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 7 - Standards › Section 1300.67.8 - Contracts with Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Written contracts must be executed between the plan and
					 each provider of health care services which regularly furnishes services under
					 the plan. All contracts with providers shall be subject to the following
					 requirements:
(a) A written contract
				  shall be prepared or arranged in a manner which permits confidential treatment
				  by the Director of payment rendered or to be rendered to the provider without
				  concealment or misunderstanding of other terms and provisions of the
				  contract.
(b) The contract shall
				  require that the provider maintain such records and provide such information to
				  the plan or to the Director as may be necessary for compliance by the plan with
				  the provisions of the Act and the rules thereunder, that such records will be
				  retained by the provider for at least two years, and that such obligation is
				  not terminated upon a termination of the agreement, whether by rescission or
				  otherwise. (See Section
				  1300.75.1)
(c) That the plan shall have access at
				  reasonable times upon demand to the books, records and papers of the provider
				  relating to the health care services provided to subscribers and enrollees, to
				  the cost thereof, to payments received by the provider from subscribers and
				  enrollees of the plan (or from others on their behalf), and, unless the
				  provider is compensated on a fee-for-service basis, to the financial condition
				  of the provider.
(d) The contract
				  shall prohibit surcharges for covered services and shall provide that whenever
				  the plan receives notice of any such surcharge it shall take appropriate
				  action.
(e) The contract shall
				  contain provisions complying with Section
				  1379 of the Act and requiring
				  that, upon termination of the contract of the provider for any cause, such
				  provider shall comply with the provisions of subdivision (a)(10) of Section
				  1300.67.4.
1. Amendment
					 filed 6-2-78; effective thirtieth day thereafter (Register 78, No.
					 22).
2. Amendment of subsection (b) filed 1-12-83; effective
					 thirtieth day thereafter (Register 83, No. 3).
3. Change without
					 regulatory effect amending subsections (a)-(b) filed 7-18-2000 pursuant to
					 section 100, title 1, California Code of
					 Regulations (Register 2000, No. 29).
4. New subsections (f)-(f)(5)
					 filed 10-20-2003; operative 11-19-2003 (Register 2003, No. 43).
5.
					 Repealer of subsections (f)-(f)(5) filed 1-24-2007; operative 2-23-2007
					 (Register 2007, No. 4).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1367,
						1381
						and
						1385,
						Health and Safety Code.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.10 - Discrimination Prohibited. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 12-26-91; operative 1-27-92 (Register 92, No.
					 12).
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 1300.67.11 - Disclosure of Conflicts of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A plan shall not enter into any
				  transaction with a person currently named in Item F of its application under
				  Section 1300.51 (or currently named
				  pursuant to Items 7, 8, or 9 of that application as in effect prior to the
				  effective date of Section
				  1300.51.3) unless, prior thereto,
				  each of the following conditions is met:
(1)
				  The material facts concerning the transaction and the person's interest therein
				  are disclosed to the governing body of the plan.
(2) The transaction is approved by a
				  disinterested majority of the governing body.
(3) Such facts and such approval are made a
				  part of the minutes of such governing body or, if no minutes are required of
				  such governing body, otherwise retained as a record of the
				  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 7 - Standards › Section 1300.67.12 - Contracts with Solicitor Firms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A plan shall not permit a solicitor firm to solicit
					 enrollments or subscriptions on its behalf except pursuant to a written
					 contract which meets all of the following minimum requirements:
(a) All funds received by the solicitor firm
				  for the account of the plan shall at all times be segregated from the assets of
				  the solicitor firm and shall be promptly deposited to a trust account in a
				  state or federal bank authorized to do business in this state and insured by an
				  appropriate federal insuring agency. "Promptly deposited" means deposited no
				  later than the business day following receipt by the solicitor firm.
(b) All funds received by the solicitor firm
				  for the account of the plan shall be transmitted to the plan, or to a person
				  designated in the contract, net of actual commissions earned under the
				  particular contract within (5) five business days after such funds are received
				  by the solicitor firm.
(c) The
				  solicitor firm shall comply and shall cause its principal persons and employees
				  to comply with all applicable provisions of the Act and the rules
				  thereunder.
(d) The solicitor firm
				  shall promptly notify the plan of the institution of any disciplinary
				  proceedings against it or against any of its principal persons or employees
				  relating to any license issued to any such person by the California Insurance
				  Commissioner.
1. Amendment
					 filed 12-20-77 as an emergency; effective upon filing (Register 77, No.
					 52).
2. 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 1300.67.13 - Coordination of Benefits ("COB")

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
(1)
				  This rule does not require the use of COB provisions in plan contracts. If a
				  contract contains a COB provision, the provision must be consistent with the
				  standard provision set forth in subdivision (b), as interpreted by the
				  "Instructions" set forth in that subdivision. COB provisions, or provisions for
				  the reduction of benefits otherwise payable because of other coverage by
				  whatever name designated, which are not consistent with the standard provision
				  set forth in subdivision (b), may not be used, except that plans of coverage
				  designed to be supplementary over the subscriber's or enrollee's underlying
				  basic plan of coverage may provide that coverage shall be excess to that
				  specific subscriber's or enrollee's plan of basic coverage from whatever source
				  provided.
(2) A COB provision may
				  not relieve a plan of a duty otherwise arising from a plan contract to deliver
				  any health care service to any subscriber or enrollee because the subscriber or
				  enrollee may be or is entitled to coverage for the service by any other plan or
				  insurer.
(3) A COB provision may
				  not result in a delay in furnishing any reasonably necessary health care
				  service to any subscriber or enrollee pursuant to a plan
				  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 1300.67.24 - Outpatient Prescription Drug Copayments, Coinsurance, Deductibles, Limitations and Exclusions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every health care service plan that
				  provides coverage for outpatient prescription drug benefits shall provide
				  coverage for all medically necessary outpatient prescription drugs except as
				  described in this section, subject to the requirements of Health and Safety
				  Code section
				  1342.7(g).
(1) Outpatient prescription drugs are
				  self-administered drugs approved by the Federal Food and Drug Administration
				  for sale to the public through retail or mail-order pharmacies that require
				  prescriptions and are not provided for use on an inpatient basis. For purposes
				  of this section "inpatient basis" has the meaning indicated in Section
				  1300.67(b), and
				  "self-administered" means those drugs that need not be administered in a
				  clinical setting or by a licensed health care provider.
(2) Coverage for outpatient prescription
				  drugs shall also include coverage for disposable devices that are medically
				  necessary for the administration of a covered outpatient prescription drug,
				  such as spacers and inhalers for the administration of aerosol outpatient
				  prescription drugs, and syringes for self-injectible outpatient prescription
				  drugs that are not dispensed in pre-filled syringes. For purposes of this
				  section, the term "disposable" includes devices that may be used more than once
				  before disposal. This section does not create an obligation for a plan to
				  provide coverage for a durable medical equipment benefit.
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 1300.67.241 - Prescription Drug Prior Authorization or Step Therapy Exception Request Form Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Health plans that utilize a prescription drug prior authorization or step
				  therapy exception process shall use and accept only the Prescription Drug Prior
				  Authorization or Step Therapy Exception Request Form, numbered 61-211 (Revised
				  12/16), which is incorporated by reference and referred to hereafter in this
				  section as "Form 61-211." This section does not apply to the following except
				  as further specified in this regulation:
(1)
				  Contracted physician groups described in Section
				  1367.241,
				  subdivision (f)(1)-(3) of the Act.
(2) Health plans or their affiliated
				  providers if the health plan owns or operates its pharmacies and does not
				  utilize prescription prior authorizations for prescription drugs.
(3) Physicians or physician groups that have
				  been delegated the financial risk for prescription drugs by a health care
				  service plan and that do not use a prior authorization
				  process.
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 1300.67.50 - Certain Medicare Supplement Contracts: Presumption of Unfairness. [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 (c), new subsection (d)(4),
					 renumbering with amendment to subsections (d)(5) and (d)(6) and amendment of
					 NOTE 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: Sections
						1367
						and
						1384(d),
						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 1300.67.51 - Medicare Supplement Contract Provisions. [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), (b)(1), (b)(10)(A),
					 (b)(10)(N), (c)(2), (c)(4)-(6), (d)(2) and new (d)(3.1)-(vii) 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
						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 1300.67.52 - Medicare Supplement Additional Benefit Requirements. [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. New subsection (b) and subsection renumbering, repealer of
					 subsection (e) and new subsections (f)-(h) filed 1-8-92; operative 1-1-92
					 (Register 92, No. 12).
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: Sections
						1344,
						1367
						and
						1367.15,
						Health and Safety Code. Reference: Sections
						1344,
						1367
						and
						1367.15,
						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 1300.67.53 - Medicare Supplement Minimum Aggregate Benefits. [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), (c), (d), new subsection (e)
					 and relettering 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
						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 1300.67.55 - Medicare Supplement Reporting Requirements. [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(c),
						1352.1
						and
						1367.15,
						Health and Safety Code; 42
						U.S.C. 1395u(h)(3)(B) and
						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 7 - Standards › Section 1300.67.56 - Transitional Requirements for the Conversion of Medicare Supplement Contracts to Conform to Medicare Program Revisions. [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(c)
						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 7 - Standards › Section 1300.67.57 - Format for Notices of Changes in 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,
						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 7 - Standards › Section 1300.67.58 - Participating Physician or Supplier Claims Form Requirement. (Compliance with Section 4081 of the Omnibus Budget Reconciliation Act of 1987) [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
						1367(h)
						and
						1367.15,
						Health and Safety Code; 42
						U.S.C. 1395u(h)(3)(B) and
						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 7 - Standards › Section 1300.67.59 - Format for Reporting Loss Ratio Experience. [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
						1367.15
						and
						1384(d),
						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 8 - Self-Policing Procedures › Section 1300.67.60 - Standing Referral to HIV/AIDS Specialist. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 12-17-2002; operative 1-16-2003 (Register 2002, No.
					 51).
2. Renumbering of former section
					 1300.67.60 to new section
					 1300.74.16 filed 1-10-2008;
					 operative 2-9-2008 (Register 2008, No. 2).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Sections
						1344
						and
						1374.16,
						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 8 - Self-Policing Procedures › Section 1300.68 - Grievance System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every health care service plan shall establish a grievance
					 system pursuant to the requirements of Section
					 1368 of the Act.
(a) The grievance system shall be established
				  in writing and provide for procedures that will receive, review and resolve
				  grievances within 30 calendar days of receipt by the plan, or any provider or
				  entity with delegated authority to administer and resolve the plan's grievance
				  system. The following definitions shall apply with respect to the regulations
				  relating to grievance systems:
(1) "Grievance"
				  means a written or oral expression of dissatisfaction regarding the plan and/or
				  provider, including quality of care concerns, and shall include a complaint,
				  dispute, request for reconsideration or appeal made by an enrollee or the
				  enrollee's representative. Where the plan is unable to distinguish between a
				  grievance and an inquiry, it shall be considered a grievance.
(2) "Complaint" is the same as
				  "grievance."
(3) "Complainant" is
				  the same as "grievant," and means the person who filed the grievance including
				  the enrollee, a representative designated by the enrollee, or other individual
				  with authority to act on behalf of the enrollee.
(4) "Resolved" means that the grievance has
				  reached a final conclusion with respect to the enrollee's submitted grievance,
				  and there are no pending enrollee appeals within the plan's grievance system,
				  including entities with delegated authority.
(A) If the plan has multiple internal levels
				  of grievance resolution or appeal, all levels must be completed within 30
				  calendar days of the plan's receipt of the grievance.
(B) Grievances that are not resolved within
				  30 calendar days, or grievances referred to the Department's complaint or
				  independent medical review system, shall be reported as "pending" grievances
				  pursuant to subsection (f) below. Grievances referred to external review
				  processes, such as reviews of Medicare Managed Care determinations pursuant to
				  42 C.F.R. Part 422 , or the Medi-Cal Fair Hearing process, shall also be
				  reported pursuant to subsection (f) until the review and any required action by
				  the plan resulting from the review is completed.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.68.01 - Expedited Review of Grievances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every plan shall include in its grievance
				  system, procedures for the expedited review of grievances involving an imminent
				  and serious threat to the health of the enrollee, including, but not limited
				  to, severe pain, potential loss of life, limb or major bodily function ("urgent
				  grievances"). At a minimum, plan procedures for urgent grievances shall
				  include:
(1) Immediate notification to the
				  complainant of the right to contact the Department regarding the grievance. The
				  plan shall expedite its review of the grievance when the complainant, an
				  authorized representative, or treating physician provides notice to the plan.
				  Notice need not be in writing, but may be accomplished by a documented
				  telephone call.
(2) A written
				  statement to the Department and the complainant on the disposition or pending
				  status of the urgent grievance within three (3) calendar days of receipt of the
				  grievance by the Plan.
(3)
				  Consideration by the plan of the enrollee's medical condition when determining
				  the response time.
(4) No
				  requirement that the enrollee participate in the plan's grievance process prior
				  to applying to the Department for review of the urgent
				  grievance.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.69 - Public Policy Participation by Subscribers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Unless a plan complies with the requirements of the Health
					 Maintenance Organization Act of 1973 in affording subscribers and enrollees
					 procedures to participate in establishing the public policy of the plan, as
					 defined in Section
					 1369 of the Act, it shall comply
					 with each of the following requirements:
(a) If the plan is a corporation, either:
(1) At least one-third of its governing board
				  shall be subscribers and/or enrollees, or
(2) There shall be established a standing
				  committee which shall be responsible for participating in establishing public
				  policy of the plan as defined in Section
				  1369 of the Act, and whose
				  recommendations and reports are regularly and timely reported to the governing
				  board. The governing board shall act upon such recommendations and such action
				  shall be recorded in the board's minutes. The membership of the standing
				  committee shall comply with each of the following:
(A) At least 51% of the members shall be
				  subscribers and/or enrollees,
(B)
				  At least one member shall be a member of the governing board of the plan,
				  and
(C) At least one member shall
				  be a provider.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.70 - Health Care Service Plan Quality Assurance Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Intent and Regulatory Purpose.
(1) The QA program must be directed by
				  providers and must document that the quality of care provided is being
				  reviewed, that problems are being identified, that effective action is taken to
				  improve care where deficiencies are identified, and that follow-up is planned
				  where indicated.
(2) This section
				  is not intended to set forth a prescriptive approach to QA methodology. This
				  section is intended to afford each plan flexibility in meeting Act quality of
				  care requirements.
(3) A plan's QA
				  program must address service elements, including accessibility, availability,
				  and continuity of care. A plan's QA program must also monitor whether the
				  provision and utilization of services meets professionally recognized standards
				  of practice.
(4) The Department's
				  assessment of a plan's QA program will focus on:
(A) the scope of QA activities within the
				  organization;
(B) the structure of
				  the program itself and its relationship to the plan's administrative
				  structure;
(C) the operation of the
				  QA program; and
(D) the level of
				  activity of the program and its effectiveness in identifying and correcting
				  deficiencies in care.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.70.4 - Independent Medical Reviews Experimental and Investigational Therapies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Enrollees of a
				  health care service plan may request an independent medical review pursuant to
				  sections 1370.4,
				  1374.30 through
				  1374.34 of the Act and section
				  1300.74.30 of title 28 when the
				  plan has denied a therapy or medical service that would otherwise be covered
				  based on the plan's determination that the therapy or medical service is
				  experimental or investigational. This eligibility also applies to Medicare
				  enrollees to the extent it does not conflict with federal law.
(b) At the time of the plan's denial of
				  coverage for experimental or investigational therapy, or denial of urgent care
				  or emergency services, as defined in section
				  1300.67(g)(2),
				  the plan shall notify the enrollee of the ability to seek independent medical
				  review.
(1) The notification must include, at
				  a minimum, information on the independent medical review process, an
				  application and envelope addressed to the Department, the physician
				  certification form and the Department's toll-free information number.
(2) Pursuant to Health and Safety Code
				  section
				  1368.03(a),
				  the Department does not require that an enrollee participate in the plan's
				  grievance system prior to seeking independent medical
				  review.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.71 - Claims Settlement Practices

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Definitions.
(1) "Automatically" means the payment of the
				  interest due to the provider within five (5) working days of the payment of the
				  claim without the need for any reminder or request by the provider.
(A) If the interest payment is not sent in
				  the same envelope as the claim payment, the plan or the plan's capitated
				  provider shall identify the specific claim or claims for which the interest
				  payment is made, include a statement setting forth the method for calculating
				  the interest on each claim and document the specific interest payment made for
				  each claim.
(B) In the event that
				  the interest due on an individual late claim payment is less than $2.00 at the
				  time that the claim is paid, a plan or plan's capitated provider that pays
				  claims (hereinafter referred to as "the plan's capitated provider") may pay the
				  interest on that claim along with interest on other such claims within ten (10)
				  calendar days of the close of the calendar month in which the claim was paid,
				  provided the plan or the plan's capitated provider includes with the interest
				  payment a statement identifying the specific claims for which the interest is
				  paid, setting forth the method for calculating interest on each claim and
				  documenting the specific interest payment made for each
				  claim.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.71.38 - Fast, Fair and Cost-Effective Dispute Resolution Mechanism

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
All health care service plans and their capitated providers
					 that pay claims (plan's capitated provider) shall establish a fast, fair and
					 cost-effective dispute resolution mechanism to process and resolve contracted
					 and non-contracted provider disputes. The plan and the plan's capitated
					 provider may maintain separate dispute resolution mechanisms for contracted and
					 non-contracted provider disputes and separate dispute resolution mechanisms for
					 claims and other types of billing and contract disputes, provided that each
					 mechanism complies with sections
					 1367(h),
					 1371,
					 1371.1,
					 1371.2,
					 1371.22,
					 1371.35,
					 1371.36,
					 1371.37,
					 1371.4,
					 and
					 1371.8
					 of the Health and Safety Code and sections
					 1300.71,
					 1300.71.38,
					 1300.71.4, and
					 1300.77.4 of title 28. Arbitration
					 shall not be deemed a provider dispute or a provider dispute resolution
					 mechanism for the purposes of this section.
(a) Definitions:
(1) "Contracted Provider Dispute" means a
				  contracted provider's written notice to the plan or the plan's capitated
				  provider challenging, appealing or requesting reconsideration of a claim (or a
				  bundled group of substantially similar multiple claims that are individually
				  numbered) that has been denied, adjusted or contested or seeking resolution of
				  a billing determination or other contract dispute (or a bundled group of
				  substantially similar multiple billing or other contractual disputes that are
				  individually numbered) or disputing a request for reimbursement of an
				  overpayment of a claim that contains, at a minimum, the following information:
				  the provider's name; the provider's identification number; contact information;
				  and:
(A) If the dispute concerns a claim or a
				  request for reimbursement of an overpayment of a claim, a clear identification
				  of the disputed item, the date of service and a clear explanation of the basis
				  upon which the provider believes the payment amount, request for additional
				  information, request for reimbursement for the overpayment of a claim, contest,
				  denial, adjustment or other action is incorrect;
(B) If the dispute is not about a claim, a
				  clear explanation of the issue and the provider's position thereon;
				  and
(C) If the dispute involves an
				  enrollee or group of enrollees: the name and identification number(s) of the
				  enrollee or enrollees, a clear explanation of the disputed item, including the
				  date of service and the provider's position thereon.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.71.39 - Unfair Billing Patterns

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except for services subject to the
				  requirements of Section
				  1367.11 of the Act, "unfair
				  billing pattern" includes the practice, by a provider of emergency services,
				  including but not limited to hospitals and hospital-based physicians such as
				  radiologists, pathologists, anesthesiologists, and on-call specialists, of
				  billing an enrollee of a health care service plan for amounts owed to the
				  provider by the health care service plan or its capitated provider for the
				  provision of emergency services.
(b) For purposes of this section:
(1) "Emergency services" means those services
				  required to be covered by a health plan pursuant to Health & Safety Code
				  sections 1345(b)(6),
				  1367(i),
				  1371.4,
				  1371.5 and Title 28, California
				  Code of Regulations, sections
				  1300.67(g) and
				  1300.71.4.
(2) Co-payments, coinsurance and deductibles
				  that are the financial responsibility of the enrollee are not amounts owed the
				  provider by the health care service plan.
(3) "The plan's capitated provider" shall
				  have the same meaning as that provided in section
				  1300.71(a).
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.73.21 - Arbitration and Settlement Agreements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All health care service plans (plans)
				  shall ensure that all arbitration decisions involving the plan and a current or
				  former enrollee shall be provided to the Department as follows:
(1) Within thirty (30) days of receiving a
				  written arbitration decision, the plan shall provide a copy of the complete
				  arbitration decision to the Department. The complete arbitration decision shall
				  have no part of the decision altered or redacted. The complete arbitration
				  decision shall indicate the prevailing party, the amount and other relevant
				  terms of any award, and the reasons for the decision.
(2) On a quarterly basis, plans shall provide
				  the Department with redacted copies of all written arbitration decisions. The
				  plan shall be responsible for redacting the written arbitration decisions
				  ensuring that the names of the enrollee, the plan, witnesses, attorneys,
				  providers, plan employees and health facilities have been removed from the
				  decision. The redacted arbitration decisions will be available for public
				  inspection on the Department's web page (www.dmhc.ca.gov).
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.16 - Standing Referral to HIV/AIDS Specialist

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The definitions and requirements of this
				  section are applicable only to standing referrals made pursuant to Section
				  1374.16 of the Act. Nothing in
				  this section requires an enrollee to transfer to a different primary care
				  provider or limits referral authorizations that are not subject to Section
				  1374.16 of the Act.
(b) For the purposes of this section "AIDS"
				  means Acquired Immunodeficiency Syndrome.
(c) For the purposes of this section
				  "category 1 continuing medical education" means:
(1) For physicians, continuing medical
				  education courses recognized as qualifying for category 1 credit by the Medical
				  Board of California;
(2) For nurse
				  practitioners, continuing education contact hours recognized by the California
				  Board of Registered Nursing;
(3)
				  For physician assistants, continuing education units approved by the American
				  Association of Physician Assistants or those described in either subsection
				  (c)(1) or (c)(2), above.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.72.01 - Scope of Required Benefits for Mental Health and Substance Use Disorders

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  health plan shall provide coverage of health care benefits for preventing,
				  diagnosing, and treating mental health conditions and substance use disorders
				  as medically necessary for an enrollee, in accordance with current generally
				  accepted standards of mental health and substance use disorder care, including
				  but not limited to, the following:
(1) Basic
				  health care services, including the following:
(A) Emergency health care services as defined
				  by Health and Safety Code section
				  1317.1
				  rendered both inside and outside the service area of the applicable network
				  consistent with the Knox-Keene Act.
(B) Urgent care services rendered inside and
				  outside the service area of the of the applicable network consistent with the
				  Knox-Keene Act.
(C) Physician
				  services, including but not limited to consultation and referral to other
				  health care providers and prescription drugs when furnished or administered by
				  a health care provider or facility.
(D) Hospital inpatient services, including
				  services of licensed general acute care, acute psychiatric, and chemical
				  dependency recovery hospitals.
(E)
				  Ambulatory care services, including but not limited to physical therapy,
				  occupational therapy, speech therapy, and infusion therapy.
(F) Diagnostic laboratory services,
				  diagnostic and therapeutic radiologic services, and other diagnostic and
				  therapeutic services.
(G) Home
				  health care service.
(H) Preventive
				  health care services, regardless of whether an enrollee has been diagnosed with
				  a mental health condition or substance use disorder.
(I) Hospice care that is, at a minimum,
				  equivalent to hospice care provided by the federal Medicare Program pursuant to
				  Title XVIII of the Social Security Act (42 U.S.C. Sec.
				  1395 et seq.), (December 2022),
				  and implementing regulations adopted for hospice care under Title XVIII of the
				  Social Security Act in Part 418 of Chapter IV of Title 42 of the Code of
				  Federal Regulations (December 2022), except Subparts A, B, G, and H.
California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.721 - Mental Health and Substance Use Disorder Utilization Review Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A health plan subject to Health and Safety Code section 1374.721 is responsible for ensuring compliance with that section regardless of contracting and/or delegation arrangements. The health plan shall ensure that any specialized health plan, including a mental health plan, or other delegated entity conducting mental health and substance use disorder (MH/SUD) medical necessity and utilization review on its behalf uses only the nonprofit criteria listed in Rule 1300.74.721(c), unless the circumstances set forth in Health and Safety Code section 1374.721(c)(1) and/or (2) apply.
(b) Utilization review as used in this Rule has the same meaning as that term is defined in Health and Safety Code section 1374.721(f)(3) and includes the following procedures or practices:
(1) Issuing or making available practice criteria or guidelines intended to help guide or assist providers in determining, diagnosing, or treating MH/SUD; or
(2) Guiding authorization, modification, or denial of a service if the plan engages in additional or heightened quality monitoring, re-training, re-educating, or adverse action(s) based on the provider's MH/SUD coverage or utilization review determinations.
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 › Section 1300.75 - Agreements with Subsequent Providers. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 9-27-79; effective thirtieth day thereafter (Register 79, No.
					 39).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Stats. 1978, Ch.
						285.
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 › Section 1300.75.1 - Fiscal Soundness, Insurance, and Other Arrangements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A plan shall demonstrate fiscal soundness
				  and assumption of full financial risk as follows:
(1) Demonstrate through its history of
				  operations and through projections (which shall be supported by a statement as
				  to the facts and assumptions upon which they are based) that the plan's
				  arrangements for health care services and the schedule of its rates and charges
				  are financially sound, and provide for the achievement and maintenance of a
				  positive cash flow, including provisions for retirement of existing and
				  proposed indebtedness.
(2)
				  Demonstrate that its working capital is adequate, including provisions for
				  contingencies.
(3) Demonstrate an
				  approach to the risk of insolvency which allows for the continuation of
				  benefits for the duration of the contract period for which payment has been
				  made, the continuation of benefits to subscribers and enrollees who are
				  confined on the date of insolvency in an in-patient facility until their
				  discharge, and payments to unaffiliated providers for services
				  rendered.
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 › Section 1300.75.2 - Plan as Subsequent Provider. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 9-27-79; effective thirtieth day thereafter (Register 79, No.
					 39).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Stats. 1978, Ch.
						285.
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 › Section 1300.75.3 - Subsequent Provider Exemption. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 9-27-79; effective thirtieth day thereafter (Register 79, No.
					 39).
Note: Authority cited: Section
						1344,
						Health and Safety Code. Reference: Stats. 1978, Ch.
						285.
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 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in these Solvency Regulations:
(a) "External party" means the Department of
					 Managed Health Care or its designated agent, which may be contracted or
					 appointed to fulfill the functions stated in these Solvency Regulations.
					 Whenever these Solvency Regulations reference the Department of Managed Health
					 Care it shall mean the Department of Managed Health Care (Department) or its
					 designated agent.
(b)
					 "Organization" means a risk-bearing organization as defined in Health and
					 Safety Code Section
					 1375.4(g).
					 An organization includes an entity that contracts directly with the plan or
					 subcontracts with another organization to arrange for the health care services
					 of a plan's enrollees and meets the requirements of Health and Safety Code
					 section
					 1375.4(g).
(c) "Plan" means full-service health care
					 service plan, as defined by Health and Safety Code section
					 1345(f).
(d) "Risk arrangement" is defined to include
					 both "risk-sharing arrangement" and "risk-shifting arrangement," which are
					 defined as follows:
(1) "Risk-sharing
					 arrangement" means any compensation arrangement between an organization and a
					 plan under which the organization shares the risk of financial gain or loss
					 with the plan.
(2) "Risk-shifting
					 arrangement" means a contractual arrangement between an organization and a plan
					 under which the plan pays the organization on a fixed, periodic or capitated
					 basis, and the financial risk for the cost of services provided pursuant to the
					 contractual arrangement is assumed by the 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 9 - Financial Responsibility › Risk-Bearing Organizations › Section 1300.75.4.3 - Plan Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Plan Quarterly Survey. Every plan that
					 contracts with an organization shall, by May 15, 2001, and not more than
					 forty-five (45) days after the close of each subsequent calendar quarter,
					 submit a quarterly survey report in an electronic format to the Director
					 listing all its contracting organizations, including their names, addresses,
					 contact persons, telephone numbers, and number of enrollees assigned to the
					 organization as of the last day of the quarter being reported.
(b) Plan Annual Survey. Along with the
					 quarterly report due May 15, 2001, and for the report due by May 15 of each
					 subsequent year (i.e., an annual reporting period), every plan shall submit an
					 annual survey report in an electronic format to the Director, containing the
					 following information, as of December 31 of the prior calendar year, for each
					 organization with which the plan has a risk arrangement:
(1) For the plan's commercial,
					 Medicare+Choice, and Medi-Cal product lines, the report shall disclose, in a
					 separate matrix for each product line, the allocation of risk between the plan,
					 the organization, and the facility by major expense category. For each of the
					 plan's commercial, Medicare+Choice, and Medi-Cal product lines, the report
					 shall disclose the number of covered lives and the counties primarily served by
					 the organization.
(2) The report
					 shall disclose whether the plan provides stop-loss insurance to the
					 organization, and if so, the nature of any and all stop-loss
					 arrangements.