Health care coverage: timeliness of care.

Existing law provides for the licensing and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of those provisions by a health care service plan a crime. Existing law provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires the department and the commissioner to develop and adopt regulations to ensure that enrollees or insureds of health care service plans and certain health insurers have access to needed health care services in a timely manner pursuant to specified indicators of timeliness. This bill would add timeliness of care for schoolage children who must receive medically necessary services during school hours as one of the indicators of timeliness. Existing law requires the department to review and adopt standards, as needed, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care so that consumers have timely access to care. In adopting those standards, the department is required to consider the nature of physician practices and circumstances affecting the delivery of care. If the department finds that health care service plans and health care providers have difficulty meeting those standards, existing law authorizes the department to make recommendations to the Assembly Committee on Health and the Senate Committee on Insurance on specified dates regarding implementation. This bill would add availability of school-based health care to the timely access to care provisions for which the department may adopt standards. The bill would instead authorize the department to report and make recommendations to the Assembly Committee on Health and the Senate Committee on Health regarding those standards. The bill would require health care service plans and health insurers to work constructively with local education agencies to provide reimbursement for covered health care services provided to a child during school hours and to ensure adequate availability of licensed health care professionals to accommodate the necessary medical needs of children during school hours. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would require the Department of Managed Health Care and the Department of Insurance to implement these provisions by regulation by January 1, 2012. 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.