CHAPTER 2.25. Disease Management [1399.900 - 1399.904]
( Heading of Chapter 2.25 renumbered from Chapter 2.5 (as added by Stats. 2000, Ch. 1065) by Stats. 2002, Ch. 664, Sec. 129. )
(a)
For the purposes of this chapter, “disease management organization” means an entity that provides disease management programs and services and that contracts with any of the following:
(1)
A health care service plan.
(2)
A contractor of a health care service plan.
(3)
An employer.
(4)
A publicly financed health care program.
(5)
A government agency.
(b)
A disease management organization shall not include an entity whose primary purpose is to market specific products or services to enrollees of a health care service plan.
(c)
No medical group, individual licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or health facility as defined in Section 1250, that provides disease management programs and services incidental to their primary professional practices, shall be considered a disease management organization.
(Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)
For the purposes of this chapter, “disease management programs and services” means services administered to patients in order to improve their overall health and to prevent clinical exacerbations and complications utilizing cost-effective, evidence-based, or consensus-based practice guidelines and patient self-management strategies. Disease management programs and services shall contain all of the following:
(a)
A population identification process.
(b)
Evidence-based or consensus-based clinical practice guidelines, risk identification, and matching of interventions with clinical need.
(c)
Patient self-management and disease education.
(d)
Process and outcomes measurement, evaluation, management, and reporting.
(Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)
(a)
Every disease management organization shall obtain physician authorization prior to the time that the disease management organization, its employees, or independent contractors do either of the following:
(1)
Provide home health care services utilized in the treatment of a patient.
(2)
Dispense, administer, or prescribe a prescription medication.
(b)
For purposes of this section, a valid prescription written by a treating physician shall constitute authorization to dispense a prescription medication.
(c)
Home health care followup visits made solely for patient assessment, monitoring, or education are not subject to the physician authorization requirement in subdivision (a).
(d)
Nothing in this section, in the absence of authorization granted by any other law, shall be construed to authorize the activities described in paragraphs (1) and (2) of subdivision (a).
(Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)
A disease management organization may receive medical information as provided in paragraph (17) of subdivision (c) of Section 56.10 of the Civil Code. However, a disease management organization shall be subject to the other provisions of the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code), including, but not limited to, subdivisions (d) and (e) of Section 56.10 of, and Section 56.36 of, the Civil Code.
(Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)
A disease management organization shall not use medical information obtained pursuant to Section 1399.903 to solicit or to offer for sale to a health care service plan enrollee any products or services in the provision of disease management services to the enrollee. However, an enrollee may elect to use a disease management organization to obtain information about health care products and services and, pursuant to that election by the enrollee, the disease management organization may offer to the enrollee health care products or services that are directly related to the enrollee’s condition.
(Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)