(a) Every health insurer, self-insured plan, group health plan, as defined in Section 607(1) of the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001 et seq.), service benefit plan, managed care organization, including health care service plans as defined in subdivision (f) of Section 1345 of the Health and Safety Code, licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, upon request of the department or a regional center for any records, or any information contained in records pertaining to, an individual or group health insurance policy or plan issued by the insurer or plan against, or pertaining to, the services paid by or claims made against the insurer or plans under a policy or plan, shall make the requested records or information available upon a certification by the department or regional center that the individual is an applicant for or recipient of services under this division, is an applicant for or recipient of services under the California Early Intervention Program, or is a person who is legally responsible for the applicant or recipient, provided that the department and regional center certifies its compliance with all state and federal laws pertaining to the confidentiality of medical information.
(b) The department or regional center shall enter into a cooperative agreement setting forth mutually agreeable procedures for requesting and furnishing appropriate information, consistent with laws pertaining to the confidentiality and privacy of medical information. These procedures shall include any financial arrangements as may be necessary to reimburse insurers or plans for necessary costs incurred in furnishing requested information, and the time and manner those procedures are to become effective. The department shall make every effort to coordinate with the State Department of Health Care Services to obtain this information for this purpose, avoid duplication and administrative costs, and to protect privacy of medical information pursuant to state and federal law.
(c) The information required to be made available pursuant to this section shall be limited to information necessary to determine whether health care services have been or should have been claimed and paid pursuant to an obligation of entities identified in subdivision (a) and the terms and conditions of the enrollee’s contract or, in the case of a Medi-Cal beneficiary, pursuant to the scope of the contract between the State Department of Health Care Services and a Medi-Cal managed care health plan, with respect to services received by a particular individual for which services under this division or under the California Early Intervention Program would be available.
(d) Not later than the date upon which the procedures agreed to pursuant to subdivision (b) become effective, the director shall establish guidelines to ensure that information relating to an individual certified to be an applicant child or consumer, furnished to any insurer or plan pursuant to this section, is used only for the purpose of identifying the records or information requested in the manner so as not to violate the confidentiality of an applicant or recipient.
(e) The department shall implement this section no later than July 1, 2011.
(Added by Stats. 2011, Ch. 9, Sec. 14. (SB 74) Effective March 24, 2011.)
Last modified: October 25, 2018