Section 1368.1 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
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.