Willful violation of provisions relating to the regulation of health care service plans is a crime. The bill would also establish procedures under which a plan, and in some cases its medical groups and individual practice associations, would be required, upon request, to share certain economic profiling information. The bill would impose similar requirements on certain disability insurers. By changing the definition of an existing crime relative to health care service plans, 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. The filing shall describe how these policies and procedures are used in utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions. The filing shall also indicate in what manner, if any, the economic profiling system being used takes into consideration risk adjustments that reflect case mix, type and severity of patient illness, age of patients, and other enrollee characteristics that may account for higher or lower than expected costs or utilization of services. Any changes to the policies and procedures shall be filed with the commissioner pursuant to Section 1352. Nothing in this section shall be construed to restrict or impair the department, in its discretion, from utilizing the information filed pursuant to this section for purposes of ensuring compliance with this chapter.