28 CA ADC § 1300.75.4.5
28 CCR s 1300.75.4.5
Cal. Admin. Code tit. 28, s 1300.75.4.5
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 1300.75.4.5. Plan Compliance.
(a) Every plan that maintains a risk arrangement with an organization
shall have adequate procedures in place to ensure:
(1) That plan personnel review all reports and financial information made
available pursuant to Health and Safety Code section 1375.4 and these
Solvency Regulations as part of the plan's responsibility to evaluate and
ensure the financial viability of its arrangements consistent with section
1300.70(b)(2)(H)(1) of Title 28, California Code of Regulations;
(2) That appropriate action(s) are taken following the Department's
written notification to an organization's contracting health plan(s) that:
(A) The organization has failed to substantially comply with the reporting
obligations specified in section 1300.75.4.2 of Title 28, California Code
of Regulations, by failing to file a required periodic financial and
organizational information disclosure, including the filing of an annual
financial survey report based upon an audited financial statement prepared
in accordance with generally accepted accounting principles (GAAP), or by
failing to include significant portions of information on a required
periodic financial organizational information disclosure;
(B) The organization has refused to permit the activities of the
Department as specified in Health and Safety Code section 1375.4 or in
these Solvency Regulations; or,
(C) The organization has failed to substantially comply with the
requirements of a final CAP for a period of more than 90 days, as
determined by the Department.
(3) Appropriate action shall include, but is not limited to, a prohibition
on the assignment or addition of any additional enrollees to the risk
arrangement with that organization without the prior written approval of
the Director. The prohibition on assignments of additional enrollees to an
organization pursuant to subsection (2) shall not apply to dependents of
enrollees who are already under the risk-arrangement with the organization
or to enrollees who selected the organization during an open enrollment or
other selection period that was prior to the effective date of the
prohibition on the assignment of additional enrollees. The prohibition on
the assignment of additional enrollees shall take effect thirty (30) days
after the date of Department's notification to the organization's
contracting plan(s), and shall remain in effect until the Department
notifies the organization's contracting health plan in writing that the
organization's non-compliance has been remedied.
(4) That the plan complies with the corrective action process and
cooperates in the implementation of a final CAP, including, but not
limited to, implementing contingency plans for continuous delivery of
health care services to plan enrollees served by the organization.
(5) That the plan shall advise the Department and the organization in
writing within five (5) days of becoming aware: 1. that a contracting
organization is not in compliance with the requirements of a final CAP, or
2. that an organization's conduct may cause the plan to be subject to
disciplinary action pursuant to Health and Safety Code section 1386.
(6) That if a plan proposes to transfer plan enrollees receiving care from
an organization that is compliant with a final CAP to alternative
providers and the reassignment is based, in part, on the organization's
failure to meet one or more of the Grading Criteria, the plan shall, prior
to transferring enrollees from that organization, file with the Department
a Block Transfer Filing pursuant to Health and Safety Code section
1373.65. In addition to all other criteria for reviewing block transfers,
the Director may disapprove, postpone or suspend the plan's proposed
transfer of enrollees if the department reasonably determines:
(A) That the proposed reassignment of enrollees will likely cause the
organization's failure or result in the organization ceasing operations
within three (3) months;
(B) That the organization has the financial and administrative capacity to
provide timely access to care through an adequate network of qualified
health care providers; and
(C) That the organization is not denying or delaying basic health care
services or continuity of care for the plan's enrollees assigned to the
organization.
(7) Notwithstanding subsection (6) of this section, nothing in these
regulations shall limit or impair 1. the Director's authority, consistent
with Health and Safety Code sections 1367, 1373.65 (b) and 1391.5, to
require a plan to reassign or transfer plan enrollees to alternate
providers or organizations on an expedited basis to avoid imminent harm to
enrollees; 2. an enrollee's right to self-select a new provider; or 3. the
plan's ability to transfer individual enrollees assigned to a provider who
terminates his/her relationship with the organization to ensure that the
enrollee receives appropriate continuity of care.
(b) Every contract involving a risk arrangement between a plan and an
organization shall provide that an organization's failure to substantially
comply with the contractual requirements required by these Solvency
Regulations shall constitute a material breach of the risk arrangement
contract. A plan shall not request or accept a waiver of any the
contractual requirements set forth in these Solvency Regulations.
(c) Within 30 days of notification pursuant to section
1300.75.4.5(a)(2)(C) of Title 28, California Code of Regulations, a plan
shall submit to the Department a specific Provider Transition Plan for the
deficient organization which provides for the continuity of care for plan
enrollees served by the organization.
(d) Any failure of a plan to comply with the requirements of Health and
Safety Code section 1375.4 and these Solvency Regulations shall constitute
grounds for disciplinary action against the plan pursuant to Health and
Safety Code section 1386.
(e) The Director may seek and employ any combination of remedies and
enforcement procedures provided under the Knox-Keene Act to enforce Health
and Safety Code section 1375.4 and these Solvency Regulations.
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
(Register
2001, No. 12). A Certificate of Compliance must be transmitted to OAL by
7-
20-2001 or emergency language will be repealed by operation of law on the
following day.
2. Certificate of Compliance as to 3-22-2001 order transmitted to OAL
7-20-2001
and filed 8-31-2001 (Register 2001, No. 35).
3. Repealer and new section filed 8-10-2005; operative 9-9-2005 (Register
2005, No. 32).
28 CA ADC s 1300.75.4.5
END OF DOCUMENT
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