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 4 - Solicitors › Section 1300.59 - Plan Assurances Prior to Solicitation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prior to allowing any person to engage in acts of
					 solicitation on its behalf, each plan shall reasonably assure itself that such
					 person has sufficient knowledge of its organization, procedures, plan
					 contracts, and the provisions of the Act and these rules to do so
					 lawfully.
1. Repealer
					 and new section filed 1-12-83; effective thirtieth day thereafter (Register 83,
					 No. 3).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1359,
						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 4 - Solicitors › Section 1300.59.1 - Examination Fee. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 1-12-83; effective thirtieth day thereafter (Register 83, No.
					 3).
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 4 - Solicitors › Section 1300.59.2 - Waiver of Examination Requirements. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Amendment
					 filed 6-2-78; effective thirtieth day thereafter (Register 78, No.
					 22).
2. Repealer filed 1-12-83; effective thirtieth day thereafter
					 (Register 83, No. 3).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1359,
						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 5 - Advertising and Disclosure › Section 1300.61 - Filing of Advertising and Disclosure Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Two copies of a proposed advertisement
				  shall be filed. An advertisement is "filed" within the meaning of Section
				  1361 of the Act when a true copy
				  thereof, accurately showing the final appearance of the advertisement, is
				  received. To minimize the expense of changes in advertising copy, it may be
				  submitted in draft form for preliminary review subject to the later filing of a
				  proof or final copy, and the later filing of a proof or final copy may be
				  waived when the draft copy is presented in a manner reasonably representing the
				  final appearance of the advertisement. The text of audio or audio/visual
				  advertising should indicate any directions for presentation, including voice
				  qualities and the juxtaposition of the visual materials with the
				  text.
(b) The Director will not
				  issue letters of nondisapproval of advertising. If the person submitting the
				  advertisement requests an order shortening the 30-day waiting period under
				  Section 1361 of the Act, such order will
				  be issued when an appropriate showing of the need therefor is made.
1. Change
					 without regulatory effect amending subsection (b) 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
						1361,
						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 5 - Advertising and Disclosure › Section 1300.61.1 - Exempt Advertising. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 1-12-83; effective thirtieth day thereafter (Register 83, No.
					 3).
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.63 - Disclosure Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				  disclosure form required under subdivision (a) of Section
				  1363 of the Act shall conform to
				  the following requirements.
(1) The text shall
				  be printed in at least 10-point block type. Titles and captions shall be in at
				  least 12-point to 15-point bold face type.
(2) It shall be written in clear, concise,
				  easily understood language.
(3) It
				  should relate to one form of plan contract; however, disclosure forms offering
				  alternative plans or options will be permitted if presented in a manner which
				  clearly identifies the alternatives and their effect upon the
				  contract.
(4) It shall be presented
				  in an easily readable format.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.63.1 - Evidence of Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Each plan shall furnish to each individual subscriber, and make available to
				  group contract holders for dissemination to all persons eligible under the
				  group contract, either an evidence of coverage or a copy of the plan contract,
				  which shall conform to the requirements of this section. The Director may
				  permit the evidence of coverage and the disclosure form prescribed by Section
				  1300.63 to be presented in a
				  single document if the purposes of each are fulfilled.
(b) Except as may be otherwise permitted by
				  the Director, the evidence of coverage shall conform to the requirements of
				  subsection (a) of Section
				  1300.63 and the following
				  requirements:
(1) It shall be clearly
				  entitled "Evidence of Coverage."
(2) The portions of the text specifying (1)
				  limitations, exclusions, exceptions and reductions; (2) rights of cancellation;
				  (3) restrictions on renewal or reinstatement; (4) rights of the health plan to
				  change benefits; (5) subsequent providers; and (6) liability of members in the
				  event of nonpayment by the health plan, shall be in type not less than 2 points
				  larger than the text relating to other provisions and in no event less than 12
				  point type.
(3) It shall be divided
				  into sections, each of which shall have a title identifying the nature of the
				  information contained therein.
(4)
				  The evidence of coverage when taken as a whole, with consideration being given
				  to format, typography and language, must constitute a fair disclosure of the
				  provisions of the health 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 5 - Advertising and Disclosure › Section 1300.63.2 - Combined Evidence of Coverage and Disclosure Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Notwithstanding Sections
					 1300.63 and
					 1300.63.1 of these rules, a plan
					 may combine the evidence of coverage and disclosure form into a single document
					 if such plan complies with each of the following requirements:
(a) Each plan shall furnish to each
				  individual subscriber, and make available to group contract holders for
				  dissemination to all persons eligible under the group contract, either a single
				  document consisting of a combined evidence of coverage and disclosure form or a
				  copy of the plan contract, which shall conform to the requirements of this
				  section.
(b) Except as may be
				  otherwise permitted by the Director, the combined evidence of coverage and
				  disclosure form shall conform to the following requirements:
(1) It shall be clearly entitled "Combined
				  Evidence of Coverage and Disclosure Form."
(2) The text shall be printed in at least ten
				  point block type. Titles and captions shall be in at least twelve point to
				  fifteen point boldface type.
(3) It
				  shall be written in clear, concise, easily understood language.
(4) It should relate to one form of plan
				  contract; however, combined evidence of coverage and disclosure forms offering
				  alternative plans or options will be permitted if presented in a manner which
				  clearly identifies the alternatives and their effect upon the
				  contract.
(5) It shall be presented
				  in an easily readable format.
(6)
				  The combined evidence of coverage and disclosure form when taken as a whole,
				  with consideration being given to format, typography and language, must
				  constitute a fair disclosure of the provisions of the health
				  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 5 - Advertising and Disclosure › Section 1300.63.3 - Experimental Disclosure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Notwithstanding those provisions of Sections
					 1300.63,
					 1300.63.1,
					 1300.63.2, and
					 1300.67.4 which require the use of
					 any particular type size, boldface type, caption, subcaption, heading, design,
					 order, or format, the Director by order may approve, for experimental use,
					 reasonable alternatives to such requirements for a disclosure form, evidence of
					 coverage, combined evidence of coverage and disclosure form, or plan contract
					 upon the written request of a plan, for such period and under such conditions
					 as the Director may specify, subject to each of the following
					 conditions:
(a) That the plan submits
				  two draft copies of the document containing the proposed alternatives, one as
				  proposed to be used and the other redlined to highlight the proposed changes,
				  along with two copies of the related plan contract, at least 30 days prior to
				  any use of the document, or such shorter period as the Director by order may
				  allow.
(b) That the plan
				  demonstrates to the satisfaction of the Director that the document containing
				  the proposed alternatives furthers the purposes of the Act, otherwise complies
				  with the Act and the rules thereunder, and will provide to actual or potential
				  subscribers or enrollees (as the case may be) unobjectionable information at
				  least as clear, concise, accurate, easily understood, and easily readable as
				  could otherwise be achieved.
(c)
				  That the plan submits a proof or final copy of the document at such time, not
				  to exceed 30 days, prior to its initial use as may be specified by the
				  Director.
1. New
					 section filed 1-12-83; effective thirtieth day thereafter (Register 83, No.
					 3).
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
						1363,
						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 5 - Advertising and Disclosure › Section 1300.63.4 - Summary of Dental Benefits and Coverage Disclosure Matrix

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Applicability
(1) This Rule shall apply to health care
				  service plans or specialized health care service plans, issuing, selling,
				  renewing, or offering a contract that covers the provision of dental
				  services.
(2) This Rule shall not
				  apply to any health care service plan contract for medical, surgical, and
				  hospital services that offers dental services as a dental benefit within the
				  medical, surgical, and hospital services contract.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.63.50 - Medicare Supplement Additional Disclosure. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 8-12-82; effective thirtieth day thereafter (Register 82, No.
					 33).
2. Repealer and new table, amendment of subsection (a)(5)(A)8.,
					 and new subsection (a)(5)(A)9. filed 11-26-91; operative 12-26-91 (Register 92,
					 No. 10).
3. Change without regulatory effect repealing section filed
					 9-14-92 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1363,
						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 5 - Advertising and Disclosure › Section 1300.64.50 - Medicare Supplement Application Information. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 8-12-82; effective thirtieth day thereafter (Register 82, No.
					 33).
2. Amendment filed 11-26-91; operative 12-26-91 (Register 92,
					 No. 10).
3. Change without regulatory effect repealing section filed
					 9-14-92 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1364,
						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 5 - Advertising and Disclosure › Section 1300.64.51 - Medicare Supplement "Buyer's Guide." [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 8-12-82; effective thirtieth day thereafter (Register 82, No.
					 33).
2. Amendment of subsections (a) and (b) filed 11-26-91;
					 operative 12-26-91 (Register 92, No. 10).
3. Change without
					 regulatory effect repealing section filed 9-14-92 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1364,
						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 5 - Advertising and Disclosure › Section 1300.64.52 - Standards for Marketing Medicare Supplement Contracts. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 11-26-91; operative 12-26-91 (Register 92, No. 10).
2.
					 Change without regulatory effect repealing section filed 9-14-92 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1346,
						1364
						and
						1367.15,
						Health and Safety Code; 42
						U.S.C.
						1395ss.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.64.53 - Reporting of Multiple Coverage. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 11-26-91; operative 12-26-91 (Register 92, No. 10).
2.
					 Change without regulatory effect repealing section filed 9-14-92 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1367.15
						and
						1384(d)(i),
						Health and Safety Code; 42
						U.S.C.
						1395ss.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.64.54 - Replacement Contracts: Elimination of Waiting Periods. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 1-8-92; operative 1-1-92 (Register 92, No. 10).
2.
					 Change without regulatory effect repealing section filed 9-14-92 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1367.15
						and
						1384(d)(i),
						Health and Safety Code; 42
						U.S.C.
						1395ss.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 5 - Advertising and Disclosure › Section 1300.64.55 - Permitted Compensation Arrangements for the Sale of Medicare Supplement Contracts. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 11-26-91; operative 12-26-91 (Register 92, No. 10).
2.
					 Change without regulatory effect repealing section filed 9-14-92 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 92, No. 38).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1346(i),
						1367(h)
						and
						1367.15,
						Health and Safety Code; 42
						U.S.C.
						1395ss.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 6 - Appeals on Cancellation › Section 1300.65.5 - Notice of Right of Enrollee to Submit a Grievance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following language regarding the right of an enrollee,
					 subscriber, or group contract holder to submit a grievance to the Department of
					 Managed Health Care must appear in at least 12-point font when required by a
					 section in this Article:
RIGHT TO SUBMIT GRIEVANCE REGARDING CANCELLATION,
					 RESCISSION, OR NONRENEWAL OF YOUR PLAN ENROLLMENT, SUBSCRIPTION, OR
					 CONTRACT.
If you believe your health care coverage has been, or will
					 be, improperly cancelled, rescinded, or not renewed, you have the right to file
					 a grievance with the plan and/or the Department of Managed Health Care.
OPTION (1) -- YOU MAY SUBMIT A GRIEVANCE TO YOUR
					 PLAN.
* You may submit a grievance to [plan] by calling [plan
					 phone number], online at [plan website], or by mailing your written grievance
					 to [plan address].
* You may want to submit your grievance to [plan] first if
					 you believe your cancellation, rescission, or nonrenewal is the result of a
					 mistake. Grievances should be submitted as soon as possible.
* [Plan] will resolve your grievance or provide a pending
					 status within three (3) calendar days. If you do not receive a response from
					 the plan within three (3) calendar days, or if you are not satisfied in any way
					 with the plan's response, you may submit a grievance to the Department of
					 Managed Health Care as detailed under Option 2 below.
OPTION (2) -- YOU MAY SUBMIT A GRIEVANCE DIRECTLY TO
					 THE DEPARTMENT OF MANAGED HEALTH CARE.
* You may submit a grievance to the Department of Managed
					 Health Care without first submitting it to the plan or after you have received
					 the plan's decision on your grievance.
* You may submit a grievance to the Department of Managed
					 Health Care online at:
www.healthhelp.ca.gov
* You may submit a grievance to the Department of Managed
					 Health Care by mailing your written grievance to:
HELP CENTER
DEPARTMENT OF MANAGED HEALTH CARE
980 NINTH STREET, SUITE 500
SACRAMENTO, CALIFORNIA 95814-2725
* You may contact the Department of Managed Health Care for
					 more information on filing a grievance at:
PHONE: 1-888-466-2219
TDD: 1-877-688-9891
FAX: 1-916-255-5241
1. New
					 section filed 7-30-2019; operative 10-1-2019 (Register 2019, No.
					 31).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1365
						and
						1368,
						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 6 - Appeals on Cancellation › Section 1300.66 - Deceptive Plan Names

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  change of plan name is a "material modification" of the plan within the meaning
				  of subdivision (b) of Section
				  1352 of the Act.
(b) A plan name will be considered deceptive
				  if it suggests the quality of care furnished by the plan, or that full benefits
				  are provided for health care or a specialized area of health care, or that the
				  cost of benefits to members of the plan is lower than the cost of similar
				  benefits purchased elsewhere, and in any such case the express or implied
				  representation contained in the plan name is demonstrably untrue or is not
				  supported by substantial evidence, at all times while such name is used by the
				  plan. Nothing in this subsection limits or restricts the Director from a
				  determination that a plan or solicitor firm name is deceptive for reasons other
				  than those stated herein.
1. Change
					 without regulatory effect amending subsection (b) 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
						1366,
						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 7 - Standards › Section 1300.67 - Scope of Basic Health Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The basic health care services required to be provided by a
					 health care service plan to its enrollees shall include, where medically
					 necessary, subject to any copayment, deductible, or limitation of which the
					 Director may approve:
(a) Physician
				  services, which shall be provided by physicians licensed to practice medicine
				  or osteopathy in accordance with applicable California law. There shall also be
				  provided consultation with and referral by physicians to other physicians.
(1) The plan may also include, when provided
				  by the plan, consultation and referral (physician or, if permitted by law,
				  patient initiated) to other health professionals who are defined as dentists,
				  nurses, podiatrists, optometrists, physician's assistants, clinical
				  psychologists, social workers, pharmacists, nutritionists, occupational
				  therapists, physical therapists and other professionals engaged in the delivery
				  of health services who are licensed to practice, are certified, or practice
				  under authority of the plan, a medical group, or individual practice
				  association or other authority authorized by applicable California
				  law.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.003 - State Medical Loss Ratio Annual Report

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every health care service plan ("health
				  plan") required to submit the Federal Medical Loss Ratio ("MLR") Annual
				  Reporting Form (CMS form-10418) to the federal Department of Health and Human
				  Services ("DHHS") shall also file the MLR Annual Reporting Form with the
				  Department of Managed Health Care ("Department").
(b) The MLR Annual Report Form shall be filed
				  with the Department no later than July 31 of the year following the end of the
				  MLR reporting year. The MLR reporting year is the calendar year during which
				  health coverage is provided by a health plan. All terms used in the MLR Annual
				  Reporting Form instructions will have the same meaning as used in 45 CFR Part
				  158 , the Public Health Service Act (42 U.S.C. Sec. 300g-18), and
				  Health and Safety Code section
				  1367.003.
(c) If a financial examination pursuant to
				  Health and Safety Code section
				  1382
				  and Title 28 California Code of Regulations section
				  1300.82 is necessary to verify the
				  health plan's representations in the MLR Annual Report, the Department shall
				  give the health plan a 30-day prior notification of the commencement of the
				  financial examination.
(d) The
				  health plan shall have 30 days from the date of notification to electronically
				  submit all requested records, books and papers authorized in Health and Safety
				  Code section
				  1381(a)
				  to the Department.
(e) The Director
				  may extend the time for a health plan to comply with subsection (d) upon a
				  finding of good cause.
1. New
					 section filed 10-7-2013; operative 1-1-2014 (Register 2013, No.
					 41).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1367.003
						and
						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 7 - Standards › Section 1300.67.005 - Essential Health Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All health plans that offer individual
				  and small group contracts subject to Health and Safety Code Section
				  1367.005
				  shall comply with the requirements of this section.
(b) In addition to any other requirements set
				  forth in the Knox-Keene Health Care Service Plan Act of 1975 (hereinafter the
				  "Act'), to demonstrate compliance with Health and Safety Code Section
				  1367.005
				  and this section, health plans shall electronically file through the
				  Department's Efile application the Essential Health Benefits Filing Worksheet
				  (EHB Filing Worksheet) no later than the date that qualified health plan
				  product filings are required to be submitted, and thereafter as necessary for
				  new or amended plan contracts.
(c)
				  The EHB Filing Worksheet shall include:
(1)
				  The benefits specified in Health and Safety Code Section
				  1367.005
				  and the federal Patient Protection and Affordable Care Act (PPACA) at section
				  1302(b)
				  (42 U.S.C. §
												18022) and 45 Code of Federal Regulations
				  (CFR) parts 156.100 and 156.115;
(2) Pursuant to Health and Safety Code
				  Section
				  1367.005(a)(2)(A)(v),
				  any "other health benefits" covered by the base-benchmark plan, the Kaiser
				  Foundation Health Plan Small Group HMO 30 plan, in the first quarter of 2014,
				  which are not otherwise required to be covered under the Act;
(3) Required benefits for pediatric vision
				  and dental care, for individuals until at least the end of the month in which
				  the enrollee turns 19 years of age, consistent with benefits described in
				  Health and Safety Code Section
				  1367.005(a)(4) -
				  (5); and
(4) Prescription drug benefits required by
				  Health and Safety Code Section
				  1367.005(d)
				  and
				  45
				  CFR part 156.122 , including the plan's prescription drug list and/or
				  formulary. The EHB Filing Worksheet shall include a certification that the
				  plan's drug list meets or exceeds the prescription drug formulary requirements
				  specified in 45 CFR part 156.122, subparagraph (a)(1).
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.01 - Covid-19 Diagnostic Testing. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 7-17-2020 as an emergency; operative 7-17-2020 (Register 2020,
					 No. 29). A Certificate of Compliance must be transmitted to OAL by 1-13-2021 or
					 emergency language will be repealed by operation of law on the following
					 day.
2. Emergency filed 7-17-2020 and operative 7-17-2020 extended
					 60 days pursuant to Executive Order N-40-20 and an additional 60 days pursuant
					 to Executive Order N-66-20 (Register 2020, No. 35). A Certificate of Compliance
					 must be transmitted to OAL by 5-14-2021 or emergency language will be repealed
					 by operation of law on the following day.
3. Repealed by operation
					 of Government Code section
					 11346.1(g)
					 (Register 2023, No. 2).
Note: Authority cited: Sections
						1343
						and
						1344,
						Health and Safety Code. Reference: Sections
						1367,
						1367.01
						and
						1367.03,
						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 7 - Standards › Section 1300.67.02 - Transfer of Enrollees Pursuant to a Public Health Order

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Applicability. This section applies to a
				  health plan offering group or individual health care coverage that includes
				  hospital, medical, or surgical benefits, including a grandfathered health plan
				  as defined in section
				  1251(e) of the
				  Patient Protection and Affordable Care Act. This section does not apply to
				  Medi-Cal managed care health plans with a contract entered into pursuant to
				  Chapter 7 (commencing with section
				  14000), Chapter 8 (commencing with
				  section 14200), or Chapter 8.75
				  (commencing with section
				  14591) of Part 3 of Division 9 of
				  the Welfare and Institutions Code.
(b) Definitions. The following definitions
				  apply for the purposes of this section:
(1)
				  Covered public health order--Means an order issued by the State Public Health
				  Officer pursuant to Division 112 (commencing with section
				  131000) of the Health and Safety
				  Code, or during a local health emergency as defined in section
				  101080
				  of the Health and Safety Code or a state of emergency or local emergency as
				  defined in section
				  8558 of
				  the Government Code, that directs or allows hospitals or other health care
				  facilities to transfer patients to other health care facilities in response to,
				  or otherwise as a result of, the COVID-19 pandemic. This specifically includes
				  an order issued to allocate or preserve health care resources in the face of
				  increased demand for health care resources related to COVID-19 during a
				  California state of emergency.
(2)
				  Transferring facility--Means the health care facility from which an enrollee is
				  transferred as directed or allowed by a covered public health order.
(3) Receiving facility--Means the health care
				  facility that receives an enrollee transferred from a transferring facility as
				  directed or allowed by a covered public health order.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.04 - Language Assistance Programs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Application.
(1) Every health care service plan, including
				  specialized health care service plans (plans), shall comply with the
				  requirements of this section. The requirements of this section shall not apply
				  to plan contracts for the provision of services to Medi-Cal enrollees or to
				  contracts between plans and the federal government for the provision of
				  services to Medicare enrollees.
(2)
				  If a plan has both Medi-Cal and non-Medi-Cal lines of business, then the plan
				  will be in compliance with the requirements of this section as to its
				  non-Medi-Cal lines of business if:
(A) The
				  Medi-Cal standards for providing language assistance services, including
				  standards for timeliness and proficiency of interpreters, are equivalent to or
				  exceed the standards set forth in Section
				  1367.04 of the Act and this
				  section;
(B) The plan applies the
				  Medi-Cal standards for language assistance programs to the plan's non-Medi-Cal
				  lines of business; and
(C) The
				  Department of Managed Health Care (Department) determines, as described in
				  Section 1367.04(h)(3) of
				  the Act, that the plan is in compliance with the Medi-Cal
				  standards.
(3) A plan
				  that seeks the Department's determination of compliance as provided in
				  subsection (a)(2) shall request such determination as part of its filing
				  pursuant to subsection (e)(2) and provide documentation sufficient to support
				  and verify the request to the Department's satisfaction. The Department's
				  determination pursuant to subsection (a)(2) shall apply only to the enrollees
				  in a plan's non-Medi-Cal lines of business to which the plan actually applies
				  the plan's Medi-Cal program standards.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.05 - Acts of War Exclusions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No health care service plan contract
				  executed or amended on or after the effective date of this regulation shall
				  limit or exclude health care services based on a determination that the need
				  for the health care service arose as a result of an Act of War.
(1) The term "contract" includes but is not
				  limited to health care service plan contracts with subscribers and health care
				  service providers.
(2) The term
				  "Act of War" includes any act or conduct, or the prevention of an act or
				  conduct, resulting from war, declared or undeclared, terrorism, or warlike
				  action by any individual, government, military, sovereign group, terrorist or
				  other organization.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.1 - Continuity of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Within each service area of a plan, basic health care
					 services shall be provided in a manner which provides continuity of care,
					 including but not limited to:
(a) The
				  availability of primary care physicians, who will be responsible for
				  coordinating the provision of health care services to each enrollee;
(b) The encouragement of each enrollee to
				  select a primary physician;
(c) The
				  maintenance and ready availability of medical records, with sharing within the
				  plan of all pertinent information relating to the health care of each
				  enrollee;
(d) The maintenance of
				  staff, including health professionals, administrative and other supporting
				  staff, directly or through an adequate referral system, sufficient to assure
				  that health care services will be provided on a timely and appropriate basis to
				  enrollees;
(e) An adequate system
				  of documentation of referrals to physicians or other health professionals. The
				  monitoring of the follow up of enrollees' health care documentation shall be
				  the responsibility of the health care service plan and associated health
				  professionals.
1. Amendment
					 filed 1-12-83; effective thirtieth day thereafter (Register 83, No.
					 3).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Section
						1367,
						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 7 - Standards › Section 1300.67.1.3 - Block Transfer Filings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Definitions. As used in this section:
(1) "Affected Enrollee" means enrollees of
				  the plan who are assigned to a Terminated Provider Group or a Terminated
				  Hospital.
(2) "Alternate Hospital"
				  means a hospital that will provide services to plan enrollees in place of a
				  Terminated Hospital.
(3) "Block
				  Transfer" means a transfer or redirection of two thousand (2,000) or more
				  enrollees by a plan from a Terminated Provider Group or Terminated Hospital to
				  one or more contracting providers that takes place as a result of the
				  termination or non-renewal of a Provider Contract.
(4) "Enrollee Transfer Notice" means a
				  written notice that is sent to enrollees who are assigned to a Terminated
				  Provider group or Terminated Hospital.
(5) "Provider Contract" means a contract
				  between a plan and one or more health care providers, through which the plan
				  arranges to provide health care services for its enrollees.
(6) "Provider Group" means a medical group,
				  an independent practice association, or any other similar organization
				  providing services to enrollees of a plan who are assigned to that provider
				  group.
(7) "Receiving Provider
				  Group" means a provider group that will provide services to Affected Enrollees
				  in place of the current Provider Group.
(8) "Terminated Hospital" means a general
				  acute care hospital that will no longer maintain a Provider Contract with the
				  plan following the termination or non-renewal of a Provider Contract.
(9) "Terminated Provider" means either a
				  Terminated Provider Group or a Terminated Hospital.
(10) "Terminated Provider Group" means a
				  Provider Group that will no longer maintain a Provider Contract with the plan
				  following the termination or non-renewal of a Provider
				  Contract.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.2 - Accessibility of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Within each network service area of a plan, basic health
					 care services and specialized health care services shall be readily available
					 and accessible to each of the plan's enrollees;
(a) The location of network providers, as
				  defined in Rule 1300.67.2.2(b)(10), providing the covered health care services
				  of the plan shall be within reasonable proximity of the business or personal
				  residences of enrollees, and so located as to not result in unreasonable
				  barriers to accessibility.
(1) For the
				  purposes of the network adequacy review conducted pursuant to Health and Safety
				  Code section
				  1367.035,
				  the plan shall meet geographic accessibility standards with respect to the
				  location of network mental health facilities and non-physician mental health
				  professionals, as established by the Department. Such geographic accessibility
				  standards and the accompanying review methodology shall be set forth in the
				  document entitled Mental Health Geographic Access Standards and Methodology,
				  which is hereby incorporated by reference. The Department shall use the version
				  of this document noticed on the Department's website at
www.dmhc.ca.gov
, on or before January 15th
				  of the reporting year as set forth in Rule 1300.67.2.2(b)(18). Meeting the
				  geographic accessibility standards set forth therein shall demonstrate
				  compliance with this provision for the identified network provider types.
(A) The geographic accessibility standards
				  set forth in the Mental Health Geographic Access Standards and Methodology may
				  also be considered by the Department when evaluating network adequacy for the
				  purposes of licensure pursuant to Health and Safety Code sections
				  1351
				  and
				  1352,
				  and Rules 1300.51, 1300.52, and 1300.52.4.
(B) For the purposes of alternative
				  geographic accessibility standards for mental health facilities and
				  non-physician mental health professionals, the alternative accessibility
				  standards methodology set forth in the Mental Health Geographic Access
				  Standards and Methodology shall apply. Rule 1300.67.2.1 shall not apply to
				  requests for alternative geographic accessibility standards for mental health
				  facilities and non-physician mental health professionals.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.2.2 - Timely Access to Non-Emergency Health Care Services and Annual Timely Access and Network Reporting Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Application.
(1) A health care service plan that provides
				  or arranges for the provision of hospital or physician services, including a
				  specialized mental health plan that provides physician or hospital services, or
				  provides mental health services pursuant to a contract with a full-service
				  plan, shall comply with the requirements of this section. A specialized mental
				  health plan includes a plan only licensed to provide the services set forth in
				  subsection (a)(3) of Health and Safety Code section
				  1374.72.
(2) A specialized dental, vision,
				  chiropractic, or acupuncture plan shall comply with this subsection and
				  subsections (c)(1), (c)(3), (c)(4), (c)(7), (c)(9), (c)(10), (d)(1), (g)(1),
				  (h)(1)(B), (h)(5), (h)(9), (i) and (j) of this Rule. These specialized plans
				  shall comply with the network access profile requirements in subsections (h)(2)
				  and (h)(8) of this Rule, and documents incorporated within this Rule, as
				  specified. Dental plans shall also comply with subsection (c)(6).
(3) The obligation of a plan to comply with
				  this section shall not be waived if the plan delegates to its provider groups
				  or other contracting entities any services or activities that the plan is
				  required to perform. A plan's implementation of this section shall be
				  consistent with the Health Care Providers' Bill of Rights, and a material
				  change in the obligations of a plan's network providers shall be considered a
				  material change to the provider contract, within the meaning of subsections (b)
				  and (h)(2) of section
				  1375.7 of the Knox-Keene
				  Act.
(4) This section confirms
				  requirements for plans to provide or arrange for the provision of health care
				  services in a timely manner, and establishes additional metrics for measuring
				  and monitoring the adequacy of a plan's network to provide enrollees with
				  timely access to needed health care services. This section does not:
(A) Establish professional standards of
				  practice for health care providers;
(B) Establish requirements for the provision
				  of emergency services; or
(C)
				  Create a new cause of action or a new defense to liability for any
				  person.
(5) All reports
				  and information submitted by the plan pursuant to this section shall be timely,
				  accurate and complete.
(6) A plan
				  that uses a tiered network shall demonstrate compliance with the standards
				  established by section
				  1367.03 of the Knox-Keene Act and
				  this Rule based on providers available at the lowest cost-sharing
				  tier.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.3 - Standards for Plan Organization

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The organization of each plan shall
				  provide the capability to furnish in a reasonable and efficient manner the
				  health care services for which subscribers and enrollees have contracted. Such
				  organization shall include:
(1) separation of
				  medical services from fiscal and administrative management sufficient to assure
				  the Director that medical decisions will not be unduly influenced by fiscal and
				  administrative management,
(2)
				  staffing in medical and other health services, and in fiscal and administrative
				  services sufficient to result in the effective conduct of the plan's business,
				  and
(3) written procedures for the
				  conduct of the business of the plan, including the provision of health care
				  services, so as to provide effective controls.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.4 - Subscriber and Group Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All subscriber and group contracts and
				  endorsements and amendments shall be printed legibly in not less than 8-point
				  type and shall include at least the following:
(1) The information required to be included
				  on disclosure forms by Section
				  1363(a) of the
				  Code and
(A) the information required to be
				  included on disclosure forms by Section
				  1300.63 (except subsections (2),
				  (3), (4) and (11) of subsection (b) thereof), and required to be included on
				  evidences of coverage by subsections (b)(2) and (c) (except subsection (16)
				  thereof) of Section
				  1300.63.1, or
(B) if the plan complies with the provisions
				  of Section
				  1300.63.2, the information
				  required to be included on combined evidences of coverage and disclosure forms
				  by Section
				  1300.63.2 (except subsections (1)
				  and (4) of subsection (b) and subsections (2), (25), and (27) of subsection (c)
				  thereof).