Health care service plans: provider network transitions.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act's requirements a crime. Existing law requires a health care service plan to notify an enrollee at least 60 days before the termination date of a contract between a health care service plan and a provider group or a general acute care hospital to which the enrollee is assigned. If the plan reaches an agreement with a terminated provider after sending that notice, existing law requires the plan to offer each affected enrollee the option to return to that provider and to reassign the enrollee to another provider if the enrollee does not exercise that option. This bill would require a health care service plan to automatically reinstate the enrollee to the enrollee's previously assigned primary care provider or provider group if a provider network transition is materially delayed, terminated, rescinded, or otherwise fails within 120 days of an enrollee reassignment and that provider or provider group remains contracted with the plan. If, after that failure, the previously assigned provider is no longer contracted with the plan, the bill would require the plan to offer continuity of care or arrange for out-of-network care at in-network cost sharing, as specified. Because a willful violation of these provisions would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.