BILL ANALYSIS
SB 1283
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Date of Hearing: August 4, 2010
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
SB 1283 (Steinberg) - As Amended: August 2, 2010
Policy Committee: Health Vote:14-5
Urgency: No State Mandated Local Program:
No Reimbursable:
SUMMARY
This bill modifies consumer health coverage grievance procedures
administered by the California Department of Managed Care
(DMHC). Specifically, this bill:
1)Requires DMHC to provide specified information to health plan
enrollees if additional time is required to evaluate a
consumer grievance, including notification that additional
information needed to evaluate a grievance, that an
application for review is complete, and final written
determination about a grievance.
2)Requires DMHC to include in the department's annual report the
number, type of complaints, and related timelines for
grievances. Timeline data points required include the number
of days before a grievance is closed, the number of days
before a grievance is sent to independent medical review
(IMR), the number of days prior to IMR resolution, and the
number and reasons for grievances remaining unresolved after
30 days.
3)Authorizes DMHC to refer specified grievances to affiliated
agencies such as the Department of Public Health and the
Department of Health Care Services for further investigation.
4)Establishes circumstances under which DMHC is required to
assess administrative penalties against health plans failing
to comply with informational submission requirements.
FISCAL EFFECT
1)Annual fee-supported (health plan fees) special fund costs of
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$50,000 to $100,000 for DMHC to increase specificity of
information provided in annual reports and fulfill other
requirements of this bill.
2)Unknown penalty revenues to the extent health plans are found
in violation of requirements established by this bill. Under
current law, DMHC is authorized to levy penalties when
provisions of state law governing health plans are violated.
Examples of violations that have led to fines include
overcharging patients, posting of confidential patient
information, illegal rescission (retroactive cancellation) of
health coverage, wrongful denial of claims, and failure to
respond to member appeals and provider disputes. Penalties
typically range from $2,500 to $5,000 per violation and can
range up to $25,000.
COMMENTS
1)Rationale . This bill, supported by a wide variety of
organizations serving individuals with autism, modifies DMHC
grievance procedures to increase the amount of information
available to consumers and their families. According to the
author and supporters, numerous grievances filed on behalf of
patients with autism are not resolved in a timely fashion. For
example, in a recent six-month period, 76 cases were filed
with DMHC related to health plan denial of services related to
a diagnosis of autism. Fewer than half of these grievances
were resolved in fewer than 30 days.
2)Grievance Procedures . Current law requires health plans to
establish a grievance system approved by DMHC through which
patients submit grievances to the plan. If an issue is not
resolved within 30 days, an individual may file a grievance
with DMHC. In certain cases, when health and safety is
threatened, DMHC determines an earlier review is warranted and
the health plan grievance procedure is not required.
After either completing a health plan's grievance process or
participating in the process for at least 30 days, a patient
may 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 may hold meetings
with parties involved, including providers. DMHC has 30 days
to provide the patient and the health plan a written notice of
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the department's final decision, along with reasons for the
decision. Although decisions made by DMHC are final, patients
may also take legal action.
3)Independent Medical Review is a process related to specified
types of grievances. Under current law, patients who have
been denied a request for medical services or treatment may
pursue Independent Medical Review (IMR). Circumstances in
which a patient is eligible to file an IMR include denials,
changes or delays in treatment because of a carrier
determination that care is not medically necessary, a health
plan that will not cover an experimental treatment for a
serious medical condition, or a carrier that denies payment
for emergency care that was already provided. The annual
volume of IMR cases since the creation of the review process
has ranged from 700 to 2,200.
Analysis Prepared by : Mary Ader / APPR. / (916) 319-2081