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› Best Practices
Knox-Keene Act 2010
- 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 |
Second Opinion / Grievance Procedures / Independent Review |
· 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 |
Plan Contracts/Documents/Advertising |
· 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 |
Prescription Drugs |
· 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 |
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
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