This law is titled the Knox-Keene Health Care Service Plan Act of 1975. It sets the foundation for regulations governing health care service plans within the state.

This section establishes the California Department of Managed Health Care within the California Health and Human Services Agency. Its job is to oversee health care service plans and ensure they provide quality care to enrollees.

The department is led by a director appointed by the Governor, who serves at the Governor's pleasure and must take an oath of office. The director is responsible for executing all duties and ensuring compliance with health care-related laws.

The director of the Department of Managed Health Care is required to have their main office in Sacramento. They can also set up additional offices in San Francisco, Los Angeles, and San Diego. The director is responsible for getting the necessary supplies and equipment for running the department smoothly.

This law outlines that the director of a department must hire and decide the pay for staff necessary to fulfill their legal duties, with approval from the Department of Finance. This includes hiring key roles like a deputy, public information officer, and legal counsel. The legal counsel acts as the director's lawyer in legal matters. Stenographic reporters are needed to record hearings. Employees in the Department of Managed Health Care will do tasks assigned by the director. Designated employees must take an oath of office within 15 days of being hired and file it with the Secretary of State.

This law requires the Director of the Department of Managed Health Care in California to have an official seal with a specific inscription. The seal must be used on all official documents, such as orders and certificates issued by the Director. Courts are required to recognize and accept this seal as legitimate.

This law creates the Managed Care Fund in the State Treasury to help the Department of Managed Health Care carry out its duties. The fund should maintain a reserve of up to 5 percent, unless the Department of Finance decides otherwise.

The director must usually publish or allow public access to information filed with or obtained by the department, unless doing so would break the law. However, the director and their staff must keep certain information confidential unless it's needed for investigations or shared with other regulators. This law doesn't change any existing legal protections for confidential information during investigations.

Additionally, the director and their staff are prohibited from using any non-public information for personal gain.

This law section explains that the Attorney General helps the Director of the Department of Managed Health Care by giving legal advice and acting as their attorney in legal cases related to the laws they manage. Additionally, certain sections of the Government Code do not apply to this Director.

This law prevents the director and their team at the Department of Managed Health Care from having business ties (like being a director, officer, or shareholder) with any health care service plan licensed or applying for a license during their association with the department. This is to avoid conflicts of interest.

However, they are allowed to buy or hold securities as long as it follows specific rules to protect the public interest.

The law also allows them to get health care services as a subscriber or enrollee of a licensed plan, following any relevant regulations.

This law states that the director has the same authority as a department head under certain government regulations. The director can make agreements they find necessary to carry out their duties effectively.

This law states that the director and department now have all the responsibilities and powers originally held by the Commissioner of Corporations and the Department of Corporations related to health plans and services. This includes overseeing the Health Plan Program and the business side of health care service plans. However, it does not change or reduce the duties or authority of the Commissioner and Department of Corporations in other areas like investments or financial services.

This law section allows the department to utilize any leftover funds that were initially available for functions now under its responsibility, following a transition from the Department of Corporations as outlined in another section.

This law section states that employees of the Department of Corporations who handle responsibilities that the department takes over will be transferred to the new department. These employees must be part of the state civil service, but not temporary workers. Their job status, positions, and rights will remain unchanged, with the exception of jobs that are not part of the civil service system.

The department is responsible for managing all the assets and documents that relate to the tasks moved to it from the Department of Corporations, as detailed in Section 1341.9. These include records, property, contracts, and funds.

This law states that any new officer or employee hired by the department after this rule goes into effect must be appointed by the director.

This law makes sure that any rules or actions created or executed by the Department of Corporations, or its officers, remain valid even after responsibilities are transferred to a different department. It also ensures that any legal proceedings that started under the Department of Corporations continue without interruption, even if duties are moved elsewhere.

This law sets up a special fund called the Managed Care Administrative Fines and Penalties Fund in California's State Treasury. Since September 30, 2008, any fines and penalties from managed care are deposited into this fund. Starting from September 1, 2009, and every year after, the first $1 million is sent to help repay loans for doctors working in underserved areas through a specific loan repayment program. Any money collected over $1 million goes into another healthcare-related fund. The money collected cannot be used to lower fees charged to healthcare service plans. Updates to this section came into effect on July 1, 2014, and July 1, 2017.

This law aims to improve the quality and delivery of healthcare for Californians enrolled in health care service plans. It ensures that healthcare professionals decide patient needs, maintains trust in patient-professional relationships, and keeps subscribers informed about their benefits. It also targets fraudulent practices and promotes affordable care by transferring financial risks to providers, ensuring financial stability through regulation, and supporting the interests of subscribers. Additionally, it seeks to make sure healthcare services are continual, accessible, and that grievances are reviewed quickly.

This section requires health care plans offering medical, surgical, and hospital benefits to cover the costs of COVID-19 testing and related health services without charging enrollees copayments, coinsurance, or deductibles, regardless of whether the provider is in-network or out-of-network. The law also covers the costs of COVID-19 preventive items, services, and immunizations without any cost-sharing.

Health plans must reimburse providers for any lost cost-sharing. If there's no pre-negotiated rate with a provider, the health plan can negotiate a rate or pay a reasonable amount reflecting the market rate. The law prohibits prior authorization or utilization management for these services, ensuring quick access.

After the federal public health emergency ends, certain coverage requirements, especially those involving out-of-network costs, will no longer apply, except as required by other laws. It does not apply to Medi-Cal plans.

This law requires health care service plans in California to cover certain medical costs without cost-sharing and without needing prior approval in the event of a public health emergency declared by the Governor. Coverage includes: (1) preventive or mitigating services or immunizations backed by reputable recommendations; (2) diagnostic and screening tests approved by recognized health authorities; and (3) therapeutics approved for emergency use by the FDA. These services must be covered promptly after relevant recommendations are updated.

Healthcare plans, including those under Medi-Cal, must comply as long as federal approval is received and funding is secure.

This regulation requires the Department of Managed Health Care and the Department of Insurance to work together to help consumers understand their health care rights and to ensure consistent regulation.

Their joint efforts include reviewing relevant laws and processes to maintain consistent consumer protection. They focus on grievance and consumer complaint procedures, law enforcement, and timely claims payments. Annually, for five years, they must report their findings to key officials and the Legislature.

The director must talk with the Insurance Commissioner before setting rules for health care service plans and similar entities. The goal is to make sure the rules from the Insurance Commissioner and the Department of Managed Health Care are as consistent as possible.

This law aims to ensure Californians get high-quality health care that is both efficient and cost-effective. It encourages various contract types between those who pay for health care and those who provide it. The law recognizes that individual providers and purchasers are not big enough to bargain effectively, so forming groups for contract negotiations is beneficial and seen as a new product in the market. These groups should only adhere to the same antitrust laws as other legitimate businesses.

However, this doesn't change current antitrust rules preventing qualified individuals from being excluded from these groups just because they don't have the same license or certification.

This law section explains how health care service plans in California can manage prescription drug benefits while ensuring they align with existing regulations and consumer protections. Health plans can propose copayments, deductibles, and exclusions for prescription drugs, but these need approval by the department. The department evaluates different designs, like cost-sharing, limits, and exclusions, considering impacts on both consumer costs and plan operations. The written exclusions cannot bypass independent medical review if they involve medical necessity. Plans serving programs like Medi-Cal or Healthy Families must still adhere to contractually required drug coverage. Regulations for approving these proposals are periodically reviewed to ensure compliance and relevance with the standards. Overall, this section clarifies the process and limitations for modifying prescription benefit structures within health care plans.

This law requires the State Department of Health Services to work with another department to coordinate audits or surveys of doctor offices. These audits are part of the requirements under the Medi-Cal program and other related tasks outlined in this chapter.

This California law aims to ensure that health care plans provide fair coverage for outpatient prescription drugs, without discriminating against individuals with chronic illnesses. It aligns with federal standards, prohibiting any practice that discourages enrollment based on health conditions or economically burdens chronically ill individuals.

Health plans must cover necessary prescription drugs, including those not typically listed, if deemed necessary. For AIDS/HIV treatments, plans should cover effective single-tablet regimens, unless multitablet alternatives are clinically proven to be better.

Prescription drug placements on cost tiers should be based only on clinical necessities and reasonable management practices. Health plans don't have to impose cost-sharing, and if a drug's retail price is lower than the copayment, the enrollee pays the lesser amount. Reasonable medical practices like formularies or prior authorization for drug coverage can be used but aren't applicable to plans with the State Department of Health Care Services.

This law sets limits on the cost-sharing amounts, like copayments and coinsurance, that individuals must pay for a 30-day supply of outpatient prescription drugs under health plans.

For most plans, the maximum a person pays per prescription is $250, or $500 for bronze-level plans, after deductibles are met. High deductible health plans follow these rules only after the annual deductible is satisfied.

If there’s a generic equivalent, the plan must ensure the person pays the lowest cost available.

Health plans with tiered drug formularies can't have more than four tiers, with each tier being defined by cost and drug type. Plans have the flexibility to place drugs in lower tiers if beneficial. However, this section does not apply to plans involving the State Department of Health Care Services.

This section of the law states that health care plans in California cannot require prior authorization or step therapy for antiretroviral drugs that prevent AIDS/HIV, like preexposure and postexposure prophylaxis, unless there's a choice of equivalent drugs approved by the FDA. If there's a choice, at least one option must be covered without these hurdles. Pharmacies cannot be blocked from dispensing these drugs, and health plans must cover the drugs and any related services provided by pharmacists, as long as the pharmacy is in-network or covered by an out-of-network benefit. However, this rule doesn't apply to Medi-Cal managed care plans if their contracts exclude such services.

This law states that any health care plan in California that offers outpatient prescription drug coverage must include at least one FDA-approved medication for specific purposes without requiring prior approval. These purposes include the reversal of opioid overdose, detoxification or maintenance of substance use disorders, and other related treatments. Specifically, it covers medications like naloxone for opioid overdoses, daily oral buprenorphine for substance use disorders, long-acting buprenorphine, and long-acting injectable naltrexone.

Additionally, health plans can choose generic or biosimilar versions of these medications to fulfill the requirement.

This law outlines when and to whom health care service plan regulations apply. It states that these regulations cover defined health care plans and contracts, but the director can exempt certain groups or contracts if it benefits the public and doesn't harm subscribers. County-operated pilot programs and certain mental health plans may be exempted upon request by specific officials. The chapter doesn't apply to insurance entities operating under a certificate, educational institutions providing health care to their own communities, certain aged care arrangements, the Major Risk Medical Insurance Board, or the California Small Group Reinsurance Fund.

This law states that the rules in this chapter do not apply to any program created under a specific section of the Welfare and Institutions Code, starting with Section 14591.

This California statute allows a pilot program in Southern California where healthcare providers can test new risk-sharing financial arrangements with voluntary employees' beneficiary associations, providing coverage for over 100,000 people between January 1, 2022, and December 31, 2027. The program aims to control healthcare costs and improve outcomes compared to traditional payment models. Participating providers must meet specific licensing, financial, and reporting requirements, and the associations must offer various essential services, including health, prescription, and language assistance services.

The program requires providers to handle risk-based payments responsibly and ensures continuity of patient care. Enrollees have mechanisms for grievances and appeals, monitored by an appointed ombudsperson, with specific reporting requirements to the department. The pilot program results, including cost savings and patient satisfaction, will be reported to the legislature by 2029. Participating entities must cover regulatory oversight costs, up to $500,000, necessary for compliance and program review.

This statute remains effective until January 1, 2030, at which point it will be repealed.

If you are involved in a legal case under this chapter and you claim that you qualify for an exemption or an exception to a definition, it's your responsibility to prove it.

This law gives the director the authority to create, change, or remove rules and orders necessary to implement the chapter's provisions. The director can tailor rules for different groups and can waive rules if they aren't needed for public protection. They can also make rules that align with federal regulations to manage Medicare-related healthcare coverage.

The director can also modify the language of required notices to make them clearer without changing their meaning. Requests for interpretive opinions on rules or regulations can be honored. Additionally, if someone acts in good faith according to the director's rules or opinions, they won't be held liable, even if those rules are later changed or invalidated.

This section defines the terms used in the health care service plan regulations in California. Key definitions include 'advertisement' for communications needed to sell plans, 'basic health care services' covering essential medical, hospital, and preventive services, and who is considered an 'enrollee' in a plan. It explains what 'evidence of coverage' is, describes 'group contracts', and defines what a 'health care service plan' is, whether it operates locally or internationally. It also gives a definition for 'out-of-area coverage' which is health coverage outside a plan's usual service area. Other definitions include 'provider,' 'person,' 'service area,' 'solicitation,' 'solicitor,' 'solicitor firm,' and 'specialized health care service plan contract.' The section also outlines what accounting terms like financial statements should adhere to. These terms clarify how health plans are marketed, managed, and what services they must provide to the enrollees and subscribers.

This section describes what constitutes "minimum essential coverage" for health insurance. It includes various government programs like Medicare, Medi-Cal, Medicaid, CHIP, TRICARE, and Department of Defense health benefits. University of California insurance plans, employer-sponsored plans, and individual health policies under the ACA also qualify. Certain types of coverage, like accident-only insurance or dental-only plans, do not count as minimum essential coverage. The Department of Health Services can provide guidance or instructions on this matter without formal regulatory action.