28 CA ADC § 1300.63


      28 CCR s 1300.63

      Cal. Admin. Code tit. 28, s 1300.63


      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
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.63. Disclosure Form.

      (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.

      (b) The disclosure form shall be arranged and captioned in the following 
      manner, except as may otherwise be permitted by the Director.

      (1) The name of the plan and, if necessary, a designation of the plan 
      contract described in the form.

      (2) The title of the form (e.g., "disclosure form," "summary of contract 
      provisions").

      (3) A statement in at least 10-point bold face type to the effect that the 
      disclosure form is a summary only and that the plan contract itself should 
      be consulted to determine the governing contractual provisions.

      (4) A statement to the effect that a specimen copy of the plan contract 
      will be furnished on request.

      (5) The caption "Principal Benefits and Coverages," followed by a 
      description of such benefits and coverages.

      (6) The caption "Principal Exclusions and Limitations on Benefits," 
      followed by a description of the principal exclusions, exceptions, 
      reductions and limitations that apply, and arranged in a uniform manner 
      with the preceding section of the form.

      (7) The caption "Prepayments Fees" followed by a statement of the methods 
      by which such premium may be paid; the full premium charge of the plan; 
      and a statement of the authority to change the fees during the term of the 
      contract.

      (8) The caption "Other Charges," followed by a description of each 
      co-payment, co-insurance, or deductible requirement that may be incurred 
      by the member or the member's family in obtaining coverage under the plan.

      (9) The caption "Choice of Physicians and Providers," followed by a 
      description of the nature, extent and circumstances under which choice is 
      permitted. This section shall include, if applicable, a subcaption 
      "Liability of Subscriber or Enrollee for Payment" followed by a 
      description of the financial liability which is, or may be, incurred by 
      the subscriber, enrollee or a third party by reason of the exercise of 
      such choice.

      (10) If applicable, the caption "Reimbursement Provisions," followed by a 
      description of the circumstances under which reimbursements are made under 
      the plan contract, the extent of reimbursement, and the method of claim 
      for reimbursement.

      (11) The caption "Facilities," followed by a statement of the principal 
      facilities available under the plan contract, including their location and 
      a description of the services, provided. The hours of availability of both 
      emergency and nonemergency services should be indicated, either 
      specifically or by general description. However, if the Director approves 
      in advance, a plan may provide a telephone number from which information 
      as to the identity and location of provider facilities defined in 
      subsection (i)(2) of Section 1300.45 may be obtained, in lieu of listing 
      such provider facilities.

      (12) The caption "Renewal Provisions," followed by a statement of the 
      terms under which the plan contract may be renewed by the group or the 
      plan member, including any reservation by the plan of any right to change 
      premiums or other plan contract provisions.

      (13) In the case of group contracts, the caption "Individual Continuation 
      of Benefits," followed by a statement of the terms and conditions under 
      which subscribers and enrollees may remain in the plan, as provided 
      pursuant to Subdivision (g) of Section 1373 of the Act.

      (14) The caption "Termination of Benefits," followed by a statement of the 
      terms and conditions for cancellation or termination of benefits, 
      including a statement as to when benefits shall cease in the event of 
      nonpayment of the prepaid or periodic charge and the effect of nonpayment 
      upon a member who is hospitalized or undergoing treatment for an ongoing 
      condition.

      (c) In the event the receipt of benefits or reimbursements to subscribers 
      or enrollees under the plan contract is subject to significant delays, 
      based upon the current experience of the plan, the disclosure form may be 
      required by the Director to disclose such facts.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Section 1363, Health and Safety Code. 


       HISTORY 
         
      1. Amendment filed 1-12-83; effective thirtieth day thereafter (Register 
      83, 
      No. 3).

      2. Change without regulatory effect amending subsections (b), (b)(11) and 
      (c)
      filed 7-18-2000 pursuant to 
      section 100, title 1, California Code ofRegulations (Register 2000, No. 
      29).
      28 CA ADC s 1300.63

      END OF DOCUMENT

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