2010 California Code
Health and Safety Code
Article 2. Emergency Physician Fair Pricing Policies

127450.  As used in this article, the following terms have the
following meanings:
   (a) "Allowance for financially qualified patient" means, with
respect to emergency care rendered to a financially qualified
patient, an allowance that is applied after the emergency physician's
charges are imposed on the patient, due to the patient's determined
financial inability to pay the charges.
   (b) "Emergency care" means emergency medical services and care, as
defined in Section 1317.1, that is provided by an emergency
physician in the emergency department of a hospital.
   (c) "Emergency physician" means a physician and surgeon licensed
pursuant to Chapter 2 (commencing with Section 2000) of the Business
and Professions Code who is credentialed by a hospital and either
employed or contracted by the hospital to provide emergency medical
services in the emergency department of the hospital, except that an
"emergency physician" shall not include a physician specialist who is
called into the emergency department of a hospital or who is on
staff or has privileges at the hospital outside of the emergency
department.
   (d) "Federal poverty level" means the poverty guidelines updated
periodically in the Federal Register by the United States Department
of Health and Human Services under authority of subsection (2) of
Section 9902 of Title 42 of the United States Code.
   (e) "Financially qualified patient" means a patient who is both of
the following:
   (1) A patient who is a self-pay patient or a patient with high
medical costs.
   (2) A patient who has a family income that does not exceed 350
percent of the federal poverty level.
   (f) "Hospital" means a facility that is required to be licensed
under subdivision (a) of Section 1250, except a facility operated by
the State Department of Mental Health or the Department of
Corrections and Rehabilitation.
   (g) "Office" means the Office of Statewide Health Planning and
Development.
   (h) "Self-pay patient" means a patient who does not have
third-party coverage from a health insurer, health care service plan,
Medicare, or Medicaid, and whose injury is not a compensable injury
for purposes of workers' compensation, automobile insurance, or other
insurance as determined and documented by the emergency physician.
Self-pay patients may include charity care patients.
   (i) "A patient with high medical costs" means a person whose
family income does not exceed 350 percent of the federal poverty
level if that individual does not receive a discounted rate from the
emergency physician as a result of his or her third-party coverage.
For these purposes, "high medical costs" means any of the following:
   (1) Annual out-of-pocket costs incurred by the individual at the
hospital that provided emergency care that exceed 10 percent of the
patient's family income in the prior 12 months.
   (2) Annual out-of-pocket expenses that exceed 10 percent of the
patient's family income, if the patient provides documentation of the
patient's medical expenses paid by the patient or the patient's
family in the prior 12 months. The emergency physician may waive the
request for documentation.
   (3) A lower level determined by the emergency physician in
accordance with the emergency physician's discounted payment policy.
   (j) "Patient's family" means the following:
   (1) For persons 18 years of age and older, spouse, domestic
partner, as defined in Section 297 of the Family Code, and dependent
children under 21 years of age, whether living at home or not.
   (2) For persons under 18 years of age, parent, caretaker
relatives, and other children under 21 years of age of the parent or
caretaker relative.


127451.  A violation of this article shall not constitute a
violation of the terms of a physician and surgeon's licensure.



127452.  (a) Uninsured patients or patients with high medical costs
who are at or below 350 percent of the federal poverty level shall be
eligible to apply to an emergency physician for a discount payment
pursuant to a discount payment policy. Notwithstanding any other
provision of this article, an emergency physician may choose to grant
eligibility for a discount payment policy to patients with incomes
over 350 percent of the federal poverty level.
   (b) An emergency physician shall limit expected payment for
services provided to a patient at or below 350 percent of the federal
poverty level and who is eligible under the emergency physician's
discount payment policy to an amount that is no greater than 50
percent of the median of billed charges based on a nationally
recognized database of physician and surgeon charges until the
nonprofit FAIR Health, Inc. creates a database that makes available
the rate of payment received by physician and surgeons from
commercial insurers for the same services in the same or similar
geographic region. When FAIR Health, Inc. makes available the rate of
payment received by physicians and surgeons from commercial insurers
for the same services in the same or similar geographic region, the
amount of expected payment under this section shall be no greater
than the median or average of rates paid by commercial insurers for
the same or similar services in the same or similar geographic
region.
   (c) (1) If an emergency physician seeks reimbursement from the
Maddy Fund pursuant to Section 1797.98c, then the emergency physician
shall, at that time, cease any further billing or collection
activity for that patient.
   (2) If the emergency physician does not receive reimbursement from
the Maddy Fund after attempting to obtain reimbursement from the
Maddy Fund, then the provisions of this article shall apply.
   (3) If the emergency physician does not attempt to seek
reimbursement from the Maddy Fund, the provisions of this article
shall apply.
   (d) A patient, or patient's legal representative, who requests a
discounted payment or other assistance in meeting his or her
financial obligation to the emergency physician shall make every
reasonable effort to provide the emergency physician with
documentation of income and health benefits coverage, if the
emergency physician requests the documentation. If the patient, or
the patient's legal representative, requests a discounted payment and
fails to provide information that is reasonable and necessary for
the emergency physician to make a determination, the emergency
physician may consider that failure in making its determination.
   (1) For purposes of determining eligibility for discounted
payment, the emergency physician may rely on the determination made
by the hospital at which emergency care was provided. If the
emergency physician chooses to make a separate determination of
eligibility for discounted payment, documentation of income shall be
limited to recent pay stubs or income tax returns. The emergency
physician, at his or her discretion, may accept self-attestation by a
patient, or a patient's legal representative, but shall not request
documentation of income other than that authorized in this paragraph.
   (2) Information obtained pursuant to paragraph (1) shall not be
used for collections activities. This paragraph does not prohibit the
use of information obtained by the emergency physician, collection
agency, or assignee independent of the eligibility process for
discounted payment.
   (3) Eligibility for discounted payments may be determined at any
time the emergency physician is in receipt of information specified
in paragraph (1) or (2), respectively.



127454.  (a) Each emergency physician shall make all reasonable
efforts to obtain from the patient, or his or her representative,
information about whether private or public health insurance or
sponsorship may fully or partially cover the charges for emergency
care rendered by the emergency physician to a patient, including, but
not limited to, any of the following:
   (1) Private health insurance.
   (2) Medicare.
   (3) The Medi-Cal program, the Healthy Families Program, the
California Children's Services Program, or other publicly funded
programs designed to provide comprehensive health coverage.
   (b) If the emergency physician or his or her representative bills
a patient who has not provided proof of coverage by a third party at
the time the care is provided or upon discharge, as a part of that
billing, the emergency physician shall provide the patient with a
clear and conspicuous notice that includes all of the following:
   (1) A statement of charges for services rendered by the emergency
physician.
   (2) A request that the patient inform the emergency physician if
the patient has health insurance coverage, Medicare, Healthy
Families, Medi-Cal, or other coverage.
   (3) A statement that if the consumer does not have health
insurance coverage, the consumer may be eligible for Medicare,
Healthy Families, Medi-Cal, California Children's Services Program,
or discounted payment care.
   (4) Information regarding the financially qualified patient and
discounted payment application, including the following:
   (A) A statement that indicates that if the patient lacks, or has
inadequate, insurance, and meets certain low-and moderate-income
requirements, the patient may qualify for discounted payment.
   (B) The name and telephone number of the emergency physician's
employee or office from whom or which the patient may obtain
information about the emergency physician's discount payment policy,
and how to apply for that assistance.
   (c) (1) In addition to the statement of the charges, if the
emergency physician's uses the following notice in any billing, that
emergency physician shall be deemed to have complied with the notice
requirements of this section: "If you are uninsured or have high
medical costs, please contact ____ (name of person responsible for
discount payment policy) at ____ (area code and phone number) for
information on discounts and programs for which you may be eligible,
including the Medi-Cal program. If you have coverage, please tell us
so that we may bill your plan."
   (2) If the emergency physician or the assignee of the emergency
physician lacks the capacity to provide the notice specified in
paragraph (1), the emergency physician or his or her assignee shall
be deemed to have complied with the notice requirements of this
section if the information required under this section is provided
upon request and if the following is printed on the bill in 14-point
bold type: "If uninsured or high medical bill, call re: discount."



127455.  (a) Each emergency physician shall have a written policy
about when and under whose authority patient debt is advanced for
collection.
   (b) Each emergency physician shall establish a written policy
defining standards and practices for the collection of debt, and
shall obtain a written agreement from any agency that collects
emergency physician receivables that it will adhere to the emergency
physician's standards and scope of practice. The policy shall not
conflict with other applicable laws and shall not be construed to
create a joint venture between the emergency physician and the
external entity, or otherwise to allow physician and surgeon
governance of an external entity that collects physician and surgeon
receivables. In determining the amount of a debt the emergency
physician may seek to recover from patients who are eligible under
the emergency physician's charity care policy or discount payment
policy, the emergency physician may consider only income and monetary
assets as limited by Section 127452.
   (c) For a patient that lacks coverage, or for a patient that
provides information that he or she may be a patient with high
medical costs, the emergency physician, any assignee of the emergency
physician, or other owner of the patient debt, including a
collection agency, shall not report adverse information to a consumer
credit reporting agency or commence civil action against the patient
for nonpayment at any time prior to 150 days after initial billing.
   (d) If a patient is attempting to qualify for eligibility under
the emergency physician's discount payment policy and is attempting
in good faith to settle an outstanding bill with the physician and
surgeon by negotiating a reasonable payment plan or by making regular
partial payments of a reasonable amount, the emergency physician or
his or her assignee, including a collection agency, shall not report
adverse information to a consumer credit agency or commence a civil
action unless that entity has agreed to comply with this article.
   (e) (1) The emergency physician or other assignee shall not, in
dealing with patients eligible under the emergency physician's
discount payment policies, use wage garnishments or liens on primary
residences as a means of collecting unpaid emergency physician bills.
   (2) A collection agency or other assignee shall not, in dealing
with any patient under the emergency physician's discount payment
policy, use as a means of collecting unpaid emergency physician
bills, any of the following:
   (A) A wage garnishment, except by order of the court upon noticed
motion, supported by a declaration filed by the movant identifying
the basis for its belief that the patient has the ability to make
payments on the judgment under the wage garnishment, that the court
shall consider in light of the size of the judgment and additional
information provided by the patient prior to, or at, the hearing
concerning the patient's ability to pay, including information about
probable future medical expenses based on the current condition of
the patient and other obligations of the patient.
   (B) Notice or conduct a sale of the patient's primary residence
during the life of the patient or his or her spouse, or during the
period a child of the patient is a minor, or a child of the patient
who has attained the age of majority is unable to take care of
himself or herself and resides in the dwelling as his or her primary
residence. In the event a person protected by this paragraph owns
more than one dwelling, the primary residence shall be the dwelling
that is the patient's current homestead, as defined in Section
704.710 of the Code of Civil Procedure or was the patient's homestead
at the time of the death of a person other than the patient who is
asserting the protections of this paragraph.
   (3) This requirement does not preclude the emergency physician,
collection agency, or other assignee from pursuing reimbursement and
any enforcement remedy or remedies from third-party liability
settlements, tortfeasors, or other legally responsible parties.
   (f) Any extended payment plans offered by an emergency physician
to assist patients eligible under the emergency physician's discount
payment policy or any other policy adopted by the emergency physician
for assisting low-income patients with no insurance or high medical
costs in settling outstanding past due emergency physician bills,
shall be interest free. The emergency physician's extended payment
plan may be declared no longer operative after the patient's failure
to make all consecutive payments due during a 90-day period. Before
declaring the emergency physician's extended payment plan no longer
operative, the emergency physician, collection agency, or assignee
shall make a reasonable attempt to contact the patient by telephone,
if the telephone number is known, and to give notice in writing that
the extended payment plan may become inoperative, and of the
opportunity to renegotiate the extended payment plan. Prior to the
emergency physician's extended payment plan being declared
inoperative, the emergency physician, collection agency, or assignee
shall attempt to renegotiate the terms of the defaulted extended
payment plan, if requested by the patient. The emergency physician,
collection agency, or assignee shall not report adverse information
to a consumer credit reporting agency or commence a civil action
against the patient or responsible party for nonpayment prior to the
time the extended payment plan is declared to be no longer operative.
For purposes of this section, the notice and telephone call to the
patient may be made to the last known telephone number and address of
the patient.
   (g) Nothing in this section shall be construed to diminish or
eliminate any protections consumers have under existing federal and
state debt collection laws, or any other consumer protections
available under state or federal law. If the patient fails to make
all consecutive payments for 90 days and fails to renegotiate a
payment plan, this subdivision does not limit or alter the obligation
of the patient to make payments on the obligation owing to the
emergency physician pursuant to any contract or applicable statute
from the date that the extended payment plan is declared no longer
operative, as set forth in subdivision (f).



127456.  (a) The period described in Section 127455 shall be
extended if the patient has a pending appeal for coverage of the
services, until a final determination of that appeal is made, if the
patient makes a reasonable effort to communicate with the emergency
physician about the progress of any pending appeals.
   (b) For purposes of this section, "pending appeal" includes any of
the following:
   (1) A grievance against a contracting health care service plan, as
described in Chapter 2.2 (commencing with Section 1340) of Division
2, or against an insurer, as described in Chapter 1 (commencing with
Section 10110) of Part 2 of Division 2 of the Insurance Code.
   (2) An independent medical review, as described in Section 10145.3
or 10169 of the Insurance Code.
   (3) A fair hearing for a review of a Medi-Cal claim pursuant to
Section 10950 of the Welfare and Institutions Code.
   (4) An appeal regarding Medicare coverage consistent with federal
law and regulations.



127457.  (a) After the period described in Section 127455, and upon
the completion of appeals consistent with Section 127456, prior to
commencing further collection activities against a patient, the
emergency physician, any assignee of the emergency physician, or
other owner of the patient debt, including a collection agency, shall
not report adverse information to a consumer credit reporting agency
or commence a civil action, until after the patient has been
provided with a clear and conspicuous written notice containing both
of the following:
   (1) A plain language summary of the patient's rights pursuant to
this article, the Rosenthal Fair Debt Collection Practices Act (Title
1.6C (commencing with Section 1788) of Part 4 of Division 3 of the
Civil Code), and the federal Fair Debt Collection Practices Act
(Subchapter V (commencing with Section 1692) of Chapter 41 of Title
15 of the United States Code). The summary shall include a statement
that the Federal Trade Commission enforces the federal act. The
summary shall be sufficient if it appears in substantially the
following form: "State and federal law require debt collectors to
treat you fairly and prohibit debt collectors from making false
statements or threats of violence, using obscene or profane language,
and making improper communications with third parties, including
your employer. Except under unusual circumstances, debt collectors
may not contact you before 8 a.m. or after 9 p.m. In general, a debt
collector may not give information about your debt to another person,
other than your attorney or spouse. A debt collector may contact
another person to confirm your location or to enforce a judgment. For
more information about debt collection activities, you may contact
the Federal Trade Commission by telephone at 1-877-FTC-HELP
(382-4357) or online at www.ftc.gov."
   (2) A statement that nonprofit credit counseling services may be
available in the area.
   (b) The notice required by subdivision (a) shall also accompany
any document indicating that the commencement of collection
activities may occur.
   (c) The requirements of this section shall apply to the entity
engaged in reporting adverse information to a consumer credit
reporting agency or commencing a civil action against the patient. If
an emergency physician assigns or sells the debt to another entity,
the obligations shall apply to the entity, including a collection
agency, engaged in the debt collection activity.



127458.  The emergency physician shall reimburse the patient or
patients any amount actually paid in excess of the amount due under
this article, including interest. Interest owed by the emergency
physician to the patient shall accrue at the rate set forth in
Section 685.010 of the Code of Civil Procedure, beginning on the date
payment by the patient is received by the emergency physician.
However, an emergency physician is not required to reimburse the
patient or pay interest if the amount due is less than five dollars
($5). The emergency physician shall give the patient a credit for the
amount due for at least 60 days from the date the amount is due.




127459.  The rights, remedies, and penalties established by this
article are cumulative, and shall not supersede the rights, remedies,
or penalties established under other laws.



127460.  Nothing in this article shall be construed to prohibit the
emergency physician from uniformly imposing charges from its
established charge schedule or published rates, nor shall this
article preclude the recognition of an emergency physician's
established charge schedule or published rates for purposes of
applying any payment limit, interim payment amount, or other payment
calculation based upon an emergency physician's rates or charges
under the Medi-Cal program, the Medicare Program, workers'
compensation, or other federal, state, or local public program of
health benefits. No health care service plan, insurer, or any other
person shall reduce the amount it would otherwise reimburse a claim
for emergency physician services because an emergency physician has
waived, or will waive, collection of all or a portion of a patient's
bill for emergency physician services in accordance with the
emergency physician's discount payment policy, notwithstanding any
contractual provision.



127461.  Notwithstanding any other provision of law, the amounts
paid by parties for services resulting from reduced or waived charges
under an emergency physician's discounted payment policy shall not
constitute an emergency physician's uniform, published, prevailing,
or customary charges, its usual fees to the general public, or its
charges to non-Medi-Cal purchasers under comparable circumstances,
and shall not be used to calculate an emergency physician's median
non-Medicare or non-Medi-Cal charges, for purposes of any payment
limit under the federal Medicare Program, the Medi-Cal program, or
any other federal or state-financed health care program.



127462.  To the extent that any requirement of this article results
in a federal determination that an emergency physician's established
charge schedule or published rates are not the physician and surgeon'
s customary or prevailing charges for services, the requirement in
question shall be inoperative for all emergency physicians. The State
Department of Public Health shall seek federal guidance regarding
modifications to the requirement in question. All other requirements
of this article shall remain in effect.