Health care coverage.

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 a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Under existing law, if a health care service plan or insurer, or one of its contracting providers, denies, modifies, or delays a health care service because the proposed service is not a covered benefit, the statement of that decision is to clearly specify the provision in the policy or contract that excludes that coverage. This bill would authorize a provider that contracts with a health care service plan or health insurer to bill an enrollee or insured for a service that is not a covered benefit if the enrollee or insured consents in writing and that written consent meets specified criteria. The bill would require a contracting provider to provide an enrollee or insured with a written estimate of the person's total cost, based on the standard rate the provider would charge for the service, if the service sought is not a covered benefit under the person's health care service plan contract or health insurance policy. The bill would require these written consent and estimate documents to be in the language spoken by the enrollee or insured, if the language is a primary language of a limited-English-proficient population group meeting a specified numeric threshold. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the 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.