Health care coverage reporting.

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. Existing law generally authorizes a health care service plan or health insurer to use prior authorization and other utilization review or utilization management functions, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law requires a health care service plan or health insurer to file various reports with the relevant regulating department. This bill would require a health care service plan or health insurer that imposes prior authorization to report specified prior authorization data from the previous calendar year on its internet website on or before February 1, 2026, for health care service plans, on or before February 1, 2028, for health insurers, and annually on or before February 1 thereafter. The bill would require a health care service plan or health insurer to annually report specified claims and prior authorization data to the relevant department by February 1 of each year, beginning February 1, 2027, for health care service plans and February 1, 2028, for health insurers. The bill would require the departments to post this information, disaggregated by plan or insurer, on their internet websites by April 15 of each year, beginning April 15, 2027, for health care service plans and April 15, 2028, for health insurers. The bill would authorize the Director of the Department of Managed Health Care and the Insurance Commissioner to reject a report required pursuant to these provisions, and would authorize the commissioner to assess an administrative penalty against a health insurer for a failure to correct a deficiency in the report. The bill would authorize the director and commissioner to make rules and regulations specifying the form and content of the reports posted online and submitted to the relevant department, as specified. 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 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.