Health Administration Responsibility Project
1999 CALIFORNIA HEALTH CARE REFORM PACKAGE
INDEPENDENT REVIEW
Requires
the Department of Corporations to establish an independent medical review
system by January 1, 2001, for patients to
dispute claims when treatment has been delayed, denied or modified by
their plan.
Requires health care service
plans to provide enrollees with written response to grievances while
expanding the right to external review for experimental treatments. It
also expedites the review process in order to respond quickly to a
patient's appeal for treatment coverage.
NEW MANAGED CARE REGULATORY AGENCY
AB 78 (Gallegos)
Establishes a state
agency devoted exclusively to the licensing and regulation of health
care service plans. The newly created Department of Managed Care will be
within the Business, Transportation and Housing Agency. This bill will
also establish a new Office of the Patient Advocate, which will assist
health plan enrollees with complaints, provide educational guides, issue
annual reports and make recommendations on consumer issues.
HMO LIABILITY
SB 21 (Figueroa)
States that a patient has the
right to sue his health plan for harm caused by failure to provide
ordinary care under the plan. It provides a remedy
for consumers who are substantially harmed by a health care service plan
or managed care entity's action to delay, deny or modify medically
necessary treatment.
See Sharon Arkin's pseudo-brief to defend this
bill against the expected ERISA attack.
CONSUMER PROTECTIONS
Requires health care
service plans to provide a second medical opinion upon request by the
patient.
Requires health plans
that provide telephone medical advice services to have a medical
license.
Prohibits health care providers from releasing medical
information regarding an individual's participation in outpatient
psychotherapy without a written request to the
provider and notice to the patient. Currently, there are protections
related to inpatient care for mental health conditions, but not for
records of outpatient psychotherapy. AB 416 resolves this issue.
SB 19 (Figueroa)
Prohibits the unauthorized selling, sharing or
use of medical information for any purpose not necessary to provide
health care services. Requires health care service plans to make
their policies and procedures available upon request.
Sets forth procedures and time
frames for health care service plans to review a treatment request by a
physician. Helps to ensure timely information and decisions
regarding a patient's treatment needs and makes certain that patients
are entitled to information regarding the process used by health
care professionals to determine whether to deny, modify or approve
health care services.
Establishes deadlines for
health plans to respond to physician requests when a patient is referred
to a specialist. This is a technical clean up bill to SB 260 by Senator
Speier.
Prohibits service plans from
inappropriately marketing and selling their provider lists to gain
additional revenue. Similar requirements on contracting agents who sell,
lease, assign or otherwise transfer a list of contracted providers are
also applied to those who pay for these contracts.
FISCAL SOLVENCY
Establishes the Financial
Solvency Standards Board within the newly created Department of Managed
Care. Addresses the fiscal solvency crisis facing medical
groups in California by adopting regulations and placing adequate
safeguards in contracts between health care service plans and risk
bearing organizations.
MANDATED HEALTH CARE BENEFITS
CONTRACEPTIVES
AB 39 (Hertzberg)
Requires health care
service plans that provide outpatient prescription drug benefits to
provide FDA approved prescription contraception methods.
Requires specified individual
and group disability insurance policies to provide contraception coverage
for spouses and other dependents. Provides exemptions for religious employers.
CANCER SCREENING
SB 5 (Rainey)
Requires coverage for the
screening, diagnosis and treatment of breast cancer. Also enrollment
cannot be denied because of a personal or family history of breast
disease or breast cancer.
Requires health care service
plans and disability insurers to cover medically accepted cancer
screening tests or any contract or policy issued, amended or renewed on
or after January 1, 2000.
MENTAL HEALTH CARE
Requires health care
service plan contracts to cover the diagnosis and medically necessary
treatment of severe mental illnesses at any age and serious emotional
disturbances of a child.
Requires coverage for
psychiatric emergency medical conditions. This bill provides additional
screening, examination and evaluation of a patient to determine whether
a psychiatric emergency medical condition exists.
OTHER BENEFITS
Adds hospice care to
the basic health care services required to be provided by health care
service plans.
Provides coverage for the
testing and treatment of phenylketonuria (PKU) for
Newborns before or soon after discharge from the hospital.
Requires coverage for diabetic services and supplies including specified
equipment, supplies, training, and prescription drugs that are
determined to be medically necessary.
THIRD-PARTY INSURANCE BAD FAITH
Allow plaintiffs to sue defendants' insurers directly for insurance bad
faith, subject to certain limitations
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