reglab/statecodes huggingface dataset:
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 3 - OPERATIONAL REQUIREMENTS › Section 53214 - Pharmaceutical Services and Prescribed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall provide, either directly
					 or through subcontracts, the services of pharmacies and pharmacists. Such
					 pharmaceutical services shall be available to members during reasonable hours
					 as specified in the contract.
(b)
					 Prescribed drugs shall be provided to members in accordance with all applicable
					 laws and regulations.
(c)
					 Pharmaceutical services shall include as a minimum the following functions:
(1) Supervising the efficient distribution of
					 drugs.
(2) Providing pharmaceutical
					 consultative services when appropriate, which are:
(A) Consultation with members concerning drug
					 therapy in which the pharmacist asks the member if he is currently taking any
					 drugs, and informs him on what is being taken, how to take it, what to expect,
					 what special precautions should be observed and how the medication is to be
					 properly stored. The purpose of this consultation is to assure that the member
					 understands the proper use of the drug and that the prescriber's intentions
					 will materialize in a drug regimen of optimal effectiveness, safety and
					 duration.
(B) Professional
					 consultation with prescribers, or other members of the health care team, in
					 which the pharmacist discusses drug effects, dosage regimens, interactions,
					 side effects, toxicities, antidotes, drugs of choice for disease conditions and
					 in all other ways acts as the drug information specialist to the health care
					 team.
(3) Participating
					 in in-service training programs for plan staff to provide current information
					 about pharmaceuticals and their proper use in member treatment.
(4) Participating in drug utilization review.
					 This shall include a review of:
(A) Member
					 medical records to determine the range and types of drugs taken by members,
					 and
(B) Drug utilization patterns
					 of the plan in general.
(5) Participating in professional review
					 activities relating to the use of pharmaceuticals.
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 3 - OPERATIONAL REQUIREMENTS › Section 53216 - Care Under Emergency Circumstances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall provide, directly or by
					 subcontract, at least one physician and a nurse on duty 24 hours a day, 7 days
					 a week, at each location designated as a location where members can obtain
					 medical services in the event of emergency circumstances, as defined in Section
					 51056.
(b) Written procedures shall be developed and
					 applied by the plan regarding care under emergency circumstances provided by
					 nonplan providers in and outside the service area. These procedures shall
					 include but not be limited to the following:
(1) Verification of membership.
(2) Transfer of the medical management of the
					 member to a plan provider.
(3)
					 Payment within 60 days of receipt of properly documented bills for the services
					 rendered to the member. Bills for services rendered to the member shall be
					 submitted not later than the second month following the month of service,
					 except for good cause.
(4) Written
					 notice of action within 60 days of receipt of bills which are denied or reduced
					 for any reason by the plan. The notice shall include a statement, subject to
					 prior approval by the Department, of the provider's right to:
(A) Dispute the plan's rejection or reduction
					 of the bill.
(B) Submit the dispute
					 to the Department pursuant to Article 7.
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 3 - OPERATIONAL REQUIREMENTS › Section 53218 - Preventive Health Care Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50). For prior history, see Register 78, No. 27.
2. Repealer filed
						12-30-81; effective thirtieth day thereafter (Register 82, No.
						1).
Note: Authority cited: Sections
						  14132
						  and
						  14308,
						  Welfare and Institutions Code. Reference: Sections
						  14304.5
						  and
						  14308,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53220 - Member Billing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 prepaid health plan, affiliate, vendor, subcontractor or sub-subcontractor
					 shall not submit a claim to, demand or otherwise collect reimbursement from, a
					 member or persons acting on behalf of a member for any services provided under
					 this Chapter except to collect:
(1)
					 Third-party payment in accordance with Section
					 53222(a).
(2) Payment for services provided pursuant to
					 Section 53210(d).
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 3 - OPERATIONAL REQUIREMENTS › Section 53222 - Recovery from Other Sources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Plans may recover and retain the cost of
					 covered services rendered to a member under the terms of this Chapter, to the
					 extent that such member is covered for such services, under any other state or
					 federal medical care program or under other contractual or legal entitlement,
					 including but not limited to, a private group or individual indemnification
					 program.
(b) Plans shall not
					 attempt recovery in circumstances involving casualty insurance, tort liability
					 or worker's compensation. Circumstances which may result in casualty insurance
					 payments, tort liability payments, or workers' compensation awards shall be
					 reported to the Department within ten days after discovery by the
					 plan.
1. New
						section filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50).
2. Amendment of subsection (b) filed 9-22-82; effective
						thirtieth day thereafter (Register 82, No. 39).
Note: Authority cited: Section
						  14124.71,
						  Welfare and Institutions Code. Reference: Section
						  14452.6,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53230 - Facilities, Service Locations and Equipment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall have available within the
					 service area sufficient facilities, service sites and service locations to meet
					 its contractual obligations.
(b)
					 Each facility shall meet the following requirements:
(1) Licensing, and accreditation where
					 applicable, by the appropriate agencies.
(2) Continued compliance with licensing
					 standards.
(3) Compliance with all
					 applicable local, state and federal standards including those for fire and
					 safety.
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 3 - OPERATIONAL REQUIREMENTS › Section 53240 - Personnel Resources. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment of subsections (b), (f) and new subsection (g) filed 7-5-78;
						effective thirtieth day thereafter (Register 78, No. 27).
2.
						Repealer filed 12-30-81; effective thirtieth day thereafter (Register 82, No.
						1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14450,
						  14456,
						  and
						  14460,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53242 - Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider of
					 services employed by or under subcontract to a plan shall meet those standards
					 for participation as a provider of health care services under the Medi-Cal
					 program set forth in this subdivision in Chapter 3, Article 3, beginning with
					 Section 51200.
(b) The Department may require that a plan
					 identify all:
(1) Physicians, by
					 specialty.
(2) Providers furnishing
					 any services, by type of service provided.
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 3 - OPERATIONAL REQUIREMENTS › Section 53244 - Allied Health Personnel. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						subsection (d) filed 7-5-78; effective thirtieth day thereafter (Register 78,
						No. 27).
2. Repealer filed 12-30-81; effective thirtieth day
						thereafter (Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14450
						  and
						  14456,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53246 - Medical Director

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall appoint a physician as medical director. His responsibilities
					 shall include, but not be limited to:
(1)
					 Ensuring that medical decisions are rendered by qualified medical personnel,
					 unhindered by fiscal or administrative management.
(2) Ensuring that the medical care provided
					 meets the standards for acceptable medical care.
(3) Ensuring that medical protocols and rules
					 of conduct for plan medical personnel are followed.
(4) Developing and implementing medical
					 policy.
(5) Resolving medically
					 related grievances. The medical director shall refer nonmedical grievances, and
					 other grievances which he determines may be appropriately resolved through the
					 grievance procedure, to the grievance coordinator.
(6) Actively participating in the functioning
					 of the plan grievance procedures.
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 3 - OPERATIONAL REQUIREMENTS › Section 53250 - Subcontracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider or
					 management subcontract entered into by a plan which is not a qualified HMO
					 shall become effective upon approval by the Department in writing, or by
					 operation of law where the Department has acknowledged receipt of the proposed
					 subcontract and has failed to approve or disapprove the proposed subcontract
					 within 60 days of receipt. Subcontract amendments shall be submitted to the
					 Department, for prior approval, at least 30 days before the effective date of
					 any proposed changes governing compensation, services or term. Proposed
					 changes, which are neither approved nor disapproved by the Department, shall
					 become effective by operation of law 30 days after the Department has
					 acknowledged receipt, or upon the date specified in the subcontract amendment,
					 whichever is later.
(b) A
					 subcontractor providing any basic health care service to members shall meet all
					 of the requirements of Chapters 3 and 4 of this subdivision, related to the
					 services the subcontractor is required to perform.
(c) Each subcontract submitted for Department
					 approval pursuant to subsection (a), above, shall contain at least the elements
					 required by subsection (e) and the following:
(1) Specification of the services to be
					 provided.
(2) Specification that
					 the subcontract shall be governed by and construed in accordance with all laws,
					 regulations and contractual obligations incumbent upon the plan.
(3) Specification that the subcontract or
					 subcontract amendments shall become effective only as set forth in subsection
					 (a).
(4) Specification of the term
					 of the subcontract, including the beginning and ending dates, as well as
					 methods of extension, renegotiation and termination.
(5) Subcontractor's agreement to submit
					 reports as required by the Contractor.
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 3 - OPERATIONAL REQUIREMENTS › Section 53251 - Assumption of Financial Risk

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Plans shall be responsible for the total
					 costs, except as otherwise provided in this Chapter, of care rendered to
					 members under the provisions of this Chapter.
(b) The Department shall bear the costs of
					 providing medically necessary covered services to a member when such costs,
					 based on Medi-Cal schedules of reimbursement and exclusive of third-party
					 recoveries, exceed the risk limit in the aggregate during the 12-month period
					 specified in the contract. The risk limit shall be determined annually, at the
					 same time and using the same data base as used in the determination of new
					 annual rates, as provided by Section
					 53321, and shall be stated in the
					 contract. The Department shall bear such costs only for the period of time
					 between the date on which the aggregate amount exceeds the risk limit, and the
					 end of the 12-month period specified in the contract. The Department shall
					 determine that services and the amounts payable therefor are reasonable and
					 medically necessary, prior to payment, and within 90 days after submittal of
					 the documentation required in subsection (b)(2).
(1) Members whose cost of care exceeds the
					 risk limit in the 12-month period shall not be disenrolled by the plan solely
					 for that reason. The plan shall remain responsible for arranging and initially
					 paying for the member's medically necessary care, at Medi-Cal reimbursement
					 levels, when the cost for such care exceeds the risk limit in the 12-month
					 period.
(2) Plans shall submit to
					 the Department documentation of accumulated costs which result in reaching the
					 risk limit and of all costs in excess of the limit. Documentation shall be
					 submitted in a format prescribed by the Department.
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 3 - OPERATIONAL REQUIREMENTS › Section 53252 - Reinsurance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provisions
					 of Section
					 53251 notwithstanding, the prepaid
					 health plan may obtain reinsurance for the cost of providing covered services,
					 subject to the following conditions:
(1)
					 Reinsurance shall not reduce plan liability below $5,000 per member for any one
					 12-month period.
(2) Reinsurance
					 may cover both of the following:
(A) The total
					 cost of services provided to members under emergency circumstances by nonplan
					 providers, including the cost of inpatient care in a nonplan facility until
					 such time as the member may be safely transported to a plan facility.
(B) Up to 90 percent of all expenditures
					 related to the contract exceeding 115 percent of the plan's gross income from
					 capitation payments and third-party recoveries under the terms of the contract
					 during any plan fiscal year.
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 3 - OPERATIONAL REQUIREMENTS › Section 53260 - Grievance Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall establish and maintain a procedure for submittal, processing
					 and resolution of all member complaints. Such procedure shall be approved by
					 the Department and shall provide for the processing of disenrollment requests
					 through the grievance procedure in sufficient time to submit requests to the
					 Department in accordance with the provision of Section
					 53440.
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50). For prior history, see Register 78, No. 27.
2. Amendment of
						subsection (a) and repealer of subsections (b)-(h) filed 9-22-82; effective
						thirtieth day thereafter (Register 82, No. 39).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14303.1,
						  14303.2,
						  14409,
						  14412,
						  14413
						  and
						  14450,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53261 - Notice to Members of Plan Action to Deny, Defer or Modify a Request for Medical Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 plan shall provide members with a notice of an action taken by the plan to deny
					 a request by a provider for any medical service. Notice in response to an
					 initial request from a provider shall be provided in accordance with this
					 section. Notice in response to a request for continuation of a medical service
					 shall be provided in accordance with section
					 51014.1. Notice of denial shall
					 not be required in the following situations:
(1) The denial is a denial of a request for
					 prior authorization for coverage for treatment that has already been provided
					 to the member.
(2) The denial is a
					 non-binding verbal description to a provider of the services which may be
					 approved by the plan.
(3) The
					 denial is a denial of a request for drugs, and a drug identical in chemical
					 composition, dosage, and bioequivalence may be obtained through prior
					 authorization from the plan or from the list, established by the plan, of drugs
					 available without prior authorization from the plan.
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 3 - OPERATIONAL REQUIREMENTS › Section 53270 - Consumer Participation in Policy Making. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 12-30-81; effective thirtieth day thereafter (Register 82, No.
						1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14450,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53280 - Quality of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 plan shall meet the standards for acceptable medical care as defined in Section
					 53100 of this Title, and use
					 effective professional review in assessing the care provided to its members in
					 accordance with the standards for health care service plans set forth in Title
					 10, California Administrative Code,Chapter 3, Subchapter 5.5, beginning with
					 Section 1300.43.
1.
						Amendment of subsections (c), (d) and (e) filed 7-5-78; effective thirtieth day
						thereafter (Register 78, No.27).
2. Amendment filed 12-30-81;
						effective thirtieth day thereafter (Register 82, No.
						1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14450
						  and
						  14458,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53282 - Medical Record System. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14455,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53284 - Medical Record Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall maintain a medical record service in accordance with the
					 requirements of Title 10, California Administrative Code, Sections
					 1300.70 and
					 1300.80.
(b) Confidentiality of medical records shall
					 be maintained in accordance with the provisions of Section
					 51009.
(c) Fifteen days prior to ceasing operation
					 each plan shall provide the Department with a plan for preserving medical
					 records.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14455,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53286 - Continuity of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 plan shall establish and operate a system to assure continuity of care in
					 accordance with the requirements of Title 10, California Administrative Code,
					 Section 1300.67.1.
(b) Each plan shall make a primary care
					 physician available to supervise and coordinate each member's health care. Any
					 member dissatisfied with the primary care physician shall be allowed to select
					 another. Any plan physician dissatisfied with the professional relationship
					 with any plan member may request that another primary care physician be
					 substituted to supervise the member's care.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14450,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53288 - Shared Responsibility for Members' Health Care. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 12-30-81; effective thirtieth day thereafter (Register 82, No.
						1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14450,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53290 - Medical Review. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14456,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53291 - General Reviews. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14457,
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53310 - Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall
					 maintain or cause to be maintained all records necessary to verify the
					 information and reports required by statute, regulation or contractual
					 obligation for four years from the date of submission of such information or
					 reports. Such records and documents shall include but not be limited to:
(1) Working papers used in the preparation of
					 reports to the Department.
(2)
					 Reports to the Department.
(3)
					 Financial documents.
(4) Medical
					 records.
(5) Prescription
					 files.
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 3 - OPERATIONAL REQUIREMENTS › Section 53312 - Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan,
					 except those that are excluded under Section
					 14308(c),
					 Welfare and Institutions Code, shall submit reports to the Department as
					 specified below.
(b) Annual reports
					 shall include:
(1) The financial audit
					 required by Section
					 53340. This report shall be
					 submitted to the Department no later than 90 days after the close of the plan's
					 fiscal year.
(2) An update of the
					 provider listing required in Section
					 53242(b).
(3) Disclosure statements in compliance with
					 Section 53601.
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 3 - OPERATIONAL REQUIREMENTS › Section 53314 - Statistical Data

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 plan shall supply statistical data and information, reported no less frequently
					 than quarterly by dates specified by the Department, including:
(1) Statistical information concerning:
(A) Utilization of services to and benefits
					 of members.
(B) Distribution of
					 members by age intervals and sex.
(C) Costs of health care.
(D) Administrative expenses.
(E) Quality of care
					 rendered.
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 3 - OPERATIONAL REQUIREMENTS › Section 53320 - Capitation Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Payment to each plan shall be on a monthly capitation payment basis. Each plan
					 shall be at risk for services provided. The capitation payment shall:
(1) Constitute payment in full by the State
					 for health care and administration services rendered under the
					 contract.
(2) Be based upon a count
					 of eligible members furnished to the plan monthly by the
					 Department.
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 3 - OPERATIONAL REQUIREMENTS › Section 53321 - Capitation Payment Rates Determination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall determine capitation
					 payment rates annually by actuarial methods with assistance from an actuary or
					 consulting actuary.
(b) The rates
					 shall not exceed actuarially equivalent Medi-Cal fee-for-service costs. These
					 costs shall be determined by viewing the total services and requirements,
					 including administration, provided under this Chapter by a prepaid health plan
					 as though such same services and requirements, including administration, were
					 reimbursable under Chapter 3. For purposes of this section:
(1) Costs of administration include, but are
					 not limited to:
(A) Salaries, bonuses or
					 benefits paid or incurred with respect to the officers, directors, partners,
					 trustees or other principal management of the plan, minus, to the extent that
					 such persons also are providers of health care services, the minimum reasonable
					 cost of obtaining such health care services from other persons.
(B) Cost of soliciting, enrolling and
					 verifying enrollment of members.
(C) Legal and accounting fees and
					 expenses.
(D) 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.
(E) Premium on
					 required fidelity and surety bonds and any insurance maintained pursuant to
					 Section
					 1377,
					 Health and Safety Code, and any insurance or other expense incurred for the
					 purpose of complying with Section
					 1375.1,
					 Health and Safety Code. Malpractice insurance is not included within this
					 subsection.
(F) Costs of preparing
					 reports required by this Chapter.
(G) Costs of maintaining facilities for
					 administrative services.
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 3 - OPERATIONAL REQUIREMENTS › Section 53322 - Capitation Rate Redetermination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Capitation rates shall be redetermined
					 during the rate year only when all of the following conditions are met:
(1) A change occurs in the obligations of the
					 plan which results in increased or decreased costs of performing under the
					 contract.
(2) The change in
					 subsection (1) is the result of either of the following:
(A) A change in federal or state law or
					 regulation.
(B) A change in the
					 Department's interpretation or implementation of federal or state law or
					 regulation.
(3) The
					 projected difference in plan costs associated with either of the conditions set
					 forth in subsection (a)(2) exceeds one percent of the statewide average
					 capitation rate for the affected categories of members.
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 3 - OPERATIONAL REQUIREMENTS › Section 53323 - Cost Reimbursement. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment of subsection (a) filed 12-10-79; effective thirtieth day thereafter
						(Register 79, No. 50). For prior history, see Register 78, No.
						27.
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14301(b),
						  Welfare and Institutions Code.
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 3 - OPERATIONAL REQUIREMENTS › Section 53324 - Financial Resources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall maintain adequate financial resources to carry out its
					 contractual obligations. The level of such resources shall be determined for
					 each plan by the Department and shall include, but not necessarily be limited
					 to, the following:
(1) Tangible net equity as
					 defined in Title 10, California Administrative Code, Section
					 1300.76.
(2) Working capital trends.
(3) Profit and loss trends.
(4) Enrollment growth.
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 3 - OPERATIONAL REQUIREMENTS › Section 53326 - Financial Security

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall provide evidence of and maintain financial security.
(b) Financial security may be in the form of,
					 but is not limited to, one of the following:
(1) A guarantee bond.
(2) A letter of credit.
(3) A time certificate of deposit.
(4) A trust agreement.
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 3 - OPERATIONAL REQUIREMENTS › Section 53330 - Affiliate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every affiliate
					 shall:
(1) Furnish, upon request, to the plan
					 and to the Department financial reports relevant to the disposition of funds
					 paid to the affiliate by the plan. Reports shall be prepared according to
					 generally accepted accounting principles and shall provide all financial data
					 required by the plan to fulfill its obligations to the Department for financial
					 reporting.
(2) Make all books and
					 records, which are pertinent to plan contracts with the Department, available
					 for inspection by the Department and HEW. These books and records shall be
					 retained for at least four years from the close of each fiscal year in which
					 the contract is in effect.
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 3 - OPERATIONAL REQUIREMENTS › Section 53340 - Financial Audit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall have an audit performed at least annually by an independent
					 certified public accountant who is independent according to the provisions of
					 Accounting Series Release Number 126 (July 5, 1972) issued by the Securities
					 Exchange Commission. A plan operated by a public entity shall have an annual
					 audit performed in a manner approved by the Department. Additional audits may
					 be required by the Director after a determination of good cause. All certified
					 financial statements shall be filed with the Department not later than 90 days
					 after the close of the plan's fiscal year. Combined financial statements shall
					 be prepared in accordance with the rules set forth in Section
					 1300.84, Title 10, California
					 Administrative Code, in order to demonstrate the financial position of the
					 overall related health care delivery system when delivery of health care or
					 other services is dependent upon affiliates. Financial statements shall be
					 presented in a form that clearly shows the financial position of the individual
					 plan separately from the combined totals. Interentity transactions and profits
					 shall be eliminated when combined statements are prepared.
(b) The plan shall authorize the independent
					 accountant to allow representatives of the Department, upon written request, to
					 inspect any and all working papers relating to the preparation of the audit
					 report. The inspection shall:
(1) Be
					 conducted at the accountant's place of business in California during normal
					 business hours.
(2) Be conducted at
					 the Department of Health Services' headquarters in Sacramento, California, if
					 the accountant's place of business is outside the State of
					 California.
(3) Include notes,
					 computations, work sheets and rough drafts.
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 3 - OPERATIONAL REQUIREMENTS › Section 53350 - Civil Penalties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Director may, except as provided in Section
					 53352 subsection (a), impose one
					 or more of the civil penalties specified in (b) upon a plan which fails to
					 comply with the provisions of Chapter 8, Part 3, Division 9, Welfare and
					 Institutions Code, the provisions of this Chapter, or the terms of the plan
					 contract.
(b) Civil penalties
					 imposed by the Director shall be in the amounts specified below with respect to
					 violation of any provision of:
(1) Article 3
					 excluding Sections
					 53312 and
					 53314.
(A) First violation: $500.
(B) Second violation: $1,000.
(C) Third and each subsequent violation:
					 $5,000.
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 3 - OPERATIONAL REQUIREMENTS › Section 53352 - Contract Termination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Director shall terminate a contract with a prepaid health plan which the
					 Secretary, HEW, has determined does not meet the requirements for participation
					 in the Medicaid program, Title XIX of the Social Security Act.
(b) The Director shall, except as provided in
					 subsection
					 53350(b),
					 terminate a plan contract for reasons including, but not limited to:
(1) Noncompliance with the requirements of
					 law or regulations or terms of the contract.
(2) Failure to pay valid accrued claims
					 within 120 days after receipt by the plan, or failure to ensure that future
					 claims will be paid.
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53400 - Marketing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall
					 be responsible for the conduct of all marketing activities. (Next page is
					 1300.54.5)
(b) Each plan shall be
					 responsible for complying with all statutory, regulatory and contractual
					 provisions relating to member enrollment and marketing activities.
(c) Each plan shall engage in marketing
					 activities only after receipt of written authorization from the
					 Department.
(d) All marketing
					 methods and presentations shall have written authorization by the Department
					 prior to use.
(e) All printed or
					 illustrated material shall be approved by the Department prior to distribution
					 to members or prospective members.
(f) All marketing orientation and training
					 programs shall have written authorization by the Department prior to
					 use.
(g) A prepaid health plan or
					 marketing representative shall not adopt or utilize any procedure to identify
					 prospective members who have medical or psychiatric problems, other than those
					 specifically excluded from coverage by the contract, in order to exclude such
					 prospective members from enrollment in the plan.
1. New
						subsection (g) filed 7-5-78; effective thirtieth day thereafter (Register 78,
						No. 27).
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53401 - Marketing on County Premises

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Counties may allow marketing of
					 prospective PHP members on county premises by a county employee under any one
					 of the following conditions:
(1) Marketing is
					 performed under the terms of a demonstration project approved by the Department
					 provided the demonstration project meets the requirements of Section
					 14411,
					 Welfare and Institutions Code.
(2)
					 The county operates the prepaid health plan for which marketing is
					 performed.
(3) The county and the
					 prepaid health plan, for which marketing is to be performed, enter into a
					 written agreement. Prepaid health plans shall obtain written departmental
					 approval to enter into such agreements prior to negotiating agreements with a
					 county.
(A) Agreements entered into pursuant
					 to (a) (3) shall:
1. Not exceed two
					 years.
2. Describe the relationship
					 between marketing activities and the eligibility process.
3. Be submitted to the Department for
					 approval at least 30 days prior to the proposed effective date of the
					 agreement.
(B) Changes to
					 the terms of the agreements, approved by the Department, shall be submitted by
					 the plan to the Department for approval at least 30 days prior to the proposed
					 effective date of the change.
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53401.1 - Marketing on State Premises

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The State may permit marketing of
					 prospective members on state premises provided the following conditions are
					 met:
(1) Marketing shall be performed by state
					 employees or prepaid health plan marketing representatives.
(2) Marketing is performed under the terms of
					 a written agreement between the Department, the State Department of General
					 Services and the prepaid health plan for which marketing is to be performed.
					 Such agreements shall be for a period not to exceed two
					 years.
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53402 - Marketing Representatives

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Plan marketing representatives shall be
					 responsible for the enrollment of members.
(b) Each plan shall establish an educational
					 program which assures that its marketing representatives have sufficient
					 knowledge about the plan to thoroughly explain how it operates to prospective
					 and new members.
(c) A marketing
					 representative shall not provide marketing services on behalf of more than one
					 plan.
(d) All marketing
					 representatives shall satisfactorily complete the plan's marketing orientation
					 and training program and the Department's examination for marketing
					 representatives prior to engaging in marketing activities on behalf of any
					 plan.
(e) Marketing representatives
					 shall neither offer nor give any form of compensation or reward to induce or
					 procure Medi-Cal beneficiary enrollment.
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53404 - Marketing Presentation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 All marketing presentations shall fully disclose the availability of and
					 restrictions upon the services provided by the plan. Such presentations shall,
					 as a minimum, specify:
(1) The scope, access
					 to and availability of services.
(2) The nature of the membership
					 identification which will authorize the member to obtain services.
(3) That members shall obtain all covered
					 health care services rendered in nonemergency situations through the plan's
					 providers.
(4) That medical
					 services required in an emergency may be obtained at all times from specified
					 plan providers or from nonplan providers, if necessary.
(5) That enrollment is voluntary.
(6) That enrollment is subject to a
					 verification and processing period from 15 to 45 days in length.
(7) That disenrollment is possible only under
					 the conditions specified in Section
					 53440 and only after action by the
					 Department.
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 4 - MARKETING, ENROLLMENT AND DISENROLLMENT › Section 53406 - Misrepresentation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Marketing
					 representatives shall not misrepresent themselves, the plan or the Medi-Cal
					 program through false advertising, false statements or in any other manner in
					 order to induce Medi-Cal beneficiaries to enroll in the plan.
(b) Violations of this section shall include,
					 but are not limited to, false or misleading claims, inferences or
					 representations that:
(1) Marketing
					 representatives are employees or representatives of the State or county or
					 anyone other than the plan or the marketing organization by which they are
					 reimbursed.
(2) The plan is
					 recommended or endorsed by any state agency or county agency or any other
					 organization which has not certified its endorsement in writing to the
					 plan.
(3) The State or county
					 recommends that a Medi-Cal beneficiary enroll in a plan.
(4) A Medi-Cal beneficiary will lose benefits
					 under the Medi-Cal program or any other health or welfare benefits to which he
					 is legally entitled if the beneficiary does not enroll in a
					 plan.