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Do You Have a PCP? - Are You Sure?

THE CONTINUITY OF CARE BILL OF 2000
by
Charles Goodman, MD, FAAP
Harvey S. Frey MD, PhD, Esq.

A Bill to: Amend Health and Safety Code Sections 1373.65(a) and (b) add Health and Safety Code Section 1373.65(e)

THE PEOPLE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1. The Legislature finds and declares as follows:

(a) Health care service plans (HCSPs) using the "Gatekeeper" model require that all referrals for procedures not performed by the "Primary Care Physician" (PCP) requiring specialists be approved by the PCP.

(b) When an enrollee has not chosen or been assigned a PCP, or his PCP has ceased to be affiliated with the HCSP, the medical group or individual practice association, significant and dangerous delays in needed referrals may occur.

(c) Failure to designate a PCP may be to the financial benefit of a HCSP, both through fewer referrals, and savings in capitation costs.

(d) Countervailing financial incentives must be applied by statute.

SECTION 2.

(a) Health and Safety Code Section 1373.65 (a) is amended to read:

(a) Thirty days prior to the termination, for any reason, of a contract with a medical group, individual practice association, or individual provider, the plan shall provide written notice of the termination to all enrollees who are at that time receiving a course of treatment from the provider, or any providers of the medical group or individual practice association, or are designated as having selected that individual provider, or a provider of the medical group or individual practice association, as their gatekeeper.
The notice shall include instructions on selecting a new gatekeeper.

(b) Thirty days prior to the termination, for any reason, of a contract with a provider, a medical group or individual practice association shall provide written notice of the termination to the contracting HCSP and to all enrollees who are at that time receiving a course of treatment from the provider, or are designated as having selected that provider as their gatekeeper. The notice to enrollees shall include instructions on selecting a new gatekeeper.

(c) Health and Safety Code Section 1373.65 (e) is added to read: (e)

(1) A "gatekeeper" is defined for purposes of this section (1373.65 ) as a primary care provider (PCP) whose initiation or approval of referrals of an enrollee to specialists and for procedures not performed by the PCP is required by the health care service plan (HCSP) before it will authorize such referrals.

(2) If an enrollee has no assigned gatekeeper either because
(i) enrollee has not been notified, as required above, that his prior gatekeeper has ceased to be affiliated with the HCSP, individual practice association or medical group, or
(ii) enrollee has failed to choose a gatekeeper after notice, and HCSP has not assigned enrollee a gatekeeper within 30 days of such notice, then requirement for gatekeeper initiation or approval of referrals shall be waived by the HCSP, and all self-referrals within the HCSP network shall be approved, until a gatekeeper is chosen or assigned.

(3) If an enrollee has no assigned gatekeeper as in section (2) above, any enrollee copayment for emergency visits, in or out of the HCSP's network, which would appear reasonable to a prudent layman, shall be waived.

(4) All notification and assignments would be by way of US mail. If the enrollee's plan is paid for in any part by his employer, said employer shall receive simultaneous notification.

(5) In the event the HCSP is unable to contact the enrollee as evidenced by returned, undeliverable US mail, it shall attempt contact by phone. If this is also unsuccessful, the HCSP shall notify the enrollee upon the first subsequent contact the enrollee initiates with the HCSP.

Return to: Do You Have a PCP? - Are You Sure?
by Charles Goodman, M.D.
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