as amended, Grove.
begin deleteHealth care service plans. end delete
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 requires health care service plans and, if applicable, specialized health care service plans, to meet specified criteria, including requiring the appropriate licensure of facilities and personnel. Willful violation of that act a crime.end delete
This bill would make technical, nonsubstantive changes to these provisions.end delete
begin deleteno end delete.
State-mandated local program: no.
The people of the State of California do enact as follows:
immediately following Section 1367.25
Section 1367 of the Health and Safety Code is
12amended to read:
A health care service plan and, if applicable, a specialized
14health care service plan shall meet the following requirements:
15(a) Facilities located in this state, including, but not limited to,
16clinics, hospitals, and skilled nursing facilities to be utilized by
17the plan shall be licensed by the State Department of Public Health,
18where licensure is required by law. Facilities not located in this
19state shall conform to all licensing and other requirements of the
20jurisdiction in which they are located.
21(b) Personnel employed
by, or under contract with, the plan
22shall be licensed or certified by their respective board or agency,
23where licensure or certification is required by law.
24(c) Equipment required to be licensed or registered by law shall
25be so licensed or registered, and the operating personnel for that
26equipment shall be licensed or certified as required by law.
27(d) The plan shall furnish services in a manner providing
28continuity of care and ready referral of patients to other providers
29at times as may be appropriate consistent with good professional
P3 1(e) (1) All
services shall be readily available at reasonable times
2to each enrollee consistent with good professional practice. To the
3extent feasible, the plan shall make all services readily accessible
4to all enrollees consistent with Section 1367.03.
5(2) To the extent that telehealth services are appropriately
6provided through telehealth, as defined in subdivision (a) of Section
72290.5 of the Business and Professions Code, these services shall
8be considered in determining compliance with Section 1300.67.2
9of Title 28 of the California Code of Regulations.
10(3) The plan shall make all services accessible and appropriate
11consistent with Section 1367.04.
12(f) The plan shall employ and utilize allied health manpower
13for the furnishing of services to the extent permitted by law and
14consistent with good medical practice.
15(g) The plan shall have the organizational and administrative
16capacity to provide services to subscribers and enrollees. The plan
17shall be able to demonstrate to the department that medical
18decisions are rendered by qualified medical providers, unhindered
19by fiscal and administrative management.
20(h) (1) Contracts with subscribers and enrollees, including
21group contracts, and contracts with providers, and other persons
22furnishing services, equipment, or facilities to, or in connection
23with, the plan, shall be fair, reasonable, and consistent with the
24objectives of this chapter. All contracts with providers shall contain
25provisions requiring a fast, fair, and cost-effective dispute
26resolution mechanism under which providers may submit disputes
27to the plan, and requiring the plan to inform its providers upon
28contracting with the plan or upon change to these provisions, of
29the procedures for processing and resolving disputes, including
30the location and telephone number where information regarding
31disputes may be submitted.
32(2) A health care service plan shall ensure that a dispute
33resolution mechanism is accessible to noncontracting providers
34for the purpose of resolving billing and claims disputes.
35(3) A health care service plan shall annually submit a report to
36the department regarding its dispute resolution mechanism. The
37report shall include information on the number of providers who
38utilized the dispute resolution mechanism and a summary of the
39disposition of those disputes.
P4 1(i) A health care service plan contract shall provide to
2subscribers and enrollees all of the basic health care services
3included in subdivision (b) of Section 1345, except that the director
4may, for good cause, by rule or order exempt a plan contract or
5any class of plan contracts from that requirement. The director
6shall by rule define the scope of each basic health care service that
7health care service plans are required to provide as a minimum for
8licensure under this chapter. Nothing in this chapter shall prohibit
9a health care service plan from charging subscribers or enrollees
10a copayment or a deductible for a basic health care service
11consistent with Section 1367.006 or 1367.007, provided that the
12copayments, deductibles, or other cost sharing are reported to the
13director and set forth to the subscriber or enrollee pursuant to the
14disclosure provisions of Section 1363. Nothing in this chapter shall
15prohibit a health care service plan from setting forth, by contract,
16limitations on maximum coverage of basic health care services,
17provided that the limitations are reported to, and held
18unobjectionable by, the director and set forth to the subscriber or
19enrollee pursuant to the disclosure provisions of Section 1363.
20(j) (1) A health care service plan shall not require registration
21under the federal Controlled Substances Act (21 U.S.C. Sec. 801
22et seq.) as a condition for participation by an optometrist certified
23to use therapeutic pharmaceutical agents pursuant to Section 3041.3
24of the Business and Professions Code.
25(2) This section shall not be construed to permit the director to
26establish the rates charged subscribers and enrollees for contractual
27health care services.
28(3) The director’s enforcement of Article 3.1 (commencing with
29Section 1357) shall not be deemed to establish the rates charged
30subscribers and enrollees for contractual health care services.
31(4) The obligation of the plan to comply with this chapter shall
32not be waived when the plan delegates services that it is required
33to perform to its medical groups, independent practice associations,
34or other contracting entities.