California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.75.4.5 - Plan and Sub-Delegating Organization Compliance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every plan and sub-delegating
					 organization that maintains a risk arrangement with an organization shall have
					 adequate procedures in place to ensure:
(1)
					 That plan or sub-delegating organization personnel review all reports and
					 financial information made available pursuant to Health and Safety Code section
					 1375.4,
					 these Solvency Regulations, and as provided under the terms of the contract
					 with an organization as part of the plan's responsibility to evaluate and
					 ensure the financial viability of its arrangements consistent with section
					 1300.70(b)(2)(H)(1)
					 of Title 28, California Code of Regulations;
(2) Appropriate action(s) are taken following
					 the Department's written notification to an organization's contracting health
					 plan(s) or sub-delegating organization(s) that the organization has:
(A) Failed to substantially comply with the
					 reporting obligations specified in section
					 1300.75.4.2 of Title 28,
					 California Code of Regulations, by failing to file a required periodic
					 financial and organizational information disclosure, including the filing of an
					 annual financial survey report based upon an audited financial statement
					 prepared in accordance with generally accepted accounting principles (GAAP), or
					 by failing to include significant portions of information on a required
					 periodic financial organizational information disclosure;
(B) Refused to permit the activities of the
					 Department as specified in Health and Safety Code section
					 1375.4
					 or in these Solvency Regulations; or,
(C) Failed to substantially comply with the
					 requirements of a final CAP for a period of more than ninety (90) days, as
					 determined by the Department.
(3) Appropriate action shall include, but is
					 not limited to, a prohibition on the assignment or addition of any additional
					 enrollees to the risk arrangement with that organization without the prior
					 written approval of the Director. The prohibition on assignments of additional
					 enrollees to an organization pursuant to subsection (2) shall not apply to
					 dependents of enrollees who are already under the risk-arrangement with the
					 organization or to enrollees who selected the organization during an open
					 enrollment or other selection period that was prior to the effective date of
					 the prohibition on the assignment of additional enrollees. The prohibition on
					 the assignment of additional enrollees shall take effect thirty (30) days after
					 the date of Department's notification to the organization's contracting
					 plan(s), and shall remain in effect until the Department notifies the
					 organization's contracting health plan in writing that the organization's
					 non-compliance has been remedied.
(4) The plan or sub-delegating organization
					 complies with the corrective action process and cooperates in the
					 implementation of a final CAP, as defined in section
					 1300.75.4.8, including, but not
					 limited to, implementing contingency plans for continuous delivery of health
					 care services to plan enrollees served by the organization.
(5) The plan or sub-delegating organization
					 shall advise the Department and the organization in writing within five (5)
					 days of becoming aware:
(A) that a contracting
					 organization is not in compliance with the requirements of a final CAP,
					 or
(B) that an organization's
					 conduct may cause the plan to be subject to disciplinary action pursuant to
					 Health and Safety Code section
					 1386.
(6) If a plan proposes to transfer plan
					 enrollees receiving care from an organization that is compliant with a final
					 CAP to alternative providers and the reassignment is based, in part, on the
					 organization's failure to meet one or more of the Grading Criteria, the plan
					 shall, prior to transferring enrollees from that organization, file with the
					 Department a Block Transfer Filing pursuant to Health and Safety Code section
					 1373.65.
					 In addition to all other criteria for reviewing block transfers, the Director
					 may disapprove, postpone or suspend the plan's proposed transfer of enrollees
					 if the department reasonably determines:
(A)
					 That the proposed reassignment of enrollees will likely cause the
					 organization's failure or result in the organization ceasing operations within
					 three (3) months;
(B) That the
					 organization has the financial and administrative capacity to provide timely
					 access to care through an adequate network of qualified health care providers;
					 and
(C) That the organization is
					 not denying or delaying basic health care services or continuity of care for
					 the plan's enrollees assigned to the organization.
(7) If a sub-delegating organization proposes
					 to transfer plan enrollees receiving care from an organization that is
					 compliant with a final CAP to alternative providers and the reassignment is
					 based, in part, on the organization's failure to meet one (1) or more of the
					 Grading Criteria, the sub-delegating organization shall notify the plan, prior
					 to transferring enrollees from the organization, and the plan shall determine
					 whether it is necessary to file with the Department a Block Transfer Filing
					 pursuant to Health and Safety Code section
					 1373.65.
					 In addition to all other criteria for reviewing block transfers, the Director
					 may disapprove, postpone or suspend the sub-delegating organization's proposed
					 transfer of enrollees if the Department reasonably determines:
(A) That the proposed reassignment of
					 enrollees will likely cause the organization's failure or result in the
					 organization ceasing operations within three (3) months;
(B) That the organization has the financial
					 and administrative capacity to provide timely access to care through an
					 adequate network of qualified health care providers; and
(C) That the organization is not denying or
					 delaying basic health care services or continuity of care for the plan's
					 enrollees assigned to the organization.
(8) Notwithstanding subsection (6) and (7) of
					 this section, nothing in these regulations shall limit or impair:
(A) the Director's authority, consistent with
					 Health and Safety Code sections
					 1367,
					 1373.65(b)
					 and
					 1391.5,
					 to require a plan to reassign or transfer plan enrollees to alternate providers
					 or organizations on an expedited basis to avoid imminent harm to
					 enrollees;
(B) an enrollee's right
					 to self-select a new provider; or
(C) the plan's ability to transfer individual
					 enrollees assigned to a provider who terminates his/her relationship with the
					 organization to ensure that the enrollee receives appropriate continuity of
					 care.