TABLE 12-1 The Covered Benefits, Mandatory Benefits, and Optional Benefits for Plans Governed by California’s Knox-Keene Act

Covered Basic Health Care ServicesBenefits Under Knox-Keenea Examples of 44 Statutorily Mandated Benefits Optional Benefits

• Hospital inpatient services* • Mental health parity* for severe mental illness and serious emotional disturbance of a child [1374.72]b • Outpatient prescription drugs* [1342.7, rule 1300.67.24]b
• Physician services* • Various cancer screenings such as cervical and prostate cancer screenings and mammography [1367.665, 1367.66, 1367.64, 1367.65] • Chiropractic services
• Outpatient/ambulatory care* • Testing for Expanded Alpha Feto Protein (AFP) (prenatal testing) [1367.54] • Dental care
• Lab and radiology* • Prohibits plans from limiting inpatient hospital care following childbirth to less than 48 hours (vaginal delivery) and 96 hours (caesarean section) [1367.62] • Hearing aids
• Home health • HIV testing [1367.68]
• Preventive health services*
• Emergency services* (including ambulance and out-of-area coverage)
• Hospice (only for group coverage)

NOTE: The asterisk (*) indicates similar benefits are also listed as categories under Section 1302(b) of the ACA. In addition to the above-starred categories, the ACA specifies maternity and newborn care, rehabilitative and habilitative services, chronic disease management, and pediatric services including oral and vision care. Maternal and newborn care, and rehabilitation/habilitation are not listed separately in Knox-Keene but considered subsumed under hospital, ambulatory, and physician services. Additionally, while prescription coverage is an optional benefit in California (but usually purchased as a rider), it is required under the ACA. The preventive health services provision under Knox-Keene includes vision screening and oral health risk assessment for children.
a Knox-Keene Act Section 1345 (b); Section 1367 (i). rule 1300.67.
b Brackets include Knox-Keene Act sections.

cancer screenings, and HIV testing. Ms. Ehnes clarified that many of these statutorily mandated benefits fall under the Knox-Keene covered benefits, but because there were disputes over whether they were covered, the state legislature took the added step of explicating their inclusion in benefit plans.

Grievance and Appeals Processes

Ms. McKennan proceeded to detail the DMHC’s policies and processes for addressing grievances and appeals when consumers seek care that has been denied. The Knox-Keene Act describes what Ms. McKennan called “the how, the what, and the when for the plan to respond to these grievances”2:

  • For standard grievances, the plan has to respond within 30 days, whereas for urgent grievances, the plan has to respond within three days.
  • The plan needs to send the enrollee a written response that includes a clear and concise explanation of the denial, including the clinical reasons, the criteria, or the guidelines that were used in making the determination.
  • For coverage denials, the plan needs to cite a specific portion of the evidence of coverage or plan contract.
  • When the plan denies a grievance, the plan needs to inform the enrollee of the right to appeal to the DMHC.

Unless an earlier review by the DMHC is warranted, enrollees must first exhaust the plan’s internal grievance and appeals processes before appealing to the DMHC, but enrollees are not limited in the content and issues about which they can appeal, including access to care and denial of service. Once these grievances and appeals reach


2 § 1368.

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