Knox-Keene Act 2010

  • Date: March 01, 2011
  • Source: Admin
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 Regulated Plans under Knox-Keene

  • All HMOs
  • Blue Cross PPO
  • Blue Shield PPO


  • 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.


  • 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 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. 


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