28 CA ADC § 1300.84.06


      28 CCR s 1300.84.06

      Cal. Admin. Code tit. 28, s 1300.84.06


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 12. REPORTS
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.84.06. Plan Annual Report.

      The annual report required of a plan pursuant to subdivision (c) of 
      section 1384 of the Act shall include or be accompanied by the following 
      information for the period covered by the report, except as otherwise 
      specified:

      (a) The "Health Maintenance Organization Financial Report of Affairs and 
      Conditions Form" as adopted by the National Association of Insurance 
      Commissioners commonly known as the "HMO Annual Reporting Form" and the 
      "Orange Blank" published by the Brandon Insurance Service Company. The 
      "HMO Annual Reporting Form," revised 1989, is incorporated by reference.

      (b) Sufficient and appropriate supplemental information to provide 
      adequate disclosure of at least the following:

      (1) An explanation of the method of calculating the provision for incurred 
      and unreported claims.

      (2) Accounts and notes receivable from officers, directors, owners or 
      affiliates, including the name of the debtor, nature of the relationship, 
      nature of the receivable and its terms.

      (3) Donated materials or services received by the plan for the period of 
      the financial statements and the donor's name and affiliation with the 
      plan, together with an explanation of the method used in determining the 
      valuation of such materials or services.

      (4) Forgiven debt or obligations during the period of the financial 
      statements, including the creditor's name and affiliation with the plan 
      and a summary of how the obligation arose.

      (5) A calculation of the plan's tangible net equity in accordance with 
      section 1300.76 of these rules. Such calculation shall include disclosure 
      of the following information used to determine the required amount of 
      tangible net equity pursuant to section 1300.76(a) and (b):

      (A) Revenues

      1. Two percent of the first $150 million, or $7.5 million for specialized 
      plans, of annualized premium revenues;

      2. One percent of annualized premium revenues in excess of $150 million, 
      or $7.5 million for specialized plans;

      3. Sum of 1. and 2. above.

      (B) Healthcare Expenditures

      1. Eight percent of the first $150 million, or $7,500,00 for specialized 
      plans of annualized health care expenditures except those paid on a 
      capitated basis or managed hospital payment basis.

      2. Four percent of the annualized health care expenditures, except those 
      paid on a capitated basis or managed hospital payment basis, which are in 
      excess of $150 million, or $7,500,000 for specialized plans;

      3. Four percent of annualized hospital expenditures paid on a managed 
      hospital payment basis.

      4. Sum of 1., 2. and 3. above.

      (6) The percentage of administrative costs to revenue obtained from 
      subscribers and enrollees.

      (7) The amount of health care expenses incurred during the six month 
      period immediately preceding the date of the report which were or will be 
      paid to noncontracting providers or directly reimbursed to subscribers and 
      enrollees.

      (8) Total costs for health care services for the immediately preceding six 
      months.

      (9) If the amount of health care expenses incurred during the six month 
      period immediately preceding the date of the report which were or will be 
      paid to noncontracting providers or directly reimbursed to subscribers and 
      enrollees exceeds 10% of the total costs for health care services for the 
      immediately preceding six months, the following information, determined as 
      of the date of the report, shall be provided:

      (A) Amount of all claims for noncontracting provider services received for 
      reimbursement but not yet processed.

      (B) Amount of all claims for noncontracting provider services denied for 
      reimbursement during the previous 60 days.

      (C) Amount of all claims for noncontracting provider services approved for 
      reimbursement but not yet paid.

      (D) An estimate of the amount of claims for noncontracting provider 
      services incurred, but not reported.

      (E) A calculation of compliance with section 1377(a) as determined in 
      accordance with such section.


      


      Note: Authority cited: Sections 1344 and 1384, Health and Safety Code. 
      Reference: Section 1384, Health and Safety Code. 


       HISTORY 
         
      1. New section filed 5-9-80; effective thirtieth day thereafter (Register 
      80, 
      No. 19).

      2. Amendment filed 7-21-86; effective thirtieth day thereafter (Register 
      86, 
      No. 30).

      3. Amendment filed 12-14-90; operative 12-31-90 (Register 91, No. 6).
      28 CA ADC s 1300.84.06

      END OF DOCUMENT

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