Health care coverage.
(1) 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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to establish criteria or guidelines that meet specified requirements to be used to determine whether or not to authorize, modify, or deny health care services.
This bill would authorize the Department of Managed Health Care and the Insurance Commissioner, as appropriate, to review a plan’s or insurer’s clinical criteria, guidelines, and utilization management policies to ensure compliance with existing law. If the criteria and guidelines are not in compliance with existing law, the bill would require the Director of the Department of Managed Health Care or the commissioner to issue a corrective action and send the matter to enforcement, if necessary. The bill would require each department, on or before July 1, 2022, to develop a methodology for a plan or insurer to report the number of prospective utilization review requests it denied in the preceding 12 months.
This bill would require a plan or insurer and its delegated entities, on or before January 1, 2023, and annually thereafter, to report, among other things, its average number of denied prospective utilization review requests, as specified. The bill would require, on and after January 1, 2023, a plan or insurer to examine a physician’s record of prospective utilization review requests during the preceding 12 months and grant the physician “deemed approved” status for 2 years, meaning an exemption from the prospective utilization review process, if specified criteria are met. The bill would authorize a plan or insurer to request an audit of a physician’s records after the initial 2 years of a physician’s deemed approved status and every 2 years thereafter, and would specify the audit criteria by which a physician would keep or lose that status. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.
(2) Existing law requires a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2017, to provide that an enrollee or insured who receives services at a contracting health facility provided by a noncontracting individual health professional is required to pay no more than the same cost sharing that they would pay for the same covered services received from a contracting individual health professional. Existing law authorizes a noncontracting individual health professional to collect that in-network cost-sharing amount directly from an enrollee or insured.
This bill would, for a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, revise those provisions to require a health care service plan or health insurer to reimburse a noncontracting individual health professional the in-network cost-sharing amount and to collect that amount from an enrollee or insured. The bill would prohibit a noncontracting individual health professional from collecting the in-network cost-sharing amount directly from an enrollee or insured.
This bill would, for a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, require a plan or insurer to reimburse an individual health professional the full contracted rate, including any cost sharing, for services provided by the individual health professional to an enrollee or insured at a licensed hospital, and would prohibit an individual health professional from collecting the cost-sharing amount from the enrollee or insured. The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, to provide that, for services rendered on or after July 1, 2022, the plan will bill and collect from the enrollee or insured the cost-sharing amounts for services provided by an individual health professional at a licensed hospital. Because a willful violation of these provisions 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.