Section 1373.95 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1373.95
. (a) (1) A health care service plan, other than a
specialized health care service plan that offers professional mental
health services on an employer-sponsored group basis, shall file a
written continuity of care policy as a material modification with the
department before March 31, 2004.
(2) A health care service plan shall include all of the following
in its written continuity of care policy:
(A) A description of the plan's process for the block transfer of
enrollees from a terminated provider group or hospital to a new
provider group or hospital.
(B) A description of the manner in which the plan facilitates the
completion of covered services pursuant to Section 1373.96.
(C) A template of the notice the plan proposes to send to
enrollees describing its policy and informing enrollees of their
right to completion of covered services.
(D) A description of the plan's process to review an enrollee's
request for the completion of covered services.
(E) A provision ensuring that reasonable consideration is given to
the potential clinical effect on an enrollee's treatment caused by a
change of provider.
(3) If approved by the department, the provisions of the written
continuity of care policy shall replace all prior continuity of care
policies. The plan shall file a revision of the policy with the
department if it makes a material change to it.
(b) (1) The provisions of this subdivision apply to a specialized
health care service plan that offers professional mental health
services on an employer-sponsored group basis.
(2) The plan shall file with the department a written policy
describing the manner in which it facilitates the continuity of care
for a new enrollee who has been receiving services from a
nonparticipating mental health provider for an acute, serious, or
chronic mental health condition when his or her employer changed
health plans. The written policy shall allow the new enrollee a
reasonable transition period to continue his or her course of
treatment with the nonparticipating mental health provider prior to
transferring to a participating provider and shall include the
provision of mental health services on a timely, appropriate, and
medically necessary basis from the nonparticipating provider. The
policy may provide that the length of the transition period take into
account on a case-by-case basis, the severity of the enrollee's
condition and the amount of time reasonably necessary to effect a
safe transfer. The policy shall ensure that reasonable consideration
is given to the potential clinical effect of a change of provider on
the enrollee's treatment for the condition. The policy shall describe
the plan's process to review an enrollee's request to continue his
or her course of treatment with a nonparticipating mental health
provider. Nothing in this paragraph shall be construed to require the
plan to accept a nonparticipating mental health provider onto its
panel for treatment of other enrollees. For purposes of the
continuing treatment of the transferring enrollee, the plan may
require the nonparticipating mental health provider, as a condition
of the right conferred under this section, to enter into its standard
mental health provider contract.
(3) A plan may require a nonparticipating mental health provider
whose services are continued pursuant to the written policy, to agree
in writing to the same contractual terms and conditions that are
imposed upon the plan's participating providers, including location
within the plan's service area, reimbursement methodologies, and
rates of payment. If the plan determines that an enrollee's health
care treatment should temporarily continue with his or her existing
provider or nonparticipating mental health provider, the plan shall
not be liable for actions resulting solely from the negligence,
malpractice, or other tortious or wrongful acts arising out of the
provisions of services by the existing provider or a nonparticipating
mental health provider.
(4) The written policy shall not apply to an enrollee who is
offered an out-of-network option or to an enrollee who had the option
to continue with his or her previous specialized health care service
plan that offers professional mental health services on an
employer-sponsored group basis or mental health provider and instead
voluntarily chose to change health plans.
(5) This subdivision shall not apply to a specialized health care
service plan that offers professional mental health services on an
employer-sponsored group basis if it includes out-of-network coverage
that allows the enrollee to obtain services from his or her existing
mental health provider or nonparticipating mental health provider.
(c) The health care service plan, including a specialized health
care service plan that offers professional mental health services on
an employer-sponsored group basis, shall provide to all new enrollees
notice of its written continuity of care policy and information
regarding the process for an enrollee to request a review under the
policy and shall provide, upon request, a copy of the written policy
to an enrollee.
(d) Nothing in this section shall require a health care service
plan or a specialized health care service plan that offers
professional mental health services on an employer-sponsored group
basis to cover services or provide benefits that are not otherwise
covered under the terms and conditions of the plan contract.
(e) The following definitions apply for the purposes of this
section:
(1) "Hospital" means a general acute care hospital.
(2) "Nonparticipating mental health provider" means a
psychiatrist, licensed psychologist, licensed marriage and family
therapist, licensed social worker, or licensed professional clinical
counselor who does not contract with the specialized health care
service plan that offers professional mental health services on an
employer-sponsored group basis.
(3) "Provider group" means a medical group, independent practice
association, or any other similar organization.