10020-10025
WELFARE AND INSTITUTIONS CODE
SECTION 10020-10025
10020. (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. (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.
(2) Respond to any 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, regarding a claim for payment for any 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 or a
provider, as defined in paragraph (2), 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 if both of the following
occur:
(A) The claim is submitted by the state or a provider, as defined
in paragraph (2), within the three-year period beginning on the date
on which the item or service was furnished.
(B) Any action by the state or a provider, as defined in paragraph
(2), 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.
10024. 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. 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.