reglab/housing_qa huggingface dataset:
CA Health & Safety Code § 1368.04 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.04.

1368.04.  (a) The director shall investigate and take enforcement action against plans regarding grievances reviewed and found by the department to involve noncompliance with the requirements of this chapter, including grievances that have been reviewed pursuant to the independent medical review system established pursuant to Article 5.55 (commencing with Section 1374.30). Where substantial harm to an enrollee has occurred as a result of plan noncompliance, the director shall, by order, assess administrative penalties 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. The director shall periodically evaluate grievances to determine if any audit, investigative, or enforcement actions should be undertaken by the department.(b) The director may, after appropriate notice and opportunity for hearing in accordance with Section 1397, by order, assess administrative penalties if the director determines that a health care service plan has knowingly committed, or has performed with a frequency that indicates a general business practice, either of the following:(1) Repeated failure to act promptly and reasonably to investigate and resolve grievances in accordance with Section 1368.01.(2) Repeated failure to act promptly and reasonably to resolve grievances when the obligation of the plan to the enrollee or subscriber is reasonably clear.(c) The administrative penalties available to the director pursuant to this section are not exclusive, and may be sought and employed in any combination with civil, criminal, and other administrative remedies deemed warranted by the director to enforce this chapter.(d) The administrative penalties authorized pursuant to this section shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45.(Amended by Stats. 2008, Ch. 607, Sec. 6. Effective September 30, 2008.)
CA Health & Safety Code § 1368.05 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.05.

1368.05.  (a) (1) By enacting this section, which was originally enacted by Assembly Bill 922 (Chapter 552 of the Statutes of 2011), the Legislature recognizes that, because of the enactment of federal health care reform on March 23, 2010, and the implementation of various provisions by January 1, 2014, and the ongoing complexities of health care reform, it is appropriate to transfer the direct consumer assistance activities to the Department of Managed Health Care, and the Legislature recognizes that these new duties are necessary to be carried out by the department in partnership with community-based consumer assistance organizations for the purposes of serving California’s health care consumers.(2) In addition to maintaining the toll-free telephone number for the purpose of receiving complaints regarding health care service plans as required in Section 1368.02, the department and its contractors shall carry out these new responsibilities, which include assisting consumers in navigating private and public health care coverage and assisting consumers in determining the regulator that regulates the health care coverage of a particular consumer. In order to further assist in implementing health care reform, the department and its contractors shall also receive and respond to inquiries, complaints, and requests for assistance and education concerning health care coverage available in California.(b) (1) The department shall annually contract with community-based organizations in furtherance of providing assistance to consumers as described in subdivision (a), as authorized by and in accordance with Section 19130 of the Government Code.(2) These organizations shall be community-based nonprofit consumer assistance programs that shall include in their mission the assistance of, and duty to, health care consumers.(3) Contracting consumer assistance organizations shall have experience in assisting consumers in navigating the local health care system, advising consumers regarding their health care coverage options, assisting consumers with problems in accessing health care services, and serving consumers with special needs, including, but not limited to, consumers with limited-English language proficiency, consumers requiring culturally competent services, low-income consumers, consumers with disabilities, consumers with low literacy rates, and consumers with multiple health conditions, including behavioral health. The organizations shall also have experience with, and the capacity for, collecting and reporting data regarding the consumers they assist, including demographic data, source of coverage, regulator, type of problem or issue, and resolution of complaints.(Amended by Stats. 2021, Ch. 696, Sec. 8. (AB 172) Effective October 8, 2021.)
CA Health & Safety Code § 1368.1 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.1.

1368.1.  (a)  A plan that denies coverage to an enrollee with a terminal illness, which for the purposes of this section refers to an incurable or irreversible condition that has a high probability of causing death within one year or less, for treatment, services, or supplies deemed experimental, as recommended by a participating plan provider, shall provide to the enrollee within five business days all of the following information: (1)  A statement setting forth the specific medical and scientific reasons for denying coverage. (2)  A description of alternative treatment, services, or supplies covered by the plan, if any. Compliance with this subdivision by a plan shall not be construed to mean that the plan is engaging in the unlawful practice of medicine. (3)  Copies of the plan’s grievance procedures or complaint form, or both. The complaint form shall provide an opportunity for the enrollee to request a conference as part of the plan’s grievance system provided under Section 1368. (b)  Upon receiving a complaint form requesting a conference pursuant to paragraph (3) of subdivision (a), the plan shall provide the enrollee, within 30 calendar days, an opportunity to attend a conference, to review the information provided to the enrollee pursuant to paragraphs (1) and (2) of subdivision (a), conducted by a plan representative having authority to determine the disposition of the complaint. The plan shall allow attendance, in person, at the conference, by an enrollee, a designee of the enrollee, or both, or, if the enrollee is a minor or incompetent, the parent, guardian, or conservator of the enrollee, as appropriate. However, the conference required by this subdivision shall be held within five business days if the treating participating physician determines, after consultation with the health plan medical director or his or her designee, based on standard medical practice, that the effectiveness of either the proposed treatment, services, or supplies or any alternative treatment, services, or supplies covered by the plan, would be materially reduced if not provided at the earliest possible date. (c)  Nothing in this section shall limit the responsibilities, rights, or authority provided in Sections 1370 and 1370.1. (Added by Stats. 1994, Ch. 582, Sec. 1. Effective January 1, 1995.)
CA Health & Safety Code § 1368.2 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.2.

1368.2.  (a) On and after January 1, 2002, every group health care service plan contract, except a specialized health care service plan contract, which is issued, amended, or renewed, shall include a provision for hospice care.(b) The hospice care shall at a minimum be equivalent to hospice care provided by the federal Medicare program pursuant to Title XVIII of the Social Security Act.(c) The hospice care provided under this section is not required to include preliminary services set forth in subdivision (d) of Section 1749. However, an enrollee who receives those preliminary services shall remain eligible for coverage of curative treatment by a health care service plan during the course of preliminary services and prior to the election of hospice services.(d) The following are applicable to this section and to paragraph (7) of subdivision (b) of Section 1345:(1) The definitions in Section 1746, except for subdivisions (o) and (p) of that section.(2) The “federal regulations” which means the regulations adopted for hospice care under Title XVIII of the Social Security Act in Title 42 of the Code of Federal Regulations, Chapter IV, Part 418, except Subparts A, B, G, and H, and any amendments or successor provisions thereto.(e) The director no later than January 1, 2001, shall adopt regulations to implement this section. The regulations shall meet all of the following requirements:(1) Be consistent with all material elements of the federal regulations that are not by their terms applicable only to eligible Medicare beneficiaries. If there is a conflict between a federal regulation and any state regulation, other than those adopted pursuant to this section, the director shall adopt the regulation that is most favorable for plan subscribers, members or enrollees to receive hospice care.(2) Be consistent with any other applicable federal or state laws.(3) Be consistent with the definitions of Section 1746, except for subdivisions (o) and (p) of that section.(f) This section is not applicable to the subscribers, members, or enrollees of a health care service plan who elect to receive hospice care under the Medicare program.(Amended by Stats. 2005, Ch. 77, Sec. 30. Effective January 1, 2006.)
CA Health & Safety Code § 1368.5 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.5.

1368.5.  (a)  Every health care service plan that offers coverage for a service that is within the scope of practice of a duly licensed pharmacist may pay or reimburse the cost of the service performed by a pharmacist for the plan if the pharmacist otherwise provides services for the plan. (b)  Payment or reimbursement may be made pursuant to this section for a service performed by a duly licensed pharmacist only when all of the following conditions are met: (1)  The service performed is within the lawful scope of practice of the pharmacist. (2)  The coverage otherwise provides reimbursement for identical services performed by other licensed health care providers. (c)  Nothing in this section shall require the plan to pay a claim to more than one provider for duplicate service or be interpreted to limit physician reimbursement. (Added by Stats. 1996, Ch. 527, Sec. 1. Effective January 1, 1997.)
CA Health & Safety Code § 1368.6 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.6.

1368.6.  (a) Effective January 1, 2020, there is established a pilot project to assess the impact of health care service plan and pharmacy benefit manager prohibitions on the dispensing of certain amounts of prescription drugs by network retail pharmacies. The provisions of subdivision (b) shall apply to pharmacy providers located in the Counties of Riverside and Sonoma.(b) Pursuant to the pilot project, a health care service plan shall not prohibit, or permit any delegated pharmacy benefit manager to prohibit, a pharmacy provider from dispensing a particular amount of a prescribed medication if the plan or pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the plan or pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the federal Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.(c) This section shall not be construed to prohibit a health care service plan or pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy network provider as for a pharmacy owned or controlled by the health care service plan or pharmacy benefit manager.(d) This section shall not be construed to prohibit differential cost sharing designed to encourage or discourage the use of mail-order pharmacy services or preferred pharmacies.(e) On or before July 1, 2020, health care service plans subject to this section shall report annually to the Department of Managed Health Care information and data relating to changes, if any, to costs and utilization of prescription drugs attributable to the prohibition of contract terms in subdivision (b). The department shall solicit and receive any additional information relevant to changes in costs or utilization attributable to the pilot project from other interested stakeholders. The department shall summarize data received pursuant to this subdivision and provide the summary to the Governor and health policy committees of the Legislature on or before December 31, 2022.(f) This section shall remain in effect only until January 1, 2023, and as of that date is repealed.(Added by Stats. 2018, Ch. 905, Sec. 3. (AB 315) Effective January 1, 2019. Repealed as of January 1, 2023, by its own provisions.)
CA Health & Safety Code § 1368.7 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1368.7.

1368.7.  (a) A health care service plan shall provide an enrollee who has been displaced by a state of emergency, as declared by the Governor pursuant to Section 8625 of the Government Code, access to medically necessary health care services.(b) Within 48 hours of a declaration by the Governor of a state of emergency that displaces or has the immediate potential to displace enrollees, a health care service plan operating in the county or counties included in the declaration shall file with the department a notification describing whether the plan has experienced or expects to experience any disruption to the operation of the plan, explaining how the plan is communicating with potentially impacted enrollees, and summarizing the actions the plan has taken or is in the process of taking to ensure that the health care needs of enrollees are met. This may require the plan to take actions, including, but not limited to, the following:(1) Relax time limits for prior authorization, precertification, or referrals.(2) Extend filing deadlines for claims.(3) Suspend prescription refill limitations and allow an impacted enrollee to refill his or her prescriptions at an out-of-network pharmacy.(4) Authorize an enrollee to replace medical equipment or supplies.(5) Allow an enrollee to access an appropriate out-of-network provider if an in-network provider is unavailable due to the state of emergency or if the enrollee is out of the area due to displacement.(6) Have a toll-free telephone number that an affected enrollee may call for answers to questions, including questions about the loss of health insurance identification cards, access to prescription refills, or how to access health care. (c) This section shall not be construed to limit the Governor’s authority under the California Emergency Services Act (Chapter 7 (commencing with Section 8550) of Division 1 of Title 2 of the Government Code), or the director’s authority under any provision of this chapter.(Added by Stats. 2018, Ch. 196, Sec. 1. (AB 2941) Effective January 1, 2019.)
CA Health & Safety Code § 1369 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1369.

1369.  Every plan shall establish procedures to permit subscribers and enrollees to participate in establishing the public policy of the plan. For purposes of this section, public policy means acts performed by a plan or its employees and staff to assure the comfort, dignity, and convenience of patients who rely on the plan’s facilities to provide health care services to them, their families, and the public.(Amended by Stats. 2005, Ch. 45, Sec. 1. Effective January 1, 2006.)
CA Health & Safety Code § 1370 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1370.

1370.  Every plan shall establish procedures in accordance with department regulations for continuously reviewing the quality of care, performance of medical personnel, utilization of services and facilities, and costs. Notwithstanding any other provision of law, there shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any person who participates in plan or provider quality of care or utilization reviews by peer review committees which are composed chiefly of physicians and surgeons or dentists, psychologists, or optometrists, or any of the above, for any act performed during the reviews if the person acts without malice, has made a reasonable effort to obtain the facts of the matter, and believes that the action taken is warranted by the facts, and neither the proceedings nor the records of the reviews shall be subject to discovery, nor shall any person in attendance at the reviews be required to testify as to what transpired thereat. Disclosure of the proceedings or records to the governing body of a plan or to any person or entity designated by the plan to review activities of the plan or provider committees shall not alter the status of the records or of the proceedings as privileged communications.The above prohibition relating to discovery or testimony shall not apply to the statements made by any person in attendance at a review who is a party to an action or proceeding the subject matter of which was reviewed, or to any person requesting hospital staff privileges, or in any action against an insurance carrier alleging bad faith by the carrier in refusing to accept a settlement offer within the policy limits, or to the director in conducting surveys pursuant to Section 1380.This section shall not be construed to confer immunity from liability on any health care service plan. In any case in which, but for the enactment of the preceding provisions of this section, a cause of action would arise against a health care service plan, the cause of action shall exist notwithstanding the provisions of this section.(Amended by Stats. 1999, Ch. 525, Sec. 105. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)
CA Health & Safety Code § 1370.1 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1370.1.

1370.1.  Nothing in this article shall be construed to prevent a plan from utilizing subcommittees to participate in peer review activities, nor to prevent a plan from delegating the responsibilities required by Section 1370, as it determines to be appropriate, to subcommittees including subcommittees composed of a majority of nonphysician health care providers licensed pursuant to the Business and Professions Code, so long as the plan controls the scope of authority delegated and may revoke all or part of this authority at any time. Persons who participate in the subcommittees shall be entitled to the same immunity from monetary liability and actions for civil damages as persons who participate in plan or provider peer review committees pursuant to Section 1370.(Amended by Stats. 1988, Ch. 828, Sec. 2.)
CA Health & Safety Code § 1370.2 (2021)
2021 California Code|Health and Safety Code - HSC|DIVISION 2 - LICENSING PROVISIONS|CHAPTER 2.2 - Health Care Service Plans|ARTICLE 5 - Standards|Section 1370.2.

1370.2.  Upon an appeal to the plan of a contested claim, the plan shall refer the claim to the medical director or other appropriately licensed health care provider. This health care provider or the medical director shall review the appeal and, if he or she determines that he or she is competent to evaluate the specific clinical issues presented in the claim, shall make a determination on the appealed claim. If the health care provider or medical director determines that he or she is not competent to evaluate the specific clinical issues of the appealed claim, prior to making a determination, he or she shall consult with an appropriately licensed health care provider who is competent to evaluate the specific clinical issues presented in the claim. For the purposes of this section, “competent to evaluate the specific clinical issues” means that the reviewer has education, training, and relevant expertise that is pertinent for evaluating the specific clinical issues that serve as the basis of the contested claim. The requirements of this section shall apply to claims that are contested on the basis of a clinical issue, the necessity for treatment, or the type of treatment proposed or utilized. The plan shall determine whether or not to use an appropriate specialist provider in the review of contested claims.(Added by Stats. 1994, Ch. 614, Sec. 2. Effective January 1, 1995.)