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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

http://www.benefitpackages.com/knox-keene.html

http://healthconsumer.org/cs016knoxkeene.pdf