Bill Text: CA SB1283 | 2009-2010 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health care coverage: grievance system.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Vetoed) 2010-09-30 - In Senate. To unfinished business. (Veto) [SB1283 Detail]

Download: California-2009-SB1283-Amended.html

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BILL NUMBER: SB 1283	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  AUGUST 2, 2010
	AMENDED IN SENATE  MAY 28, 2010
	AMENDED IN SENATE  APRIL 27, 2010
	AMENDED IN SENATE  APRIL 8, 2010

INTRODUCED BY   Senator Steinberg

                        FEBRUARY 19, 2010

   An act to amend Section 1368 of the Health and Safety Code,
relating to health care coverage.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1283, as amended, Steinberg. Health care coverage: grievance
system.
   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. A willful violation
of the act constitutes a crime. Existing law requires every health
care service plan to establish and maintain a grievance system
approved by the department under which enrollees and subscribers may
submit a grievance to the plan. Existing law authorizes a subscriber
or enrollee to submit his or her grievance to the department for
review after completing the grievance process or after having
participated in that process for at least 30 days. Existing law
requires the department to send a written notice of the final
disposition of the grievance to an enrollee or subscriber within 30
days of receiving the request for review, unless the director
determines that additional time is reasonably necessary to fully
review the grievance.
   This bill would, upon a determination by the director that
additional time is necessary to review a grievance, set forth the
procedures that would apply to the department with regard to the
review of that grievance and the payment of specified costs by the
department. Upon a failure of a health care service plan to comply
with a request from the department for information related to the
grievance, the bill would authorize the department to impose an
administrative fine on that plan  , pursuant to specified
procedures,  as determined by the department.  The bill wou
  ld also authorize the department to take specified actions
in reviewing grievances that involve clinical services that have
been denied on the basis of a coverage decision. 
   Existing law requires the director to make and file annually with
the department as a public record an aggregate summary of grievances
against plans filed with the department, as specified.
   This bill would require the director to include in that report
specified information related to the department's review of
grievances against health care service plans.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1368 of the Health and Safety Code is amended
to read:
   1368.  (a) Every plan shall do all of the following:
   (1) Establish and maintain a grievance system approved by the
department under which enrollees may submit their grievances to the
plan. Each system shall provide reasonable procedures in accordance
with department regulations that shall ensure adequate consideration
of enrollee grievances and rectification when appropriate.
   (2) Inform its subscribers and enrollees upon enrollment in the
plan and annually thereafter of the procedure for processing and
resolving grievances. The information shall include the location and
telephone number where grievances may be submitted.
   (3) Provide forms for grievances to be given to subscribers and
enrollees who wish to register written grievances. The forms used by
plans licensed pursuant to Section 1353 shall be approved by the
director in advance as to format.
   (4) (A) Provide for a written acknowledgment within five calendar
days of the receipt of a grievance, except as noted in subparagraph
(B). The acknowledgment shall advise the complainant of the
following:
   (i) That the grievance has been received.
   (ii) The date of receipt.
   (iii) The name of the plan representative and the telephone number
and address of the plan representative who may be contacted about
the grievance.
   (B) Grievances received by telephone, by facsimile, by e-mail, or
online through the plan's Internet Web site pursuant to Section
1368.015, that are not coverage disputes, disputed health care
services involving medical necessity, or experimental or
investigational treatment and that are resolved by the next business
day following receipt are exempt from the requirements of
subparagraph (A) and paragraph (5). The plan shall maintain a log of
all these grievances. The log shall be periodically reviewed by the
plan and shall include the following information for each complaint:
   (i) The date of the call.
   (ii) The name of the complainant.
   (iii) The complainant's member identification number.
   (iv) The nature of the grievance.
   (v) The nature of the resolution.
   (vi) The name of the plan representative who took the call and
resolved the grievance.
   (5) Provide subscribers and enrollees with written responses to
grievances, with a clear and concise explanation of the reasons for
the plan's response. For grievances involving the delay, denial, or
modification of health care services, the plan response shall
describe the criteria used and the clinical reasons for its decision,
including all criteria and clinical reasons related to medical
necessity. If a plan, or one of its contracting providers, issues a
decision delaying, denying, or modifying health care services based
in whole or in part on a finding that the proposed health care
services are not a covered benefit under the contract that applies to
the enrollee, the decision shall clearly specify the provisions in
the contract that exclude that coverage.
   (6) Keep in its files all copies of grievances, and the responses
thereto, for a period of five years.
   (b) (1) (A) After either completing the grievance process
described in subdivision (a), or participating in the process for at
least 30 days, a subscriber or enrollee may submit the grievance to
the department for review. In any case determined by the department
to be a case involving an imminent and serious threat to the health
of the patient, including, but not limited to, severe pain, the
potential loss of life, limb, or major bodily function, or in any
other case where the department determines that an earlier review is
warranted, a subscriber or enrollee shall not be required to complete
the grievance process or to participate in the process for at least
30 days before submitting a grievance to the department for review.
   (B) A grievance may be submitted to the department for review and
resolution prior to any arbitration.
   (C) Notwithstanding subparagraphs (A) and (B), the department may
refer any grievance that does not pertain to compliance with this
chapter to the State Department of Health Care Services, the State
Department of Public Health, the California Department of Aging, the
federal Health Care Financing Administration, or any other
appropriate governmental entity for investigation and resolution.
   (2) If the subscriber or enrollee is a minor, or is incompetent or
incapacitated, the parent, guardian, conservator, relative, or other
designee of the subscriber or enrollee, as appropriate, may submit
the grievance to the department as the agent of the subscriber or
enrollee. Further, a provider may join with, or otherwise assist, a
subscriber or enrollee, or the agent, to submit the grievance to the
department. In addition, following submission of the grievance to the
department, the subscriber or enrollee, or the agent, may authorize
the provider to assist, including advocating on behalf of the
subscriber or enrollee. For purposes of this section, a "relative"
includes the parent, stepparent, spouse, adult son or daughter,
grandparent, brother, sister, uncle, or aunt of the subscriber or
enrollee.
   (3) The department shall review the written documents submitted
with the subscriber's or the enrollee's request for review, or
submitted by the agent on behalf of the subscriber or enrollee. The
department may ask for additional information, and may hold an
informal meeting with the involved parties, including providers who
have joined in submitting the grievance or who are otherwise
assisting or advocating on behalf of the subscriber or enrollee. If
after reviewing the record, the department concludes that the
grievance, in whole or in part, is eligible for review under the
independent medical review system established pursuant to Article
5.55 (commencing with Section 1374.30), the department shall
immediately notify the subscriber or enrollee, or agent, of that
option and shall, if requested orally or in writing, assist the
subscriber or enrollee in participating in the independent medical
review system.
   (4) If after reviewing the record of a grievance, the department
concludes that a health care service that is eligible for coverage
and payment under a health care service plan contract has been
delayed, denied, or modified by a plan, or by one of its contracting
providers, in whole or in part due to a determination that the
service is not medically necessary, and that determination was not
communicated to the enrollee in writing along with a notice of the
enrollee's potential right to participate in the independent medical
review system, as required by this chapter, the director shall, by
order, assess administrative penalties. A proceeding for the issuance
of an order assessing administrative penalties shall be subject to
appropriate notice of, and the opportunity for, a hearing with regard
to the person affected in accordance with Section 1397. The
administrative penalties shall not be deemed an exclusive remedy
available to the director. These penalties shall be paid to the
Managed Care Administrative Fines and Penalties Fund and shall be
used for the purposes specified in Section 1341.45.
   (5) (A) The department shall send a written notice of the final
disposition of the grievance, and the reasons therefor, to the
subscriber or enrollee, the agent, to any provider that has joined
with or is otherwise assisting the subscriber or enrollee, and to the
plan, within 30 calendar days of receipt of the request for review
unless the director, in his or her discretion, determines that
additional time is reasonably necessary to fully and fairly evaluate
the relevant grievance. If the director determines that additional
time is necessary to evaluate a grievance and make a determination,
the department shall do all of the following:
   (i) Make a determination, within 30 calendar days of receipt of
the request for review, as to what additional information is
necessary for the department to complete its review of the grievance
and make a determination.
   (ii) Notify the subscriber or the enrollee in writing, within 30
calendar days of receipt of the request for review, of the additional
information that the department has identified for it to complete
the grievance review and to make a determination.
   (iii) Upon receipt of all information that constitutes a completed
application, notify the subscriber or the enrollee, in writing
within five business days, of the date the application was completed.

   (iv) Make a determination of the final disposition of the
grievance, and the reasons therefor, within 30 calendar days of
having established a completed application.
   (v) Notify the subscriber or enrollee of the decision in writing
within five business days of the final disposition of the grievance.
   (B) Notwithstanding the requirements of subparagraph (A), the
department may not request from the subscriber or enrollee any
information, data, or further evaluation that imposes additional
costs, expenses, or other fiscal responsibilities upon the subscriber
or enrollee, unless paid for by the department.
   (C) A plan shall provide all information that is requested by the
department pursuant to subparagraph (A) within five  business
days of the department's request. If the plan fails to comply with
that request, the department shall impose an administrative fine upon
the plan. The amount of the fine shall be determined by the
department consistent with other administrative fines and penalties
authorized under this chapter.   calendar days of the
department's request. If the requested information cannot be provided
to the department within this timeframe, the plan's response will
describe the actions being taken to obtain the information or records
and when receipt is expected. The department shall provide
appropriate oversight to determine that the plan complies with
information requests described in this subdivision. If the department
determines that noncompliance with an information request is the
result of factors that were within the purview and responsibility of
the plan, the department shall impose an administrative fine upon the
plan and all other appropriate remedies and corrective actions that
the department deems necessary, including, but not limited to, any
applicable regulatory penalties the department is authorized to
impose. The amount of the fine shall be   determined by the
department consistent with other administrative fines and penalties
authorized under this chapter. The department shall notify the
subscriber or enrollee in writing of all remedies and corrective
actions imposed upon the plan under this provision. 
   (D) In any case not eligible for the independent medical review
system established pursuant to Article 5.55 (commencing with Section
1374.30), the department's written notice shall include, at a
minimum, the following:
   (i) A summary of its findings and the reasons why the department
found the plan to be, or not to be, in compliance with any applicable
laws, regulations, or orders of the director.
   (ii) A discussion of the department's contact with any medical
provider, or any other independent expert relied on by the
department, along with a summary of the views and qualifications of
that provider or expert.
   (iii) If the enrollee's grievance is sustained in whole or in
part, information about any corrective action taken. 
   (6) If the grievances to the department involve clinical services
that are being denied on the basis of a "coverage decision," the
department may pursue the following:  
   (A) Provide the completed application to an independent health
care provider, independent medical expert, or independent panel of
appropriate medical specialists who are knowledgeable and qualified
to address the issues in question.  
   (B) Request that the individual or individuals identified in
subparagraph (A) review the completed application, as well as all
relevant data and information, and provide findings and
recommendations to the department that include, but are not limited
to, the following:  
   (i) Whether the requested services are considered to be health
care services.  
   (ii) Whether the requested services are considered to be
non-health-care services.  
   (iii) Whether the requested services are a covered benefit. 

   (C) Any individual or individuals consulted for the purposes of
this section, shall be identified by an independent medical review
organization that substantially meets the requirements of Section
1374.32.  
   (6) 
    (7)  In any department review of a grievance involving a
disputed health care service, as defined in subdivision (b) of
Section 1374.30, that is not eligible for the independent medical
review system established pursuant to Article 5.55 (commencing with
Section 1374.30), in which the department finds that the plan has
delayed, denied, or modified health care services that are medically
necessary, based on the specific medical circumstances of the
enrollee, and those services are a covered benefit under the terms
and conditions of the health care service plan contract, the
department's written notice shall do either of the following:
   (A) Order the plan to promptly offer and provide those health care
services to the enrollee.
   (B) Order the plan to promptly reimburse the enrollee for any
reasonable costs associated with urgent care or emergency services,
or other extraordinary and compelling health care services, when the
department finds that the enrollee's decision to secure those
services outside of the plan network was reasonable under the
circumstances.
   The department's order shall be binding on the plan. 
   (7) 
    (8)  Distribution of the written notice shall not be
deemed a waiver of any exemption or privilege under existing law,
including, but not limited to, Section 6254.5 of the Government Code,
for any information in connection with and including the written
notice, nor shall any person employed or in any way retained by the
department be required to testify as to that information or notice.

   (8) 
    (9)  The director shall establish and maintain a system
of aging of grievances that are pending and unresolved for 30 days or
more that shall include a brief explanation of the reasons each
grievance is pending and unresolved for 30 days or more. The director
shall also include, in its annually published report that details
the number and types of complaints or grievances received during the
calendar year pursuant to Section 1397.5, data regarding the
timeframes for grievance resolution. This data shall include, but is
not limited to, the average number of days before a grievance is
closed, the average number of days before a grievance is sent to
independent medical review, the average number of days before the
independent medical review process is resolved and a decision is
rendered by the director, and a breakdown of the number of cases
resolved in less than 30 days and in more than 30 days. The director
shall also include in the report a review of the grievances not
resolved within 30 days and shall report on the number, proportion by
type and medical condition, and causes of the grievances, as well as
the reasons for the failure to resolve any grievance pending for
more than 30 days. 
   (9) 
    (10)  A subscriber or enrollee, or the agent acting on
behalf of a subscriber or enrollee, may also request voluntary
mediation with the plan prior to exercising the right to submit a
grievance to the department. The use of mediation services shall not
preclude the right to submit a grievance to the department upon
completion of mediation. In order to initiate mediation, the
subscriber or enrollee, or the agent acting on behalf of the
subscriber or enrollee, and the plan shall voluntarily agree to
mediation. Expenses for mediation shall be borne equally by both
sides. The department shall have no administrative or enforcement
responsibilities in connection with the voluntary mediation process
authorized by this paragraph.
   (c) The plan's grievance system shall include a system of aging of
grievances that are pending and unresolved for 30 days or more. The
plan shall provide a quarterly report to the director of grievances
pending and unresolved for 30 or more days with separate categories
of grievances for Medicare enrollees and Medi-Cal enrollees. The plan
shall include with the report a brief explanation of the reasons
each grievance is pending and unresolved for 30 days or more. The
plan shall also include in the quarterly report data regarding the
timeframes for grievance resolution. This data shall include, but is
not limited to, the average number of days before a grievance is
closed, a breakdown of the number of cases resolved in less than 30
days and in more than 30 days, and for grievances not resolved within
30 days, the number, proportion by type and medical condition, and
causes of the grievances, as well as the reasons for the failure to
resolve any grievance pending for more than 30 days. The plan may
include the following statement in the quarterly report that is made
available to the public by the director:



"Under Medicare and Medi-Cal law, Medicare enrollees and Medi-Cal
enrollees each have separate avenues of appeal that are not available
to other enrollees. Therefore, grievances pending and unresolved may
reflect enrollees pursuing their Medicare or Medi-Cal appeal rights."




If requested by a plan, the director shall include this statement in
a written report made available to the public and prepared by the
director that describes or compares grievances that are pending and
unresolved with the plan for 30 days or more. Additionally, the
director shall, if requested by a plan, append to that written report
a brief explanation, provided in writing by the plan, of the reasons
why grievances described in that written report are pending and
unresolved for 30 days or more. The director shall not be required to
include a statement or append a brief explanation to a written
report that the director is required to prepare under this chapter,
including Sections 1380 and 1397.5.
   (d) Subject to subparagraph (C) of paragraph (1) of subdivision
(b), the grievance or resolution procedures authorized by this
section shall be in addition to any other procedures that may be
available to any person, and failure to pursue, exhaust, or engage in
the procedures described in this section shall not preclude the use
of any other remedy provided by law.
   (e) Nothing in this section shall be construed to allow the
submission to the department of any provider grievance under this
section. However, as part of a provider's duty to advocate for
medically appropriate health care for his or her patients pursuant to
Sections 510 and 2056 of the Business and Professions Code, nothing
in this subdivision shall be construed to prohibit a provider from
contacting and informing the department about any concerns he or she
has regarding compliance with or enforcement of this chapter.