28 CA ADC § 1300.75.4.1
28 CCR s 1300.75.4.1
Cal. Admin. Code tit. 28, s 1300.75.4.1
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
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.75.4.1. Risk Arrangement Disclosure.
(a) Every contract involving a risk arrangement between a plan and an
organization shall require the plan to do all of the following:
(1) Disclose through electronic transmission (or in writing, if agreeable
to both the organization and the plan) to the organization, on amonthly
basis, beginning with the month of May, 2001, within 10 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) to the organization, on a monthly
basis, beginning with the month of May, 2001, within 10 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 contract served by the organization.
(3) If the information provided in paragraphs (1) and (2) is provided in
more than one report, the plan will disclose through electronic
transmission (or in writing, if agreeable to both the organization and the
plan)to the organization, on a quarterly basis, within 45 calendar days of
theclose of each quarter, a reconciliation of the variances between the
information provided in paragraphs (1) and (2) above. Beginning no
laterthan January 1, 2002, if the information in paragraphs (1) and (2) is
provided in more than one report, all reports shall be processed as of the
samedate.
(4) On or before October 1, 2001, and annually thereafter 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
everytype of risk arrangement (Medicare + Choice, Medi-Cal, traditional
commercial, Point of Service, small group, and individual plans) under the
contract:
(A) a matrix of responsibility for medical expenses (physician,
institutional, ancillary, and pharmacy) which will be allocated to the
organization, facility, or the plan 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) Beginning with the first quarter of calendar year 2001, disclose
through electronic transmission (or in writing, if agreeable to both the
organization and the plan) to the organization, on a quarterly basis,
within 45 calendar days of the close of each quarter, a detailed
description ofeach and every amount (including expenses and income) that
is sufficient to allow verification of the amounts allocated to the
organization and tothe plan under each and every risk-sharing arrangement.
Where applicable, the following information, at a minimum, shall be
provided: 1. the total number of member months; 2. the total budget
allocation for the member months; 3. the total expenses paid during the
period; 4. a description of the incurred but not reported (IBNR) claims
methodology used for incurred expenses during the period; and 5. 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 150 days and payment no later than 180 days after the
close of the organization's contract year, or the contract termination
date, whichever occurs first.
(b) In addition to the disclosures required by subsection (a) of this
regulation, every contract involving a risk-sharing arrangement between a
plan and an organization shall require the plan to disclose, on or before
October 1, 2001, and annually thereafter on the contract anniversary date,
the amount of payment for each and every service to be provided under the
contract, including any fee schedules or other factors or units used in
determining the fees for each and every service. To the extent that
reimbursement is made pursuant to a specified fee schedule, the contract
shall incorporate that fee schedule by reference, and further specify the
Medicare RBRVS year if RBRVS is the methodology used for fee schedule
development. For any proprietary fee schedule, the contract must include
sufficient detail that payment amounts related to that fee schedule can be
accurately predicted.
(c) In addition to the disclosures required by subsection (a) of this
regulation, every contract involving a risk-shifting arrangement between a
plan and an organization shall require the plan to disclose, on or before
October 1, 2001, and annually thereafter on the contract anniversary date,
in the case of capitated payment, the amount to be paid per enrollee per
month. For any deductions that the plan may take from any capitation
payment, details sufficient to allow the organization to verify the
accuracy and appropriateness of the deduction shall be provided.
Note: Authority cited: Sections 1344 and 1375.4, Health and Safety Code.
Reference: Section 1375.4, Health and Safety Code.
HISTORY
1. New section filed 3-22-2001 as an emergency; operative 3-22-2001
(Register2001, No. 12). A Certificate of Compliance must be transmitted to
OAL by7-20-2001 or emergency language will be repealed by operation of law
on
thefollowing day.
2. Certificate of Compliance as to 3-22-2001 order, including amendment
section, transmitted to OAL 7-20-2001 and filed 8-31-2001 (Register 2001,
No.35).
28 CA ADC s 1300.75.4.1
END OF DOCUMENT
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