California Physician

Untitled Document

Which Health Plans Are Covered by
the Unfair Payment Practices Law?
[Posted 04/08/04]

For More Information

Unfair Payment Practices Resource Center

The CMA-sponsored unfair payment practices regulations (AB 1455) apply to Knox-Keene licensed health plans that are regulated by the Department of Managed Health Care (DMHC), including their contracting claims processing organizations, medical groups, and IPAs with delegated claims adjudication responsibilities. The Knox-Keene Health Care Service Plan Act of 1975 regulates all California HMOs, as well as Blue Cross and Blue Shield PPOs.

PPOs (except Blue Cross and Blue Shield PPOs) and other non-HMO insurers are regulated by the Department of Insurance (DOI), and are therefore not subject to the DMHC’s unfair payment practices regulations.

Below is a chart comparing some of the major DMHC and DOI regulated insurers. For a complete list of health plans regulated by DMHC, click here.

Name of Plan	Product	Regulated by...
Name of Plan	Product	DMHC (AB 1455 does apply)	DOI (AB 1455 does not apply )
Aetna	HMO	X
Aetna	PPO		X
Blue Cross of CA	HMO	X
Blue Cross of CA	PPO	X
Blue Shield of CA	HMO	X
Blue Shield of CA	PPO	X
CIGNA	HMO	X
CIGNA	PPO		X
Health Net	HMO	X
Health Net	PPO		X
Kaiser	HMO	X
PacifiCare	HMO	X
PacifiCare	PPO		X
PHCS	PPO		X

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