News & Regulations Page

CALIFORNIA MANAGED CARE REGULATIONS (2000-2001 Legislation) Notice

AB 525, effective January 1, 2001 - requires plans to provide a specific statement regarding access to family planning and contraceptive services in their provider directory and evidence of coverage and disclosure forms.

AB 2130, effective January 1, 2001 - In cases where one parent has custody and the other provides the child with health care coverage, then plans/insurers are required to provide information about a child’s health care coverage to the non-covered parent or person having custody of the child. Also requires that the covered and non-covered parent or person having custody be notified if the child’s coverage is altered or terminated.

AB 2168, effective January 1, 2001 - Requires that the eligibility requirement for standing referrals be interpreted broadly for members requiring treatment for HIV or AIDS.

AB 2246, effective January 1, 2001 - Requires a business to ensure the privacy of a customer's personal information contained in records by destroying, shredding, erasing, or otherwise modifying the customer record to make the information unreadable or undecipherable through any means.

AB 2799, effective January 1, 2001 - Amends the Public Records Act: requires state or local agency that has public records in electronic format to make that information available in electronic format, unless otherwise prohibited by law, requires an agency that withholds a public record to justify its withholding in writing, and authorizes an agency or the superior court to disclose or order to be disclosed any record made exempt by express provisions of the act if the public interest served by disclosing the record clearly outweighs the public interest served by not disclosing the record.

SB 129, effective January 1, 2001 - Establishes an Office of Privacy Protection in the Department of Consumer Affairs for the purpose of protecting the privacy of individuals' personal information by identifying consumer problems and facilitating development of fair information practices that comply with the Information Practices Act of 1977. Requires the office to inform the public of potential options for protecting the privacy of, and avoiding the misuse of, personal information. Each state department or state agency must designate a position responsible for the privacy policy within the department or agency.

SB 265, effective January 1, 2001 - Enact some requirements from HIPAA related to eligible individuals purchasing coverage on a guaranteed basis. If a plan/insurer provides coverage under an individual plan contract then the plan/insurer cannot decline to offer coverage or enrollment of a federally eligible defined individual. Mandates other related coverage requirements (e.g. preexisting condition exclusions, marketing rules, premiums, etc.)

SB 764, effective January 1, 2001 - Enacts provisions that are similar to the National Association of Insurance Commissioners’ Model Regulation to Implement Medicare Supplement Insurance Minimum Standards Model Act. These laws incorporate federal changes to Medicare supplemental insurance enacted in the federal Balanced Budget Act of 1997.

SB 1814, effective January 1, 2001 - Amends Medicare supplement coverage laws related to disabled individuals under 65 eligible for Medicare and also addresses several other areas of supplemental coverage requirements. This law also requires the Insurance Commissioner to prepare an annual rate guide covering Medicare supplement policies and issue it prior to Medicare’s annual open enrollment.

SB 1471, effective January 1, 2001 - Prohibits a plan and medical groups/IPAs from issuing a lien against members to recover more than an amount paid to the enrollee’s provider for health care services. The bill includes several other provisions related to liens for capitated and non-capitated services.

SB 1746, effective January 1, 2001 - Requires plans to notify members if their primary care physician is terminated by the plan. Also specifies notification requirements and permits a member to self refer under specified conditions when proper notification has not occurred.

SB 1764, effective January 1, 2001 - Requires the Legislative Analyst to perform surveys, review data and research regarding the cost effectiveness of providing substance abuse treatment parity in health care policies and to report the findings to the Legislature.

SB 1903, effective January 1, 2001 - Amends the Confidentiality of Medical Information Act by applying the provisions prohibiting sharing, selling and use of medical information to corporations and affiliates. Allows a patient to attach a written addendum on disputed portions of their medical record.

SB 2046, effective January 1, 2001 - Plans cannot limit or exclude coverage for off-label use of prescription drugs for a chronic and seriously debilitating condition. Also allows members to request an independent medical review if coverage for off-label use is denied based on experimental/ investigational reasons.

CALIFORNIA MANAGED CARE REGULATIONS (1999-2000 Legislation) Notice

AB 78, effective January 1, 2000, establishes the Department of Managed Care to administer the Knox-Keene Health Care Service Plan Act of 1975, as amended. This bill also establishes an Advisory Committee on Managed Care, a Clinical Advisory Panel, and an Office of Patient Advocate.

SB 21, for services rendered effective January 1, 2000, is known as the “Managed Health Care Insurance Accountability Act of 1999”. This bill allows enrollees to sue health plans for substantial harm (defined in law) resulting from a plan’s failure to exercise ordinary care in their actions to modify, deny, or delay recommended health care services.

AB 55, with sections effective January 1, 2000 & January 1, 2001, requires the Dept. of Managed Care to establish an independent medical review system to review disputed health care services that have been delayed, modified or denied in whole or part based on lack of medical necessity. This bill includes definitions, notification and timeframe requirements as well as criteria for the independent medical review organizations.

SB 189, with sections effective January 1, 2000 & January 1, 2001, revises timeframes, mandates written notification requirements for all grievances and additional specifics for grievances involving a delay, denial or modification of health care services. Addresses Dept. of Managed Care grievance process duties and coordinates the grievance process with the requirements of AB 55. Expands the definition of conditions qualifying for external independent review under the current law and coordinates this external review process with AB 55 requirements.

AB 12, effective January 1, 2000 and requires filing by July 1, 2000, mandates that a second opinion be authorized or provided upon enrollee or participating provider request. Bill addresses reasons an enrollee can request second opinion, timeframe requirements, out of network coverage and more.

AB 416, effective January 1, 2000, provides that prior to release of medical information for outpatient psychotherapist treatment, the person/entity agent requesting the records must submit a written request to the provider and notice to the patient.

SB 19, with sections effective January 1, 2000 & July 1, 2001 and requiring filings by July 1, 2001, amends Confidentiality of Medical Information Act by revising definitions, adding prohibitions on disclosure of medical information, addressing violations of Act and requiring plans to have written policies and procedures addressing security of medical information.

SB 59, effective January 1, 2000, mandates UM decision timeframes, notification requirements, Medical Director responsibility in UM process, UM clinical criteria and review process disclosure requirements. This applies to prospective, concurrent, or retrospective determinations to approve, modify, delay or deny in part or whole based on medical necessity treatment requests by providers.

AB 39, effective January 1, 2000, is also known as the “Women’s Contraception Equity Act”. This law states that if a health plan covers outpatient prescription drug benefits then coverage must include a variety of FDA approved prescription contraceptive methods. Allows exception for religious employers.

SB 41, effective January 1, 2000, is the same regulation as AB 39 except that it applies to disability insurance.

SB 5, effective January 1, 2000, mandates coverage for screening, diagnosis of, and treatment for breast cancer. Cannot deny enrollment or coverage to enrollees with personal/family history of breast cancer or breast disease.

SB 205, effective July 1, 2000, provides that health plan contracts are deemed to cover all generally medically accepted cancer screening tests.

AB 88, effective July 1, 2000, mandates coverage for the diagnosis and medically necessary treatment of severe mental illnesses at any age (specific conditions listed in bill) and severe emotional disturbances of children as defined in the bill. This benefit must be treated in the same manner as other benefits in regards to lifetime maximums, copayments, and deductibles, etc.

SB 349, effective January 1, 2000, requires coverage of additional screening, evaluation and examination of a patient to determine if a psychiatric emergency medical condition exists. Benefits for psychiatric emergency medical conditions cannot be denied reimbursement solely because the patient also received an evaluation for a non-psychiatric medical emergency condition during the same visit.

AB 892, effective January 1, 2002, adds hospice care (at a minimum must be equivalent to the Medicare hospice benefit) as a basic benefit.

SB 148, effective July 1, 2000, mandates coverage for the testing and treatment of phenylketonuria (PKU).

SB 64, effective January 1, 2000, mandates coverage of specified equipment, supplies, treatment, prescriptions (if plan offers prescription drug benefits), outpatient self-management training, education, and medical nutrition therapy for diabetes. Appropriately licensed or registered health care professionals must provide the latter three services.

AB 394, by January 1, 2001, DHS must establish minimum licensed nurse to patient ratios for all health facilities as defined in specified sections of 1250.
Also, effective January 1, 2000, prohibits assigning unlicensed personnel to perform specified nursing functions in lieu of a RN and prohibits allowing such activities to be performed by unlicensed personnel under the direct supervision of a RN.

AB 891, effective July 1, 2000 creates a new act called the Health Care Decisions Law. This law repeals the provisions regarding durable power of attorney for health care under the existing Power of Attorney Law and repeals the Natural Death Act. These provisions are revised and recast as part of the new act.

SB 475, states that he Department of insurance must prepare an annual consumer rate guide for long term care insurance comparisons. this guide must be published no later than December 1 of every year with the first guide issued by December 1, 2000.

SB 870, effective January 1, 2000 makes several changes to the long-term care insurance provision and has varying effective dates affecting the provisions.

SB 737, effective January 1, 2000 modifies "late enrollee" provisions for dependents of eligible employees subject to certain criteria as specified in the law.

SB 1185, effective January 1, 2000 clarifies and expands the definition of "genetic characteristics" as related to the laws dealing with the use of genetic information.

CALIFORNIA MANAGED CARE REGULATIONS (1998-1999 Legislation) Notice

SB 742, effective January 1, 1999, establishes requirements for continuity of care for managed care Medicare enrollees whose place of residence is a skilled nursing facility (defined in the law). This covers Medicare enrollees who's residence prior to acute care is not contracted with the health plan or their representative provider partner. Specific requirements are further described in the law.

SB 956 requires every health care service plan to establish an antifraud plan. The plan must be submitted to the department no later than July 1, 1999. Thereafter, an annual report must be submitted to the commissioner documenting the findings of the antifraud unit.

SB 1443, effective July 1, 1999, amends section 1368 and amends, repeals and adds section 1368.02 of the code. The bill adds to the language on grievance information that must be included with all communications sent to health plan enrollees upon enrollment and annually thereafter.

AB 1621, effective July1, 1999, expands the coverage for reconstructive surgery to include procedures that would create a normal appearance. This law includes specific definitions for reconstructive cosmetic surgery. It further outlines requirements for "like" specialty review in assessment for treatment authorization. Reconstructive surgery must also be covered by Medi-Cal under specific criteria from DHS.

SB 750, effective January 1, 1999, amends Section 1367.10 of the Health and Safety Code by adding the requirement(s) to disclose basic methods of reimbursement including the scope and methods of reimbursement, financial bonuses and incentives. It requires any plan, medical group, IPA or participating health care provider who may use or receive financial bonuses or any other incentives to provide a written summary of the bonuses or incentives to any person requesting the information. The summary must also describe if and how bonuses or incentives relate to a providers use of referred services.

SB 1129, which has 2 parts effective January 1, 1999 and July 1, 1999, provides that health plan enrollees can continue with their provider that has been terminated for any reason other than medical disciplinary cause, fraud, or other criminal activity. This covers enrollees with acute conditions, serious chronic conditions, and woman in the second and third trimester of pregnancy. Also reference AB 607.

SB 2020, effective January 1, 1999, establishes coverage for the screening and diagnosis of prostate cancer including, but not limited to, prostate specific antigen (PSA) testing and digital rectal examinations when medically indicated and consistent with nationally recognized professional standards of practice. This amendment to the Health and Safety Code further supports SB 1 which amended the business and professional code in 1997. SB 1, known as the Grant H. Kenyon Prostate Cancer Detection Act, set forth as a violation constituting unprofessional conduct in cases where providers knowingly withhold knowledge of the availability of appropriate diagnostic procedures such as prostage specific antigen (PSA) test.

AB 7, which has 2 parts effective January 1, 1999 and July 1, 1999 provides extended rules related to mastectomies and lymph node dissections and prohibits the pre-certification for length of stay for these procedures. It further outlines coverage for prosthetic devices or reconstructive surgery. This does not preclude a HCSP from authorizing the admission for the procedures. Includes disability insurers.

AB 12, effective January 1, 1999, provides that health plan enrollees can not be required to obtain prior approval from another physician, provider, or the health plan before obtaining direct access to ob/gyn physician services. However, the plan can establish requirements for certain utilization management guidelines for the use of ob/gyns.

AB 607, which has 2 parts effective January 1, 1999 and July 1, 1999, requires health plan disclosure forms to contain plan telephone numbers, information on the availability of an evidence of coverage before enrollment, provision of a uniform benefit and coverage matrix, and other disclosure form information. Medi-Cal and Medicare programs are excluded. Reference SB 1129.

AB 974, which has 2 parts effective January 1, 1999 and July 1, 1999, provides for prescription drug benefit notices to be more detailed (re: formularies in place). To insure continuity of care, HCSP's will not be able to disallow coverage of a drug that the enrollee had previous coverage for.

AB 984, which has several parts effective January 1, 1999 and July 1, 1999 requires insurers and health care service plans to include information in plan documents encouraging enrollee use of the "911" system in an emergency. Subject to certain criteria, health care and insurance plans cannot require prior authorization or refuse payment for transports resulting from the "911" system.

AB 1181, effective January 1, 1999, establishes the requirement to allow for standing referrals to specialists and/or specialty care centers. This allows for specialists to coordinate the care of enrollees with a condition or disease that requires specialized medical care over a prolonged period of time and is life threatening, degenerative or disabling. However, the HCSP or provider organization can establish requirements for utilization management guidelines for standing referrals.

AB 1560, effective July 1, 1999, includes the enrollee right to view the health care service plan's evidence of coverage before enrollment.

AB 1899, effective January 1, 1999, adds to covered basic health care service plan services - ambulance and ambulance transport services provided through "911" systems.

AB 2003, effective January 1, 1999, mandates coverage subject to certain conditions, for general anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center setting.

SB 1654, effective January 1, 1999 extends indefinitely previous "temporary" legislation regarding prohibitions on the use of information about a person's genetic characteristics.

SB 1702, effective January 1, 1999 states if health care service plans use arbitration to settle disputes with enrollees, then certain information is required to be in written decision to all parties involved in the arbitration.

SB 1948, effective July 1, 1999 requires the Department of Insurance to make available a written report on complaints and enforcement information involving individual insurers