BILL ANALYSIS
SB 1283
Page 1
Date of Hearing: June 29, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1283 (Steinberg) - As Amended: May 28, 2010
SENATE VOTE : 23-10
SUBJECT : Health care coverage: grievance system.
SUMMARY : Imposes specified requirements on the Department of
Managed Health Care (DMHC), if the Director determines that
additional time is necessary to evaluate a grievance filed by a
health care service plan (health plan) subscriber or enrollee
and make a determination. Requires the Director of DMHC to
include specified information related to timeframes for
grievance resolution in its annually published report that
details the number and types of complaints or grievances
received during the calendar year, and requires health plans to
also include this information in their quarterly report.
Specifically, this bill :
1)Requires DMHC, if the Director determines that additional time
is necessary to evaluate a grievance and make a determination
to:
a) Make a determination, within 30 calendar days of receipt
of the request for review, as to what additional
information is necessary for DMHC to complete its review of
the grievance and make a determination;
b) Notify the subscriber or the enrollee in writing, within
30 calendar days of receipt of the request for review, of
the additional information necessary to complete the
grievance review and to make a determination;
c) Upon receipt of all information that constitutes a
completed application, notify the subscriber or the
enrollee, in writing within five business days, of the date
the application was completed;
d) Make a determination of the final disposition of the
grievance, and the reasons for doing so, within 30 calendar
days of having established a completed application; and,
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e) Notify the subscriber or enrollee of the decision in
writing within five business days of the final disposition
of the grievance.
2)Prohibits DMHC from requesting from the subscriber or the
enrollee any information, data, or further evaluation that
imposes additional costs, expenses, or other fiscal
responsibilities upon the subscriber or enrollee, unless paid
for by DMHC.
3)Requires a health plan to provide specified information
requested by DMHC within five business days of the request and
requires DHMC to impose specified administrative fines against
the plan if it fails to comply with the request.
4)Requires the Director of DMHC to include in its annually
published report that details the number and types of
complaints and grievances received during the calendar year,
as specified, data regarding timeframes for grievance
resolution, and requires the data to include, but not be
limited to:
a) The average number of days before a grievance is closed;
b) The average number days before a grievance is sent to
independent medical review (IMR);
c) The average number days before the independent medical
review process is resolved and a decision is rendered by
the Director of DMHC; and,
d) A breakdown of the number of cases resolved in less than
30 days and in more than 30 days.
5)Requires the Director of DMHC to include in the report a
review of the grievances not resolved within 30 days and to
report on the number, proportion by type and medical
condition, and causes of the grievances, as well as reasons
for the failure to resolve any grievance pending for more than
30 days.
6)Requires health plans to also include in its specified
quarterly report, data regarding the timeframes for grievance
resolution and requires the data to include but not be limited
to the following:
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a) The average number of days before a grievance is closed;
b) A breakdown of the number of cases resolved in less than
30 days and in more than 30 days; and,
c) For grievances not resolved within 30 days, the number,
proportion by type and medical condition, and causes of the
grievances, as well as the reasons for the failure to
resolve any grievance pending for more than 30 days.
EXISTING LAW :
1)Provides for the regulation of health plans by DMHC.
2)Requires all health plans to establish and maintain a
grievance process, approved by DMHC, under which enrollees and
subscribers may submit their grievances to the plan.
3)Authorizes an enrollee or subscriber, who has either completed
his or her plan's grievance process, or participated in the
plan's grievance process for a minimum of 30 days, to submit
his or her grievance to DMHC for review.
4)Allows providers to assist their patients in the filing of
grievances with DMHC.
5)Upon receiving a request to review a grievance, requires DMHC
to send a written notice of the final disposition of the
grievance to the enrollee or subscriber within 30 days, unless
the Director of DMHC determines that additional time is
reasonably needed to complete the review.
6)Requires the Director of DMHC to file annually a summary of
grievances against health plans filed with DMHC, as specified.
7)Requires a health plan to provide a quarterly report to the
Director of DMHC of grievances pending and unresolved for 30
or more days with separate categories of grievances for
Medicare and Medi-Cal enrollees to DMHC. Requires the plan to
include a brief explanation of the reasons each grievance is
pending and unresolved for 30 days or more.
FISCAL EFFECT : This bill, as amended, has not been analyzed by
a fiscal committee.
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COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, consumer
grievances that are filed with DMHC against private health
plans, especially related to autism spectrum disorders (ASDs),
are not resolved in a timely and appropriate manner. The
author states that between September 1, 2009 and March 1, 2010
the DMHC Help Center processed 76 cases that were filed
against private health plans for denial of services
specifically related to autism treatment. Data show that
consumers were notified within 30 days in only 42% of autism
complaints. The author states that while this data are only
for autism-related complaints, these results raise the
possibility that other consumers with health challenges face
comparable delays. The author states that this bill will
clarify existing law and assure that complaints of consumers
are evaluated in an appropriate and timely manner.
2)BACKGROUND . In order to assist health plan enrollees with
filing grievances with both DMHC and their health plan, DMHC
established a Help Center that provides health plan enrollees
and subscribers assistance with navigating the grievance
process. Although the Help Center does not provide legal
advice, it reviews complaints and makes determinations if a
health plan has followed existing law. The Help Center, which
is available to consumers 24 hours a day, 7 days a week, has
assisted over 1 million consumers in resolving complaints and
problems with their health plans in 148 different languages.
3)GRIEVANCE PROCESS . Consumers may file grievances concerning
benefits and coverage disputes, claims and billing problems,
eligibility, inadequate access to care, or service concerns.
Grievances must first be filed first with an individual
enrollee or subscriber's health plan. However, before a
complaint is eligible for review, the health plan, through its
own grievance and appeals process, must have an opportunity to
assess and resolve the issue within 30 days, or 72 hours for
expedited urgent grievances. After either completing the
grievance process or participating in the process for at least
30 days, a subscriber or enrollee can also submit the
grievance to DMHC for review. DMHC must review all written
documents submitted with the grievance form, may ask for
additional materials, and hold meetings with parties involved.
DMHC has 30 days to provide the enrollee or subscriber, and
the health plan, a written notice of DMHC's final decision,
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along with reasons for the decision. Although decisions made
by DMHC are final, patients are allowed to take legal action.
During their review process, DMHC determines whether a case
involves an issue that is eligible for an IMR, which provides
health plan members the opportunity to receive an outside
review of their health care dispute from doctors and other
health care professionals, completely independent of the
member's health plan. The Director of DMHC must formally
adopt the IMR determination. If the health plan's decision is
overturned, the health plan is required to implement the
findings within five days. Generally, IMR cases are processed
within 30 days of qualification of the application. The
Director of DMHC is required to establish and maintain a
system of aging of grievances that are pending and unresolved
for 30 days or more, including a brief explanation of the
reasons each grievance is pending and unresolved for 30 days
or more.
4)AUTISM SPECTRUM DISORDERS . Autism and ASDs are complex
neurobiological disorders that typically last throughout a
person's lifetime, and may cause significant impairments in
language, communications, social interactions, abnormalities
in behaviors, and other physical manifestations. Current law
requires that private health plans and insurers provide
medically necessary services for the diagnosis, care, and
treatment of individuals with autism and pervasive
developmental disorders. According to DMHC, it conducted a
series of workgroup meetings in 2008 to address concerns from
individuals about problems encountered in securing treatment
for ASD from health plans. DMHC states that it has actively
monitored the performance and progress of health plans in
addressing these concerns. In March 2009, DMHC issued a memo
indicating that DMHC would review ASD and other autism
treatment denials through DMHC's own internal grievance
system, as urged by insurers, rather than through the IMR
process. The Los Angeles Superior Court, in October 2009,
ruled against DMHC, citing that DMHC's memo constituted an
illegal "underground regulation" because it violated state law
requiring state agencies to follow a public hearing process
when the agency seeks to adopt or change state regulations
governing health care policies.
5)SUPPORT . According to the Autism Deserves Equal Coverage,
this bill will provide relief to families facing autism and
autism related disorders in their struggle to secure equitable
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insurance coverage. According to supporters, the current
grievance process allows for too much discretion and delaying
of resolutions of many grievances, despite a 30-day statutory
intent.
6)OPPOSE UNLESS AMENDED . The California Association of Health
Plans (CAHP) opposes this bill unless it as amended to ensure
that the timelines and penalties established in this bill
recognize that there are legitimate reasons why a health plan
may not be able to provide DMHC with information within five
days of the request. According to CAHP, this bill appears to
compel plans, when DMHC seeks an extension for a grievance, to
provide "all requested information" within five days or be
subject to a penalty. CAHP is concerned that this provision
will require health plans to pay a fine even if the delay is
not a result of plan actions as there is no provision for
flexibility if a plan is struggling to secure a response from
a provider.
7)PREVIOUS LEGISLATION .
a) AB 2085 (Corbett), Chapter 796, Statutes of 2002,
requires every health plan with a Web site to provide an
online form through its Web site that subscribers or
enrollees can use to file a grievance with their health
plan online, as specified.
b) SB 189 (Schiff and Assemblymember Migden), Chapter 542,
Statutes of 1999, establishes an independent review process
for health insurance beneficiaries in the event they are
denied care and are unsatisfied with the result of the
insurer's internal grievance process.
c) AB 78 (Gallegos), Chapter 525, Statutes of 1999,
established a new Department of Managed Care and
transferred the regulation of health plans from the
Department of Corporations (DOC) to the new department.
d) SB 454 (Russell), Chapter 788, Statutes of 1995,
establishes requirements on health plans and DOC related to
establishing and maintaining a formal enrollee grievance
process, as specified.
e) SB 689 (Rosenthal), Chapter 789, Statutes of 1995, among
other things, requires DOC to establish a toll-free number
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for the filing of grievances by enrollees concerning health
plans, and requires health plans to inform enrollees of the
toll-free number and to resolve grievances within specified
time frames.
REGISTERED SUPPORT / OPPOSITION :
Support
Alliance of California Autism Organization
Association of Regional Center Agencies
Autism Deserves Equal Coverage
Autism Health Insurance Project
California Parents for Choice in Autism Treatment Options
Central Valley Regional Center, Inc.
DIR/FLOORTIME Coalition of California
Educate. Advocate.
Special Education Local Plan Area Administrators
Special Needs Network, Inc.
The Help Group
United Cerebral Palsy of Los Angeles, Ventura & Santa Barbara
Counties
Opposition
California Association of Health Plans (Unless Amended)
Analysis Prepared by : Martin Radosevich / HEALTH / (916)
319-2097