BILL NUMBER: AB 2847	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MARCH 13, 2008

INTRODUCED BY   Assembly Member Krekorian
   (Principal coauthor: Assembly Member Huffman)

                        FEBRUARY 22, 2008

   An act to  amend Section 1374.33 of, to add Sections 1368.013
and 1374.37 to, and to  repeal Section 1371.25 of  , 
the Health and Safety Code,  and to add Sections 10169.4 and
10169.6 to the Insurance Code,   relating to health care
 service plans   coverage  .


	LEGISLATIVE COUNSEL'S DIGEST


   AB 2847, as amended, Krekorian. Health care  service
plans: liability.   coverage.  
    Existing 
    (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.  Existing law provides for the regulation of health
insurers by the Department of Insurance. Existing law provides that a
willful violation of provisions governing health care service plans
is a crime. Under those laws, an  enrollee or insured denied
certain health care services may appeal that denial through
specified grievance and medical review processes.  
   This bill would require a plan or insurer to disprove medical
necessity during any grievance or medical review process, as
specified. The bill would also allow a treating provider to directly
appeal the denial of enrollee or insured health care services to the
Department of Managed Health Care or Department of Insurance, as
applicable.  
   Under existing law 
    (2)     Under the Knox-Keene Health Care
  Service Plan Act of 1975  , a plan, an entity
contracting with a plan, and providers are each  be 
responsible for their own acts or omissions and are not liable for
the acts or omissions of, or the costs of defending, others, except
as specified. Existing law makes contractual provisions to the
contrary void and unenforceable.
   This bill would repeal those provisions.
   Vote: majority. Appropriation: no. Fiscal committee:  no
  yes  . State-mandated local program: no.



THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

   SECTION 1.    Section 1368.013 is added to the 
 Health and Safety Code   , to read:  
   1368.013.  Notwithstanding any other provision of law, the plan
has the burden of proof in any medical necessity determination or any
determination to deny, reduce, limit, or delay health care services,
including, but not limited to, any determination made pursuant to
this article. For purposes of this section, "burden of proof" means
that there shall be a presumption of medical necessity, unless the
plan proves otherwise in accordance with the standard established in
Section 115 of the Evidence Code. 
   SECTION 1.   SEC. 2.   Section 1371.25
of the Health and Safety Code is repealed.
   SEC. 3.    Section 1374.33 of the   Health
and Safety Code   is amended to read: 
   1374.33.  (a)   (1)    Upon receipt of
information and documents related to a case, the medical professional
reviewer or reviewers selected to conduct the review by the
independent medical review organization shall promptly review all
pertinent medical records of the enrollee, provider reports, as well
as any other information submitted to the organization as authorized
by the department or requested from any of the parties to the dispute
by the reviewers. If reviewers request information from any of the
parties, a copy of the request and the response shall be provided to
all of the parties. The reviewer or reviewers shall also review
relevant information related to the criteria set forth in subdivision
(b). 
   (2) Notwithstanding any other provision of law, the plan has the
burden of proof in any medical review conducted pursuant to this
article. For purposes of this subdivision, "burden of proof" means
that there shall be a presumption of medical necessity, unless the
plan proves otherwise in accordance with the standard established in
Section 115 of the Evidence Code. 
   (b)  Following its review, the reviewer or reviewers shall
determine whether the disputed health care service was medically
necessary based on the specific medical needs of the enrollee and any
of the following:
   (1)  Peer-reviewed scientific and medical evidence regarding the
effectiveness of the disputed service.
   (2)  Nationally recognized professional standards.
   (3)  Expert opinion.
   (4)  Generally accepted standards of medical practice.
   (5)  Treatments that are likely to provide a benefit to a patient
for conditions for which other treatments are not clinically
efficacious.
   (c)  The organization shall complete its review and make its
determination in writing, and in layperson's terms to the maximum
extent practicable, within 30 days of the receipt of the application
for review and supporting documentation, or within less time as
prescribed by the director. If the disputed health care service has
not been provided and the enrollee's provider or the department
certifies in writing that an imminent and serious threat to the
health of the enrollee may exist, including, but not limited to,
serious pain, the potential loss of life, limb, or major bodily
function, or the immediate and serious deterioration of the health of
the enrollee, the analyses and determinations of the reviewers shall
be expedited and rendered within three days of the receipt of the
information. Subject to the approval of the department, the deadlines
for analyses and determinations involving both regular and expedited
reviews may be extended by the director for up to three days in
extraordinary circumstances or for good cause.
   (d)  The medical professionals' analyses and determinations shall
state whether the disputed health care service is medically
necessary. Each analysis shall cite the enrollee's medical condition,
the relevant documents in the record, and the relevant findings
associated with the provisions of subdivision (b) to support the
determination. If more than one medical professional reviews the
case, the recommendation of the majority shall prevail. If the
medical professionals reviewing the case are evenly split as to
whether the disputed health care service should be provided, the
decision shall be in favor of providing the service.
   (e)  The independent medical review organization shall provide the
director, the plan, the enrollee, and the enrollee's provider with
the analyses and determinations of the medical professionals
reviewing the case, and a description of the qualifications of the
medical professionals. The independent medical review organization
shall keep the names of the reviewers confidential in all
communications with entities or individuals outside the independent
medical review organization, except in cases where the reviewer is
called to testify and in response to court orders. If more than one
medical professional reviewed the case and the result was differing
determinations, the independent medical review organization shall
provide each of the separate reviewer's analyses and determinations.
   (f)  The director shall immediately adopt the determination of the
independent medical review organization, and shall promptly issue a
written decision to the parties that shall be binding on the plan.
   (g)  After removing the names of the parties, including, but not
limited to, the enrollee, all medical providers, the plan, and any of
the insurer's employees or contractors, director decisions adopting
a determination of an independent medical review organization shall
be made available by the department to the public upon request, at
the department's cost and after considering applicable laws governing
disclosure of public records, confidentiality, and personal privacy.

   SEC. 4.    Section 1374.37 is added to the  
Health and Safety Code   , to read:  
   1374.37.  A treating provider may directly apply to the department
for an independent medical review of a decision to deny, modify, or
delay health care services with respect to a specific enrollee
pursuant to this article. 
   SEC. 5.    Section 10169.4 is added to the  
Insurance Code   , to read:  
   10169.4.  Notwithstanding any other provision of law, the insurer
has the burden of proof in any medical necessity determination or any
determination to deny, reduce, limit, or delay health care services,
including, but not limited to, any determination made pursuant to
this article. For purposes of this section, "burden of proof" means
that there shall be a presumption of medical necessity, unless the
insurer proves otherwise in accordance with the standard established
in Section 115 of the Evidence Code. 
   SEC. 6.    Section 10169.6 is added to the  
Insurance Code   , to read:  
   10169.6.  A treating provider may directly apply to the department
for an independent medical review of a decision to deny, modify, or
delay health care services with respect to a specific insured
pursuant to this article.