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's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth specified coverage requirements for health care service plan contracts and health insurance policies. Existing law requires an individual or small group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act. Existing law requires an essential health benefit to be provided only to the extent that federal law does not require the state to defray the costs of the benefit. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, that provides coverage for the application of fluoride varnish as a pediatric oral care benefit to provide coverage without cost sharing for the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a medical benefit, except as specified. If this coverage requirement creates an obligation for the state to defray costs for an individual, the bill would not require coverage unless there is an appropriation for this purpose, as specified. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to low-income individuals. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes a schedule of benefits under the Medi-Cal program and provides for various services, including certain dental services, that are rendered by Medi-Cal enrolled providers. Under existing law, silver diamine fluoride treatments are a covered benefit for eligible children 0 to 6 years of age, inclusive, as specified, and application of fluoride or other appropriate fluoride treatment is covered for children 17 years of age and under. This bill would make the application of fluoride or other appropriate fluoride treatment, as defined by the department, a covered benefit under the Medi-Cal program for children under 21 years of age. The bill would require the State Department of Health Care Services, no later than July 1, 2027, to issue billing guidance and make any necessary updates to ensure the coverage policy for Medi-Cal beneficiaries under 21 years of age is consistent with certain federal benefits and would require that policy to allow the application of fluoride varnish, as specified. 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. This bill would incorporate additional changes to Section 14132 of the Welfare and Institutions Code proposed by AB 1949 and SB 944 to be operative only if this bill and either or both AB 1949 and SB 944 are enacted and this bill is enacted last.
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 and a health insurer that contracts with providers for alternative rates of payment to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law authorizes the departments to require a plan or insurer to provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on materially inaccurate, incomplete, or misleading information contained in a plan's or insurer's provider directory or directories. This bill would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. The bill would require plans and health insurers to submit their provider directories to the central utility for analysis, and would require the central utility to create a consistency report for each directory. This bill would require a plan or insurer to provide coverage for all covered benefits provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in the plan's or insurer's provider directory or directories and to reimburse the provider the agreed upon amount, or, if none, a reasonable and customary amount, as specified, for those services. The bill would prohibit a provider from collecting an additional amount from an enrollee or insured other than the applicable in-network cost sharing, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require the health care service plan or the insurer, as applicable, to ensure the accuracy of a request to add back a provider who was previously removed from a directory and approve the request within 10 business days of receipt, if accurate. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plan's or insurer's annual notification. The bill would require a plan or insurer to comply with its provisions on and after July 1, 2027. Because a violation of the bill's requirements 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 requires the Department of Insurance to regulate health insurers. Existing law requires an individual or small group health insurance policy issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act. Existing law requires a health insurance policy to cover the same health benefits that the benchmark plan, the Kaiser Foundation Health Plan Small Group HMO 30 plan, offered during the first quarter of 2014, as specified. This bill would express the intent of the Legislature to review California's essential health benefits benchmark plan and establish a new benchmark plan for the 2027 plan year for health insurers. The bill would require, commencing January 1, 2027, if the United States Department of Health and Human Services approves a new essential health benefits benchmark plan for the state, as specified, the benchmark plan for health insurers to include certain additional benefits, including coverage for specified fertility services and specified durable medical equipment.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, requires the Department of Managed Health Care to license and regulate health care service plans and makes a willful violation of the act a crime. Existing law requires an individual or small group health care service plan contract issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act. Existing law requires a health care service plan contract to cover the same health benefits that the benchmark plan, the Kaiser Foundation Health Plan Small Group HMO 30 plan, offered during the first quarter of 2014, as specified. This bill would express the intent of the Legislature to review California's essential health benefits benchmark plan and establish a new benchmark plan for the 2027 plan year for health care service plans. The bill would require, commencing January 1, 2027, if the United States Department of Health and Human Services approves a new essential health benefits benchmark plan for the state, as specified, the benchmark plan for health care service plans to include certain additional benefits, including coverage for specified fertility services and specified durable medical equipment. Because a violation of the bill 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, 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's requirements 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 disability insurance policy issued, amended, delivered, or renewed on or after January 1, 2000, that covers prescription benefits to include coverage for insulin if it is determined to be medically necessary. This bill would prohibit a large group health care service plan contract or health insurance policy issued, amended, delivered, or renewed on or after January 1, 2026, or an individual or small group health care service plan contract or health insurance policy on or after January 1, 2027, from imposing a copayment, coinsurance, deductible, or other cost sharing of more than $35 for a 30-day supply of an insulin prescription drug, except as specified. On and after January 1, 2026, the bill would prohibit a health care service plan or health insurer from imposing step therapy as a prerequisite to authorizing coverage of insulin, and, for a large group health care service plan contract or health insurance policy, would require at least one insulin for a given drug type in all forms and concentrations to be on the prescription drug formulary. The bill would limit the $35 cap for an individual or small group health care service plan contract or health insurance policy to only Tier 1 and Tier 2 insulin if the drug formulary is grouped into tiers, except as provided. 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, 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 disability insurers by the Department of Insurance. Existing law requires a health care service plan or disability insurer to allow an individual to enroll in or change their health benefit plan as a result of a specified triggering event. This bill, the PARENT Act, would make pregnancy a triggering event for purposes of enrollment or changing a health benefit plan. Because a willful violation of this provision 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, 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's requirements a crime. Existing law provides for the regulation of disability and health insurers by the Department of Insurance. This bill would require every full service health care service plan or health insurer, or its delegate, to subscribe to and use the Council for Affordable Quality Healthcare credentialing form on and after January 1, 2028, except as specified. Existing law requires a health care service plan or disability insurer that provides coverage for mental health and substance use disorders and that credentials health care providers of those services for its networks to assess and verify the qualifications of a health care provider within 60 days after receiving a completed provider credentialing application. This bill would, except as provided above and within one year of the bill's operative date, require every health care service plan or health insurer, or its delegate, that credentials health care providers for its networks to make a determination regarding the credentials of a provider within 90 days after receiving a completed provider credentialing application. The bill would require every health care service plan or health insurer to activate the provider upon successful approval and notify the applicant of the activation, as specified. If the health care service plan or health insurer, or its delegate, does not meet the 90-day requirement, the bill would require the applicant's credentials to be provisionally approved for 120 days unless specified circumstances apply, including that the applicant is subject to discipline by the licensing entity for that applicant. The bill would exclude Medi-Cal managed care plans from these provisions. 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. 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, 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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism and defines "behavioral health treatment" to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional. Existing law defines "qualified autism service provider," "qualified autism service professional," and "qualified autism service paraprofessional" for those purposes. Those definitions are contained in the Health and Safety Code and the Insurance Code. This bill would move those definitions to the Business and Professions Code. The bill would also make technical and conforming changes. This bill would incorporate additional changes to Section 1367.27 of the Health and Safety Code and Section 10133.15 of the Insurance Code proposed by AB 280 to be operative only if this bill and AB 280 are enacted and this bill is enacted last. This bill would incorporate additional changes to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code proposed by AB 951 to be operative only if this bill and AB 951 are enacted and this bill is enacted last. This bill would incorporate additional changes to Section 11165.7 of the Penal Code proposed by AB 653 and SB 848, to be operative only if this bill and either or both of those bills are enacted and this bill is enacted last.
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 disability insurers by the Department of Insurance. Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including pursuant to contracts with various types of managed care plans. Existing law generally authorizes a health care service plan, including a Medi-Cal managed care plan, or disability insurer to use utilization review, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. For a request prior to or concurrent with the provision of health care services, existing law requires utilization review decisions to be made within 5 business days from the plan's or insurer's receipt of the information reasonably necessary and requested by the plan or insurer to make the determination, or within 72 hours if the enrollee or insured faces an imminent and serious threat to their health or the normal timeframe would be detrimental to their life or health, as specified. This bill would change the timeline for prior or concurrent authorization requests to no more than 3 business days from the plan's or insurer's receipt via electronic submission, or 5 business days from receipt via submission that is not electronic, of the information reasonably necessary and requested by the plan or insurer to make the determination. The bill would require a utilization review decision to be made within 24 hours from receipt of a prior or concurrent authorization request via electronic submission, or 48 hours from receipt via submission that is not electronic, if the enrollee or insured faces an imminent and serious threat to their health or the normal timeframe would be detrimental to their life or health. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would exclude Medi-Cal managed care plans from the above-described timeline changes. 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.
(1) 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, which is under the control of the Insurance Commissioner. Existing law requires the Department of Managed Health Care and the commissioner to develop and adopt regulations establishing standards and requirements to provide enrollees and insureds with appropriate access to language assistance in obtaining health care services and covered benefits. Existing law requires the Department of Managed Health Care and commissioner, in developing the regulations, to require health care service plans and health insurers to assess the linguistic needs of the enrollee and insured population, and to provide for translation and interpretation for medical services, as indicated. This bill would require a health care service plan or health insurer to take reasonable steps to provide meaningful access to each individual with limited English proficiency, including companions with limited English proficiency, eligible to receive services or likely to be directly affected by its programs and activities. The bill would require a health care service plan or health insurer to offer a qualified interpreter or to utilize a qualified translator when interpretation or translation services are required, as specified. The bill would prohibit a health care service plan or health insurer from requiring an individual with limited English proficiency to provide or pay for the costs of their own interpreter. The bill would require a health care service plan or health insurer to comply with specified requirements when providing remote interpreting services. The bill would make a health care service plan or health insurer that violates these provisions liable for administrative penalties, as specified. (2) Existing law requires certain vital documents containing enrollee- or insured-specific information to include a written notice of the availability of interpretation services in certain threshold languages. Existing law requires a health care service plan or health insurer, upon request, to provide a written translation of those documents within a specified timeframe. For those documents that also relate to expedited plan review of a grievance for a case involving an imminent and serious threat to the health of the patient, existing law authorizes a health care service plan or health insurer to satisfy the requirement by providing notice of the availability of oral interpretation services. This bill would authorize a health care service plan or health insurer to satisfy the notice requirement by taking reasonable steps to inform the enrollee or insured of any required actions, including by providing a sight translation of a document. (3) Existing law requires a health care service plan or health insurer that advertises or markets products in a non-English language, as specified, to provide specified documents in the same non-English language. This bill would add to the list of documents required to be provided in the advertised or marketed non-English language, (A) notices related to any termination of coverage and change in covered services, (B) complaint forms to file a grievance or appeal, and (C) communications related to costs and payment of covered services, as specified. (4) Existing law requires a health care service plan or health insurer to notify enrollees or insureds, as applicable, and members of the public of nondiscrimination policies, grievance or complaint procedures, as applicable, and the availability of language assistance services and appropriate auxiliary aids and services, as specified. This bill would require a health care service plan or health insurer to also provide the information to persons seeking coverage. The bill would require a health care service plan or health insurer to notify enrollees or insureds, persons seeking coverage, and members of the public that the plan or insurer provides language assistance services and appropriate auxiliary aids and services, as specified. Existing law requires this information to be provided upon initial enrollment, upon renewal, and annually in or with materials that are routinely disseminated. This bill would require a health care service plan or health insurer to also provide the above-described information in clear and prominent physical locations, as specified, and upon request. The bill would require a health care service plan or health insurer to provide information regarding the provision of language assistance services, as described above, in a notice when specified forms or communications are provided, as specified. (5) Existing law requires a health care service plan or health insurer to report to the applicable department on internal policies and procedures relating to cultural appropriateness in specified contexts. This bill would require a health care service plan or health insurer to additionally report to the applicable department on internal policies and procedures relating to language access, as specified. (6) 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. 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.
