Chapter 1.5 - Health Care Insurance - California Welfare and Institutions Code

Sections (4)

Amended by Stats. 2007, Ch. 188, Sec. 32. Effective August 24, 2007.

(a)No person having private health care coverage shall be entitled to receive the same health care items or services furnished or paid for by a publicly funded health care program.

(b)As used in this chapter:

(1)“Publicly funded health care program” shall mean care or services rendered by a local government or any facility thereof, or health care services for which payment is made under the California Medical Assistance Program established by Chapter 7 (commencing with Section 14000) of Part 3 of this division by the State Department of Health Services or by its fiscal intermediary, or by a carrier or other organization with which the State Department of Health Services has contracted to furnish those services or to pay providers who furnish those services.

(2)As used in this chapter, “private health care coverage” means any health insurer, self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, 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.

(c)If a person receives health care furnished or paid for by a publicly funded health care program, the carrier of the person’s private health care coverage shall reimburse the publicly funded health care program the cost incurred in rendering that care to the extent of the benefits provided under the terms of the policy for the items provided or the services rendered.

§ 10022

Amended by Stats. 2024, Ch. 492, Sec. 16. (SB 1511) Effective January 1, 2025.

(a)Each publicly funded health care program, as defined in paragraph (1) of subdivision (b) of Section 10020, that furnishes or pays for health care items or services under this division to a person having private health care coverage shall be entitled to be subrogated to the rights that person has against the carrier of the coverage to the extent of the health care items provided or services rendered.

(b)An entity providing private health care coverage, as defined in paragraph (2) of subdivision (b) of Section 10020, shall do all of the following:

(1)Accept the state’s right of recovery and the assignment to the state

of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the state plan, waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code, or through a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101.

(2)Respond to an inquiry by the state or a provider, as defined in subdivision (o) of Section 14043.1, including a billing agent or a billing agent of the provider, as defined in subdivision (a) of Section 14040.1, or a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, regarding a claim for payment for a health care item or service that is submitted not later than three years after the date of the provision of that health care item or service.

(3)Agree not to deny a claim submitted by the state, a provider as defined in paragraph (2), or a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, or in the case of a responsible third party, a failure to obtain a prior authorization for the item or service for which the claim is being submitted if both of the following occur:

(A)The claim is submitted by the state, a provider as defined in paragraph (2), or a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, within the three-year period beginning on the date on which the

item or service was furnished.

(B)An action by the state, a provider as defined in paragraph (2), or a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, to enforce its rights with respect to that claim is commenced within six years of the state’s or provider’s submission of the claim.

(4)Request a refund of a claim paid in error no later than three years from the date the payment was made to the State Department of Health Care Services. The State Department of Health Care Services shall not refund a claim paid in error if the request for a refund is more than three years from the date the payment was made to the State Department of Health Care Services.

(5)Respond to a request for payment by the

state, a provider as defined in paragraph (2), or a Medi-Cal managed care plan, as defined in paragraph (2), within 60 days by providing one of the following:

(A)Payment on the claim.

(B)A written request for additional information necessary to process the claim.

(C)A written explanation for the denial of the claim.

§ 10024

Amended by Stats. 2007, Ch. 188, Sec. 34. Effective August 24, 2007.

Every contract or agreement for private health care coverage entered into or renewed after January 1, 1972, is deemed to provide for payment to a publicly funded health care program for the actual cost that the program incurs in providing health care items or rendering health care services to any party or beneficiary of that contract or agreement to the extent of the benefits provided under the terms of the policy for the items provided or services rendered.

§ 10025

Added by Stats. 1971, Ch. 812.

The state shall not reimburse any local government or any facility thereof, under Medi-Cal or under any other health program where the state pays part or all of the costs, for care provided to a person covered under any disability insurance, health insurance, or prepaid health plan.

In local programs fully or partially funded by the state, state participation shall be reduced in an amount proportionate to the cost of service provided to a person violating Section 10020.