28 CA ADC § 1300.43.3
28 CCR s 1300.43.3
Cal. Admin. Code tit. 28, s 1300.43.3
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 1. EXEMPTIONS
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.43.3. Ambulance Plans: Conditional Exemption.
(a) Definitions. For the purposes of this section:
(1) "Ground ambulance services" means the emergency, including advanced
life support services, and non-emergency transportation of an enrollee by
an individual licensed pursuant to Articles 1 and 2 of Chapter 2.5 of
Division 2 of the Vehicle Code where health care services are provided to
an enrollee for the duration of such transportation.
(2) "Air ambulance services" means the emergency, including advanced life
support services, and non-emergency transportation of an enrollee by
legally authorized air ambulance where health care services are provided
to the enrollee for the duration of such transportation.
(b) A health care service plan which lawfully operates air and/or ground
ambulances and provides pursuant to a plan contract only air and/or ground
ambulance services to subscribers and enrollees in ambulances owned or
leased by it and operated by its employees (hereinafter "Ambulance Plan")
is exempted from all provisions of the Knox-Keene Health Care Service Plan
Act of 1975 (Health and Safety Code section 1340 et seq.) except those
provisions specified herein, and subject to the condition that the
Ambulance Plan complies with each of the following requirements:
(1) Every Ambulance Plan shall directly provide ground and/or air
ambulance services for its enrollees throughout the Ambulance Plan's
service area exclusively in ambulances owned or leased by it and operated
by its employees.
(2) At the time of initial enrollment or renewal, every plan contract
between an Ambulance Plan and a group or individual subscriber, and every
disclosure form, evidence of coverage or plan brochure shall prominently
display as a separate article the following legend, in boldface type and
font size not smaller than the font size used in the general body of the
document, either on the first page or on another page if referenced as
"See Important Notices on Page [insert page number] Prior to Purchase" in
boldface type and font size not smaller than the font size used in the
general body of the document on the front page:
(A) "BEFORE YOU PURCHASE: If you are currently enrolled in a health
maintenance organization (HMO) or other health insurance, the benefits
provided by an Ambulance Plan may duplicate the benefits provided by your
HMO or other health insurance. If you have a question regarding whether
your HMO or other health insurance offers benefits for ambulance services,
you should contact that other company directly."
(B) "WARNING: This Ambulance Plan is not an insurance program. It will not
compensate or reimburse another ambulance company that provides emergency
transportation to you or your family. This may occur when the 911
Emergency System has independently determined that another company could
provide more expeditious service or is next in the rotation to receive a
call. This might also occur when this Ambulance Plan is unable to perform
within a medically appropriate timeframe due to a mechanical or
maintenance problem or being on another call." Immediately following this
warning, the Ambulance Plan shall include the words, "sign or initial
here," and include a line for the subscriber's signature or initials.
(C) "COMPLAINTS: For complaints regarding this Ambulance Plan, first
attempt to call the plan at [plan's toll-free telephone number]. If the
Ambulance Plan fails to resolve the complaint to your satisfaction,
contact the Department of Managed Health Care at 1-800-400-0815. The
Department's website is http:// www.dmhc.ca.gov. You may obtain complaint
forms and instructions online."
(D) "OPERATING UNDER CONDITIONAL EXEMPTION: This Ambulance Plan is
operating pursuant to an exemption from the Knox-Keene Health Care Service
Plan Act of 1975 (Health and Safety Code section 1340 et seq.)."
The Ambulance Plan may amend the wording of the legend to use its name and
personal pronouns.
(3) Ambulance Plans that fail to comply with all of subsection (b)(2),
including obtaining the signature or initials of subscribers next to or
under the "WARNING" statement, shall be responsible for paying,
reimbursing, or covering the enrollee's cost for ambulance transportation
services provided by another ambulance company, less any compensation
received from the subscriber's HMO, health insurer, or managed care
organization, if any, and less any applicable overall annual deductible or
any co-payment.
(4) An Ambulance Plan shall operate in compliance with the requirements of
each local emergency medical services agency (Health and Safety Code
section 1797.94) that regulates emergency services in any portion of the
plan's service area and that has developed an emergency medical services
plan (Health and Safety Code section 1797.76) for an emergency medical
services system (Health and Safety Code section 1797.78), implemented
pursuant to the authority granted in Health and Safety Code section
1797.105(b).
(5) No Ambulance Plan shall offer or sell plan contracts to or for persons
who do not live or work in the plan's service area, or use or permit the
use of any advertising or solicitation regarding its services outside of
its service area. Every Ambulance Plan shall comply with the following
sections of the Health and Safety Code: 1360, 1363.1, 1365(a), 1365.5,
1366, subsections (a), (b), (c), (d), (e)(1), (f), (g), and (h)(1) of
section 1367, 1368, 1368.01, 1368.02(b), 1373(a), 1379, 1381, subsections
(a), (d), and (f) of 1384, and 1385, except that approval by the
Department under section 1368(a)(1) is waived.
(6) Every Ambulance Plan shall maintain a procedure whereby enrollees, or
authorized persons on their behalf, may submit grievances to the plan and
in each case receive from the plan a written acknowledgement within five
days of receipt of the grievance and a written response sent within 30
days of receipt of the grievance indicating what the plan will do to
resolve the grievance. Both the acknowledgement and the response shall
include a notice that the enrollee may contact the Department of Managed
Health Care through the Department's toll-free telephone number after the
grievance has been pending with the plan for at least 30 days.
(7) No Ambulance Plan contract shall require, nor shall the Ambulance Plan
or any contracting provider collect, a co-payment of greater than 50
percent of an ambulance or other emergency care provider's negotiated
fee-for-service rate pursuant to a contract with the ambulance service,
or, in the absence of such a contract, 50 percent of the ambulance
company's usual, customary, and reasonable rate (within the meaning of
Business and Professions Code section 657(c)) for the particular service,
or $500, whichever amount is less. An Ambulance Plan that does not impose
any co-payments may impose an overall annual deductible of a specified
dollar amount applicable to all covered services, provided that the
deductible for an enrollee shall not exceed:
(A) 200 percent of the amount of prepaid or periodic charge for one year
for the enrollee; or
(B) 200 percent of the amount of prepaid or periodic charge for one year
for the family, whichever is less.
(8) Every Ambulance Plan operating ground or air ambulances shall:
(A) If operating a ground ambulance, provide proof to the Director upon
request that the Ambulance Plan currently complies with Articles 1 and 2
of Chapter 2.5 of Division 2 of the California Vehicle Code, including but
not limited to license and certification requirements, and with
professionally recognized standards of patient care and safety in
emergency medical services and transport.
(B) If operating an air ambulance, provide proof to the Director upon
request that the Ambulance Plan currently complies with regulations
established by the Federal Aviation Administration and with professionally
recognized standards of patient care and safety in emergency medical air
services and transport.
(9) Every Ambulance Plan operating air ambulances shall comply with the
general standards and other applicable standards and provisions of the
"Association of Air Medical Services Standards and Safety Guidelines for
Fixed Wing, Rotorwing, & Critical Care Ground Services," revised June 2000
and published by the Association of Air Medical Services, which is
incorporated by reference.
(10) No Ambulance Plan shall receive prepaid or periodic charges pursuant
to its plan contract for more than one year in advance.
(11) Every Ambulance Plan shall deliver:
(A) To each prospective subscriber, upon presenting a plan contract for
offer or sale, a disclosure form, combined disclosure form and evidence of
coverage, or copy of its plan contract,
(B) Annually, to each subscriber a copy of its plan contract and evidence
of coverage, and
(C) To each subscriber and enrollee a membership card or other form of
identification easily carried by the subscriber or enrollee that indicates
that the subscriber or enrollee is an Ambulance Plan member and that lists
phone numbers and other instructions for activating ambulance transport.
(12) The plan contract and any disclosure form and evidence of coverage
used by the Ambulance Plan, shall comply with Health and Safety Code
sections 1362 and 1363 and the rules of the Director of the Department of
Managed Health Care pursuant to and including sections 1300.63, 1300.63.1,
1300.63.2, and 1300.63.3 of title 28.
(13) Every Ambulance Plan must maintain documentation demonstrating
compliance with all the conditions of the exemption and provide to the
Department of Managed Health Care all or any part of such documentation as
required by the Department within 30 days of request.
(14) No Ambulance Plan shall purport to rely on the exemption pursuant to
this section if the Director has issued an order of termination pursuant
to subsection (c).
(c) An Ambulance Plan's exemption pursuant to this section may be
terminated by order of the Director, upon a determination that such action
is in the public interest and for the protection of enrollees, or for any
of the following reasons:
(1) The services of the Ambulance Plan are not accessible to enrollees.
(2) The Ambulance Plan, or a person employed by the Ambulance Plan, has
failed to comply with licensing or certification requirements imposed by
law.
(3) The Ambulance Plan is operating in an unsafe, unfair, unreasonable or
discriminatory manner as to its enrollees or as to its enrollment
practices.
(4) The financial condition of the Ambulance Plan is such that its
continued operation will constitute a substantial risk to its subscribers
and enrollees.
(5) The Ambulance Plan has engaged in conduct proscribed by the Health and
Safety Code section 1386(b), subsections (5), (6), (7), (8), (9), (10),
(11), or (14).
(6) The Ambulance Plan has been or is subject to a limitation,
requirement, condition, adverse action, or disciplinary action taken by a
licensing agency or an emergency medical services agency that would
materially impair its ability to perform its plan contracts or constitute
or result in a violation of the provisions of this section or of the
referenced provisions of the Act.
(7) The Ambulance Plan has violated any condition of this exemption.
(d) An Ambulance Plan's exemption pursuant to this section shall terminate
automatically by operation of law upon the plan's failure to comply with
any of the conditions set forth in subsection (b).
(e) An Ambulance Plan whose exemption has been terminated by operation of
law because of failure to comply with the conditions set forth in
subsection (b) or by order of the Director under subsection (c) shall be
in violation of section 1349 of the Health and Safety Code and shall be
subject to all of the provisions of the Knox-Keene Health Care Service
Plan Act of 1975, including but not limited to the provisions relating to
discipline and enforcement procedures.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Section 1343(b), Health and Safety Code.
HISTORY
1. New section filed 9-30-76 as an emergency; effective upon filing
(Register
76, No. 40).
2. Certificate of Compliance filed 1-27-77 (Register 77, No. 5).
3. Amendment filed 4-2-79; effective thirtieth day thereafter (Register
79,
No. 14).
4. Editorial correction of subsections (a)7.f. and (b)(6) (Register 80,
No.
4).
5. Change without regulatory effect amending section filed 4-4-2000
pursuant
to section 100, title 1, California Code of Regulations (Register 2000,
No. 14).
6. Change without regulatory effect amending section filed 7-18-2000
pursuant
to section 100, title 1, California Code of Regulations (Register 2000,
No. 29).
7. Change without regulatory effect updating title references in Notice
filed
12-22-2000 pursuant to section 100, title 1, California Code of
Regulations
(Register 2000, No. 51).
8. Change without regulatory effect amending subsection (a) -form filed
11-21-
2002 pursuant to section 100, title 1, California Code of Regulations
(Register 2002, No. 47).
9. Repealer and new section heading and section and amendment ofNote filed
7-
24-2003; operative 8-23-2003 (Register 2003, No. 30).
28 CA ADC s 1300.43.3
END OF DOCUMENT
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