summary
Introduced
02/13/2025
02/13/2025
In Committee
06/05/2025
06/05/2025
Crossed Over
05/28/2025
05/28/2025
Passed
Dead
Introduced Session
2025-2026 Regular Session
Bill Summary
An act to add Sections 1374.37 and 1374.38 to the Health and Safety Code, and to add Sections 10169.6 and 10169.7 to the Insurance Code, relating to health care coverage.
AI Summary
This bill requires health care service plans and health insurers to provide detailed annual reports to their respective state departments (Department of Managed Health Care and Department of Insurance) about their treatment denials and modifications. The reports must break down denials by type of care (surgical, medical, behavioral, pharmaceutical), age groups, available demographic data, and reasons for denial (such as medical necessity or insufficient information). If more than 50% of independent medical reviews in any care category result in overturning or reversing a treatment denial, the health plan or insurer will be subject to administrative penalties ranging from $25,000 for a first violation to $500,000 for subsequent violations. The bill creates special funds (the Managed Care Independent Medical Review Administrative Penalties Subaccount and the Health Insurance Independent Medical Review Administrative Penalties Fund) to collect these penalties, which can be used to offset implementation costs and other administrative expenses. The departments are also required to analyze and publish data about these denials and independent medical review outcomes annually, providing transparency into healthcare coverage decisions. Starting in 2026, health plans and insurers must submit these comprehensive reports, which will help regulators monitor and potentially reduce improper treatment denials.
Committee Categories
Budget and Finance, Health and Social Services
Sponsors (5)
Last Action
Referred to Com. on HEALTH. (on 06/05/2025)
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