Committee on Health. Health care service plans. 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 requires a health care service plan, including a specialized health care service plan, to reimburse a claim or portion of a claim no later than 30 working days after receipt of the claim, unless the plan contests or denies the claim, in which case the plan is required to notify the claimant within 30 working days that the claim is contested or denied. Existing law extends these timelines to 45 working days for a health maintenance organization. Existing law specifies that the obligation of a specialized health care service plan to comply with these provisions is not waived if the plan requires its medical groups, independent practice associations, or other contracting entities to pay claims for covered services.
This bill would instead provide that the obligation of a plan to comply with those provisions is not deemed to be waived if the plan requires its medical groups, independent practice associations, or other contracting entities to pay claims for covered services.
Existing law requires a health care service plan to provide department contact information in specified materials, including on the application form for a Medicare supplement contract, on its online grievance form, and in communications that concern contract termination or a block transfer.
This bill would update the information a health care service plan is required to provide pursuant to those provisions, as specified. Because a willful violation of these requirements 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.