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Monday, February 27, 2012

 

DMHC Issues Cease and Desist Order Against Kaiser Health Plan Due to Denials of Physical, Occupational and Speech Therapy

(Sacramento) – The California Department of Managed Health Care (DMHC) today ordered Kaiser Foundation Health Plan, Inc. to cease and desist from denying its members access to physical, occupational, and speech therapy. Complaints to DMHC show that Kaiser denies coverage for these services for non-physical conditions without determining medical necessity.

“Kaiser Health Plan’s policy to deny physical, occupational, and speech therapy services for non-physical conditions is not permitted under the Knox-Keene Act,” said Anthony Manzanetti, DMHC’s chief of enforcement. “The DMHC is taking this action to ensure Kaiser follows the law.”

Under California law, health plans are required to cover medically necessary basic health care services, including speech, physical, and occupational therapy services. In addition, the state mental health parity law requires health plans to cover medically necessary diagnosis and treatment for certain mental health conditions. Since 2009, DMHC has received more than 100 complaints from Kaiser members who were denied access to medically necessary speech, physical, and occupational therapy services because, according to Kaiser, they did not have a “physical condition.”

The full order can be found here:
http://healthhelp.ca.gov/library/reports/news/order71667.pdf

In California, consumers have the right to appeal a health plan’s refusal to provide medically necessary health care services. They also have the right to receive an independent medical review if they disagree with the plan’s decision. To learn more about health care options, consumer rights, or to receive assistance filing complaints and appeals, Californians can contact the DMHC Help Center at 1-888-466-2219 or visit www.HealthHelp.ca.gov. Since 2000, the Help Center has assisted more than 1 million Californians resolve health coverage complaints.

The DMHC regulates managed care health plans, protects the rights of 21 million California enrollees, ensures prompt and accurate provider payments, and preserves the financial stability of the managed health care system. 


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