty physician and professional provider, respectively, to include a physician who meets the criteria for an HIV specialist, as specified. require access to HIV specialists to be subject to the regulations, standards, and reporting requirements developed pursuant to the above specified provisions. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2017, to include an HIV specialist, as defined, as an eligible primary care provider, as defined, if the provider requests primary care provider status and meets the plans or health insurers eligibility criteria for all specialists seeking primary care provider status. Because a willful violation of these requirements by a health care service plan would be a crime, the 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. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would define for these purposes specialty physician and professional provider, respectively, to include a physician who meets the criteria for an HIV specialist, as specified. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2017, to include an HIV specialist, as defined, as an eligible primary care physician, provided that he or she provider, as defined, if the provider requests primary care provider status and meets the plans or health insurers eligibility criteria for all specialists seeking primary care physician provider status. Because a willful violation of these requirements by a health care service plan would be a crime, the 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. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would define for these purposes specialty physician and professional provider, respectively, to include a physician who meets the criteria for an HIV specialist, as specified. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2017, to include an HIV specialist, as defined, as an eligible primary care physician, provided that he or she meets the plans or health insurers eligibility criteria for all specialists seeking primary care physician status. Because a willful violation of these requirements by a health care service plan would be a crime, the 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.

Date of Hearing: May 4, 2016

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 2372

Author:(Burke) – As Amended Ver:April 25, 2016

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill allows HIV specialists, as defined, to be included as an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan’s eligibility criteria for all specialists seeking primary care provider status.

It also stipulates that access to HIV specialists is subject to regulations that govern network adequacy, consistent with the specialty designation.

FISCAL EFFECT:

1. If this bill is interpreted to designate HIV specialists as a distinct specialty for the purposes of ensuring compliance with timely access standards, it would be difficult and costly for plans and insurers to meet such standards, given the California Health Benefits Review Program (CHBRP) found there are only 900 HIV specialists in the state that meet the bill's definition. Regulators have some discretion to decide how to apply these timely access standards, but it would appear very difficult to meet these existing specialty standards for HIV specialists, particularly in areas where there are few practicing specialists.

Difficulty meeting these standards would lead to difficulty in negotiating fair prices for contracts, leading to a situation similar to an "any willing provider" clause, whereby plans would lose bargaining leverage because they would be essentially forced to accept any HIV specialist they could entice to join their network through high reimbursements, in order to meet the regulatory standards. Higher reimbursement rates for HIV specialists as a result of this market imbalance would be expected to lead to higher premiums. Although the amount is unknown, price hikes and statewide impacts on premiums across all payers could be significant, conceivably in the millions of dollars statewide.

1. Difficulty (or impossibility) of meeting network standards would also potentially lead to a higher number of consumer complaints and enforcement actions, resulting in unknown, potentially significant costs to Department of Managed Health Care (DMHC) (Managed Care Fund) and California Department of Insurance (Insurance Fund).
2. Finally, this bill appears likely to require the California Department of Insurance (CDI), and possibly DMHC, to reopen regulations related to network adequacy. If this is the case, there would be additional legal and regulatory costs to both departments.

COMMENTS:

1. Purpose. According to the author, as people living with HIV have entered managed care instead of relying on the network of Ryan White CARE Act providers who are HIV specialists, access to HIV specialists has dwindled. People with HIV often do not have access to providers who are well suited to provide medical care for this unique medical condition. They state HIV specialty is a recognized discipline with national certification standards that physicians meet to be designated an HIV specialist. The sponsor, AIDS Healthcare Foundation, notes that health plans and health insurers have, instead of contracting with HIV specialists, relied on infectious disease specialists to meet their obligation to ensure that people with HIV have appropriate access to specialty medical care.
2. Background. HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. According to CHBRP, there are about 900 of these providers statewide. Other providers may care for people with HIV, including infectious disease specialists and primary care providers.
3. Existing Access Requirements. In California, a primary care physician is defined as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician is either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, OB/GYN, or family practitioner.

A specialist is defined as a physician who is board certified or board eligible in the specialty of medical care provided. Additionally, regulations require health plans to provide accessibility to all medically necessary specialists and designate specialists as allergy, anesthesiology, dermatology, cardiology and other internal medicine specialists, neonatology, neurology, oncology, ophthalmology, orthopedics, pathology, psychiatry, radiology, surgeries, otolaryngology, urology, and others designated as appropriate. Existing law requires health plans to make standing referrals to specialists when medically necessary. Plans are not required to refer out of network, unless there is no contracting specialist in that discipline within the plan’s network — in which case the plan would have to cover an out-of-network specialist referral.

Regulations also require that there are adequate full-time equivalents of primary care and specialist providers in the network accepting new patients. They also stipulate access standards for primary and specialty visits. Persons living with HIV have a standing order for HIV specialty care—they do not need a referral to access such care.

1. Support. AIDS Healthcare Foundation (AHF), the sponsor of this bill, notes health plans and insurers have relied on infectious disease specialists to meet their obligation to ensure that people with HIV have appropriate access to specialty medical care. AHF contends that while all HIV specialists are infectious disease specialists, most infectious disease specialists are not HIV specialists and do not have training or experience to treat this condition.
2. Opposition. California Association of Health Plans (CAHP), the Association of California Life and Health Insurance Companies, and America’s Health Insurance Plans contend that health insurance mandates threaten efforts of all health care stakeholders to provide consumers with meaningful health care choices and affordable coverage options. Additionally, CAHP notes that a person with HIV currently benefits from a standing order for care that is provided by an HIV specialist, infectious disease specialist of pulmonary/critical care specialists. CAHP also notes that not all areas of the state have HIV specialists, but may have other specialists qualified to treat HIV, and with a shortage of HIV specialists available, it may be difficult for health plans to implement the statewide mandate.
3. Staff Comments. Allowing HIV specialists to be primary care providers pursuant to this bill's standards does not generate fiscal concern, but applying specialist standards would likely have a significant fiscal impact. Evidence of a widespread problem with quality of HIV care under current law has not been demonstrated. The intent of the language related to specialty standards appears to be to ensure the more stringent primary care timely access standards do not apply to HIV specialists working as primary care providers. This language could be clarified to remove what appears to be a newly created standard for HIV specialists.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 19, 2016

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2372

Author:(Burke) – As Amended Ver:April 13, 2016

SUBJECT: Health care coverage: HIV specialists.

SUMMARY: Designates an Human immunodeficiency virus (HIV) specialist as an eligible primary care provider (PCP). Specifically, this bill:

1. Requires a health care service plan (health plan) or health insurance policy (health policy) that is issued, amended, or renewed on or after January 1, 2017, that provides hospital, medical or surgical coverage, to include HIV specialists as an eligible PCP, provided that the provider requests inclusion and meets the health plan or health insurer’s eligibility criteria for all specialists seeking PCP status.
2. Defines a PCP as a physician, or a non-physician provider who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Provides that this means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychological issues.
3. Clarifies that accessibility to HIV specialists is subject to existing regulations and will be included in the reports and other information required under existing law.
4. Defines an HIV specialist as a physician or a nurse practitioner who meets the criteria for an HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990, as specified.
5. Excludes specialized health care service plans from this bill’s requirements.

EXISTING LAW:

1. Regulates health plans under the Knox-Keene Health Care Service Plan Act of 1975 through the Department of Managed Health Care (DMHC) and regulates health insurers under the Insurance Code through the California Department of Insurance (CDI).
2. Requires every health plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state, to include obstetrician-gynecologists (OB/GYNs) as eligible primary care physicians, provided they meet the plan’s eligibility criteria for all specialists seeking primary care physician status.
3. Defines a PCP as a physician, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Includes in this definition, providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
4. Requires the Insurance Commissioner to promulgate regulations applicable to health insurers that contract with providers for alternative rates for group policy holders to ensure that insureds have the opportunity to access needed health care services in a timely manner, as specified.
5. Requires that every policy of disability insurance that covers hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed in this state to include OB/GYNs as eligible primary care physicians provided they meet the insurer’s written eligibility criteria for all specialists seeking primary care physician status.
6. Requires health plans to provide PCP access to all enrollee within 30 minutes or 15 miles, as specified.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. While health plans currently include infectious disease specialists in their provider networks, not all infectious disease specialists are HIV specialists. Studies have shown that patients with HIV who are managed by clinicians with greater HIV experience and expertise have better health outcomes and receive more appropriate and cost-effective care. By clearly defining access to HIV specialists in statute, including them in the category of specialty physicians, and allowing HIV specialists to serve as PCPs for their patients, we can ensure that patients receive the care they need.
   
   Additionally, the author states that prior to the advent of the Patient Protection and Affordable Care Act (ACA), HIV specialty care was frequently provided by professionals who were contracted under the Ryan White CARE Act. As a result, a network of providers grew across the country, ensuring reasonable access to specialists who knew how to treat a person with HIV. Following the implementation of the ACA, health plans have generally relied upon infectious disease specialists to meet their obligation to ensure that people with HIV have appropriate access to specialty medical care. While all HIV specialists are infectious disease specialists, most infectious disease specialists are not HIV specialists and do not have the training or experience to treat the complex and unique needs of patients living with HIV. As a result, the network of Ryan White CARE Act providers who are HIV specialists and available to plan beneficiaries has dwindled. People with HIV often do not have access to providers who are well suited to provide medical care for this unique medical condition. HIV specialty is a recognized discipline with national certification standards that physicians meet to be designated an HIV specialist.
   
2. BACKGROUND. California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on essential health benefits (EHBs), and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics.  In its analysis of this bill, CHBRP found the following:
   1. Enrollees Covered. CHBRP estimates that in 2016, 25.2 million Californians have state-regulated coverage that would be subject to this bill.
   2. Benefit Coverage. This bill does not alter benefit coverage, but could increase enrollees’ choice of type of PCPs who are HIV specialists.
   3. Utilization. CHBRP is unable to estimate enrollee utilization of designating an HIV specialist as a PCP.
   4. Impact on expenditures. Unknown.
   5. EHBs. This bill does not expand or mandate coverage for services; the bill allows for HIV specialists to be designated as PCPs.
   6. Medical effectiveness. The preponderance of evidence from moderate to strong studies also indicates that care provided by physicians with more experience and expertise with HIV results in worse outcomes for non-acquired immunodeficiency syndrome (AIDS) comorbidities, such as diabetes and hypertension, than care provided by physicians with less experience/expertise in HIV.
   7. Public health. There appear to be more than 800 HIV specialists (some of whom are AAHVIM credentialed and many more who likely meet this bill’s definition of specialist) who treat some of the 120,000 people living with HIV (PLWH) in California. However, the use of primary care services provided by HIV specialists and the resulting health outcomes for PLWH is unknown.
      
3. CHBRP BACKGROUND. HIV attacks the body’s immune system, specifically the CD4 cells (T cells) that fight infections, thus greatly increasing the risk of opportunistic diseases. HIV infection leads to acquired immunodeficiency syndrome (AIDS) if left untreated. Due to advances in drug treatment, HIV/AIDS has progressed from an acute illness with a high mortality rate to a manageable chronic illness where patients achieve close to normal life expectancy.
   
   HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. (See Policy Context for description of credentialing.) PLWH may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center. Additionally, PLWH (especially those who are underinsured or uninsured, and thus not subject to this bill) may seek care at the clinics funded through the Ryan White CARE Act. These clinics were foundational to the control of the AIDS epidemic in the early 1990s, through their provision of HIV treatment and management.
   
4. DEFINITIONS OF SPECIALTY PHYSICIAN. The CHBRP analysis sets forth the HIV specialist designation according to the bill: the published criteria established by AAHIVM; the HIV Medicine Association; or, a provider who is contracted to provide outpatient medical care under the federal Ryan White CARE Act.
   
5. EXISTING CALIFORNIA LAW AND REGULATIONS. In California, primary care physicians are defined as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician is either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, OB/GYN, or family practitioner. Specialists are defined as a physician who is board certified or board eligible in the specialty of medical care provided. Additionally, regulations require health plans to provide accessibility to all medically necessary specialists and designate specialists as allergy, anesthesiology, dermatology, cardiology and other internal medicine specialists, neonatology, neurology, oncology, ophthalmology, orthopedics, pathology, psychiatry, radiology, surgeries, otolaryngology, urology, and others designated as appropriate. Existing law requires health plans to make standing referrals to specialists when medically necessary. Plans are not required to refer out of network, unless there is no contracting specialist in that discipline within the plan’s network — in which case the plan would have to cover an out-of-network specialist referral. Existing law specifically recognizes HIV/AIDS as a specialty as defined by the federal government or a national voluntary health organization. Regulations also require that there are adequate full-time equivalents of primary care and specialist providers in the network accepting new patients covered by the policy to accommodate anticipated enrollment growth.
   
6. SIMILAR REQUIREMENTS IN OTHER STATES. CHBRP is aware of two other states that have regulations regarding the definition of an HIV specialist similar to those proposed in this bill. New York law requires that managed care organizations provide treatment for those on HIV Special Needs Plans (SNPs) by HIV specialists. An HIV specialist is defined by the New York State Department of Health AIDS Institute; the result of an expert panel. Maryland, in its administrative code, requires that health insurers cover treatment by HIV/AIDS specialists. An HIV specialist must either have an American Board of Medical Specialties certification in infectious diseases, or have performed a minimum amount of HIV care and completed an HIV education requirement, which can be filled by passing the American Academy of HIV Medicine credentialing exam.
7. SUPPORT. AIDS Healthcare Foundation (AHF) notes that health plans and health insurers have relied on infectious disease specialists to meet their obligation to ensure that people with HIV have appropriate access to specialty medical care. AHF contends that while all HIV specialists are infectious disease specialists, most infectious disease specialists are not HIV specialists and do not have training or experience to treat this condition. AHF states that the HIV specialist becomes a patient’s de facto PCP in that the HIV specialist will be by the patient’s side for the rest of his or her life, however because not designated as a PCP, cannot order tests, make referrals to other specialists, or any of the other services a PCP can provide. AHF raises concerns with the flu vaccine in that a PCP without the expertise of an HIV specialist could order a partial live virus flu vaccine for a person without being aware of the consequences. AHF also notes that this bill’s proposal regarding the definition of an HIV specialist is consistent with state regulations and aligns with a longstanding federal contracting process and with national discipline bodies. Additionally similar to OB/GYN as PCPs, AHF states that a similar situation, similar limitations that affect the quality of medical care are occurring with HIV specialists.
8. OPPOSITION. California Association of Health Plans (CAHP), the Association of California Life and Health Insurance Companies, and America’s Health Insurance Plans contend that health insurance mandates threaten efforts of all health care stakeholders to provide consumers with meaningful health care choices and affordable coverage options. They state that the ACA requires the state to pay for the increased cost associated with the mandate for those enrollees who purchase health insurance on the Exchange. They also state that benefit mandates eliminate the ability of health insurers and HMOs to provide unique benefit packages aimed at the needs of consumers by requiring individuals and employers to purchase benefits prescribed by the Legislature, not driven by consumer choice. Finally, they note that health benefit mandates stifle the use of innovative, evidence based medicine.

CAHP additionally states that this bill will hinder a health plan’s ability to meet network adequacy requirements since network requirements are more stringent for PCPs than for specialists, including specific time and distance standards. CAHP states that HIV specialists may not meet PCP qualifications, established by delegated medical groups in certain instances, and therefore the health plan may not be able to comply with this bill. Additionally, CAHP notes that a person with HIV currently benefits from a standing order for care that is provided by an HIV specialist, infectious disease specialist of pulmonary/critical care specialists. CAHP also notes that not all areas of the state have HIV specialists, but may have other specialists qualified to treat HIV, and with a shortage of HIV specialists available, it may be difficult for health plans to implement the statewide mandate. Finally CAHP states that this bill is similar to the existing OB/GYN mandate and at the time, regulators required health plans with delegated medical groups to reach out to every OB/GYN in their network and invite them to be a PCP. CAHP states that it will be difficult for health plans to comply with the time and distance standards for PCPs due to the limited number of HIV specialists throughout the state.

1. PREVIOUS LEGISLATION. AB 2168 (Gallegos), Chapter 426, Statutes of 2000, requires standing referrals to an HIV specialist.
2. POLICY COMMENT. This bill designates an HIV specialist as eligible PCPs. Under existing law, PCPs are subject to specific network adequacy requirements with respect to geographic access and availability. Consequentially, health plans may not be able to meet these PCP network adequacy requirements especially for enrollees in rural areas.

REGISTERED SUPPORT / OPPOSITION:

Support

AIDS Healthcare Foundation (sponsor)

Opposition

America’s Health Insurance Plans

Association of California Life and Health Insurance Companies

California Association of Health Plans

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097

Date of Hearing: April 12, 2016

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Rudy Salas, Chair

ABPCA Bill Id:AB 2372

Author:(Burke) – As Introduced Ver:February 18, 2016

NOTE: This bill is double-referred, and if passed by this Committee, it will be referred to the Assembly Committee on Health.

SUBJECT: Health care coverage: HIV specialists.

SUMMARY: Requires a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2017, to include a HIV specialist, as defined, as an eligible primary care physician, provided that the physician meets the plan’s or health insurer’s eligibility criteria for all specialists seeking primary care physician status.

EXISTING LAW:

1. Requires the Department of Managed Health Care (DMHC) to adopt regulations to ensure that enrollees have access to needed health care services in a timely manner, as specified. (Health and Safety Code (HSC) § 1367.03)
2. Provides that every health care service plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state, shall include obstetrician-gynecologists as eligible primary care physicians, provided they meet the plan’s eligibility criteria for all specialists seeking primary care physician status. (HSC § 1367.69(a))
3. Defines, for purposes of this section, “primary care physician” as a physician, as defined in the Welfare and Institutions Code (WIC) § 14254, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. (HSC § 1367.69(b))
4. Requires the Insurance Commissioner to promulgate regulations applicable to health insurers that contract with providers for alternative rates for group policy holders to ensure that insureds have the opportunity to access needed health care services in a timely manner, as specified. (Insurance (INS) § 10133.5)
5. Provides that every policy of disability insurance that covers hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed in this state shall include obstetrician-gynecologists as eligible primary care physicians provided they meet the insurer’s written eligibility criteria for all specialists seeking primary care physician status. (INS § 10123.83(a))
6. Defines, for purposes of this section, “primary care physician” as a physician, as defined in WIC § 14254, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. (INS § 10123.83(b))

THIS BILL:

1. Defines “specialty physician,” for purposes of the DMHC’s access regulations under HSC § 1367.03, as including a physician who meets the criteria for a HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).
2. Provides that every health care service plan contract that is issued, amended, or renewed on or after January 1, 2017, that provides hospital, medical, or surgical coverage shall include a HIV specialist as an eligible primary care physician, provided he or she meets the health care service plan’s eligibility criteria for all specialists seeking primary care physician status.
3. Defines, for purposes of this section, “primary care physician” as a physician, as defined in WIC § 14254, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
4. Defines, for purposes of this section, “HIV specialist” as a physician or a nurse practitioner who meets the criteria for a HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).
5. Defines, for purposes of the Insurance Commissioners group policy access regulations, “professional provider” as a physician who meets the criteria for a HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).
6. Provides that every health insurance policy that is issued, amended, or renewed on or after January 1, 2017, that provides hospital, medical, or surgical coverage shall include a HIV specialist as an eligible primary care physician, provided he or she meets the health insurer’s eligibility criteria for all specialists seeking primary care physician status.
7. Defines, for purposes of this section, “primary care physician” as a physician, as defined in WIC § 14254, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
8. Defines, for purposes of this section, “HIV specialist” as a physician or a nurse practitioner who meets the criteria for a HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the AIDS Healthcare Foundation. According to the author, “Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. While health plans currently include infectious disease specialists in their provider networks, not all infectious disease specialists are HIV specialists. Studies have shown that patients with HIV who are managed by clinicians with greater HIV experience and expertise have better health outcomes and receive more appropriate and cost-effective care. By clearly defining access to HIV specialists in statute, including them in the category of specialty physicians, and allowing HIV specialists to serve as primary care providers for their patients, we can ensure that patients receive the care they need.”

Background. Existing law requires health plans and health insurance carriers to meet network adequacy standards, which ensure that beneficiaries and insured individuals have timely access to care, including access to medically-necessary specialists. According to the sponsor, there has been an issue with health plans relying upon infectious disease specialists to meet their network needs. The sponsor notes that, while “all HIV specialists are infectious disease specialists, most infectious disease specialists are not HIV specialists and do not have the training or experience to treat the complex and unique needs of patients living with HIV.” As a result, this bill seeks to do two things: 1) require a health plan to use a qualified HIV specialist as a PCP, and 2) include HIV specialist physicians as a category of specialty physicians for purposes of network adequacy.

HIV Specialist as a PCP. According to the author, “because of the unique and life-long care provided by HIV specialists, many of them become the patient’s de facto primary care physician. However, because the plans do not recognize them as a PCP, the HIV specialist cannot order tests, make referrals to other specialists or any of the other services a PCP can provide, even though the plan PCP provided to the person with HIV does nothing more than act as a proxy for the HIV specialist when authorizing services for the patient with HIV.”

To resolve the issue, this bill would require that health plans and health insurance policies allow a HIV specialist to serve as a primary care physician if the specialist meets the health plan or carrier’s requirements for a PCP. Because a physician’s scope of practice is unlimited, it would be up to the individual specialist to determine whether serving as a HIV patient’s primary care physician is within the specialist’s competence.

CHBRP Analysis. Because this bill creates a health plan mandate, it is currently under review by the California Health Benefits Review Program (CHBRP). The CHBRP responds to requests from the State Legislature to provide independent analysis of the medical, financial, and public health impacts of proposed health insurance benefit mandates and repeals. The CHBRP analysis is expected to be completed by the time this bill is heard in the Assembly Health Committee.

Prior Related Legislation. AB 2168 (Gallegos), Chapter 426, Statutes of 2000, required health plans to develop procedures for standing referrals to an HIV specialist.

AB 2493 (Speier), Chapter 759, Statutes of 1995, required that health care service plan contracts, nonprofit hospital service plan contracts, and disability insurance policies, that cover hospital, medical, or surgical expenses, issued, amended, delivered, or renewed in this state , include obstetrician-gynecologists as primary care physicians or providers, as defined, provided they meet certain eligibility criteria.

IMPLEMENTATION ISSUES:

One of the goals of the bill is to include nurse practitioners (NPs) as HIV specialists eligible for inclusion as primary care physicians. However, because NPs are not physicians as defined under WIC § 14254, the bill as written does not include them.

AMENDMENTS:

To address the implementation issue mentioned above, and provide additional clarity, the author should make the following amendments:

1. Strike all references to “primary care physician” and replace with “primary care provider.”
2. Add “or a nonphysician medical practitioner, as defined in Section 14254 of the Welfare and Institutions Code” to the definition of “primary care provider.”
3. Include additional clarifying language specifying that a HIV specialist must meet a health plan’s network criteria for inclusion as primary care provider before the health plan is required to include the specialist.

REGISTERED SUPPORT:

AIDS Healthcare Foundation (sponsor)

REGISTERED OPPOSITION:

None on file.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301