SB 133: Health care coverage: continuity of care.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan and a health insurer that provides services at alternative rates of payment, at the request of an enrollee or insured, to provide the completion of services by a terminated provider if the enrollee or insured is undergoing a course of treatment for one of any specified conditions, including a serious chronic condition, as defined, at the time of the contract or policy termination. Existing law also requires a health care service plan to provide for the completion of covered services by a nonparticipating provider to a newly covered enrollee who, at the time his or her coverage became effective, was receiving services from that provider for one of any specified conditions. Existing law requires a health care service plan to provide a disclosure form regarding the benefits, services, and terms of a plan contract and requires the disclosure form to include a description of how an enrollee can request continuity of care under the provisions described above.

This bill would require a health care service plan to include notice of the process to obtain continuity of care in its disclosure form and in any evidence of coverage issued after January 1, 2018. The bill would also require a plan to provide a written copy of this information to its contracting providers and provider groups, and a copy to its enrollees upon request. The bill would require a plan and health insurer to include notice of the availability of the right to request completion of covered services as part of, to accompany, or to be sent simultaneously with any termination of coverage notice sent under specified circumstances.

Existing law requires a health care service plan and a health insurer to arrange for the completion of covered services by a nonparticipating provider for one of any specified conditions for a newly covered enrollee or a newly covered insured under an individual health care service plan contract or an individual health insurance policy if, at the time his or her coverage became effective, the newly covered enrollee or newly covered insured was receiving services from that nonparticipating provider for a specified condition and whose prior coverage was withdrawn from the market between December 1, 2013, and March 31, 2014, inclusive, as specified.

This bill would delete the requirement that coverage was withdrawn from the market between December 1, 2013, and March 31, 2014, inclusive, thereby extending the requirement described above to any prior coverage that was withdrawn from the market, and would specify that, for purposes of these provisions, withdrawn from the market includes circumstances when a health benefit plan is withdrawn from any portion of a market.

Because a willful violation of these requirements by a health care service plan would, in part, be a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.