reglab/statecodes huggingface dataset:
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.75.4.6 - Department Costs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Department's costs incurred in the administration of
						Health and Safety Code Sections
						1347.15
						and
						1375.4
						shall come from amounts paid by plans, except specialized plans, pursuant to
						Health and Safety Code Section
						1356.
1. New
						section filed 3-22-2001 as an emergency; operative 3-22-2001 (Register 2001,
						No. 12). A Certificate of Compliance must be transmitted to OAL by 7-20-2001 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 3-22-2001 order transmitted
						to OAL 7-20-2001 and filed 8-31-2001 (Register 2001, No.
						35).
Note: Authority cited: Sections
						  1344
						  and
						  1375.4,
						  Health and Safety Code. Reference: Sections
						  1347.15,
						  1356
						  and
						  1375.4,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.75.4.7 - Organization Evaluation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every contract involving a risk arrangement between a
						plan and an organization or a sub-delegating organization and an organization
						shall:
(a) Require the organization to
					 comply with the Department of Managed Health Care's review and audit process,
					 in determining the organization's satisfaction of the Grading Criteria;
					 and
(b) Permit the Department to
					 perform any of the following activities in conjunction with the plan's
					 oversight process:
(1) Obtain and evaluate
					 supplemental financial information pertaining to the organization when:
(A) the organization fails to satisfactorily
					 demonstrate its compliance with the Grading Criteria;
(B) the organization experiences an event
					 that materially alters its ability to remain compliant with the Grading
					 Criteria;
(C) the external party's
					 review or audit process indicates that the organization may have insufficient
					 financial capacity to continue to accept financial risk for the delivery of
					 health care services consistent with the requirements of sections
					 1300.70(b)(2)(H)(1)
					 of Title 28, California Code of Regulations; or
(D) the Department receives information from
					 complaints submitted to the HMO Help Center, health plan reporting, medical
					 audits and surveys or any other source that indicates the organization may be
					 delaying referrals or authorizations or failing to meet access standards for
					 basic health care services based on financial
					 considerations.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.76 - Plan Tangible Net Equity Requirement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as provided in subsection (b),
					 each plan licensed pursuant to the provisions of the Act shall, at all times,
					 have and maintain a tangible net equity at least equal to the greater of:
(1) $1 million; or
(2) the sum of two percent (2%) of the first
					 $150 million of annualized premium revenues plus one percent (1%) of annualized
					 premium revenues in excess of $150 million; or
(3) an amount equal to the sum of:
(A) eight percent (8%) of the first $150
					 million of annualized health care expenditures except those paid on a capitated
					 basis or managed hospital payment basis; plus
(B) four percent (4%) of the annualized
					 health care expenditures, except those paid on a capitated basis or managed
					 hospital payment basis, which are in excess of $150 million; plus
(C) four percent (4%) of annualized hospital
					 expenditures paid on a managed hospital payment
					 basis.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.76.2 - Solicitor Firm Financial Requirement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each solicitor firm which handles funds
					 of plans, subscribers, or other persons contracting with plans, shall at all
					 times maintain a tangible net worth at least equal to 20 percent of such firm's
					 aggregate indebtedness or $10,000, whichever is greater, and shall maintain
					 liquid net assets of at least $5,000 in excess of it current
					 liabilities.
(b) A solicitor firm
					 which accepts only funds in the form of checks payable to plans, subscribers or
					 other persons contracting with plans and forwards such checks to the payee by
					 the close of the business day following receipt thereof does not "handle funds"
					 within the meaning of this section.
1.
						Editorial correction adding NOTE filed 12-8-82 (Register 82, No.
						50).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Section
						  1376,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.76.3 - Fidelity Bond

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 plan shall at all times maintain a fidelity bond covering each officer,
					 director, trustee, partner and employee of the plan, whether or not they are
					 compensated. The fidelity bond may be either a primary commercial blanket bond
					 or a blanket position bond written by an insurer licensed by the California
					 Insurance Director, and it shall provide for 30 days' notice to the Director
					 prior to cancellation. The fidelity bond shall provide at least the minimum
					 coverage for the plan determined by the following schedule:
Annual
Minimum
Gross
								  Income
Coverage
Up to $100,000
........................................................
..........................$10,000
100,000
to
$300,000
..........................
..........................20,000
300,000
to
500,000
..........................
..........................30,000
500,000
to
750,000
..........................
..........................50,000
750,000
to
1,000,000
..........................
..........................75,000
1,000,000
to
2,000,000
..........................
..........................100,000
2,000,000
to
4,000,000
..........................
..........................200,000
4,000,000
to
6,000,000
..........................
..........................400,000
6,000,000
to
10,000,000
..........................
..........................600,000
10,000,000
to
20,000,000
..........................
..........................1,000,000
20,000,000
and
								over..........................................
..........................2,000,000
(b) The fidelity bond required pursuant to
					 subsection (a) may contain a provision for a deductible amount from any loss
					 which, except for such deductible provision, would be recoverable from the
					 insurer. A deductible provision shall not be in excess of 10 percent of the
					 required minimum bond coverage, but in no event shall the deductible amount be
					 in excess of $100,000.
1.
						Editorial correction adding NOTE filed 12-8-82 (Register 82, No.
						50).
2. Change without regulatory effect amending subsection (a)
						filed 7-18-2000 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Section
						  1376,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.76.4 - Prohibited Financial Practices

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No solicitor shall maintain, and no plan
					 or solicitor firm shall permit a solicitor in its employ to maintain, an
					 account with a financial institution for funds of the plan, solicitor firm,
					 subscribers or group representatives, except an account which is in the name of
					 and under the control of the plan or solicitor firm.
(b) No solicitor shall receive funds on
					 behalf of a plan or solicitor firm, and no plan or solicitor firm shall permit
					 a solicitor in its employ to receive funds on behalf of the plan or solicitor
					 firm, but this section shall not prohibit a solicitor from receiving only funds
					 in the form of checks payable to the plan or solicitor firm if such solicitor
					 deposits such checks to an account of the plan or solicitor firm by the close
					 of the business day following receipt thereof or forwards such checks to the
					 plan or solicitor firm by the close of the business day following receipt
					 thereof.
1. New
						section filed 11-9-77 as an emergency; effective upon filing (Register 77, No.
						46).
2. Certificate of Compliance filed 2-6-78 (Register 78, No.
						6).
3. Amendment filed 12-8-82; effective thirtieth day thereafter
						(Register 82, No. 50).
4. Amendment of NOTE filed 1-12-83; effective
						thirtieth day thereafter (Register 83, No. 3).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Section
						  1376,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.77.1 - Estimated Liability for Reimbursements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A plan subject to subdivision (b) of Section
						1377 shall estimate its liability
						for incurred and unreported claims and record such estimate as an accrual in
						its books and records at least monthly.
1.
						Amendment filed 12-8-82; effective thirtieth day thereafter (Register 82, No.
						50).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Sections
						  1375.1,
						  1376
						  and
						  1377,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.77.3 - Report on Reimbursements Exceeding Ten Percent

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every plan which reimburses providers of
					 health care services or subscribers and enrollees in the manner described in
					 subdivision (a) or (b) of Section
					 1377 of the Act shall make and
					 maintain as part of its records a computation for each calendar month and
					 calendar quarter of reimbursements made, classified as provided in Section
					 1377, and showing the percentage
					 of each class of reimbursements made to total expenditures for health care
					 services during such month or quarter.
(b) When a report is required by subdivision
					 (a) of Section
					 1377 of the Act, such report shall
					 be filed with the Director no later than 30 business days after the close of
					 the calendar quarter.
(c) When a
					 report is required by subdivision (b) of Section
					 1377 of the Act, such report shall
					 be filed with the Director no later than 30 business days after the close of
					 the calendar month during which actual reimbursements made, or the amount
					 estimated for incurred and unreported claims, exceeds 10 percent of its total
					 expenditures for health care services.
1.
						Editorial correction adding NOTE filed 12-8-82 (Register 82, No.
						50).
2. Change without regulatory effect amending subsections (b)
						and (c) filed 7-18-2000 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Section
						  1377,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.77.4 - Reimbursements on a Fee-for-Services Basis: Determination of Status of Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every plan shall institute procedures whereby all claim
						forms received by the plan from providers of health care services for
						reimbursement on a fee-for-service basis and from subscribers and enrollees for
						reimbursement are maintained and accounted for in a manner which permits the
						determination of the date of receipt of any claim, the status of any claim, the
						dollar amount of unpaid claims at any time, and rapid retrieval of any claim.
						Although any categories for status-determination held unobjectionable by the
						Director may be used, for the purposes of this section, the following
						status-determination categories, as a group, shall be presumptively
						reasonable:
(1) to be
					 processed,
(2) processed, waiting
					 for payment,
(3) pending, waiting
					 for approval for payment or denial,
(4) pending, waiting for additional
					 information,
(5) denied,
(6) paid, and, if appropriate,
(7) other. These procedures shall involve the
					 use of either a claims log, claims numbering system, electronic data processing
					 records, and/or any other method held unobjectionable by the
					 Director.
1. New
						section filed 3-3-83; effective thirtieth day thereafter (Register 83, No.
						10).
2. Change without regulatory effect amending first paragraph
						and subsection (7) filed 7-18-2000 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						  1344,
						  Health and Safety Code. Reference: Sections
						  1375.1,
						  1376
						  and
						  1377,
						  Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.78 - Administrative Costs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 For the purposes of Section
					 1378 of the Act, "administrative
					 costs" include only those costs which arise out of the operation of the plan as
					 such, excluding direct and overhead costs incurred in the furnishing of health
					 care services which would be ordinarily incurred in the provision of such
					 services whether or not through a plan. Administrative costs include the
					 following:
(1) Salaries, bonuses and benefits
					 paid or incurred with respect to the officers, directors, partners, trustees or
					 other principal management of the Plan, less to the extent that such persons
					 also are providers of health care services, the minimum reasonable cost of
					 obtaining such services from others.
(2) The cost of soliciting and enrolling
					 subscribers and enrollees, including the solicitation of group contracts, and
					 including any indirect costs of enrollment borne on behalf of the plan by the
					 holder of a group contract.
(3) The
					 cost of receiving, processing and paying claims of providers of health care
					 services and of claims for reimbursement by subscribers and enrollees,
					 excluding the actual amount paid on such claims.
(4) Legal and accounting fees and
					 expenses.
(5) The premium on the
					 fidelity and surety bonds, and any insurance maintained pursuant to Section
					 1377, and any insurance or other
					 expense incurred for the purposes of complying with Section
					 1375 of the Act. Malpractice
					 insurance is not included within this subsection.
(6) All costs associated with the
					 establishment and maintenance of agreements with providers of health care
					 services, excluding the cost of reviewing quality and utilization of such
					 services, and the cost of reviewing utilization of health care services on a
					 referral basis.
(7) The direct or
					 pro rata portion of all expenses incurred in the operation of the plan which
					 are not essential to the actual provision of health care services to
					 subscribers and enrollees, including but not limited to office supplies and
					 equipment, clerical services, interest expense, insurance, dues and
					 subscriptions, licenses (other than licenses for medical facilities, equipment
					 or personnel), utilities, telephone, travel, rent, repairs and maintenance,
					 depreciation of facilities and equipment, and charitable or other
					 contributions.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 10 - Medical Surveys › Section 1300.80 - Medical Survey Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Unless the Director in his discretion
				  determines that advance notice will render the survey less useful, a plan will
				  be notified approximately four weeks in advance of the date for commencement of
				  an onsite medical survey. The Director may, without prior notice, conduct
				  inspections of plan facilities or other elements of a medical survey, either in
				  conjunction with the medical survey or as part of an unannounced inspection
				  program.
(b) The onsite medical
				  survey of a plan shall include, but not be limited to, the following procedures
				  to the extent considered necessary based upon prior experience with the plan
				  and in accordance with the procedures and standards developed by the
				  Department.
(1) Review of the procedures for
				  obtaining health services including, but not limited to, the scope of basic
				  health care services.
(A) The availability and
				  adequacy of facilities for telephone communication with health personnel,
				  emergency care facilities, out-of-the-area coverage, referral procedures, and
				  medical encounters.
(B) The means
				  of advising enrollees of the procedures to obtain care, including the hours of
				  operation, location and nature of facilities, types of care, telephone and
				  other arrangements for appointment setting.
(C) The availability of qualified personnel
				  at each facility referred to in Section
				  1368(b) to
				  receive and handle inquiries concerning care, plan contracts, and
				  grievances.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 10 - Medical Surveys › Section 1300.80.10 - Medical Survey: Report of Correction of Deficiencies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prior to or immediately upon the expiration of the 45-day
					 period following notice to a plan of a deficiency as provided in subdivision
					 (h) of Section
					 1380 of the Act, the plan shall
					 file a written statement with the Director identifying the deficiency and
					 describing the action taken to correct the deficiency and the results of such
					 action. The report shall be signed by a principal officer of the plan.
Where such deficiencies may be reasonably adjudged to
					 require long-term corrective action or to be of a nature which may be
					 reasonably expected to require a period longer than 45 days to remedy, in some
					 instances evidence that the plan has initiated remedial action and is on the
					 way to achieving acceptable levels of compliance may be
					 submitted.
1. Amendment
					 filed 12-8-8; effective thirtieth day thereafter (Register 82, No.
					 50).
2. Change without regulatory effect amending section filed
					 7-18-2000 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
3. Amendment filed 5-7-2014;
					 operative 7-1-2014 (Register 2014, No. 19).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1380,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 11 - Examinations › Section 1300.81 - Removal of Books and Records from State

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The books and records of a plan, management company,
					 solicitor firm, and any provider or subcontractor providing health care or
					 other services to a plan, management company, or solicitor firm shall not be
					 removed from this state without the prior consent of the
					 Director.
1. Amendment
					 filed 12-8-82; effective thirtieth day thereafter (Register 82, No.
					 50).
2. Change without regulatory effect amending section filed
					 7-18-2000 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1381,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 11 - Examinations › Section 1300.82 - Examination Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Regular and additional or nonroutine examinations conducted
					 by the Department pursuant to Section
					 1382 will ordinarily be commenced
					 on an unannounced basis. To the extent feasible, deficiencies noted will be
					 called to the attention of the responsible officers of the company under
					 examination during the course of the examination, and in that event the company
					 should take the corrective action indicated. When deemed appropriate, the
					 company will be advised by letter of the deficiencies noted upon the
					 examination. If the deficiency letter requires a report from the company, such
					 report must be furnished within 15 days or such additional time as may be
					 allowed.
1. Amendment
					 filed 12-8-82; effective thirtieth day thereafter (Register 82, No.
					 50).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1382,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 11 - Examinations › Section 1300.82.1 - Additional or Nonroutine Examinations and Surveys

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An examination or survey is additional or
				  nonroutine for good cause for the purposes of Section
				  1382(b) when the
				  reason for such examination or survey is any of the following:
(1) The plan's noncompliance with written
				  instructions from the Department;
(2) The plan has violated, or the Director
				  has reason to believe that the plan has violated, any of the provisions of
				  Sections 1352,
				  1370,
				  1371,
				  1371.35,
				  1371.37,
				  1375.1,
				  1376,
				  1384 and
				  1385 of the Act and Sections
				  1300.71,
				  1300.71.38,
				  1300.76,
				  1300.80.10,
				  1300.81,
				  1300.82(a),
				  1300.84.2 and
				  1300.84.3 of these
				  regulations.
(3) The plan has
				  committed, or the Director has reason to believe that the plan has committed,
				  any of the acts or omissions enumerated in Section
				  1386 of the Act.
(4) The Director deems such additional or
				  nonroutine examination or survey necessary to verify representations made to
				  this Department by a plan in response to a deficiency
				  letter.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.83 - Annual Report. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 5-9-80; effective thirtieth day thereafter (Register 80, No.
					 19).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Stats. 1979, Ch.
						1083.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84 - Financial Statements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Whenever pursuant to these rules or
				  pursuant to an order or request of the Director pursuant to the Act a financial
				  statement or other report is required to be audited or be accompanied by the
				  opinion of a certified public accountant or public accountant, such accountant
				  shall be independent of the licensee, determined in accordance with section
				  602.02 of Financial Reporting
				  Release Number 1 issued by the Securities and Exchange Commission.
(b) The financial statements required under
				  subsections (a), (b) and (c) of Section
				  1384 of the Act shall be audited
				  by an independent accountant in accordance with section
				  1300.45(e).
(c) Except as provided in subsection (d),
				  financial statements of a plan required pursuant to these rules must be on a
				  combining basis with an affiliate, if the plan or such affiliate is
				  substantially dependent upon the other for the provision of health care,
				  management or other services. An affiliate will normally be required to be
				  combined, regardless of its form of organization, if the following conditions
				  exist:
(1) The affiliate controls, is
				  controlled by, or is under common control with, the plan, either directly or
				  indirectly (see subsections (c) and (d) of section
				  1300.45), and
(2) The plan or the affiliate is
				  substantially dependent, either directly or indirectly, upon the other for
				  services or revenue.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.03 - Required Notice to the Department

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall maintain internal
				  procedures that provide one or more of its principal officers on at least a
				  monthly basis with the information necessary for the reports required pursuant
				  to Rule 1300.84.3.
(b)
(1) Each plan shall notify the Department if,
				  based on a review of its financial and business records, it determines that
				  currently or within 30 business days the plan will:
(A) Be unable to meet its obligations as they
				  become due; or
(B) Have tangible
				  net equity below the amount required by subdivisions (a) or (b) of Rule
				  1300.76, as applicable.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.05 - Change of Independent Accountant

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Whenever the financial statements required pursuant to
					 subdivisions (a), (b) or (c) of Section
					 1384 are to be reported upon or
					 certified by an accountant other than the accountant certifying the plan's most
					 recent filing, the plan must furnish the Director with a separate letter
					 stating whether in the eighteen (18) months preceding the engagement of the new
					 accountants there was any disagreement with the former accountants on any
					 matter of accounting principles or practices, financial statement disclosure or
					 auditing procedures, which such disagreement if not resolved to the
					 satisfaction of the former accountants would have caused him to make reference
					 to the subject matter of such disagreement in his opinion or report. This
					 letter must be verified by a principal officer of the plan. The plan shall also
					 request the former accountants to furnish them with a letter addressed to the
					 Director stating whether he agrees with the statements contained in the letter
					 of the plan and, if not, stating the respects in which he does not agree. The
					 notification by the plan along with the former accountant's letter, if
					 necessary, must be furnished to the Director within 45 days of the engagement
					 of the new accountants.
1. New
					 section filed 6-2-78; effective thirtieth day thereafter (Register 78, No.
					 22).
2. Change without regulatory effect amending section filed
					 7-14-99 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 99, No. 29).
3. Change without regulatory
					 effect amending section filed 7-18-2000 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1345
						and
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.06 - Plan Annual Report. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 5-9-80; effective thirtieth day thereafter (Register 80, No.
					 19).
2. Amendment filed 7-21-86; effective thirtieth day thereafter
					 (Register 86, No. 30).
3. Amendment filed 12-14-90; operative
					 12-31-90 (Register 91, No. 6).
4. Repealer and new subsection (a)
					 filed 12-9-2015; operative 4-1-2016 (Register 2015, No. 50).
5.
					 Renumbering of former section
					 1300.84.06 to section
					 1300.84.1 filed 5-18-2022;
					 operative 7-1-2022 (Register 2022, No. 20).
Note: Authority cited: Sections
						1344
						and
						1384,
						Health and Safety Code. Reference: Section
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.1 - Plan Annual Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Each plan shall submit the "Annual DMHC Financial Reporting Form," hereinafter
				  "Annual Report," (Form No. 10-072) dated July 1, 2022, as incorporated herein
				  by reference, and published by the Department on its website: www.dmhc.ca.gov,
				  within 120 days after the close of the fiscal year, or as otherwise required by
				  Health and Safety Code section
				  1384.
(b) The Annual Report shall be submitted to
				  the Department in the manner described in the "Annual, Quarterly, and Monthly
				  Financial Reporting Forms Instruction Manual," hereinafter "Annual, Quarterly,
				  and Monthly Financial Reporting Forms Instruction Manual," dated July 1, 2022,
				  as incorporated herein by reference, and published by the Department on its
				  website: www.dmhc.ca.gov.
(c) The
				  Annual Report shall be considered the plan's annual financial statement report
				  for purposes of Health and Safety Code section
				  1384
				  and shall include all the requested information prescribed in both the Annual
				  Report and the Annual, Quarterly, and Monthly Financial Reporting Forms
				  Instruction Manual. The information provided by the plan in the Annual Report
				  shall cover the applicable time period specified in the Annual, Quarterly, and
				  Monthly Financial Reporting Forms Instruction Manual.
1.
					 Renumbering of former section
					 1300.84.06 to section
					 1300.84.1 filed 5-18-2022;
					 operative 7-1-2022 (Register 2022, No. 20). For prior history of section
					 1300.84.1, see Register 86, No.
					 30.
Note: Authority cited: Sections
						1344,
						1348.95
						and
						1384,
						Health and Safety Code. Reference: Sections
						1348.95
						and
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.2 - Quarterly Financial Reports

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall submit the "Quarterly
				  DMHC Financial Reporting Form", hereinafter "Quarterly Report" (Form No.
				  10-071), dated July 1, 2022, as incorporated herein by reference, and published
				  by the Department on its website: www.dmhc.ca.gov, within 45 days after the
				  close of each quarter of its fiscal year.
(b) The Quarterly Report shall include all of
				  the requested information prescribed in both the Quarterly Report and the
				  Annual, Quarterly, and Monthly Financial Reporting Forms Instruction Manual, as
				  incorporated by reference in Rule 1300.84.1.
(c) The Quarterly Report shall be submitted
				  to the Department in the manner described in, and shall cover the applicable
				  time period specified in, the Annual, Quarterly, and Monthly Financial
				  Reporting Forms Instruction Manual, as incorporated by reference in Rule
				  1300.84.1.
1. Amendment
					 filed 5-9-80; effective thirtieth day thereafter (Register 80, No.
					 19).
2. Amendment filed 7-21-86; effective thirtieth day thereafter
					 (Register 86, No. 30).
3. Change without regulatory effect amending
					 first paragraph and subsection (a) filed 7-18-2000 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
4. Amendment of subsection (a)
					 filed 12-9-2015; operative 4-1-2016 (Register 2015, No. 50).
5.
					 Repealer and new section and amendment of NOTE filed 5-18-2022; operative
					 7-1-2022 (Register 2022, No. 20).
Note: Authority cited: Sections
						1344,
						1348.95
						and
						1384,
						Health and Safety Code. Reference: Sections
						1348.95
						and
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.3 - Monthly Financial Reports

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan that has not been licensed by
				  the Department and operated as a health care service plan for twelve (12)
				  consecutive calendar months shall file with the Department the "Monthly DMHC
				  Financial Reporting Form," hereinafter "Monthly Report" (Form No. 10-070),
				  dated July 1, 2022, as incorporated herein by reference, and published by the
				  Department on its website: www.dmhc.ca.gov, within 30 calendar days after the
				  last day of the month.
(b) Each
				  plan shall file the Monthly Report with the Department within 30 calendar days
				  after the last day of any month during which its:
(1) Tangible net equity, individually or on a
				  combined basis with affiliates, is less than 150%, or less than 130% for a
				  point-of-service contract, of the minimum tangible net equity required by
				  subdivisions (a) or (b) of Rule 1300.76, as applicable; or
(2) Report # 2 within the Monthly Report,
				  individually or on a combined basis with affiliates, reflects a loss for the
				  month the amount of which exceeds the difference between the tangible net
				  equity of the plan (or the combined entity) as of the end of such month and the
				  minimum net equity required by subdivisions (a) or (b) of Rule 1300.76, as
				  applicable.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.4 - Financial Reports by Solicitor Firms. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Amendment
					 filed 1-12-83; effective thirtieth day thereafter (Register 83, No.
					 3).
2. Repealer filed 7-3-84; effective thirtieth day thereafter
					 (Register 84, No. 27).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.6 - Plan Annual Enrollee Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On or before May 15th of each year, each
				  licensed plan shall file a report in the following form and containing the
				  information specified therein:
State of California
Dept. of Managed
							 Care
Department of Managed Care
File
							 Number___________________________
REPORT OF ENROLLMENT IN PLAN
Knox-Keene Health Care Service Plan Act
___________________________
1. Name of Plan:
___________________________
2. Name, mailing address, and telephone
				  number of Plan official to whom communications concerning this report should be
				  addressed:
( )
Name
Phone No.--Include
							 area code
___________________________
Mailing Address
___________________________
City, State and ZIP Code
3. For the purposes of Section
				  1356(b) of the
				  Knox-Keene Health Care Service Plan Act, the Plan reports that, as of March 31
				  of the year in which this report is made, its records reflected the following
				  enrollments, in accordance with the definitions contained in Section
				  1345,
				  Health and Safety Code:
Number of subscribers___________________________
Number of enrollees___________________________
(Note: As required by Section
					 1356(b), if the
					 number of enrollees is estimated, the method used for determining the estimated
					 enrollment must be disclosed.)
4. Execution: I certify under penalty of
				  perjury that the above statement is true.
Executed at________________________________________(City
					 and State) on ____________________(Date)
___________________________
Signature
___________________________
Print or Type Name of Declarant
___________________________
Position with Plan
___________________________
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 12 - Reports › Section 1300.84.7 - Special Reports Relating to Charitable or Public Activities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any plan whose
				  purposes involve any charitable or public purposes shall provide a special
				  report to the Director upon filing with the Attorney General any notice,
				  request, or other materials pursuant to any law administered by the Attorney
				  General and relating to matters which will or may have any financial effect on
				  or implications for the plan. Such special report shall include the information
				  provided to the Attorney General together with representations as to whether
				  the transactions, actions, or other facts set forth in the materials submitted
				  to the Attorney General will or may have any deleterious effect on the
				  financial condition of the plan.
(b) Any plan whose purposes involved any
				  charitable or public purposes shall provide a special report to the Director
				  upon engaging in any transaction to which the corporation is a party and in
				  which one or more of its directors has a material financial interest, if such
				  transaction will or may have any material financial effect on or implications
				  for the plan. Such special report shall specifically describe the transaction
				  and shall contain representations as to whether the transaction will or may
				  have any deleterious effect on the financial condition or operations of the
				  plan.
(c) Any filing pursuant to
				  this section may be combined with any appropriate filings pursuant to Article
				  2, Part 11, Division 2, Title 1 of the Corporations Code and may utilize common
				  exhibits, subject to the provisions of Section
				  1300.824(c).
1. New
					 section filed 4-16-82; effective thirtieth day thereafter (Register 82, No.
					 16).
2. Change without regulatory effect amending subsections (a)
					 and (b) filed 7-18-2000 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						1344,
						Health and Safety Code, Reference: Section
						1384,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 13 - Books and Records › Section 1300.85 - Books and Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Each plan, solicitor firm, and solicitor shall keep and maintain their books of
				  account and other records on a current basis.
(b) Each plan shall make or cause to be made
				  and retain books and records which accurately reflect:
(1) The names and last known addresses of all
				  subscribers to the plan.
(2) All
				  contracts required to be submitted to the Department and all other contracts
				  entered into by the plan.
(3) All
				  requests made to the plan for payment of moneys for health care services, the
				  date of such requests, and the dispositions thereof.
(4) A current list of the names and addresses
				  of all individuals employed by it as a solicitor.
(5) A current list of the names and addresses
				  of all solicitor firms with which it contracts.
(6) A current list of the names and addresses
				  of all of the plan's officers, directors, principle shareholders, general
				  managers, and other principle persons.
(7) The amount of any commissions paid to
				  persons who obtain members for plans and the manner in which said commissions
				  are determined.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 13 - Books and Records › Section 1300.85.1 - Retention of Books and Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every plan and solicitor firm shall preserve for a period
					 of not less than five years, the last two years of which shall be in an easily
					 accessible place at the offices of the plan or solicitor firm, the books of
					 account and other records required under the provisions of, and for the purpose
					 of the Act. After such books and records have been preserved for two years,
					 they may be warehoused or stored, or microfilmed, subject to their availability
					 to the Director within not more than 5 days after request
					 therefore.
1. Change
					 without regulatory effect amending section and adding NOTE filed 7-18-2000
					 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1385,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 14 - Miscellaneous Provisions › Section 1300.86 - Assessment of Administrative Penalties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) When assessing administrative penalties
				  against a health plan the Director shall determine the appropriate amount of
				  the penalty for each violation of the Act based upon one or more of the factors
				  set forth in subsection (b).
(b)
				  The factors referred to in subsection (a) include, but are not limited to the
				  following:
(1) The nature, scope, and gravity
				  of the violation;
(2) The good or
				  bad faith of the plan;
(3) The
				  plan's history of violations;
(4)
				  The willfulness of the violation;
(5) The nature and extent to which the plan
				  cooperated with the Department's investigation;
(6) The nature and extent to which the plan
				  aggravated or mitigated any injury or damage caused by the violation;
(7) The nature and extent to which the plan
				  has taken corrective action to ensure the violation will not recur;
(8) The financial status of the
				  plan;
(9) The financial cost of the
				  health care service that was denied, delayed, or modified;
(10) Whether the violation is an isolated
				  incident; and/or
(11) The amount of
				  the penalty necessary to deter similar violations in the
				  future.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 14 - Miscellaneous Provisions › Section 1300.87 - Civil Penalties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For purposes of section
					 1387
					 of the Health and Safety Code:
(a) A
				  violation that is ongoing and continuous is subject to a civil penalty not to
				  exceed two thousand five hundred dollars ($2,500) for each day that the
				  violation continues.
(b) Each
				  enrollee harmed by a violation of the Act constitutes a separate and distinct
				  violation subject to a civil penalty not to exceed two thousand five hundred
				  dollars ($2,500).
1. New
					 section filed 9-18-2003; operative 9-18-2003 pursuant to Government Code
					 section
					 11343.4
					 (Register 2003, No. 38).
Note: Authority cited: Sections
						1344
						and
						1387,
						Health and Safety Code. Reference: Section
						1387,
						Health and Safety Code; and Section
						11425.50,
						Government Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 14 - Miscellaneous Provisions › Section 1300.89.21 - Rescissions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Definitions
(1) Rescission or rescind means a
				  cancellation of coverage for fraud or intentional misrepresentation of material
				  fact that has a retroactive effect. A cancellation of coverage with only a
				  prospective effect is not a rescission.
(2) "Effective date of the rescission" in
				  section
				  1389.21
				  subdivision (b) of the Health and Safety Code means the date on which the plan
				  retroactively cancels coverage based on fraud or intentional misrepresentation
				  of material fact.