Appendix EUseful Code Sections of the California Knox-Keene Health Care Service Plan Act and Regulations1
Doctor-Patient Relationship / Assurance of Quality Care / Continuity of Care / Emergency Care
§ 1342 Intent and Purpose of Legislature- (a) Ensures the continued role of the professional (doctor) as the determiner of your health needs and fosters the traditional relationship of trust and confidence between you and your doctor.
(g) Ensures that you receive available and accessible medical services providing for continuity of care.
§1348.6 Contracts between Health Care Service Plans and Licensed Health Care Practitioners; Prohibition on Certain Incentive Plans- Prohibits contracts between your health plan and your doctor, or doctor's group, that contain any type of incentive plan which encourages the denial, limitation or delay of specific medically necessary treatments. Does not prohibit capitated payment agreements, wherein doctors are paid a fixed budget for all patients they treat, as long as the payment agreements do not pertain to your doctor making specific medical decisions.
§1367 Requirements- (d) Your health plan must provide medical services to you providing for continuity of care and ready referral to other providers when good professional practice requires such.
(g) Your health plan must assure that medical decisions are made by qualified medical providers, without influence of fiscal or administrative management.
***For use when medical director blocks your referral
Code of Regulations § 1300.67 Scope of Basic Health Care Services- sets forth the basic health care services required to be provided by a health care service plan to its enrollees, including the availability of emergency services.
Code of Regulations § 1300.67.1 Continuity of Care- requires that basic health care services shall be provided in a manner which provides continuity of care, including but not limited to:
(a) The availability of primary care physicians, who will be responsible for coordinating the provision of health care services to each enrollee;
(b) The maintenance and ready availability of medical records, with sharing within the plan of all pertinent information relating to the health care of each enrollee;
(c) The maintenance of staff, including health professionals, administrative and other supporting staff, directly or through an adequate referral system, sufficient to assure that health care services will be provided on a timely and appropriate basis to enrollees;
(d) An adequate system of documentation of referrals to physicians or other health professionals. The monitoring of the follow up of enrollees' health care documentation shall be the responsibility of the health care service plan and associated health professionals.
Cal. Code of Regulations § 1300.67.2 Accessibility of Services- provides that health services must be readily accessible within each service area of a plan, including that "the location of facilities providing the primary health care services of the plan shall be within reasonable proximity of the business or personal residences of enrollees, and so located as to not result in unreasonable barriers to accessibility" and "that there shall be at least one full- time equivalent physician to each one thousand two hundred (1,200) enrollees and there shall be approximately one full-time equivalent primary care physician for each two thousand (2,000) enrollees, or an alternative mechanism shall be provided by the plan to demonstrate an adequate ratio of physicians to enrollees."
Cal. Code of Regulations § 1300.67.3 Standards for Plan Organization- (a)(1) provides that plans must separate medical services from administrative and financial management so that the medical decisions will not be "unduly influenced by fiscal and administrative management."
Cal. Code of Regulations § 1300.67.4 Subscriber and Group Contracts- (a)(3)(A) provides that a benefit can not be subject to any reduction or limitation that would render the benefit illusory.
Cal. Code of Regulations § 1300.70 Quality Assurance Program- sets forth the standards for plans to include in their quality assurance program including that such a program shall be designed to, among other things, ensure that health care providers or institutions are not pressured to render care beyond the scope of their training or experience. Plans that have capitation or risk-sharing contracts must "ensure that each contracting provider has the administrative and financial capacity to meet its contractual obligations" and the plan must "have systems in place to monitor QA functions."
§1363.5 Authorization or Denial of Services; Process; Disclosures; Criteria- Your plan must disclose to the Director of the Department of Managed Health Care and network providers the process under which the company authorizes, modifies or denies health care services. This information also must be made available to you upon request.
§1367.01 Written policies and procedures for review and approval or denial of services
Your plan must have written policies and procedures establishing the process by which it reviews and approves, modifies, delays, or denies health care services based in whole or in part on medical necessity.
§1371.4 Emergency Services and Care; Authorization; Payments Providers; Treatment Following Stabilization; Payments to Providers; Assumption and Delegation of Responsibilities- Your health plan must pay for you to receive emergency services until which time you are stabilized. Your health plan must pay for 24 hour access when your emergency condition has been stabilized but your treating provider deems you too unsafe to discharge. Even if you are not at an HMO-contracted hospital you may receive treatment until the treating provider stabilizes your condition. Once you have been stabilized, your plan may require pre-authorization for medical care after you have been stabilized. If your plan disagrees with your treating provider's recommendation for medical care once you have been stabilized, the plan must have their own medical personnel take over your care or transfer you to one of their facilities.
Cal. Code of Regulations § 1300.71.4 Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services- In addition to the requirement that your plan pay for all services until you are stabilized, your plan must approve or disapprove your health care provider's request for authorization to provide necessary post-stabilization medical with 30 minutes of the request.
§1380 Onsite Medical Survey of Health Delivery System of Plan- The DMHC shall conduct periodic medical surveys of your plan to determine the overall performance of your plan in the delivery of health care. These surveys must be made open to public inspection within 180 days of completion of the survey unless the director of the DMHC requires more time for a full and fair report. You may receive a single copy of a summary of the final report's findings free of charge upon request to the DMHC.
Second Opinion / Grievance Procedures / Independent Review
§1383.1 Second Medical Opinions; Policy Statement of Plan; Notice to Enrollees- Your plan must provide you with information regarding how and under what circumstances you may receive a second medical opinion.
§1383.15 Second opinion
Your health plan must provide or authorize a second opinion by an appropriately qualified health care professional who has the training and expertise relating to your particular condition for which you are requesting a second opinion.
§1368 Grievance System- Your health plan must have a grievance system in place that you may submit your grievance to. The plan must adequately consider and rectify grievances. Your plan must notify you upon enrollment and annually thereafter where and how to file a grievance, including the appropriate location and phone number to contact. After participating in your plan's grievance system for 30 days, you may submit your grievance to the Department of Managed Health Care for review. In cases where there is a serious threat to your health, however, you may submit your grievance to the Department without having to participate in your plan's process for thirty days.
§1368.01 Resolution Period; Grievance Status and Disposition Statement; Expedited Review- (a) Your plan's grievance system must resolve your grievance within 30 days.
(b) Your plan must provide for expedited reviews in cases where there is an imminent and serious threat to your health, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function. Your plan must inform you and the Department of Managed Health Care (DMHC) in writing of their expedited review decision, or its pending status, no later than 72 hours after receiving the grievance.
§1368.02 Complaints About Health Care Service Plans, Toll-Free Number; Notice of Number; Ombudsperson- You may call the DMHC for assistance you have a grievance involving an emergency, your plan has not satisfactorily resolved your grievance, or your grievance has remained unresolved for more than 30 days. Your plan must provide you with the DMHC's toll-free complaint hotline number in your plan contract, "Evidence of Coverage" document and any grievance process documents you receive.
§1370.4 Independent Review Process; Experimental and Investigational Therapies for Individual Enrollees; Requirements; Definitions; Accreditation; Record- Your plan must have an external, independent review process to review the plan's decisions regarding experimental or investigational therapies when you meet specific requirements including, but not limited to, having a life-threatening condition and standard therapies have not helped to improve your condition.
§ 1374.30 Independent Review System- Commencing January 1, 2001, all enrollees in health care service plans have the right to an "independent review" of any disputed health care service, including any denial, delay or modification by the plan of a covered health care service due to a finding that the service is not medically necessary. This review is conducted by an independent medical review organization approved by the Department of Managed Health Care. Your health care plan must inform you of this right in your member handbook, plan contract or other evidence of coverage forms.
§ 1374.31 Imminent threat to health; Expeditious review- When your health is seriously threatened, all necessary documents must be transferred from your plan to the independent review organization within 24 hours after your request for independent review is approved. In "extraordinary and compelling cases" the Department may grant your request for review without your having participated in your plan's grievance process.
§ 1374.34 Disputed health care service; Review; Reimbursement for urgent care; Audit of cases- Your plan must act promptly to provide you with services that are determined through the independent review process to be medically necessary and may not do anything to prolong the independent review process. If had to secure urgent care outside of your plan's network for services that were later found to be medically necessary, your plan must reimburse you for the cost of those services.
Plan Contracts / Documents / Advertising
§ 1352.1 New or Modified Plan Contract; Publication or Distribution of Disclosure Form or Evidence of Coverage- All "Evidence of Coverage" documents written by your plan must not be deceptive, untrue or misleading.
Cal. Code of Regulations § 1300.52.1 Material Modification to Plan Contract- Any material modification to a plan contract must be preapproved by the Department of Managed Health Care.
§1360 (b)(3) Advertising or Solicitation; Written or Printed Statement or Item; Verbal Statement- All coverage statements and promises made verbally by your HMO must be held to the same standards as those for printed matter.
§1361 Advertising; Requirements; Correction or Retraction- All advertisements by your plan must meet the same level of scrutiny as any other plan document, such as your health care contract. Advertisements cannot be false or misleading. All advertising documents must be sent to the DMHC by your plan.
§1363 Disclosure Forms; Contents; Uniform Health Plan Benefits and Coverage Matrix- Your health plan must use disclosure forms that indicate all benefits, services and terms your contract with the company. The disclosure forms must be in clearly organized and readily understandable, and include any limitations of coverage, full cost of premiums, co-payment requirements, renewal terms, and the like.
Cal. Code of Regulations § 1300.63 Disclosure Forms- sets forth the specific requirements to which a plan's disclosure forms must conform.
§1395 Soliciting and Advertising; Nature of Plan; Operation; Ownership
by a Professional; Construction- Your plan's advertisements may refer to services or costs, or use "words of comparison" (e.g. "lowest prices") unless the plan has verifiable data to substantiate the claims. Your plan cannot advertise prices that are fraudulent, misleading or deceitful.
§1367.20 Prescription Drug Benefits; Formulary List
Every health care plan that provides prescription drug benefits and maintains one or more lists of drugs covered by the plan (known as a "drug formulary") must provide a copy of the list to members of the public upon request. The list must be broken down by health categories and indicate whether any drugs on the list are preferred over other drugs.
§1367.21 Prescription Drugs Under Health Care Service Plans; Nonapproved Uses
Health plans that provide prescription drug benefits are prohibited from excluding coverage for drugs that are prescribed for a use other than the use that has been approved for marketing by the federal Food and Drug Administration (FDA)(known as an "off-label use"), when the drug is 1) approved by the FDA; 2) prescribed by a licensed health care professional that contracts with the plan for a life-threatening or chronic and seriously debilitating conditions; and 3) the drug has been recognized for treatment of that condition by one of the medical sources specified in the statute. If you are denied coverage for an off-label use of a drug pursuant to this section on the basis that its use is experimental or investigational, that decision is subject to the independent review process under section 1370.4. (Medi-Cal plans are exempt from the requirements of this code section)
§1367.215 Requests for pain management medications for terminally ill patients; time in which authorized or denied
Every health plan that provides prescription drug benefits must provide coverage for appropriately prescribed pain management medications for terminally ill patients when medically necessary. The plan must approve requests for authorization of coverage for a terminally ill patient within 72 hours.
§1367.22 Prescription drug benefits; coverage for drugs approved before July 1, 1999
Any health plan contract that is issued, amended, or renewed on or after July 1, 1999 that covers prescription drug benefits may not limit or exclude coverage for a drug that had been previously prescribed to you when a plan doctor continues to prescribe the drug, provided that the drug is appropriately prescribed and is considered safe and effective. The doctor is not prohibited from prescribing another drug covered by the plan that is medically appropriate for the patient, nor are generic drug substitutions prohibited.
§1367.24 Authorization for nonformulary prescription drugs
Every plan that provides prescription drug benefits must maintain an expeditious process through which doctors can obtain authorization for drugs which are not on the list of drugs specifically covered by the plan (nonformulary prescription drugs). A description of the process must be on file with the Department of Managed Health Care, including timelines. If your plan denies a request for authorization for a nonformulary drug, it must provide the reasons for the denial in a notice to you and notify you that you have a right to file a grievance with the plan if you object to the denial.