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| 1 | + | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 1429Introduced by Assembly Member BainsFebruary 21, 2025 An act to add Article 3.6 (commencing with Section 1358.30) to Chapter 2.2 of Division 2 of, and to repeal Section 1358.31 of, the Health and Safety Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 1429, as introduced, Bains. Behavioral health reimbursement. 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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy on or after October 12, 2023, until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department. The bill would require an enrollee to submit specified documents for reimbursement and would require Kaiser to pay the reimbursement within 60 calendar days of an enrollees submission of documented expenses. If Kaiser fails to provide this reimbursement, the bill would require it to pay the original amount plus 10% interest to the enrollee, as well as a $5,000 fine per incident. The bill would require Kaiser to establish specified procedures, and would require Kaiser to submit a monthly report to the department with specified information. Because a willful violation of the bills provisions would be a crime, the bill would impose a state-mandated local program.This bill would make legislative findings and declarations as to the necessity of a special statute for Kaiser Foundation Health Plan.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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care.1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed.1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial.1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident.SEC. 2. The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients of Kaiser Foundation Health Plan receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in Kaisers behavioral health care services, until Kaiser has fully corrected the deficiencies identified in the Department of Managed Health Cares Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. | |
| 2 | 2 | ||
| 3 | - | ||
| 3 | + | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 1429Introduced by Assembly Member BainsFebruary 21, 2025 An act to add Article 3.6 (commencing with Section 1358.30) to Chapter 2.2 of Division 2 of, and to repeal Section 1358.31 of, the Health and Safety Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 1429, as introduced, Bains. Behavioral health reimbursement. 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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy on or after October 12, 2023, until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department. The bill would require an enrollee to submit specified documents for reimbursement and would require Kaiser to pay the reimbursement within 60 calendar days of an enrollees submission of documented expenses. If Kaiser fails to provide this reimbursement, the bill would require it to pay the original amount plus 10% interest to the enrollee, as well as a $5,000 fine per incident. The bill would require Kaiser to establish specified procedures, and would require Kaiser to submit a monthly report to the department with specified information. Because a willful violation of the bills provisions would be a crime, the bill would impose a state-mandated local program.This bill would make legislative findings and declarations as to the necessity of a special statute for Kaiser Foundation Health Plan.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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES | |
| 4 | 4 | ||
| 5 | - | Amended IN Assembly April 02, 2025 | |
| 6 | 5 | ||
| 7 | - | Amended IN Assembly April 02, 2025 | |
| 6 | + | ||
| 7 | + | ||
| 8 | 8 | ||
| 9 | 9 | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION | |
| 10 | 10 | ||
| 11 | 11 | Assembly Bill | |
| 12 | 12 | ||
| 13 | 13 | No. 1429 | |
| 14 | 14 | ||
| 15 | - | Introduced by Assembly Member | |
| 15 | + | Introduced by Assembly Member BainsFebruary 21, 2025 | |
| 16 | 16 | ||
| 17 | - | Introduced by Assembly Member Bains | |
| 17 | + | Introduced by Assembly Member Bains | |
| 18 | 18 | February 21, 2025 | |
| 19 | 19 | ||
| 20 | 20 | An act to add Article 3.6 (commencing with Section 1358.30) to Chapter 2.2 of Division 2 of, and to repeal Section 1358.31 of, the Health and Safety Code, relating to health care coverage. | |
| 21 | 21 | ||
| 22 | 22 | LEGISLATIVE COUNSEL'S DIGEST | |
| 23 | 23 | ||
| 24 | 24 | ## LEGISLATIVE COUNSEL'S DIGEST | |
| 25 | 25 | ||
| 26 | - | AB 1429, as | |
| 26 | + | AB 1429, as introduced, Bains. Behavioral health reimbursement. | |
| 27 | 27 | ||
| 28 | - | 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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy | |
| 28 | + | 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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy on or after October 12, 2023, until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department. The bill would require an enrollee to submit specified documents for reimbursement and would require Kaiser to pay the reimbursement within 60 calendar days of an enrollees submission of documented expenses. If Kaiser fails to provide this reimbursement, the bill would require it to pay the original amount plus 10% interest to the enrollee, as well as a $5,000 fine per incident. The bill would require Kaiser to establish specified procedures, and would require Kaiser to submit a monthly report to the department with specified information. Because a willful violation of the bills provisions would be a crime, the bill would impose a state-mandated local program.This bill would make legislative findings and declarations as to the necessity of a special statute for Kaiser Foundation Health Plan.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. | |
| 29 | 29 | ||
| 30 | 30 | 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 requires a health care service plan contract issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions. | |
| 31 | 31 | ||
| 32 | - | This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy | |
| 32 | + | This bill would require Kaiser Foundation Health Plan to fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities or mental health prescription medication obtained from a non-Kaiser pharmacy on or after October 12, 2023, until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department. The bill would require an enrollee to submit specified documents for reimbursement and would require Kaiser to pay the reimbursement within 60 calendar days of an enrollees submission of documented expenses. If Kaiser fails to provide this reimbursement, the bill would require it to pay the original amount plus 10% interest to the enrollee, as well as a $5,000 fine per incident. The bill would require Kaiser to establish specified procedures, and would require Kaiser to submit a monthly report to the department with specified information. Because a willful violation of the bills provisions would be a crime, the bill would impose a state-mandated local program. | |
| 33 | 33 | ||
| 34 | 34 | This bill would make legislative findings and declarations as to the necessity of a special statute for Kaiser Foundation Health Plan. | |
| 35 | 35 | ||
| 36 | 36 | 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. | |
| 37 | 37 | ||
| 38 | 38 | This bill would provide that no reimbursement is required by this act for a specified reason. | |
| 39 | 39 | ||
| 40 | 40 | ## Digest Key | |
| 41 | 41 | ||
| 42 | 42 | ## Bill Text | |
| 43 | 43 | ||
| 44 | - | The people of the State of California do enact as follows:SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling | |
| 44 | + | The people of the State of California do enact as follows:SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care.1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed.1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial.1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident.SEC. 2. The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients of Kaiser Foundation Health Plan receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in Kaisers behavioral health care services, until Kaiser has fully corrected the deficiencies identified in the Department of Managed Health Cares Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. | |
| 45 | 45 | ||
| 46 | 46 | The people of the State of California do enact as follows: | |
| 47 | 47 | ||
| 48 | 48 | ## The people of the State of California do enact as follows: | |
| 49 | 49 | ||
| 50 | - | SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling | |
| 50 | + | SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care.1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed.1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial.1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident. | |
| 51 | 51 | ||
| 52 | 52 | SECTION 1. Article 3.6 (commencing with Section 1358.30) is added to Chapter 2.2 of Division 2 of the Health and Safety Code, to read: | |
| 53 | 53 | ||
| 54 | 54 | ### SECTION 1. | |
| 55 | 55 | ||
| 56 | - | Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling | |
| 56 | + | Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care.1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed.1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial.1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident. | |
| 57 | 57 | ||
| 58 | - | Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling | |
| 58 | + | Article 3.6. Behavioral Health Reimbursement 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care.1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed.1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial.1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident. | |
| 59 | 59 | ||
| 60 | 60 | Article 3.6. Behavioral Health Reimbursement | |
| 61 | 61 | ||
| 62 | 62 | Article 3.6. Behavioral Health Reimbursement | |
| 63 | 63 | ||
| 64 | - | 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling | |
| 64 | + | 1358.30. For purposes of this article:(a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser.(b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California.(c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following:(1) Copayments.(2) Deductibles.(3) Prescription medication costs.(4) Provider visit fees.(5) Telehealth consultation fees.(6) Transportation costs directly related to obtaining behavioral health care. | |
| 65 | 65 | ||
| 66 | 66 | ||
| 67 | 67 | ||
| 68 | 68 | 1358.30. For purposes of this article: | |
| 69 | 69 | ||
| 70 | - | (a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, | |
| 70 | + | (a) Behavioral health care includes behavioral health services, psychiatric services, psychological services, counseling, and related prescription medications that are offered by Kaiser. | |
| 71 | 71 | ||
| 72 | 72 | (b) Kaiser means Kaiser Foundation Health Plan and all its subsidiaries operating in California. | |
| 73 | 73 | ||
| 74 | 74 | (c) Out-of-pocket costs means any expenses paid directly by an enrollee, including all of the following: | |
| 75 | 75 | ||
| 76 | 76 | (1) Copayments. | |
| 77 | 77 | ||
| 78 | 78 | (2) Deductibles. | |
| 79 | 79 | ||
| 80 | 80 | (3) Prescription medication costs. | |
| 81 | 81 | ||
| 82 | 82 | (4) Provider visit fees. | |
| 83 | 83 | ||
| 84 | 84 | (5) Telehealth consultation fees. | |
| 85 | 85 | ||
| 86 | 86 | (6) Transportation costs directly related to obtaining behavioral health care. | |
| 87 | 87 | ||
| 88 | - | 1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy | |
| 88 | + | 1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities.(b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy.(c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser:(1) Receipts or invoices showing actual costs paid.(2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider.(3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser.(d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023.(e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed. | |
| 89 | 89 | ||
| 90 | 90 | ||
| 91 | 91 | ||
| 92 | 92 | 1358.31. (a) Kaiser shall fully reimburse an enrollee who incurs out-of-pocket costs for behavioral health care services obtained from non-Kaiser providers or facilities. | |
| 93 | 93 | ||
| 94 | - | (b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy. | |
| 94 | + | (b) Kaiser shall reimburse an enrollee for the full retail cost the enrollee paid for a mental health prescription medication obtained from a non-Kaiser pharmacy. | |
| 95 | 95 | ||
| 96 | 96 | (c) Reimbursement shall be provided pursuant to this section within 60 calendar days of an enrollees submission of documented expenses. To receive reimbursement, an enrollee shall submit all of the following to Kaiser: | |
| 97 | 97 | ||
| 98 | 98 | (1) Receipts or invoices showing actual costs paid. | |
| 99 | 99 | ||
| 100 | 100 | (2) Documentation that the service or medication was prescribed or recommended by a licensed mental health provider. | |
| 101 | 101 | ||
| 102 | 102 | (3) A signed statement affirming that the expense was incurred due to the enrollees inability to obtain timely and appropriate care through Kaiser. | |
| 103 | 103 | ||
| 104 | - | (d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023. | |
| 104 | + | (d) Reimbursement pursuant to this section shall be available for out-of-pocket costs incurred on or after October 12, 2023. | |
| 105 | 105 | ||
| 106 | - | (e) This section shall remain in effect only until the department certifies | |
| 106 | + | (e) This section shall remain in effect only until the department certifies that Kaiser has successfully completed implementation of the corrective action work plan resulting from its 2023 settlement agreement with the department, and as of that date is repealed. | |
| 107 | 107 | ||
| 108 | - | 1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests. | |
| 108 | + | 1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31:(1) Enrollee submission of reimbursement requests.(2) Kaisers processing of reimbursement requests.(3) Appeals of denied reimbursement requests.(4) Statistical monitoring of submitted, approved, and denied reimbursement requests.(b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a).(c) Kaiser shall submit a monthly report to the department that includes all of the following:(1) Number of reimbursement requests received.(2) Total amount reimbursed.(3) Average processing time for reimbursement requests.(4) Number of denied reimbursement requests and reasons for denial. | |
| 109 | 109 | ||
| 110 | 110 | ||
| 111 | 111 | ||
| 112 | 112 | 1358.32. (a) Kaiser shall establish procedures for all of the following actions pursuant to Section 1358.31: | |
| 113 | 113 | ||
| 114 | - | (1) Enrollee submission of reimbursement requests. | |
| 114 | + | (1) Enrollee submission of reimbursement requests. | |
| 115 | 115 | ||
| 116 | 116 | (2) Kaisers processing of reimbursement requests. | |
| 117 | 117 | ||
| 118 | - | (3) Appeals of denied reimbursement requests. | |
| 118 | + | (3) Appeals of denied reimbursement requests. | |
| 119 | 119 | ||
| 120 | 120 | (4) Statistical monitoring of submitted, approved, and denied reimbursement requests. | |
| 121 | 121 | ||
| 122 | - | (b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a). | |
| 122 | + | (b) The department shall review and determine if Kaiser has fulfilled the requirements pursuant to subdivision (a). | |
| 123 | 123 | ||
| 124 | 124 | (c) Kaiser shall submit a monthly report to the department that includes all of the following: | |
| 125 | 125 | ||
| 126 | 126 | (1) Number of reimbursement requests received. | |
| 127 | 127 | ||
| 128 | 128 | (2) Total amount reimbursed. | |
| 129 | 129 | ||
| 130 | 130 | (3) Average processing time for reimbursement requests. | |
| 131 | 131 | ||
| 132 | 132 | (4) Number of denied reimbursement requests and reasons for denial. | |
| 133 | 133 | ||
| 134 | - | 1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent | |
| 134 | + | 1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following:(a) Payment of the original amount plus 10 percent interest to the enrollee.(b) A fine of five thousand dollars ($5,000) per incident. | |
| 135 | 135 | ||
| 136 | 136 | ||
| 137 | 137 | ||
| 138 | 138 | 1358.33. In addition to the sanctions that may be imposed pursuant to Section 1390, failure to provide reimbursement as required pursuant to Section 1358.31 shall result in both of the following: | |
| 139 | 139 | ||
| 140 | - | (a) Payment of the original amount plus 10 percent | |
| 140 | + | (a) Payment of the original amount plus 10 percent interest to the enrollee. | |
| 141 | 141 | ||
| 142 | 142 | (b) A fine of five thousand dollars ($5,000) per incident. | |
| 143 | 143 | ||
| 144 | 144 | SEC. 2. The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients of Kaiser Foundation Health Plan receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in Kaisers behavioral health care services, until Kaiser has fully corrected the deficiencies identified in the Department of Managed Health Cares Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055. | |
| 145 | 145 | ||
| 146 | 146 | SEC. 2. The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients of Kaiser Foundation Health Plan receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in Kaisers behavioral health care services, until Kaiser has fully corrected the deficiencies identified in the Department of Managed Health Cares Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055. | |
| 147 | 147 | ||
| 148 | 148 | SEC. 2. The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the need to ensure that patients of Kaiser Foundation Health Plan receive adequate compensation for out-of-pocket behavioral health care expenses incurred due to deficiencies in Kaisers behavioral health care services, until Kaiser has fully corrected the deficiencies identified in the Department of Managed Health Cares Enforcement Matter Number 22-469 and 2022 Non-Routine Survey 933-0055. | |
| 149 | 149 | ||
| 150 | 150 | ### SEC. 2. | |
| 151 | 151 | ||
| 152 | 152 | SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. | |
| 153 | 153 | ||
| 154 | 154 | SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. | |
| 155 | 155 | ||
| 156 | 156 | SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. | |
| 157 | 157 | ||
| 158 | 158 | ### SEC. 3. |