Existing law requires each county to provide aid, commonly known as a general assistance program, to the county's indigent residents who are not supported by other means and are ineligible for the Medi-Cal program, as specified. Existing law sets forth various provisions relating to county-based health care services for indigent individuals and to reporting systems for those services. This bill would require the State Department of Health Care Services, by July 1, 2027, to establish an internet website where the public can access information on safety-net health care services in the state. The bill would require that the website include certain information and resources, including, among other items, information about each county that provides health care to low-income county residents who are uninsured or underinsured, including eligibility requirements, the cost structure for applicants, and other specified elements. The bill would require the department, in consultation with certain entities, to review the information and resources on the website, as specified. The bill would require each county to submit any changes to the above-described elements to the department within 120 calendar days, as specified. By creating new data-reporting duties for counties, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
(1) Existing law provides for the licensing and regulation of health facilities, including, but not limited to, long-term health care facilities, as defined, by the State Department of Health Care Services. Existing law requires a contract for admission to a long-term care facility to state that a resident shall not be involuntarily transferred within, or discharged from, a long-term health care facility unless the resident is given reasonable notice in writing, and transfer or discharge planning, as specified. Willful or repeated violations of the provisions relating to long-term health care facilities is a misdemeanor. This bill would require long-term health care facilities to provide residents with a notice of a facility-initiated transfer or discharge at least 30 days before a resident is transferred or discharged, unless an exception applies. The bill would require the notice of transfer or discharge to be acknowledged by the signature of the resident or, if applicable, the resident's representative. The bill would make a violation of these provisions a class "B" violation and would make knowingly making a false verification regarding the delivery of a notice of transfer or discharge a willful violation for purposes of the criminal provision described above. The bill would require a notice of discharge or transfer to be provided to a resident and, if applicable, the resident's representative in a translated or accessible format at the same time as the written notice in English if the resident's primary language is not English or if the resident is vision impaired or blind, as specified. The bill would also require the translated or accessible-format notices to be made available to the local long-term care ombudsman upon request. The bill would require the translator to attest, under penalty of perjury, to the accuracy of the translation, thereby expanding the crime of perjury. The bill would require a resident's primary language or sensory impairments to be included in the minimum dataset maintained by the facility. The bill would make a violation of these provisions a class "B" violation. Existing law requires that a copy of the notice of transfer or discharge be sent to the local long-term care ombudsman at the same time notice is provided to the resident or the resident's representative by facsimile machine, email, or first-class mail, as specified. Existing law requires, if a resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis, the notice to be provided to the local long-term care ombudsman as soon as practicable. This bill would instead require the notices described above to be sent to the long-term care ombudsman by facsimile, email, or other electronic means. For emergency transfer notices, the bill would require a copy of the notice to be provided to the local long-term care ombudsman as soon as practicable, but in no event later than 24 hours after the transfer. Because a willful or repeated violation of long-term care facilities provisions is a crime and because the crime of perjury is expanded, the bill would impose a state-mandated local program. (2) Existing law requires the State Department of Public Health to establish an inspection and reporting system to ensure that long-term health care facilities are in compliance with state statutes and regulations. Existing law, the Medi-Cal Long-Term Care Reimbursement Act, requires, among other things, that long-term health care facilities timely comply with hearing decisions issued by the department's Office of Administrative Hearings and Appeals for improperly transferring, discharging, or refusing to readmit a resident. Existing law authorizes the department to assess a penalty of $750 for each calendar day a facility fails to comply with the hearing decision and caps aggregate penalties for each individual hearing decision at $75,000. The bill would authorize the State Department of Public Health to prohibit the admission of new residents to a long-term health care facility upon notification that a facility has failed to timely comply with a hearing decision. The bill would require the prohibition to remain in effect until the facility has achieved compliance, the maximum aggregate of penalties have been collected, or the facility has formally sought judicial review of the hearing decision. The bill would increase the daily penalty described above to $1,000 for each calendar day and increase the maximum aggregate penalty amount to $100,000. (3) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law establishes the Children and Youth Behavioral Health Initiative, administered by the California Health and Human Services Agency and its departments, as applicable. Under existing law, the purpose of the initiative is to transform the state's behavioral health system into an innovative ecosystem in which all children and youth 25 years of age and younger, regardless of payer, are screened, supported, and served for emerging and existing behavioral health needs. Existing law requires, as a part of the initiative, the State Department of Health Care Services to develop and maintain a school-linked statewide fee schedule for outpatient mental health or substance use disorder treatment provided to a student who is 25 years of age or younger at a schoolsite. Existing law requires providers of medically necessary schoolsite services to be reimbursed by health care service plans, insurers, and Medi-Cal managed care plans, at a minimum, at the fee schedule rate or rates, regardless of network provider status. This bill would establish the Fee Schedule Intensive Technical Support for Onboarding Program. The bill would require the State Department of Education, upon appropriation and subject to the terms of the appropriation, to select through a competitive process, and, no later than July 1 of the year after an appropriation is made to fund the program, allocate funding to, a local educational agency that will serve as the lead entity that will administer the program over a 3-year period, as provided. The bill would require the lead entity, in coordination with the State Department of Education and the State Department of Health Care Services, to, no later than November 1 of the year after an appropriation is made to fund the program, select up to 25 entities to participate in the program and prioritize certain applicants, including, among others, applicants who will increase the number and amount of statewide fee schedule reimbursements. The bill would require that an entity meet specified criteria in order to be eligible to participate in the program, including, among other things, that the entity has past experience in serving children and youth that are of the age that the entity intends to serve. The bill would require a participating entity, as a condition of participation, to commit to increasing, among other things, the number of transition-age youth 16 to 25 years of age receiving behavioral health services. The bill would require the lead entity, starting on or before December 1 of the year after an appropriation is made to fund the program, and ending no earlier than 3 years after the program begins, to provide intensive technical assistance and support with regard to specified activities to the participating entities. The bill would require the lead entity to submit a progress report on or before September 1 of the year that is 3 years after an appropriation is made to fund the program, and submit a summative report by January 1 of the year that is 4 years after an appropriation is made to fund the program, regarding the program to the appropriate policy and fiscal committees of the Legislature.
Existing law establishes the State Department of Public Health, headed by the State Public Health Officer, and sets forth its powers and duties, including the administration of provisions relating to the prevention and control of communicable diseases. Existing law authorizes the department to take necessary measures to ascertain the nature and prevent the spread of communicable diseases. Existing law prohibits the governing authority of a school or other institution from unconditionally admitting or advancing to the 7th grade level any person as a pupil of any public or private elementary or secondary school, childcare center, day nursery, nursery school, family daycare home, or development center, unless, prior to their admission or advancement to that institution, they have been fully immunized against various communicable diseases, as provided, subject to any specific age criteria. Existing law requires the governing authority of a school or other institution, on at least an annual basis, to file a written report on the immunization status of new entrants to the school or institution under their jurisdiction with the department and the local health department at times and on forms prescribed by the department. This bill, the Informed Parents, Healthy Schools Act, would require the department to establish, and update as needed, levels of immunization rates needed to prevent the spread of specified communicable diseases. The bill would require the department to establish notification procedures designed to annually inform designated parties, including schools, daycare centers, and county departments of public health, when an immunization rate is determined to fall below the rate established by the department, among other things. The bill would require that the notification be translated into any language, in addition to English, that is spoken by 15% or more of enrolled children. The bill would require the department to apply existing data de-identification standards and methodologies to protect individual privacy, consistent with applicable state and federal law, in implementing these provisions. The bill would require a school or institution, as defined, to distribute the above-described notification to parents or guardians of enrolled children within 10 business days of receiving the notification from the department. The bill would authorize the school or institution to determine the manner of distribution for the notification, consistent with specified requirements. The bill would require the governing authority of the school or institution to cooperate with the department in carrying out these provisions. By requiring school districts to comply with these requirements, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
Existing law requires that, as a condition of parole, a prisoner who has a severe mental health disorder, as specified, be treated by the State Department of State Hospitals, if the prisoner meets certain requirements, including, among others, that the person in charge of treating the prisoner and a practicing psychiatrist or psychologist from the State Department of State Hospitals have evaluated the prisoner and that a chief psychiatrist of the Department of Corrections and Rehabilitation certify to the Board of Parole Hearings that by reason of the prisoner's severe mental health disorder, the prisoner represents a substantial danger of physical harm to others. This bill would require that certain factors be considered in determining whether an offender poses a substantial danger of physical harm to others, including, but not limited to, a history of violent behavior and prior history of state hospital commitment. Existing law allows a prisoner to request a hearing before the Board of Parole Hearings for the purpose of proving that the prisoner meets the criteria to be treated by the State Department of State Hospitals. Existing law allows a prisoner who disagrees with the determination of the Board of Parole Hearings to file a petition in court for a hearing on whether they met the criteria and, if the court reverses the determination of the Board of Parole Hearings, existing law authorizes the court to require the parties to return to court to ensure that the entities involved in the release of the prisoner have coordinated an exit plan for the prisoner. This bill would require that an exit plan include the submission of an application for Medi-Cal benefits and a recommendation, as appropriate, to the supervising county's behavioral health department by a licensed behavioral health professional, as specified, supervising the treatment of, or treating, the prisoner for a mental health disorder for certain resources and programs, including substance use disorder treatment, assisted outpatient treatment, and early psychosis intervention services. Existing law, the Mental Health Services Act (MHSA) , an initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general election, funds a system of county mental health plans for the provision of mental health services, as specified. The MHSA establishes the Mental Health Services Fund, a continuously appropriated fund, which is administered by the State Department of Health Care Services (department) , to fund specified county mental health programs. Existing law, the Behavioral Health Services Act (BHSA) , a legislative act amending the MHSA that was approved by the voters as Proposition 1 at the March 5, 2024, statewide primary election, recast the MHSA by, among other things, renaming the fund to the Behavioral Health Services Fund and reallocating how moneys from that fund may be spent. The BHSA requires each county to establish and administer a full-service partnership program that includes, among other things, outpatient behavioral health services, as specified, and housing interventions. Existing law establishes criteria for an individual with a serious mental illness to be presumptively eligible for a full-service partnership, including, among other things, the person is transitioning to the community after 6 months or more in the state prison or county jail. This bill would add to the criteria for presumptively eligibility for a full-service partnership an individual transitioning to the community after 6 months or more in a state hospital. Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law, the California Advancing and Innovating Medi-Cal (CalAIM) Act, supports the stated goals of identifying and managing the risk and needs of Medi-Cal beneficiaries, transitioning and transforming the Medi-Cal program to a more consistent and seamless system, and improving quality outcomes. Existing law makes a qualifying inmate of a public institution eligible, commencing no sooner than January 1, 2023, to receive targeted Medi-Cal services, limited to those services approved in the CalAIM Terms and Conditions for 90 days, as specified. This bill would also make a qualifying inmate of a state hospital eligible to receive targeted Medi-Cal services, as described. By expanding the population receiving benefits under the BHSA and to the extent that the bill would create new duties for counties relating to Medi-Cal eligibility determinations, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy to provide coverage for all generally medically accepted cancer screening tests. This bill would require a health care service plan contract or health insurance policy, except as specified, that is issued, amended, or renewed on or after January 1, 2027, to provide coverage for followup screening or diagnostic services for lung cancer, as specified. The bill would prohibit a contract or policy from imposing a copayment, coinsurance, deductible, or any other form of cost sharing for this coverage. If a health care service plan contract or health insurance policy is a high deductible health plan, the bill would prohibit the contract or policy from imposing a deductible, coinsurance, or any other cost sharing on this coverage unless not imposing the deductible, coinsurance, or cost sharing would conflict with the federal requirements for high deductible health plans. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is in part governed by, and funded pursuant to, federal Medicaid program provisions. Existing federal law, enacted on July 4, 2025, sets forth various changes to Medicaid eligibility with regard to community engagement reporting, redeterminations, retroactive coverage, and cost sharing, among other factors, for certain Medicaid populations pursuant to a specified implementation timeline. This bill would require the department to establish a data dashboard that provides data on applications, enrollment, redeterminations, disenrollments, and terminations, with certain objectives in consideration, related to the impact of the above-described federal law on Medi-Cal eligibility and enrollment, as specified. The bill would require the dashboard to track and report on the specific data for work or community engagement requirements and exemptions. The bill would require the department, commencing no later than January 1, 2028, to operationalize the dashboard and to post the information on a monthly basis in a downloadable format. The bill would require the department to undertake efforts to conduct outreach about work or community engagement requirements, more frequent redeterminations, and changes to retroactive eligibility to impacted Medi-Cal beneficiaries, and to conduct listening sessions, as specified. Under the bill, beneficiary outreach and education would be coordinated across public social services programs to help minimize barriers to administrative disenrollments. The bill would require a Medi-Cal managed care plan to establish and conduct an outreach and education plan for its enrollees about the work or community engagement guidelines set forth in federal law based on guidance provided by the department. The bill would require the outreach and education plan to address certain information on Medi-Cal eligibility, the right to appeal or reinstate Medi-Cal coverage, and resources, and to meet certain cultural and linguistic appropriateness standards. Existing law requires a county to undertake outreach efforts to beneficiaries receiving Medi-Cal benefits in order to, in part, facilitate the Medi-Cal redetermination process. Existing law authorizes a county to collaborate with community-based organizations in implementing this provision. This bill would incorporate the requirements of the above-described federal law into the Medi-Cal redetermination facilitation process. The bill would require a county to make a good faith effort to collaborate with community-based organizations, as specified. The bill would require the county outreach efforts to meet cultural and linguistic appropriateness standards. By creating new duties for counties relating to Medi-Cal outreach, the bill would impose a state-mandated local program. Existing law requires the department to encourage and facilitate efforts by managed care plans to report updated beneficiary contact information to counties. When a managed care plan obtains a beneficiary's updated contact information, existing law requires the plan to ask the beneficiary for approval to provide the beneficiary's updated contact information to the appropriate county. If the managed care plan does not obtain that approval, existing law requires the county to attempt to verify that the information that it receives from the plan is accurate, as specified, before updating the beneficiary's case file. This bill would remove the requirement for the managed care plan to ask the beneficiary for approval for purposes of providing the contact information to the county. The bill would remove the requirement for the county to make the verification attempt and would remove a related provision on the method of contact. The bill would require the department to share, or require each county to share, beneficiary redetermination data with applicable managed care plans to aid in managed care plans' efforts to assist beneficiaries with retaining Medi-Cal coverage, as specified. To the extent the bill creates new duties for counties relating to the sharing of Medi-Cal redetermination data, it would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
Existing law authorizes a court to grant pretrial diversion to a defendant suffering from a mental disorder, on an accusatory pleading alleging the commission of a misdemeanor or felony offense, to allow the defendant to undergo mental health treatment. Existing law prescribes specified criteria for a defendant to be eligible for pretrial diversion and for a court to consider whether the defendant is suitable for pretrial diversion. Existing law authorizes a court to require the defendant to make a prima facie showing that they will meet the minimum requirements of eligibility for diversion and that the defendant and the offense are suitable for diversion and authorizes the court, if that showing is not made, to summarily deny diversion and grant alternate relief. This bill, if the court intends to summarily grant diversion or any other relief, would require the court to conduct an additional hearing if requested by either party. By increasing the duties on local prosecutors, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
(1) Existing law, the Community Assistance, Recovery, and Empowerment (CARE) Act (the act) , authorizes specified persons, including a person with whom the respondent resides, family members, and first responders, among others, to petition a civil court to create a voluntary CARE agreement or a court-ordered CARE plan and implement services, to be provided by county behavioral health agencies, to provide behavioral health care, including stabilization medication, housing, and other enumerated services, to adults who are currently experiencing a severe mental illness and have a diagnosis identified in the disorder class schizophrenia and other psychotic disorders, and who meet other specified criteria. Existing law, the Lanterman-Petris-Short Act, authorizes a conservator of the person, of the estate, or of the person and the estate to be appointed for a person who is gravely disabled as a result of a mental health disorder or impairment by chronic alcoholism. Existing law requires the officer providing the conservatorship investigation, which may include a public guardian or a county mental health program, to investigate all available alternatives to conservatorship and to recommend conservatorship to the court only if no suitable alternatives are available. Existing law requires a conservatorship under these provisions to terminate after one year and specifies procedures if the conservator determines conservatorship is still required. This bill would authorize a conservator to, upon the termination of a conservatorship, request the court refer the conservatee to CARE court, as specified. (2) The act authorizes services and supports to be provided to adults who are currently experiencing a qualifying severe mental illness and who meet other specified criteria, including that the person is not clinically stabilized in ongoing voluntary treatment and is either unlikely to survive safely in the community without ongoing supervision and the person's condition is substantially deteriorating or the person is in need of services and supports to prevent a relapse or deterioration that would likely result in grave disability or serious harm to the person or others. This bill would authorize the court, beginning July 1, 2028, and if it dismisses a CARE petition because a respondent needs a higher level of services, to order the county to develop an exit plan for the respondent. The bill would require the State Department of Health Care Services, by July 1, 2028, to develop, with input from certain stakeholder groups, a CARE Act model exit plan that identifies appropriate services and ongoing monitoring of an individual with a petition dismissed because the individual needed a higher level of services. This bill would update the definition of a petitioner for the purposes of the act. (3) Existing law requires the Judicial Council to develop a mandatory form or forms to use to file a CARE process petition. Existing law requires the petition to be signed under the penalty of perjury and to contain specified information, including the petitioner's relationship to the respondent and either an affidavit of a licensed behavioral health professional stating the licensed behavioral health professional or their designee has examined or made multiple unsuccessful attempts to examine the respondent within 60 days of submission of the petition, or that the respondent was detained for a minimum of 2 intensive treatments pursuant to state law. This bill would extend the 60-day period for examination of the respondent to 120 days. The bill would also authorize a petition to include evidence that the respondent was either detained for a minimum of 2 involuntary holds in the last 120 days or that they were referred to a full service partnership program more than once, but was not enrolled due to inability or unwillingness to engage in the previous 120 days. (4) Existing law authorizes a court to terminate a respondent's participation in the CARE process if the court determines that the respondent is not participating in the CARE process or is not adhering to their CARE plan, as specified. Existing law authorizes the court to order an evaluation under the Lanterman-Petris-Short Act, as specified, to ensure the respondent's safety. Existing law requires the court to consider the respondent's failure to successfully complete their CARE plan and the reasons for that failure in a subsequent hearing under the Lanterman-Petris-Short Act, provided that the hearing occurs within 6 months of the termination of the CARE plan, and creates a presumption that the respondent needs additional intervention beyond the supports and services provided by the CARE plan. This bill would prohibit the court from terminating a respondent's participation in the CARE process solely due to a failure of the county or other local government entity to properly engage with the CARE process. (5) Existing law requires CARE Act proceedings to occur in person unless the court, in its discretion, allows a party or witness to appear remotely through the use of remote technology. Existing law authorizes the respondent to be in person for all hearings. This bill would instead authorize all parties and witnesses to appear remotely through the use of remotely technology. The bill would authorize the court with discretion to order a party or witness to appear in person if necessary. This bill would authorize the parties to agree to an alternative method of service for all subsequent reports and notices after the notice of initial appearance. This bill would require, by January 1, 2028, all counties to establish a process for electronic submission of CARE Act documents using a secured portal. By increasing the duties on county behavioral health agencies, the bill would create a state-mandated local program. (6) Existing law authorizes a provider of health care or a covered entity, as defined, to disclose to the county behavioral health agency any information, including protected health information, and mental health records excluding psychotherapy notes, in its possession about the respondent that is relevant to the county behavioral health agency's provision, coordination, or management or services or supports. Existing law specifies protections for this information and required procedures when such a disclosure is made. This bill would authorize a county behavioral health agency to disclose to a provider of health care or a covered entity any information, including protected health information, and mental health records, excluding psychotherapy notes, in its possession about the respondent that is relevant to the provider or entity's provision, coordination, or management of services and supports. The bill would also specify protections for this information and required procedures when such a disclosure is made. (7) Existing law requires the department to develop, in consultation with specified entities, an annual CARE Act report that includes specified information on CARE Act petitions, including the number of initial appearances, and information compiled from county behavioral health departments and courts. This bill would expand the information on CARE Act petitions to include the number of petitions submitted electronically as well as other specified information. The bill would also expand the data to be compiled from county behavioral health departments and courts to include the number of individuals who were enrolled in a Full Service Partnership program postreferral, among other things. The bill would also require the data collected from county behavioral health departments and courts to be collected for cases involving dismissed respondents, where available. (8) Existing law requires the California Health and Human Services Agency, or a designated department within the agency, to perform specified functions, including engaging an independent, research-based entity to advise on the development of data-driven process and outcome measures to guide the planning, collaboration, reporting, and evaluation of the CARE Act. This bill would require the agency to annually release a list of overperforming counties and shall annually provide written notice identifying areas of concern and opportunities for improvement to underperforming counties. This bill would also establish within the California Health and Human Services Agency the position of a CARE Court Ombudsperson, as specified. (9) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law establishes the Independent Medical Review System within each department, under which an enrollee or insured may seek review if a health care service has been denied, modified, or delayed by a health care service plan or health insurer and the enrollee or insured has previously filed a grievance that remains unresolved after 30 days. This bill would require a health care service plan or health insurer to annually report to the appropriate department the total number of claims processed by the health care service plan or health insurer for the prior year and its number of treatment denials or modifications, separated and disaggregated as specified, commencing on or before June 1, 2026. The bill would require the departments to compare the number of a health care service plan's or health insurer's treatment denials and modifications to (1) the number of successful independent medical review overturns of the plan's or insurer's treatment denials or modifications and (2) the number of treatment denials or modifications reversed by a plan or insurer after an independent medical review for the denial or modification is requested, filed, or applied for. For a health care service plan or health insurer with 10 or more independent medical reviews in a given year, the bill would make the health care service plan or health insurer liable for an administrative penalty, as specified, if more than 50% of the independent medical reviews filed with a health care service plan or health insurer result in an overturning or reversal of a treatment denial or modification in any one individual category of specified general types of care. The bill would make a health care service plan or health insurer liable for additional administrative penalties for each independent medical review resulting in an additional overturned or reversed denial or modification in excess of that threshold. The bill would require the departments to annually include data, analysis, and conclusions relating to these provisions in specified reports. Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. Existing law creates the Managed Care Administrative Fines and Penalties Fund in the State Treasury for the deposit of fines and administrative penalties collected pursuant to provisions licensing and regulating health care service plans. This bill would create the Managed Care Independent Medical Review Administrative Penalties Subaccount in the Managed Care Administrative Fines and Penalties Fund for the receipt and deposit of moneys generated from the administrative penalties described above with respect to health care service plans. The bill would create the Health Insurance Independent Medical Review Administrative Penalties Fund in the State Treasury for the receipt and deposit of moneys generated from the administrative penalties described above with respect to health insurers. The bill would authorize the moneys in the Managed Care Independent Medical Review Administrative Penalties Subaccount and Health Insurance Independent Medical Review Administrative Penalties Fund to be expended, as specified, upon appropriation by the Legislature. This bill would declare that its provisions are severable. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
