- Date: March 01, 2011
- Source: Admin
Regulated Plans under Knox-Keene
- All HMOs
- Blue Cross PPO
- Blue Shield PPO
Provisions
- Health insurance policy contracts issued, amended, or renewed on or after January 1, 2011 are exempt until the Department of Managed Health Care or the Department of Insurance issues a declaration finding that the state unemployment rate has been no more than 5.5% for 4 consecutive quarters
- Mandated health care consumer protections are removed permitting healthcare service plans to deny coverage for screening, diagnosis, treatment of a particular disease or condition or to deny coverage of a particular type of health care treatment, service, or medical equipment.
Purpose
- To ensure that the physician maintains confidentiality and remains a trusted source for medical advice.
- To ensure that health insurance programs include plans for quality assurance for the continued health care meeting contractual obligations for consumers
- To ensure that health plans provide medical referrals to other providers regardless of monetary or administrative decisions.
- To prohibit encouragement or limitation on specific medical treatments by the health care plan and doctor or doctorýs group.
- The purpose of this important legislation is to ensure that your physician maintains her or his role as a trusted source for medical advice and maintains confidentiality. Your physician is responsible for making sure you receive accessible medical services.
Quick Reference
| Doctor-Patient Relationship/Assurance of Quality Care/Continuity of Care / Emergency Care |
· Intent and Purpose of Legislature
· Contracts between Health Care Service Plans and Licensed Health Care Practitioners; Prohibition on Certain Incentive Plans
· Requirements
· Scope of Basic Health Care Services
· Continuity of Care
· Accessibility of Services
· Standards for Plan Organization
· Subscriber and Group Contracts
· Quality Assurance Program
· Authorization or Denial of Services; Process; Disclosures; Criteria
· Written policies and procedures for review and approval or denial of services
· Emergency Services and Care; Authorization; Payments Providers; Treatment Following Stabilization; Payments to Providers; Assumption and Delegation of Responsibilities
· Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services
· Onsite Medical Survey of Health Delivery System of Pla
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Second Opinion / Grievance
Procedures / Independent Review
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· Second Medical Opinions; Policy Statement of Plan; Notice to Enrollees
· Second opinion
· Grievance System
· Resolution Period; Grievance Status and Disposition Statement; Expedited Review
· Complaints About Health Care Service Plans, Toll-Free Number; Notice of Number; Ombudsperson
· Independent Review Process; Experimental and Investigational Therapies for Individual Enrollees; Requirements; Definitions; Accreditation; Record
· Independent Review System
· Imminent threat to health; Expeditious review
· Disputed health care service; Review; Reimbursement for urgent care; Audit of cases
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Plan Contracts/Documents/Advertising
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· New or Modified Plan Contract; Publication or Distribution of Disclosure Form or Evidence of Coverage
· Material Modification to Plan Contract
· Advertising or Solicitation; Written or Printed Statement or Item; Verbal Statement
· Advertising; Requirements; Correction or Retraction
· Disclosure Forms; Contents; Uniform Health Plan Benefits and Coverage Matrix
· Disclosure Forms
· Soliciting and Advertising; Nature of Plan; Operation; Ownership by a Professional; Constructio
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Prescription Drugs
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· Prescription Drug Benefits; Formulary List
· Prescription Drugs Under Health Care Service Plans; Nonapproved Uses
· Requests for pain management medications for terminally ill patients; time in which authorized or denied
· Prescription drug benefits; coverage for drugs approved before July 1, 1999
· Authorization for nonformulary prescription drugs
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Noncompliance
Noncompliance with the Knox Keene Act is a considered a crime against public health and safety.
DMHC has power to investigate and enforce noncompliance with grievance procedure requirements. It may levy administrative penalties.
Source
http://totalcapitol.com/?bill_id=200920100SB1379
http://www.ehealthhelp.com/questions.html
http://www.calphys.org/html/knox_keene.htm
http://www.calhealthplans.org/pressroom/pressKit-FAQs.cfm
http://www.disabilityrightsca.org/legislature/Legislation/2010/AB2587.htm
http://www.benefitpackages.com/knox-keene.html
http://healthconsumer.org/cs016knoxkeene.pdf
