Section 1367.10 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.10
. (a) Every health care service plan shall include within
its disclosure form and within its evidence of coverage a statement
clearly describing how participation in the plan may affect the
choice of physician, hospital, or other health care providers, the
basic method of reimbursement, including the scope and general
methods of payment made to its contracting providers of health care
services, and whether financial bonuses or any other incentives are
used. The disclosure form and evidence of coverage shall indicate
that if an enrollee wishes to know more about these issues, the
enrollee may request additional information from the health care
service plan, the enrollee's provider, or the provider's medical
group or independent practice association regarding the information
required pursuant to subdivision (b).
(b) If a plan, medical group, independent practice association, or
participating health care provider uses or receives financial
bonuses or any other incentives, the plan, medical group, independent
practice association, or health care provider shall provide a
written summary to any person who requests it that includes all of
the following:
(1) A general description of the bonus and any other incentive
arrangements used in its compensation agreements. Nothing in this
section shall be construed to require disclosure of trade secrets or
commercial or financial information that is privileged or
confidential, such as payment rates, as determined by the director,
pursuant to state law.
(2) A description regarding whether, and in what manner, the
bonuses and any other incentives are related to a provider's use of
referral services.
(c) The statements and written information provided pursuant to
subdivisions (a) and (b) shall be communicated in clear and simple
language that enables consumers to evaluate and compare health care
service plans.
(d) The plan shall clearly inform prospective enrollees that
participation in that plan will affect the person's choice of
provider by placing the following statement in a conspicuous place on
all material required to be given to prospective enrollees including
promotional and descriptive material, disclosure forms, and
certificates and evidences of coverage:
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM
OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE
OBTAINED
It is not the intent of this section to require that the names of
individual health care providers be enumerated to prospective
enrollees.
If the health care service plan provides a list of providers to
patients or contracting providers, the plan shall include within the
provider listing a notification that enrollees may contact the plan
in order to obtain a list of the facilities with which the health
care service plan is contracting for subacute care and/or
transitional inpatient care.