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 1300.75.4.1 - Risk Arrangement Disclosure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every contract involving a risk
					 arrangement between a plan and an organization or between a sub-delegating
					 organization and an organization shall require the plan or the sub-delegating
					 organization to do all of the following:
(1)
					 Disclose through electronic transmission (or in writing, if agreeable to both
					 the organization and the plan or the sub-delegating organization) to the
					 organization, on a monthly basis within fifteen (15) calendar days of the
					 beginning of each report month, the following information for each enrollee
					 assigned to the organization: member identification number, name, birth date,
					 gender, address (including zip code), plan contract selected, employer group
					 identification, the identity of any other third party coverage, if known to the
					 health plan, enrollment/disenrollment dates, medical group/IPA number, provider
					 effective date, type of change to coverage, co-payment, deductible, the amount
					 of capitation to be paid per enrollee per month, and the primary care physician
					 when the selection of a primary care physician is required by the
					 plan.
(2) Disclose through
					 electronic transmission (or in writing, if agreeable to both the organization
					 and the plan or the sub-delegating organization) to the organization, on a
					 monthly basis within fifteen (15) calendar days of the beginning of each report
					 month, the names, member identification numbers, and total numbers of enrollees
					 added or terminated under each benefit plan or sub-delegating organization
					 contract served by the organization.
(3) If the information provided in paragraphs
					 (1) and (2) is provided in more than one report, the plan or sub-delegating
					 organization shall disclose through electronic transmission (or in writing, if
					 agreeable to both the organization and the plan or the sub-delegating
					 organization) to the organization, on a quarterly basis, within forty-five (45)
					 calendar days of the close of each quarter, a reconciliation of the variances
					 between the information provided in paragraphs (1) and (2) above. If the
					 information in paragraphs (1) and (2) is provided in more than one report, all
					 reports shall be processed as of the same date.
(4) On the contract anniversary date,
					 disclose to the organization, for the purpose of assisting the organization to
					 be informed regarding the financial risk assumed under the contract, the
					 following information for each and every type of risk arrangement (including,
					 but not limited to, Medicare Advantage, Medi-Cal, and commercial, including
					 large group, small group, and individual) under the contract, including:
(A) a matrix of responsibility for medical
					 expenses (physician, institutional, ancillary, and pharmacy) which will be
					 allocated to the organization, facility, the plan or the sub-delegating
					 organization under the risk arrangement;
(B) expected/projected utilization rates and
					 unit costs for each major expense service group (inpatient, outpatient, primary
					 care physician, specialist, pharmacy, home health, durable medical equipment
					 (DME), ambulance and other), the source of the data and the actuarial methods
					 employed in determining the utilization rates and unit costs by benefit plan
					 type for the type of risk arrangement; and
(C) all factors used to adjust payments or
					 risk-sharing targets, including but not limited to the following: age, sex,
					 localized geographic area, family size, experience rated, and benefit plan
					 design, including copayment/deductible levels.
(5) Disclose through electronic transmission
					 (or in writing, if agreeable to both the organization and the plan or the
					 sub-delegating organization) to the organization, on a quarterly basis, within
					 forty-five (45) calendar days of the close of each quarter, a detailed
					 description of each and every amount (including expenses and income) that is
					 sufficient to allow verification of the amounts allocated to the organization
					 and to the plan or the sub-delegating organization under each and every
					 risk-sharing arrangement. Where applicable, the following information, at a
					 minimum, shall be provided:
(A) The total
					 number of member months;
(B) The
					 total budget allocation for the member months;
(C) The total expenses paid during the
					 period;
(D) A description of the
					 incurred but not reported (IBNR) claims methodology used for incurred expenses
					 during the period; and
(E) A
					 description of each and every amount of expense allocated to the risk
					 arrangement by member identification number, date of service, description of
					 service by claim codes, net payment and date of payment.
(6) For all risk-sharing arrangements,
					 provide the organization with a preliminary payment report consistent with the
					 requirements of paragraph (5) no later than one-hundred and fifty (150) days
					 and payment no later than one-hundred and eighty (180) days after the close of
					 the organization's contract year, or the contract termination date, whichever
					 occurs first.