Health care coverage: grievance system.

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. A willful violation of the act constitutes a crime. Existing law requires every health care service plan to establish and maintain a grievance system approved by the department under which enrollees and subscribers may submit a grievance to the plan. Existing law authorizes a subscriber or enrollee to submit his or her grievance to the department for review after completing the grievance process or after having participated in that process for at least 30 days. Existing law requires the department to send a written notice of the final disposition of the grievance to an enrollee or subscriber within 30 days of receiving the request for review, unless the director determines that additional time is reasonably necessary to fully review the grievance. This bill would, upon a determination by the director that, do to extraordinary circumstances, additional time is necessary to review a grievance, set forth the procedures that would apply to the department with regard to the review of that grievance and the payment of specified costs by the department. Upon a failure of a health care service plan to comply with a request from the department for information related to the grievance, the bill would authorize the department to impose an administrative fine on that plan, pursuant to specified procedures, as determined by the department. Existing law requires the director to make and file annually with the department as a public record an aggregate summary of grievances against plans filed with the department, as specified. This bill would require the director to include in that report specified information related to the department's review of grievances against health care service plans.