July 12, 2022
The California Health-related Association (CMA) just lately submitted an amicus curiae letter with the California Supreme Courtroom in help of a petition for evaluate of an appellate court decision that if authorized to stand would generate a sizeable hole in managed care regulation that ultimately could destabilize the health and fitness treatment market.
In this circumstance, County of Santa Clara v. Medical doctors Medical Centre of Modesto, et al., an appeals court ruled that Santa Clara County—through Valley Well being Prepare its county-based Knox-Keene accredited well being plan—is immune from frequent regulation reimbursement promises beneath community entity immunity in the Government Code.
Even though Santa Clara County is demanded to reimburse unexpected emergency solutions at the “usual, customary and reasonable” (UCR) amount under the California Overall health & Safety Code, the appeals courtroom identified Santa Clara County is vested with discretion to determine the UCR quantity.
The appellate court’s opinion insulates Valley Wellness System from civil legal responsibility for violating the Knox-Keene Act’s requirement for acceptable reimbursement for emergency care.
The ruling unjustifiably gets rid of any accountability or obligation of county wellbeing options to fairly reimburse vendors of crisis care. The disruption and uncertainty that will outcome if this ruling is permitted to stand could also impair patients’ obtain to care as far more vendors abandon the managed care current market.
This ruling would disproportionately impact the neediest patients, as 95% of county-dependent wellbeing plan enrollment is Medi-Cal beneficiaries collaborating in Medi-Cal managed care. This is an underserved population that simply cannot afford to pay out out-of-pocket for medically needed expert services.
“There is no content distinction among Knox-Keene designs presented by a county, like Valley Health Program, and those people offered by industrial organizations. All licensed, comprehensive-support wellbeing designs ought to be matter to the similar demands underneath the Knox-Keene Act,” the CMA letter reported. “To allow or else would create a patchwork of service provider networks and service ranges. That sort of uncertainty would threaten the monetary viability of the managed care procedure, to the detriment of people.”
For much more data, see CMA’s letter.