TITLE 28. Managed Health Care

DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
 
CHAPTER 1. DEPARTMENT ADMINISTRATION
 
ARTICLE 1. CONFLICT OF INTEREST
s 1000. Conflict of Interest Code for the Department of Managed Health Care.

Appendix
 
ARTICLE 2. ADMINISTRATION
s 1001. Department Internet Web Page and Web Addresses.

s 1002. Appearance and Practice Before the Department.

s 1003. Public Comment During Department Meetings.

s 1004. Verification.

s 1005. Interpretive Opinions.

s 1006. Inspection of Public Records.

s 1007. Request for Confidentiality.

s 1008. Availability of Department Forms, Publications and Notices; Fees.

s 1009. Retention of Department Records.

s 1010. Consumer Participation Program.

s 1011. Assessment for University of California Analysis of Proposed Mandate Legislation.
 
ARTICLE 3. ELECTRONIC FILING
s 1300.41.8. Electronic Filing.
 
CHAPTER 2. HEALTH CARE SERVICE PLANS
28 CA ADC T. 28, Div. 1, Chap. 2, References and Annotations
 
ARTICLE 1. EXEMPTIONS
s 1300.43. Small Plans.

s 1300.43.1. New Plans.

s 1300.43.2. Extension for Enrollers Under Medi-Cal Program.

s 1300.43.3. Ambulance Plans: Conditional Exemption.

s 1300.43.4. Employee Welfare Benefit Plans.

s 1300.43.5. Exemption for Licensees of Insurance Commissioner.

s 1300.43.6. Moribund Plans.

s 1300.43.7. Student Emergency Care Arrangements.

s 1300.43.8. Public Agencies.

s 1300.43.9. Unlicensed Solicitors and Solicitor Firms.

s 1300.43.10. Nonprofit Retirees' Plan.

s 1300.43.11. Exemption for Solicitors of Nonprofit Retirees' Plans.

s 1300.43.12. Medi-Cal Dental Contract.

s 1300.43.13. Mutual Benefit Plans.

s 1300.43.14. Employee Assistance Programs.

s 1300.43.15. Foreign Plans.
 
ARTICLE 2. ADMINISTRATION
s 1300.44. Interpretive Opinions.

s 1300.44.1. Application for Exemption from Rule.

s 1300.45. Definitions.

s 1300.46. Prohibition of Bonuses or Gratuities in Solicitations.

s 1300.47. Advisory Committee on Managed Health Care.
 
ARTICLE 3. PLAN APPLICATIONS AND AMENDMENTS
s 1300.50. Notice of Intention to Apply for Plan License.

s 1300.51. Application for License as a Health Care Service Plan or Specialized Health Care Service Plan.

s 1300.51.1. Individual Information Sheet.

s 1300.51.2. Consent to Service of Process.

s 1300.51.3. Preparation and Amendment of Application for License As a Health Care Service Plan Under Section 1300.51.

s 1300.52. Amendments to Plan Application.

s 1300.52.1. Notice of Material Modification.

s 1300.52.2. Change in Plan Personnel.

s 1300.52.3. Filings and Actions Relating to Charitable or Public Activities.

s 1300.52.4. Standards for Amendments and Notices of Material Modification.
 
ARTICLE 4. SOLICITORS
s 1300.57. Solicitor Application.

s 1300.57.1. Solicitor Firm Application by Person Not Licensed by Insurance Commissioner.

s 1300.57.2. Amendment to Solicitor Firm Application.

s 1300.57.3. Fees Payable by Licensed Insurance Agents and Brokers.

s 1300.57.4. Solicitor Financial Records Authorization.

s 1300.59. Plan Assurances Prior to Solicitation.

s 1300.59.1. Examination Fee.

s 1300.59.2. Waiver of Examination Requirements.
 
ARTICLE 5. ADVERTISING AND DISCLOSURE
s 1300.61. Filing of Advertising and Disclosure Forms.

s 1300.61.1. Exempt Advertising.

s 1300.61.3. Deceptive Advertising.

s 1300.63. Disclosure Form.

s 1300.63.1. Evidence of Coverage.

s 1300.63.2. Combined Evidence of Coverage and Disclosure Form.

s 1300.63.3. Experimental Disclosure.

s 1300.63.50. Medicare Supplement Additional Disclosure.

s 1300.64.50. Medicare Supplement Application Information.

s 1300.64.51. Medicare Supplement "Buyer's Guide."

s 1300.64.52. Standards for Marketing Medicare Supplement Contracts.

s 1300.64.53. Reporting of Multiple Coverage.

s 1300.64.54. Replacement Contracts: Elimination of Waiting Periods.

s 1300.64.55. Permitted Compensation Arrangements for the Sale of Medicare Supplement Contracts.
 
ARTICLE 6. APPEALS ON CANCELLATION
s 1300.65. Cancellation of Enrollment.

s 1300.65.1. Cancellation Complaint Form.

s 1300.66. Deceptive Plan Names.
 
ARTICLE 7. STANDARDS
s 1300.67. Scope of Basic Health Care Services.

s 1300.67.05. Acts of War Exclusions.

s 1300.67.1. Continuity of Care.

s 1300.67.1.3. Block Transfer Filings.

s 1300.67.2. Accessibility of Services.

s 1300.67.2.1. Geographic Accessibility Standards.

s 1300.67.3. Standards for Plan Organization.

s 1300.67.4. Subscriber and Group Contracts.

s 1300.67.8. Contracts with Providers.

s 1300.67.10. Discrimination Prohibited.

s 1300.67.11. Disclosure of Conflicts of Interest.

s 1300.67.12. Contracts with Solicitor Firms.

s 1300.67.13. Coordination of Benefits ( "COB").

s 1300.67.24. Outpatient Prescription Drug Benefits.

s 1300.67.50. Certain Medicare Supplement Contracts: Presumption of Unfairness.

s 1300.67.51. Medicare Supplement Contract Provisions.

s 1300.67.52. Medicare Supplement Additional Benefit Requirements.

s 1300.67.53. Medicare Supplement Minimum Aggregate Benefits.

s 1300.67.55. Medicare Supplement Reporting Requirements.

s 1300.67.56. Transitional Requirements for the Conversion of Medicare Supplement Contracts to Conform to Medicare Program Revisions.

s 1300.67.57. Format For Notices of Changes in Coverage.

s 1300.67.58. Participating Physician or Supplier Claims Form Requirement. (Compliance with Section 4081 of the Omnibus Budget Reconciliation Act of 1987)

s 1300.67.59. Format for Reporting Loss Ratio Experience.

s 1300.67.60. Standing Referral to HIV/AIDS Specialist.
 
ARTICLE 8. SELF-POLICING PROCEDURES
s 1300.68. Grievance System.

s 1300.68.01. Expedited Review of Grievances.

s 1300.68.2. Hospice Services.

s 1300.69. Public Policy Participation by Subscribers.

s 1300.70. Health Care Service Plan Quality Assurance Program.

s 1300.70.4. Independent Medical Reviews Experimental and Investigational Therapies.

s 1300.71. Claims Settlement Practices.

s 1300.71.38. Fast, Fair and Cost-Effective Dispute Resolution Mechanism.

s 1300.71.4. Emergency Medical Condition and Post-Stabilization Responsibilities for Medically Necessary Health Care Services.

s 1300.73.21. Arbitration and Settlement Agreements.

s 1300.74.30. Independent Medical Review System.

s 1300.74.72. Mental Health Parity.
 
ARTICLE 9. FINANCIAL RESPONSIBILITY
s 1300.75. Agreements with Subsequent Providers.

s 1300.75.1. Fiscal Soundness, Insurance, and Other Arrangements.

s 1300.75.2. Plan As Subsequent Provider.

s 1300.75.3. Subsequent Provider Exemption.
RISK-BEARING ORGANIZATIONS


s 1300.75.4. Definitions.

s 1300.75.4.1. Risk Arrangement Disclosure.

s 1300.75.4.2. Organization Information.

s 1300.75.4.3. Plan Reporting.

s 1300.75.4.4. Confidentiality.

s 1300.75.4.5. Plan Compliance.

s 1300.75.4.6. Department Costs.

s 1300.75.4.7. Organization Evaluation.

s 1300.75.4.8. Corrective Action.

s 1300.76. Plan Tangible Net Equity Requirement.

s 1300.76.1. Deposits.

s 1300.76.2. Solicitor Firm Financial Requirement.

s 1300.76.3. Fidelity Bond.

s 1300.76.4. Prohibited Financial Practices.

s 1300.77. Reimbursements.

s 1300.77.1. Estimated Liability for Reimbursements.

s 1300.77.2. Calculation of Estimated Liability for Reimbursements.

s 1300.77.3. Report on Reimbursements Exceeding Ten Percent.

s 1300.77.4. Reimbursements on a Fee-for-Services Basis: Determination of Status of Claims.

s 1300.78. Administrative Costs.
 
ARTICLE 10. MEDICAL SURVEYS
s 1300.80. Medical Survey Procedure.

s 1300.80.10. Medical Survey: Report of Correction of Deficiencies.
 
ARTICLE 11. EXAMINATIONS
s 1300.81. Removal of Books and Records from State.

s 1300.82. Examination Procedure.

s 1300.82.1. Additional or Nonroutine Examinations and Surveys.
 
ARTICLE 12. REPORTS
s 1300.83. Annual Report.

s 1300.84. Financial Statements.

s 1300.84.05. Change of Independent Accountant.

s 1300.84.06. Plan Annual Report.

s 1300.84.1. Verification of Reports.

s 1300.84.2. Quarterly Financial Reports.

s 1300.84.3. Monthly Financial Reports.

s 1300.84.4. Financial Reports by Solicitor Firms.

s 1300.84.5. Public Entity Plans.

s 1300.84.6. Plan Annual Enrollee Report.

s 1300.84.7. Special Reports Relating to Charitable or Public Activities.
 
ARTICLE 13. BOOKS AND RECORDS
s 1300.85. Books and Records.

s 1300.85.1. Retention of Books and Records.
 
ARTICLE 14. MISCELLANEOUS PROVISIONS
s 1300.86. Assessment of Administrative Penalties.

s 1300.87. Civil Penalties.

s 1300.89. Petition for Restoration.

s 1300.99. Application to Surrender License.

s 1300.99.7. Application for Conversion or Restructuring.
 
ARTICLE 15. CHARITABLE OR PUBLIC ACTIVITIES
s 1300.824. Requirements Relating to Charitable or Public Activity Filings.

s 1300.824.1. Notices and Requests for Approval of Certain Transactions.

s 1300.826. Request for Ruling on Proposed Action or Article Amendment.
 
 
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