28 CA ADC § 1300.67.4
28 CCR s 1300.67.4
Cal. Admin. Code tit. 28, s 1300.67.4
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
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.67.4. Subscriber and Group Contracts.
(a) All subscriber and group contracts and endorsements and amendments
shall be printed legibly in not less than 8-point type and shall include
at least the following:
(1) The information required to be included on disclosure forms by Section
1363(a) of the Code and
(A) the information required to be included on disclosure forms by Section
1300.63 (except subsections (2), (3), (4) and (11) of subsection (b)
thereof), and required to be included on evidences of coverage by
subsections (b)(2) and (c) (except subsection (16) thereof) of Section
1300.63.1, or
(B) if the plan complies with the provisions of Section 1300.63.2, the
information required to be included on combined evidences of coverage and
disclosure forms by Section 1300.63.2 (except subsections (1) and (4) of
subsection (b) and subsections (2), (25), and (27) of subsection (c)
thereof).
(2) Definitions of all terms contained in the contract.
(A) Which are defined by the Act or Chapter 1 of Title 28 of the
California Code of Regulations,
(B) Which are any of the following: "pre-existing condition," "guaranteed
renewable," or "non-cancellable," or,
(C) Which require definition in order to be understood by a reasonable
person not possessing special knowledge of law, medicine, or plans;
(D) Which specifically describes the eligibility of persons as subscribers
or enrollees.
(3) Appropriate captions, in boldface type, for the following provisions:
limitations, exclusions, exceptions, reductions, deductibles, copayments
and other provisions which may decrease or limit benefits to, or increase
costs of, any subscriber or enrollee;
(A) A benefit afforded by the contract shall not be subject to any
limitation, exclusion, exception, reduction, deductible, or copayment
which renders the benefit illusory.
(4) In the same section describing any particular benefit(s), any
provisions described in (3) above which are applicable only to any such
particular benefit(s);
(5) Provisions relating to cancellation under an appropriate caption, in
boldface type, which provisions shall include:
(A) A statement of the bases for cancellation, which shall conform to
Section 1365(a) of the Act and these rules;
(B) A statement of the opportunity for review of certain cancellations by
the Director as provided in Section 1365(b) of the Code;
(C) A statement that, in the event of cancellation by either the plan
(except in the case of fraud or deception in the use of services or
facilities of the plan or knowingly permitting such fraud or deception by
another) or the other party, the plan shall within 30 days return to the
other part the pro rata portion of the money paid to plan which
corresponds to any unexpired period for which payment had been received
together with amounts due on claims, if any, less any amounts due the
plan;
(D) A statement of the time when a notice of cancellation becomes
effective;
(E) A statement that receipt by the plan of the proper prepaid or periodic
payment after cancellation of the contract for nonpayment shall reinstate
the contract as though it had never been cancelled if such payment is
received on or before the due date of the succeeding prepaid or periodic
payment, provided, however, that the contract may specify one or more of
the following methods by which the plan may avoid such reinstatement:
1. In the notice of cancellation, the plan notifies the other party that
if payment is not received within 15 days of issuance of the notice of
cancellation, a new application is required and the conditions under which
a new contract will be issued or the original contract reinstated; or
2. If such payment is received more than 15 days after issuance of the
notice of cancellation, the plan refunds such payment within 20 business
days; or
3. If such payment is received more than 15 days after issuance of the
notice of cancellation, the plan issues to the other party, within 20
business days of receipt of such payment, a new contract accompanied by
written notice stating clearly those respects in which the new contract
differs from the cancelled contract in benefits, coverage or otherwise;
(6) A provision prohibiting the plan from increasing the amount paid by
the other party, except after a period of at least 30 days from and after
the postage paid mailing to the other party at the other party's most
current address of record with the plan;
(7) A provision prohibiting the plan from decreasing in any manner the
benefits stated in the contract, except after a period of at least 30 days
from and after the postage paid mailing to the other party at the other
party's most current address of record with the plan;
(8) A provision requiring the plan to provide written notice within a
reasonable time to the other party of any termination or breach of
contract by, or inability to perform of, any contracting provider if the
other party may be materially and adversely affected thereby;
(9) A provision that (i) the plan is subject to the requirements of
Chapter 2.2 of Division 2 of the Code and of Chapter 1 of Title 28 of the
California Code of Regulations, and (ii) any provision required to be in
the contract by either of the above shall bind the plan whether or not
provided in the contract.
(10) A provision that, upon termination of a provider contract, the plan
shall be liable for covered services rendered by such provider (other than
for copayments as defined in subdivision (g) of Section 1345) to a
subscriber or enrollee who retains eligibility under the applicable plan
contract or by operation of law under the care of such provider at the
time of such termination until the services being rendered to the
subscriber or enrollee by such provider are completed, unless the plan
makes reasonable and medically appropriate provision for the assumption of
such services by a contracting provider.
(11) In the case of a group contract, a reasonable provision requiring the
group contract holder to mail promptly to each subscriber a legible, true
copy of any notice of cancellation of the plan contract which may be
received from the plan and to provide promptly to the plan proof of such
mailing and the date thereof, if the plan wishes to obligate the group
contract holder in connection with the obligations imposed on the plan by
Section 1300.65.
(b) For the purposes of this section:
(1) "Other party" means (i) in the case of a group contract, the group
representative designated in the contract, and (ii) in the case of an
individual contract, the subscriber.
(2) Any express or implied requirement of notice to the other party, in
the context of a group contact, requires notice to the group
representative designated in the contract and, with respect to material
matters, to subscribers and enrollees under the group contract; however, a
plan may fulfill any obligation imposed by this section to notify
subscribers and enrollees under a group contract if it provides notice to
the group representative designated in the contract, and the group
contract requires the group representative to disseminate such notice to
subscribers and enrollees in the group by the next regular communication
to the group but in no event later than 30 days after the receipt thereof.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Sections 1367 and 1379, Health and Safety Code.
HISTORY
1. New subsection (a)(10) filed 6-2-78; effective thirtieth day thereafter
(Register 78, No. 22).
2. Amendment of subsection (a)(5) filed 9-27-79; effective thirtieth day
thereafter (Register 79, No. 39).
3. Amendment of subsection (a) filed 1-12-83; effective thirtieth day
thereafter (Register 83, No. 3).
4. Amendment of subsections (a)(2)(A), (a)(6), (a)(7) and (a)(9) filed
12-26-
91; operative 1-27-92 (Register 92, No. 12).
5. Change without regulatory effect amending subsection (a)(5)(B) filed
7-18-
2000 pursuant to section 100, title 1, California Code of Regulations
(Register 2000, No. 29).
6. Change without regulatory effect amending subsections (a)(2)(A) and
(a)(9)
filed 12-22-2000 pursuant to
section 100, title 1, California Code ofRegulations (Register 2000, No.
51).
28 CA ADC s 1300.67.4
END OF DOCUMENT
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