Common use of Million Californians Clause in Contracts

Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Plan re-reviewed the file, this time concurring that the services were emergent in nature. The Plan reprocessed the service under the enrollee’s emergency services benefits, leaving the enrollee with a zero balance, thereby resolving the enrollee’s Help Center complaint. The Plan failed to adequately consider and rectify the enrollee’s grievance. (Health & Saf. Code, § 1368, subd. (a)(1).) Health and Safety Code section 1368, subdivision (a)(1), requires a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. In this case, the enrollee filed a grievance with the Plan and clearly indicated that the enrollee was at an in-network emergency facility. Despite this explicit statement, the Plan’s grievance analyst failed to consider whether the services rendered were actually for emergency services. Accordingly, the Plan failed to adequately consider and rectify the enrollee’s grievance, in violation of Health and Safety Code section 1368, subdivision (a)(1). The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that an administrative penalty of $7,500 is warranted. The Department agrees that payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1368, subdivision (a)(1). / / / / / / / / / / / / / / / / / / / / / / / / This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16, 2022 /Original Signed/ Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross of California Dated: October 17, 2022 /Original Signed/ Xxxxx Xxxxxx Associate General Counsel Blue Cross of California

Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Plan re-reviewed the file, this time concurring that the services were emergent in nature. The Plan reprocessed the service under the enrollee’s emergency services benefits, leaving the enrollee with a zero balance, thereby resolving the enrollee’s Help Center complaint. The Plan failed to adequately consider and rectify the enrollee’s grievance. (Health & Saf. Code, § 1368, subd. (a)(1).) Health and Safety Code section 1368, subdivision (a)(1), requires a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. In this case, the enrollee filed a grievance with the Plan and clearly indicated that the enrollee was at an in-network emergency facility. Despite this explicit statement, the Plan’s grievance analyst failed to consider whether the services rendered were actually for emergency services. Accordingly, the Plan failed to adequately consider and rectify the enrollee’s grievance, acted in violation of Health and Safety Code section 13681386, subdivision (a)(1b)(1), when it failed to provide agreed-upon benefits to the enrollees. Health and Safety Code section 1386, subdivision (b)(1), states that a health plan may be subject to discipline where it has been found to be operating at variance to a plan document on file with the Department. Pursuant to Section 1351, subdivision (f), health plans are required to file all EOCs with the Department for approval upon filing for an initial license, and any subsequent changes to the EOC must be filed pursuant to Section 1352, subdivision (a). The EOCs at issue provided that office visits were not subject to the plan annual deductible. These office visits included primary care and behavioral health office visits. Each of the 16 affected products were grandfathered plans which are exempted from many of the benefit requirements mandated by the Affordable Care Act. As such, the benefits afforded by these plans are dependent upon the enumerated benefits provided in the EOC. The Plan was in violation of Health and Safety Code section 1386, subdivision (b)(1), when it failed to properly exclude office visits from the plan deductible as required by the applicable EOCs. The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that a Corrective Action Plan (CAP) and an administrative penalty of $7,500 is 750,000 are warranted. The Department has accepted the CAP proposed by the Plan as detailed below. The Department agrees that performance of the CAP to the Department’s satisfaction and payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1368, subdivision (a)(1). / / / / / / / / / / / / / / / / / / / / / / / / This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16, 2022 /Original Signed/ Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross of California Dated: October 17, 2022 /Original Signed/ Xxxxx Xxxxxx Associate General Counsel Blue Cross of California.

Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx The Plan re-reviewed was in violation of Health and Safety Code section 1386, subdivision (b)(1), when it failed to honor the fileterms of the EOC. Health and Safety Code section 1386, this time concurring subdivision (b)(1), provides that a health plan may be subject to discipline where it is determined to be operating at variance to a document filed with the services were emergent Department as required by Health and Safety Code sections 1351 or 1352. EOC documents are required to be filed with the Department. (Health & Saf. Code, § 1351, subd. (f).) Here, the enrollee’s EOC provided for coverage of infertility services, with a lifetime maximum of $25,000. However, the Plan erroneously applied a $10,000 lifetime maximum benefit to the enrollee’s infertility prescriptions. The Plan’s failure to provide the proper benefits as provided for in naturethe EOC was in violation of Health and Safety Code section 1386, subdivision (b)(1), and the Plan is subject to discipline. The Plan reprocessed the service under the enrollee’s emergency services benefitswas in violation of Health and Safety Code section 1368, leaving the enrollee with a zero balancesubdivision (a)(1), thereby resolving the enrollee’s Help Center complaint. The Plan when it failed to adequately consider and rectify the enrollee’s January 26, 2021, grievance. Health plans must establish and maintain a grievance system which shall ensure adequate consideration and rectification of enrollees’ grievances. (Health & Saf. Code, § 1368, subd. (a)(1).) Health and Safety Code section 1368, subdivision (a)(1), requires a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. In this case, the The enrollee filed a grievance with the Plan on January 26, 2021, and clearly indicated that requested the Plan cover the outstanding amount related to her infertility prescriptions. The Plan’s February 25, 2021, grievance response to the enrollee was at failed to address the enrollee’s complaint when it cited to an in-network emergency facility. Despite this explicit statement, inapplicable EOC provision and failed to identify the Plan’s grievance analyst failed to consider whether error in applying the services rendered were actually for emergency serviceslifetime maximum benefit amount. AccordinglyAs such, the Plan failed to adequately consider and rectify the enrollee’s grievance, grievance in violation of Health and Safety Code section 1368, subdivision (a)(1). The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that a Corrective Action Plan (CAP) and an administrative penalty of $7,500 is 15,000 are warranted. The Department has accepted the CAP proposed by the Plan as detailed below. The Department agrees that performance of the CAP to the Department’s satisfaction and payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. / / / / / / Corrective Action Plan Deliverable 1: The Plan provided written confirmation that the prescription claims were reprocessed and the enrollee was reimbursed with interest. The deliverable was provided on November 2, 2021. (Health & Saf. Code, § 1386, subd. (b)(1).) In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1386, subdivision (b)(1); • Health and Safety Code section 1368, subdivision (a)(1). / / / / / / / / / / / / / / / / / / / / / / / / This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16January 4, 2022 /Original Signed/ Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross of California Dated: October 17November 18, 2022 2021 /Original Signed/ Xxxxx Xxxxxx Associate General Counsel Blue Cross of California

Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx The enrollee filed a complaint with the Plan re-reviewed in December 2020, seeking coverage of the file, this time concurring that the services were emergent in naturerecovered claim. The Plan reprocessed purported to resolve the service under complaint in January 2021 by providing a written response suggesting that the coverage determination be upheld “because of Coordination of Benefit.” The Plan’s response ultimately concluded with the following: “Our records indicate that you hae dual coverage . Please call this provider and provide you Primary and Secondary Insutance.” (Spelling and formatting preserved from original.) In fact, the enrollee did have coverage through the Plan. In August 2020, the enrollee’s emergency services benefitsemployer provided payment for the enrollee, leaving retroactively reinstating the enrollee to June 2020. Thus, at the time the enrollee filed the complaint with a zero balancethe Plan, thereby resolving the Plan had reinstated the enrollee. However, the Plan did not reprocess the claim and repay the provider. The provider continued to seek payment from the enrollee. The enrollee contacted the Department’s Help Center complaintCenter, seeking assistance. Following the Help Center’s involvement, the Plan reviewed its records and agreed to reprocess the claim, with interest. The Plan failed thereafter reissued the payment to adequately consider and rectify the enrollee’s grievanceprovider. (Health & Saf. Code, § 1368, subd. (a)(1).) Health and Safety Code section 1368, subdivision (a)(1), requires a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. In this caseFollowing review, the enrollee filed a grievance with Department has determined the Plan and clearly indicated that the enrollee was at an in-network emergency facility. Despite this explicit statement, the following: The Plan’s January 2021 grievance analyst failed to consider whether the services rendered were actually for emergency services. Accordingly, resolution letter demonstrates that the Plan failed to adequately consider and rectify the enrollee’s grievance, in violation of Health and Safety Code section 1368, subdivision (a)(1). Further, the grievance resolution letter failed to provide a clear and concise explanation of the reasons for the Plan’s response, in violation of Health and Safety Code section 1368, subdivision (a)(5). Under Health and Safety Code section 1368, subdivision (a)(1), health plans are required to maintain a grievance system that ensures adequate consideration and rectification of enrollee grievances. Further, under Health and Safety Code section 1368, subdivision (a)(5), a health plan’s written response to an enrollee grievance must contain a clear and concise explanation for the reasons for the plan’s response. In this case, the Plan’s grievance resolution letter indicated that the Plan did not adequately consider the enrollee’s grievance. The grievance resolution letter stated that the enrollee’s service had been denied due to “Coordination of Benefit.” Had the Plan adequately considered the enrollee’s grievance, it would have, as of the time it received and reviewed the grievance in January 2021, understood that the Plan recouped the claim for services based on a lack of coverage, and that the enrollee had now been retroactively reinstated. Instead, the Plan erroneously concluded that the provider lacked information about the enrollee’s health insurance and directed the enrollee to contact the provider. Accordingly, the Plan’s grievance system failed to ensure adequate consideration and rectification of the enrollee’s grievance, in violation of Health and Safety Code section 1368, subdivision (a)(1). In attempting to explain the inapplicable Coordination of Benefits issue, the Plan’s January 27, 2021, grievance resolution letter contained an overly lengthy and circuitous explanation. The text of the explanation is omitted here to preserve space. Upon review, the Office of Enforcement determined that the Plan’s explanation was not clear or concise. Accordingly, the Plan’s grievance resolution letter failed to comply with Health and Safety Code section 1368, subdivision (a)(5). The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that an administrative penalty of $7,500 10,000 is warranted. The Department agrees that payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1368, subdivision (a)(1); and • Health and Safety Code section 1368, subdivision (a)(5). / / / / / / / / / / / / / / / / / / / / / / / / This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16September 20, 2022 /Original Signed/ Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross UHC of California Dated: October 17September 14, 2022 /Original Signed/ Xxxxx Xxxxxx Xxxxxx Associate General Counsel Blue Cross UHC of California

Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Plan re-reviewed the file, this time concurring that the services were emergent in nature. The Plan reprocessed improperly processed the November 14, 2018, claim with the incorrect copay in violation of Health and Safety Code section 1386, subdivision (b)(1), for acts at variance with the terms of the EOC. Health care service under the enrollee’s emergency services benefits, leaving the enrollee with a zero balance, thereby resolving the enrollee’s Help Center complaint. The Plan failed plans may be subject to adequately consider and rectify the enrollee’s grievanceadministrative penalties if they commit any acts or omissions that constitute grounds for disciplinary actions. (Health & Saf. Code, § 13681386, subd. (a)(1a).) Health and Safety Code section 1368, subdivision (a)(1), requires Among the acts or omissions that constitute grounds for disciplinary actions are acts at variance with a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriatehealth care service plan’s published plan. In this case, the enrollee filed a grievance with the Plan and clearly indicated received laboratory services on or about November 14, 2018. The EOC for year 2018 provided that the enrollee was at an in-network emergency facilityshould only be responsible for a $40 copayment for diagnostic laboratory services. Despite this explicit statementThe Plan, however, initially processed the enrollee’s claim by line for the services performed resulting in the enrollee being charged a $40 copayment eight times rather than a single $40 copayment for the date of service. Based on the above facts and the Plan’s grievance analyst failed own admission to consider whether the services rendered were actually for emergency services. AccordinglyDepartment, the Plan failed to adequately consider and rectify acted at variance with the enrollee’s grievanceterms of the EOC, in violation of Health and Safety Code section 13681386, subdivision (a)(1b)(1). The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that an administrative penalty of $7,500 5,000 is warranted. The Department agrees that payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1368, subdivision (a)(1). / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / In summary, the statutes prosecuted herein are: • Health and Safety Code section 1386, subdivision (b)(1) This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16July 26, 2022 /Original Signed/ / Original Signature / Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross of California Dated: October 17July 8, 2022 /Original Signed/ / Original Signature / Xxxxx Xxxxxx Managing Associate General Counsel Blue Cross of California