BILL ANALYSIS
SB 1283
Page 1
SENATE THIRD READING
SB 1283 (Steinberg)
As Amended August 2, 2010
Majority vote
SENATE VOTE :23-10
HEALTH 14-5 APPROPRIATIONS 12-5
-----------------------------------------------------------------
|Ayes:|Monning, Fletcher, |Ayes:|Fuentes, Bradford, |
| |Ammiano, Carter, De La | |Charles Calderon, Coto, |
| |Torre, De Leon, Eng, | |Davis, De Leon, Gatto, |
| |Hayashi, Hernandez, | |Hall, Skinner, Solorio, |
| |Jones, Bonnie Lowenthal, | |Torlakson, Torrico |
| |Nava, V. Manuel Perez, | | |
| |Salas | | |
| | | | |
|-----+--------------------------+-----+--------------------------|
|Nays:|Conway, Gaines, Smyth, |Nays:|Conway, Harkey, Miller, |
| |Audra Strickland, Silva | |Nielsen, Norby |
| | | | |
-----------------------------------------------------------------
SUMMARY : Modifies consumer health coverage grievance procedures
administered by the California Department of Managed Health Care
(DMHC). 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
SB 1283
Page 2
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,
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 calendar days of the request and
requires the plan to describe the actions being taken to
obtain the information or records and when receipt is
expected, if the requested information cannot be provided to
the DMHC.
4)Requires DMHC to provide appropriate oversight to determine
that the plan complies with specified information requests and
requires DMHC to impose specified administrative fines upon
the plan and all other appropriate remedies and corrective
actions that DMHC deems necessary if DMHC determines that
noncompliance with an information request is the result of
factors that were within the purview and responsibility of the
plan.
5)Requires DMHC to notify the subscriber or enrollee in writing
of all specified remedies and corrective actions imposed upon
the plan.
6)Authorizes DMHC to pursue the following if the grievances to
the department involve clinical services that are being denied
on the basis of a coverage decision:
a) Provide the completed application to a specified medical
provider or panel who are knowledgeable and qualified to
address the issues in question.
b) Request that the specified medical provider or panel
SB 1283
Page 3
review the completed application, as well as relevant data
and information, and provide findings and recommendations
to the department that include but are not limited to the
following whether the requested services are considered to
be health care services or non-health-care services or
whether the requested services are a covered benefit.
7)Requires any individual or individuals consulted for purposes
of this bill to be identified by a specified independent
medical review organization.
8)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 the average number of days before a grievance is
closed; the average number days before a grievance is sent to
independent medical review; the average number days before the
independent medical review process is resolved and a decision
is rendered by the Director of DMHC; and, a breakdown of the
number of cases resolved in less than 30 days and in more than
30 days.
9)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.
10) 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 average number of days before a grievance is closed; a
breakdown of the number of cases resolved in less than 30 days
and in more than 30 days; and, 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.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, this bill will have $50,000 to $100,000 in special
SB 1283
Page 4
fund costs for DMHC to increase specificity of information
provided in annual reports and fulfill other requirements of
this bill. Additionally, this bill will generate unknown
penalty revenues to the extent health plans are found in
violation of requirements established by this bill.
COMMENTS : According to the author, consumer grievances that are
filed with DMHC against private health plans, especially related
to autism spectrum disorders, 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.
Analysis Prepared by : Martin Radosevich / HEALTH / (916)
319-2097
FN: 0005688