California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 5 - APPLICATIONS, CONTRACTS AND PUBLIC HEARINGS › Section 53500 - Application Information

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each organization applying to establish a plan, and each plan applying to renew
					 its contract with the State,shall submit to the Department a package containing
					 the following information:
(1) A brief
					 history and general description of its organization.
(2) A description of its proposed or existing
					 administrative structure, including:
(A) The
					 functions and responsibilities of all principals, policymakers, administrator,
					 medical director and other executive officers.
(B) An organization chart and functional
					 description of each organizational unit.
(3) A list of all principals, policymakers,
					 executive officers, providers of health care services and other key personnel,
					 including the following information:
(A) Full
					 name.
(B) Business
					 address.
(C) Date and place of
					 birth.
(D) Internal Revenue Service
					 employer number, when applicable.
(E) License number, medical specialty and
					 Medi-Cal provider number, when applicable.
(4) Evidence of a current Knox-Keene license
					 or a license application with related correspondence or a license as a
					 nonprofit hospital service plan issued pursuant to Section
					 11493(e) and
					 Sections
					 11501 to
					 11505 of
					 the Insurance Code.
(5) Financial
					 information including:
(A) A detailed cash
					 flow budget, including all written assumptions, estimates and projections,
					 demonstrating the availability and sources of funds to meet the obligations
					 under the contract, for the prospective contract period. Supporting budgets for
					 such affiliates must be provided when the contractor relies upon affiliates to
					 provide services under the contract (see Section
					 53102 for the definition of
					 "affiliate").
(B) A projected
					 calculation of tangible net equity.
(C) Certified financial statements, presented
					 on a combined basis with all affiliates, as of the contractor's fiscal or
					 calendar year end. No additional disclosures are required when the contractor's
					 submission is within 90 days after the end of the contractor's fiscal year.
					 Unaudited financial statements to the most current quarter end shall also be
					 submitted if the contractor's submission occurs prior to or more than 90 days
					 after the close of the contractor's fiscal year. Unaudited statements shall be
					 prepared on a combined basis.
(D) A
					 listing of all subcontracts between the plan and affiliates.
(E) Proof of adequate professional liability
					 insurance coverage.
(6) A
					 description of the proposed or existing health care delivery system, including
					 information concerning the following:
(A) The
					 scope and availability of services to be provided under the proposed
					 contract.
(B) The ratios of
					 physicians to the prepaid patient population and primary care physicians to the
					 prepaid patient population.
(C)
					 Location and description of all service sites, hospitals, pharmacies,
					 laboratory and X-ray facilities and skilled nursing facilities, with
					 information about the service availability at each location.
(D) The availability of services in emergency
					 circumstances.
(E) The preventive
					 health care programs offered.
(F)
					 The medical record and medical record service system to be used by the
					 plan.
(G) A description of the
					 proposed or existing system to set standards for acceptable medical care,
					 evaluate the quality of care provided, including procedures for the
					 establishment and continuous professional review of the standards for
					 acceptable medical care, review of the performance of medical personnel and
					 review of the effectiveness of controls upon the utilization and costs of
					 services.
(7) A
					 delineation of the zip codes of the proposed or existing contract service area
					 and the location of the Medi-Cal beneficiary target population within the
					 service area.
(8) A description of
					 proposed marketing efforts, with realistic enrollment and marketing cost
					 projections, for both Medi-Cal and private target population
					 enrollment.
(9) Copies of all
					 proposed or existing subcontracts related to securing health care services,
					 administrative and management services or any other services necessary to
					 fulfill its contractual obligations, unless the Department already has a
					 current copy of the subcontract on file.
(10) A description of the proposed or
					 existing system for promptly reimbursing nonplan providers for emergency
					 services rendered to members.
(11)
					 Certification of willingness and ability to enroll members regardless of their
					 race, creed, color, religion, age, sex, national origin, sexual orientation,
					 marital status or ancestry; and without reference to preexisting medical
					 conditions other than those specifically excluded from coverage under the
					 contract.
(12) A description of the
					 proposed or existing procedures by which grievances submitted by members are to
					 be promptly processed and resolved.
(13) Any other information required by the
					 Department for proper evaluation of the application.