28 CA ADC § 1300.69


      28 CCR s 1300.69

      Cal. Admin. Code tit. 28, s 1300.69


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

      s 1300.69. Public Policy Participation by Subscribers.

      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.

      (b) If the plan is a partnership, trust or unincorporated association, 
      there shall be established a standing committee of the governing body or 
      executive committee of the plan, which committee shall be responsible for 
      participation 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 body or executive committee 
      of the plan. The governing body or executive committee of the plan shall 
      act upon such recommendations and such action shall be recorded in its 
      minutes. The membership of the standing committee shall comply with each 
      of the following:

      (1) At least 51% of the members shall be subscribers and/or enrollees,

      (2) At least one member shall also be a member of the governing body or 
      executive committee of the plan, and

      (3) At least one member shall be a provider.

      (c) If the plan is a sole proprietorship, it shall establish a standing 
      committee which shall be responsible for participation in establishing 
      public policy of the plan as defined in Section 1369 of the Act and whose 
      recommendations are reported regularly and timely to the sole proprietor. 
      The sole proprietor shall act upon such recommendations and such action 
      shall be recorded. The membership of the standing committee shall comply 
      with each of the following:

      (1) At least 51% of the members shall be subscribers and/or enrollees,

      (2) The sole proprietor shall be a member, and

      (3) At least one provider shall be a member.

      (d) Those individuals who fulfill the requirements stated in this section 
      for subscriber and/or enrollee membership upon the governing body or 
      standing committee shall be persons who are not employees of the plan, 
      providers of health care services, subcontractors to the plan or group 
      contract brokers, or persons financially interested in the plan.

      (e) Advisory committees do not meet the requirements of subsections (a), 
      (b) or (c).

      (f) Enrollees and subscribers participating in establishing public policy 
      shall have access to information available from the plan regarding public 
      policy, including financial information and information about the specific 
      nature and volume of complaints received by the plan and their 
disposition.

      (g) In connection with the selection of enrollee and subscriber members of 
      any governing board or standing committee, the plan shall generally 
      consider the makeup of its enrollee and subscriber population, including 
      but not limited to factors such as ethnic extraction, demography, 
      occupation and geography as well as identifiable and individual group 
      participation. Any such selection or election of enrollee or subscriber 
      members shall be conducted on a fair and reasonable basis. This subsection 
      does not require the plan to maintain supporting statistical data.

      (h) The public policy participation procedure shall be incorporated into 
      the bylaws or other governing documents of the plan. The terms of 
      subscriber and enrollee members of the public policy making body shall be 
      of reasonable length and overlap so as to provide continuity and 
      experience in representation. A standing committee shall meet at least 
      quarterly.

      (i) The plan shall (1) in each evidence of coverage or combined evidence 
      of coverage and disclosure form, or at least annually by other means, 
      furnish to its subscribers and enrollees a description of its system for 
      their participation in establishing public policy, and (2) communicate 
      material changes affecting public policy to subscribers and enrollees.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Section 1369, Health and Safety Code. 


       HISTORY 
         
      1. Amendment of subsection (i) filed 1-12-83; effective thirtieth day
      thereafter (Register 83, No. 3).
      28 CA ADC s 1300.69

      END OF DOCUMENT

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