reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14257.

14257. Nothing in this act shall preclude the director from contracting with licensed specialized health care service plans which provide only dental, pharmaceutical, optometric, or psychological services in accordance with regulations issued by the department.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14258.

14258. “Service area” means a geographical area designated by the department within which a prepaid health plan shall provide health care services and within which the Medi-Cal beneficiaries eligible for enrollment in the prepaid health plan reside.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14261.

14261. “Vendor” means any person who provides services or supplies to a prepaid health plan or a subcontractor of a prepaid health plan and who does not have a subcontract as defined by Section 14253 with either the prepaid health plan or its subcontractors.
(Repealed and added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14263.

14263. “Marketing” means any activity conducted by or on behalf of a prepaid health plan where information regarding the services offered by a prepaid health plan is disseminated in order to persuade Medi-Cal beneficiaries to enroll or accept any application for enrollment in the prepaid health plan. Marketing shall also include any similar activity to procure the endorsement of the prepaid health plan from any individual or organization.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14264.

14264. “Marketing organization” means any subcontractor who agrees to provide marketing services for a prepaid health plan.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14265.

14265. “Marketing representative” means any person who engages in marketing activities on behalf of a marketing organization or the prepaid health plan.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14300.

14300. The department shall publish a notice of intent to contract at least 60 days prior to the effective date of any initial or renewed contract. The notice shall appear in local newspapers circulated in the service areas of the prepaid health plan. The notice shall announce the department’s intent to contract and any person affected by the contract shall have the opportunity to request that a public hearing be held. The request for public hearing shall be accompanied by an explanation of the reason for the request and a description of problems or questions regarding the plan’s ability to meet its contractual obligations. A hearing shall be held by the department if the director determines that the request is reasonable and warrants a full public hearing. A request shall be considered reasonable if there is a question regarding the plan’s ability to meet its contractual obligations.
No contract shall be signed by the department until the department determines that the plan has the ability to fully comply with its contractual obligations.
(Amended by Stats. 1984, Ch. 1338, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14301.2.

14301.2. (a) The director may defer fee-for-service payments or payments to Medi-Cal managed care health plans contracting with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), Article 2.9 (commencing with Section 14088), or Article 2.91 (commencing with Section 14089) of this chapter, or Chapter 8 (commencing with Section 14200) or Chapter 8.75 (commencing with Section 14591), the Senior Care Action Network Health Plan, and Medi-Cal managed care health plan providers, as applicable, which are payable during the final month of the state fiscal year. This section may be implemented only to the extent consistent with federal law.
(b) Notwithstanding subdivisions (c) and (d) of Section 34 of Chapter 37 of the Statutes of 2013, this section shall not be made inoperative as a result of any determination made by the Director of Finance pursuant to Section 34 of Chapter 37 of the Statutes of 2013.
(Amended by Stats. 2017, Ch. 52, Sec. 76. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14301.3.

14301.3. The department shall ensure that Medi-Cal managed care plans demonstrate ongoing ability and readiness to perform the obligations set forth in Section 14132.195. The department shall, as may be appropriate and in its discretion, adjust the capitation rate of a Medi-Cal managed care plan to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes.
(Added by Stats. 2019, Ch. 387, Sec. 4. (AB 1004) Effective January 1, 2020.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14302.

14302. Except as provided in Section 14490, the duration of initial contracts entered into pursuant to this chapter shall be for a maximum of one year and of renewed contracts for a maximum of five years.
(Amended by Stats. 1979, Ch. 1061.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14303.

14303. No contract between the department and the prepaid health plan shall be amended without the public notice and if necessary the holding of a public hearing as required in Section 14300 if such amendments make any of the following changes in the contract:
(a) Reduction in the scope or availability of services.
(b) Enlargement of the service area.
(c) Increase in the maximum enrollment permitted under the contract.
(d) Any other change in the plan’s organization, operation, or delivery of services which the director determines will have a substantial impact on the ability of enrollees to obtain health care services.
(Amended by Stats. 1980, Ch. 1073, Sec. 3.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14303.1.

14303.1. The department shall have authority to amend a prepaid health plan contract in accordance with the terms of a merger of a prepaid health plan with another organization or organizations other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, provided the surviving organization meets the following conditions:
(a) The surviving organization assures the continued and accessible delivery of health care services to enrollees.
(b) The plans concerned have satisfactorily demonstrated the fiscal and administrative soundness of the newly proposed organization.
(c) The enrollees of the plans concerned are informed of the impending merger, any resulting changes in the service area or delivery of health care services, and such other information required by subdivision (a) of Section 14406 at least 30 days in advance of the merger.
(d) The enrollees of the plans concerned are given the option of disenrolling for any cause within 60 days following the effective date of the merger.
(e) Public notice is given and if necessary a public hearing is held as required by Section 14300.
(f) The organization meets such other requirements as deemed necessary by the department in order to carry out the purpose of this chapter.
(Amended by Stats. 1980, Ch. 1073, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14303.2.

14303.2. The department shall have authority to amend a prepaid health plan contract in accordance with the terms of the reorganization of a prepaid health plan or a merger of the plan with its subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, provided the following conditions are met:
(a) The resulting or surviving organization assures the continued and accessible delivery of health care services to enrollees.
(b) The plan has satisfactorily demonstrated the fiscal and administrative soundness of the newly proposed organization.
(c) If the proposed reorganization or merger results in any change of the plan’s service area or delivery of health care services, or if the director otherwise deems it to be appropriate, the following additional conditions shall be met:
(1) Public notice is given and if necessary a public hearing is held as required by Section 14300.
(2) The enrollees of the plan are informed of the impending reorganization or merger, any resulting changes in the service area or delivery of health care services, and such other information required by subdivision (a) of Section 14406 at least 30 days in advance of the reorganization or merger.
(3) The enrollees of the plan are given the option of disenrolling for any cause within 60 days following the effective date of the reorganization or merger.
(d) The plan meets such other requirements as deemed necessary by the department in order to carry out the purpose of this chapter.
(Amended by Stats. 1980, Ch. 1073, Sec. 5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14303.3.

14303.3. The department shall renew a contract unless good cause is shown for nonrenewal.
(Added by Stats. 1980, Ch. 1073, Sec. 6.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14304.5.

14304.5. Each prepaid health plan shall provide directly or through subcontractors, not less than the basic scope of health care benefits as defined in Section 14256. The director shall establish the scope and duration of such services and may require other services listed in Section 14053 be provided on a risk or nonrisk basis. The director shall encourage the prepaid health plan to provide all of the services enumerated in Section 14053 on a prepaid basis. When mutually agreeable to the prepaid health plan, the department, and the hospital involved, and provided that the confidentiality of the selected hospital contracting rates negotiated pursuant to Chapter 7 (commencing with Section 14081) is maintained by all parties, contracts entered into by the department pursuant to this chapter may provide for alternative arrangements in any or all of a prepaid health plan’s Medi-Cal service area for the payment of inpatient hospital services using Medi-Cal hospital inpatient rates.
Subject to prior approval by the director, any additional services other than those listed in Section 14053 may be provided at reasonable cost to Medi-Cal enrollees, provided the enrollees are notified of services for which they will be charged and the amount of the charge prior to rendering such services.
(Amended by Stats. 1988, Ch. 1348, Sec. 14.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14305.

14305. The department may limit the scope of health care benefits provided by a prepaid health plan under this chapter to exclude the care of illness or injury which results from or is greatly aggravated by, a catastrophic occurrence, including, but not limited to, an act of war, declared or undeclared, and which occurs subsequent to enrollment in the prepaid health plan.
(Repealed and added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14308.

14308. (a) Each prepaid health plan shall furnish to the director such information and reports as required by Title XIX of the federal Social Security Act.
(b) The director may require a prepaid health plan to provide the director with information and reports that are furnished by the prepaid health plan to the Director of the Department of Managed Health Care pursuant to the provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, the Knox-Keene Health Care Service Plan Act of 1975.
(c) The director may, by regulation, require plans to furnish statistical information to the extent the information is necessary for the department to establish rates of payment pursuant to Section 14301.1 and to provide reports pursuant to Section 14313. The department shall, to the extent feasible, accept this information in a form which is consistent with reports required to be provided pursuant to the Knox-Keene Health Care Service Plan Act of 1975. In the case of a hospital based plan that is a health maintenance organization qualified pursuant to Title XIII of the federal Public Health Service Act, and that has more than one million enrollees, of whom less than 10 percent are Medi-Cal enrollees, information required pursuant to this subdivision shall consist of reports required to be made to the United States Department of Health and Human Services pursuant to Title XIII of the federal Public Health Service Act.
(Amended by Stats. 2023, Ch. 266, Sec. 3. (AB 614) Effective January 1, 2024.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14309.

14309. The department shall provide for a continuing study of the quality of care and services resulting from the operation of this chapter and for surveys and reports on prepaid health plans. With respect to such plans contracted for under this chapter, the department may contract with professional organizations for studies and reports of the experience of such plans as to the standards of care available to eligible persons, gross and net costs, administrative costs, benefits, utilization of benefits, the portion of actual personal expenditures of eligible persons for health care which are being met by prepaid benefits, and the methods of evaluating and improving the quality of, and controlling the costs of, health care provided under such contracts. However, this section shall not be construed to require any prepaid health plan to provide accounting data or statistical data not required by regulations adopted by the director.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14311.

14311. Prepaid health plans, the services they provide, and the persons receiving these services shall not be subject to the limitations on services set forth in Section 14133, 14133.1, 14133.25, or 14133.3 or subdivisions (c), (d), and (e) of Section 14120, or subdivision (c) of Section 14105. Notwithstanding this section, the requirements set forth in Section 14301 for the determination of prospective per capita rates of payment for services provided under this chapter to Medi-Cal beneficiaries enrolled in a prepaid health plan shall remain unchanged.
Nothing in this section or in Article 7 (commencing with Section 14490) shall relieve the director of his responsibility to provide the benefits provided for in Section 14132. Where a contract between the department and a prepaid health plan does not require the prepaid health plan to provide a benefit to which a Medi-Cal recipient is otherwise entitled, the recipient shall be entitled to receive such benefit pursuant to Chapter 7 (commencing with Section 14000) of this part.
(Amended by Stats. 1984, Ch. 780, Sec. 1.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14312.

14312. The director shall adopt all necessary rules and regulations to carry out the provisions of this chapter. In adopting such rules and regulations, the director shall be guided by the needs of eligible persons as well as prevailing practices in the delivery of health care on a prepaid basis. Except where otherwise required by federal law or by this part, the rules and regulations shall be consistent with the requirements of the Knox-Keene Health Care Service Plan Act of 1975.
(Amended by Stats. 2014, Ch. 442, Sec. 38. (SB 1465) Effective September 18, 2014.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14314.

14314. The director may recover a due and payable overpayment made to a prepaid health plan by means of a repayment agreement executed between such prepaid health plan and the director, and by any other means available at law.
(Amended by Stats. 1979, Ch. 373.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14315.

14315. When it has been determined that a prepaid health plan has received an overpayment which is due and payable, the director may recover such overpayment by offset against any amount currently due to the prepaid health plan under the provisions of this chapter or Chapter 7 (commencing with Section 14000) of this part.
(Added by Stats. 1977, Ch. 1046.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 3 - Administration › Section 14316.

14316. Notwithstanding any other provisions of law, contracts with plans which are entered into, renewed, or amended pursuant to this article may include one or more of the following:
(1) A provision to the effect that if the rate for a plan is less than 90 percent of the estimated Medi-Cal fee-for-service cost, the plan’s rate shall be increased by one-half the difference between the rate fixed and 90 percent of the estimated fee-for-service cost. The rate shall not, however, be less than 85 percent of the estimated fee-for-service costs.
(2) Guaranteed capitation payments for Medi-Cal beneficiaries, who are entitled to benefits under Title IV of the Social Security Act, for a period of six months or less, even if the eligibility for benefits of such beneficiaries terminates prior to the end of the guaranteed payment period. Each guaranteed payment period shall be calculated beginning on the date a beneficiary’s enrollment takes effect.
(3) Benefits in addition to those listed under Section 14132, as long as the provision of such additional services permits plans to remain more cost effective than fee-for-service reimbursement.
(Added by Stats. 1982, Ch. 328, Sec. 45. Effective June 30, 1982.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14400.

14400. Every prepaid health plan shall have an open enrollment period at least once every year. During the open enrollment period the plan shall accept up to the limit of its capacity or the limit of its contract, without restrictions, other than those which may be required by the director, Medi-Cal beneficiaries who are eligible to enroll in such plans. Eligible enrollees shall be accepted in the order in which they apply for enrollment.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14401.

14401. No Medi-Cal beneficiary shall be enrolled in a prepaid health plan prior to the time a contract under this chapter is signed by the department and such prepaid health plan is approved by the appropriate state agencies.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14402.

14402. The prepaid health plan shall enroll only those Medi-Cal beneficiaries who reside within the contract service area. Prepaid health plans shall use a standard application form prescribed by the department which is readily understandable to the enrollees. A beneficiary shall be enrolled in the prepaid health plan when the beneficiary voluntarily signs the enrollment application agreeing to utilize the health services provided by the prepaid plan and his eligibility for enrollment in that plan is verified by validation of the application by the department.
Notwithstanding the provisions of this section requiring voluntary enrollment, the department may approve the transfer of the enrollees of one or more prepaid health plans to another prepaid health plan in accordance with the terms of a merger or reorganization approved by the department pursuant to the conditions set forth in Sections 14303.1 and 14303.2.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14403.

14403. No Medi-Cal beneficiary shall be enrolled in more than one prepaid health plan at any time.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14406.

14406. (a) Within seven days after the effective date of enrollment, the prepaid health plan shall provide in writing the following information to a new enrollee or the family unit of the new enrollee:
(1) An appropriate document identifying the enrollee and authorizing the services or benefits to which that person is entitled under the plan subject to verification of eligibility.
(2) A description of all services and benefits provided by the plan.
(3) An explanation of the procedure for obtaining these services and benefits, including in the case of medical foundations or independent practice associations, the address and telephone number of each primary care physician, dentist, optometrist, psychologist, and in the case of other plans, the address and telephone number of each service site and the location of primary care physicians, dentists, optometrists and psychologists, and in the case of all prepaid health plans, the address and telephone numbers of each hospital, pharmacy, and skilled nursing facility where health care benefits may be obtained. In addition, the explanation shall state the hours and days where each of these facilities are open and the services and benefits available.
(4) The location, telephone number, and procedure for securing 24-hour emergency care and an explanation of and procedure for obtaining out-of-area emergency coverage.
(5) Information setting forth the term of enrollment in the prepaid health plan including the causes for which an enrollee shall lose eligibility in the prepaid health plan.
(6) The procedure for processing and resolving any grievance by enrollees. Such information shall include the name, address, and telephone number of the person responsible for resolving grievances or initiating a grievance procedure.
(7) The procedure by which enrollees may request disenrollment.
(8) Any other information essential to the use of the prepaid health plan as may be required by the department.
(b) The information made available under this section shall be revised and distributed annually to each enrollee or enrollee’s family unit and whenever there is a change in the services provided or the location where they may be obtained. Except for a change which is unforeseeable, all enrollees affected by the change in service or the location of services shall be notified at least 14 days prior to such a change.
(Amended by Stats. 1979, Ch. 1061.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14407.

14407. Enrollment in a prepaid health plan shall be voluntary and a prepaid health plan shall not use false advertising or false statements to induce enrollment. No solicitation of enrollees shall include the granting or offering of any monetary or other valuable consideration for enrollment.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14407.1.

14407.1. (a) A contractor that has entered into a contract with the department under this chapter, or under another Medi-Cal managed care contracting authority, may offer nonmonetary incentives to promote good health practices by its existing Medi-Cal enrollees.
(b) No Medi-Cal managed care contractor may offer an incentive to promote good health practices by its Medi-Cal enrollees prior to written approval by the department. In the absence of other countervailing considerations, the department shall approve, to the extent permitted by federal law, the use by health plans of nonmonetary incentives to enhance health education program efforts to increase member participation, learning, and motivation to do any of the following:
(1) Effectively use managed health care services, including preventive and primary care services, obstetric care, and health education services.
(2) Modify personal health behaviors, achieving and maintaining healthy lifestyles and treatment therapies and positive health outcomes.
(3) Follow self-care regimens and treatment therapies for existing medical conditions, chronic diseases, or health conditions.
(c) If a contractor is a publicly operated entity, the offering of a department-approved, nonmonetary incentive to promote good health practices by enrollees shall not constitute a gift of public funds.
(d) Violations of this section shall be subject to the requirements and penalties set forth in Sections 14408 and 14409, and any regulations adopted by the department pursuant to this article.
(e) The department shall develop and publish written guidelines for the appropriate use of nonmonetary incentives that may be offered to Medi-Cal enrollees.
(Amended by Stats. 2008, Ch. 179, Sec. 248. Effective January 1, 2009.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14407.6.

14407.6. (a) Notwithstanding Section 14407.5, the department shall, to the extent permitted by federal law or under federal waivers which the department may obtain, establish a minimum enrollment period for Medi-Cal beneficiaries enrolling in managed care plans under any of the following:
(1) This chapter.
(2) Any of the following provisions of Chapter 7 (commencing with Section 14000):
(A) Article 2.7 (commencing with Section 14087.3).
(B) Article 2.9 (commencing with Section 14088).
(C) Article 2.91 (commencing with Section 14089).
(b) (1) Except as otherwise required by federal law, disenrollment during the minimum enrollment period shall only be for good cause.
(2) For purposes of this section, the meaning of “good cause” shall be as defined in subdivision (b) of Section 14407.8, and shall include “good cause” as defined by federal laws or regulations governing Medi-Cal managed care contracting.
(Added by Stats. 1991, Ch. 95, Sec. 12. Effective June 30, 1991.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14408.5.

14408.5. A prepaid health plan that contracts with Medi-Cal managed care or contracts with the Healthy Families Program may provide application assistance pursuant to Section 12693.325 of the Insurance Code during the eligibility redetermination process in order to allow persons to retain coverage.
(Added by Stats. 2000, Ch. 93, Sec. 97. Effective July 7, 2000.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14409.

14409. (a) No prepaid health plan, marketing representative, or marketing organization shall in any manner misrepresent itself, the plans it represents, or the Medi-Cal program. A violation of this section shall include, but is not limited to, all of the following:
(1) False or misleading claims that marketing representatives are employees or representatives of the state, county, or anyone other than the prepaid health plan or the organization by whom they are reimbursed.
(2) False or misleading claims that the prepaid health plan is recommended or endorsed by any state or county agency, or by any other organization which has not certified its endorsement in writing to the prepaid health plan.
(3) False or misleading claims that the state or county recommends that a Medi-Cal beneficiary enroll in a prepaid health plan.
(4) Claims that a Medi-Cal beneficiary will lose their benefits under the Medi-Cal program or any other health or welfare benefits to which they are legally entitled, if they do not enroll in a prepaid health plan.
(b) Violations of this article or regulations adopted by the department pursuant to this article shall result in one or more of the following sanctions that are appropriate to the specific violation, considering the nature of the offense and frequency of occurrence within the prepaid health plan:
(1) Revocation of one or more permitted methods of marketing.
(2) Termination of authorization for a plan to provide application assistance.
(3) Refusal of the department to accept new enrollments for a period specified by the department.
(4) Refusal of the department to accept enrollments submitted by a marketing representative or organization.
(5) Forfeiture by the plan of all or part of the capitation payments for persons enrolled as a result of such violations.
(6) Requirement that the prepaid health plan in violation of this article personally contact each enrollee enrolled to explain the nature of the violation and inform the enrollee of their right to disenroll.
(7) Application of sanctions as provided in Section 14197.7.
(8) Temporarily suspend capitation payments for beneficiaries enrolled in violation of this article, or regulations adopted thereunder, until the prepaid health plan is in substantial compliance with the statutory and regulatory requirements.
(c) Any marketing representative who violates subdivision (a) while engaged in door-to-door solicitation is guilty of a misdemeanor, and shall be subject to a fine of five hundred dollars ($500) or imprisonment in a county jail for six months, or both.
(Amended by Stats. 2019, Ch. 465, Sec. 9. (AB 1642) Effective January 1, 2020.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14410.

14410. No prepaid health plan or marketing representative shall adopt or utilize any procedure to identify prospective enrollees with medical or psychiatric problems in order to exclude them from enrollment in the prepaid health plan, other than medical conditions specifically excluded from coverage by the contract.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14411.

14411. (a) No prepaid health plan or marketing organization shall solicit prospective enrollees on county premises for benefits or services available pursuant to this chapter except under any one of the following conditions:
(1) Such marketing activities are performed by a county employee under an agreement between the county and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.
(2) Such marketing activities are performed by a state employee under an agreement between the department, county, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.
(3) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the county, the prepaid health plan and the department, and all marketing presentations and materials to be used have been approved by the department.
(b) No prepaid health plan or marketing organization shall solicit prospective enrollees on state premises for benefits or services available pursuant to this chapter, except under any one of the following conditions:
(1) Such marketing activities are performed by a state employee under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.
(2) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14412.

14412. (a) The enrollment of a Medi-Cal beneficiary in the prepaid health plan shall not be terminated except for loss of eligibility, for good cause as determined by the department, or at the request of the beneficiary.
(b) Enrollment shall be terminated at the request of the Medi-Cal beneficiary, to the extent required by federal law.
(c) Any Medi-Cal beneficiary enrolled in a prepaid health plan who would remain eligible for Medi-Cal program benefits for three additional months pursuant to Section 14005.8 shall remain enrolled in the prepaid health plan and shall not receive a Medi-Cal card unless disenrollment is requested by the beneficiary, and the request is submitted in accordance with state and federal law.
(d) It is the intent of the Legislature that the department shall develop such policies and procedures to maximize continuity of care for persons enrolled in prepaid health plans and to insure that the eligibility determination or redetermination process does not unnecessarily interfere with such enrollment or create gaps in the delivery of health services.
(Amended by Stats. 1983, Ch. 822, Sec. 1.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 4 - Enrollment and Disenrollment › Section 14413.

14413. (a) Requests for disenrollment shall be made to an authorized representative of the prepaid health plan or to the department. All requests for disenrollment, except those submitted pursuant to subdivision (c) of Section 14303.1, subdivision (c) of Section 14303.2, or paragraph (6) of subdivision (b) of Section 14409, or for other good cause as determined by the director, shall be processed through the prepaid health plan’s grievance procedure as approved by the department. Disenrollment requests received by the prepaid health plan shall be submitted to the department, on standard disenrollment forms prescribed by the department, within a reasonable time following the date of such signed request, as determined by the director, to permit the department to terminate enrollment effective the beginning of the first calendar month following a full calendar month after the request is made.
(b) All applications for disenrollment shall be processed by the department, and where Medi-Cal eligibility continues or Medi-Cal coverage is extended under Section 14005.8, a Medi-Cal card shall be issued effective not later than the beginning of the first calendar month following a full calendar month after the request for disenrollment is made. Submittal of a request for disenrollment for processing through the grievance procedure of a prepaid health plan shall not be deemed to infringe on this entitlement.
(Amended by Stats. 2020, Ch. 370, Sec. 287. (SB 1371) Effective January 1, 2021.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14450.5.

14450.5. (a) No contract between the department and a prepaid health plan that is contracting with, or that is governed, owned, or operated by, a county board of supervisors, shall be approved or renewed unless the standards set forth in Section 1374.16 of the Health and Safety Code are met. The treatment plan developed pursuant to Section 1374.16 of the Health and Safety Code shall be consistent with federal and state medicaid requirements. Nothing in Section 1374.16 of the Health and Safety Code is intended to alter or abrogate any other requirements of federal or state law with regard to medicaid.
(b) The requirements of this section shall apply to all managed care plan contracts entered into under any of the following:
(1) The act that added this subdivision.
(2) Any of the following provisions of Chapter 7 (commencing with Section 14000).
(A) Article 2.7 (commencing with Section 14087.3).
(B) Article 2.9 (commencing with Section 14088).
(C) Article 2.91 (commencing with Section 14089).
(3) Article 7 of Chapter 8 (commencing with Section 14490).
(Added by Stats. 1998, Ch. 31, Sec. 2. Effective January 1, 1999.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14451.

14451. Services under a prepaid health plan contract shall be provided in accordance with the requirements of the Knox-Keene Health Care Service Plan Act of 1975.
(Amended by Stats. 2014, Ch. 442, Sec. 39. (SB 1465) Effective September 18, 2014.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14451.5.

14451.5. (a) A prepaid health plan contractor may not enter into subcontracts when such an action would remove from the contractor his obligation to bear a significant portion of the risk encountered in providing the covered services.
(b) The prepaid health plan may obtain reinsurance for the cost of providing covered services. Such reinsurance shall not limit the contractor’s liability below five thousand dollars ($5,000) per enrollee for any one 12-month period, except that the contractor may also obtain reinsurance for the total cost of services provided to enrollees by noncontractor emergency service providers, and for 90 percent of all costs exceeding 115 percent of its income during any contractor fiscal year.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14452.

14452. (a) (1) All subcontracts shall be entered into pursuant to the requirements of the Knox-Keene Health Care Service Plan Act of 1975 and federal law. All subcontracts shall be in writing, a copy of which shall be transmitted to the department.
(2) Each subcontract shall contain the amount of compensation or other consideration that the subcontractor will receive under the terms of the subcontract with the prepaid health plans. These provisions shall not apply to a provider who is employed or salaried by the prepaid health plan. Unless the department objects, a prepaid health plan may enter into a subcontract in which consideration is determined by a percentage of the primary contractor’s payment from the department. This subdivision shall not be construed to prohibit any subcontract in which consideration is determined on a capitation basis.
(3) Subcontracts between a prepaid health plan and the subcontractor shall be public records on file with the department. The names of the officers and owners of the subcontractor, stockholders owning more than 10 percent of the stock issued by the subcontractor, and major creditors holding more than 5 percent of the debt of the subcontractor shall be submitted by each prepaid health plan to the department and shall be public records on file with the department.
(b) A prepaid health plan that is not a qualified health maintenance organization pursuant to Title XIII of the federal Public Health Service Act shall submit all provider and management subcontracts to the department for approval prior to the subcontract taking effect.
(c) Each subcontract shall require that the subcontractor make all of its books and records pertaining to the goods and services furnished under the terms of the subcontract available for inspection, examination, or copying by the department during normal working hours at the subcontractor’s place of business, or another mutually agreeable location in California.
(Amended by Stats. 2023, Ch. 266, Sec. 5. (AB 614) Effective January 1, 2024.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14452.3.

14452.3. Each prepaid health plan shall provide the services of an optometrist and ophthalmologist when the prepaid health plan contract requires the provision of vision care services.
Vision care services shall be provided so that an enrollee may be seen initially by either a physician or an optometrist.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14452.4.

14452.4. Where the prepaid health plan agrees to provide dental services such services shall be provided in a manner that does not require the enrollees to receive prior screening or authorization by nondental personnel.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14452.5.

14452.5. Each prepaid health plan shall provide the services of a psychologist and psychiatrist when the prepaid health plan contract requires the provision of mental health services. Mental health services shall be provided so that an enrollee may be seen initially by either a physician or a psychologist, or by psychiatric social workers under qualified supervision as otherwise allowed by law.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14452.6.

14452.6. Prepaid health plans, or their subcontractors, shall not bill any enrollee for covered benefits provided under this chapter and for which capitation has been paid, except as provided in Article 7 (commencing with Section 14490) of this chapter. Health care providers shall not seek reimbursement from enrollees for any services provided under this chapter.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14453.

14453. In compensating directors and officers, the prepaid health plan shall not compensate at a rate substantially greater than the prevailing charge for similar services in the community. For purposes of this chapter, salaries or other compensation from the prepaid health plan and its subcontractors, excluding reasonable expenses, shall be considered as one.
(Repealed and added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14455.

14455. The prepaid health plan shall maintain a complete unit medical record for each enrollee. Enrollee medical records shall also include records of all treatment received from subcontractors. Such records shall be maintained and preserved in a manner prescribed by the director and shall be available for review by the department and the United States Department of Health, Education, and Welfare.
(Repealed and added by Stats. 1977, Ch. 1036.)