CHAPTER 8. Prepaid Plans
Chapter 8 added by Stats. 1972, Ch. 1366.
§§ 14200–14499.77 · 113 sections
ARTICLE 1. General Provisions §§ 14200–14206 · 7 sections
- § 14200 This chapter shall be known and may be cited as the Waxman-Duffy Prepaid Health Plan Act.
- § 14200.1 The purpose of this chapter is to afford persons eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part the opportunity to…
- § 14201 The intent of the Legislature is to provide, to the extent feasible, through the provisions of this chapter and the necessarily related provisions of Chapter 7…
- § 14203 (a) For purposes of administering this chapter and Chapter 7 (commencing with Section 14000) of this part, the department is hereby designated as the single or…
- § 14204 (a) Pursuant to the provisions of this chapter, the department may contract with one or more prepaid health plans in order to provide the benefits authorized…
- § 14205 Except where the context otherwise requires, or where specific exceptions are authorized, all provisions of Chapter 7 (commencing with Section 14000) of this…
- § 14206 (a) No prepaid health plan or pilot program shall be deemed to transact insurance or to be subject to any provision of the Insurance Code by virtue of…
ARTICLE 2. Definitions §§ 14250–14265 · 15 sections
- § 14250 Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter.
- § 14251 (a) (1) “Prepaid health plan” means a plan that meets all of the following criteria: (A) Is licensed as a health care service plan by the Director of the…
- § 14252 “Medi-Cal beneficiary” means a person who is eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part.
- § 14253 “Subcontract” means an agreement entered into by the prepaid health plan with any of the following: (a) A provider of health care services who agrees to…
- § 14254 (a) “Primary care physician” is a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of…
- § 14255 “Specialist” means a physician who is board certified or board eligible in the specialty of medical care provided.
- § 14256 The “basic scope of health care benefits” means: (a) Physician’s services; (b) Hospital outpatient services; (c) Laboratory and X-ray; (d) Prescription drugs;…
- § 14257 Nothing in this act shall preclude the director from contracting with licensed specialized health care service plans which provide only dental, pharmaceutical,…
- § 14258 “Service area” means a geographical area designated by the department within which a prepaid health plan shall provide health care services and within which…
- § 14259 “Director” means the State Director of Health Services.
- § 14260 “Department” means the State Department of Health Services.
- § 14261 “Vendor” means any person who provides services or supplies to a prepaid health plan or a subcontractor of a prepaid health plan and who does not have a…
- § 14263 “Marketing” means any activity conducted by or on behalf of a prepaid health plan where information regarding the services offered by a prepaid health plan is…
- § 14264 “Marketing organization” means any subcontractor who agrees to provide marketing services for a prepaid health plan.
- § 14265 “Marketing representative” means any person who engages in marketing activities on behalf of a marketing organization or the prepaid health plan.
ARTICLE 3. Administration §§ 14300–14316 · 23 sections
- § 14300 The department shall publish a notice of intent to contract at least 60 days prior to the effective date of any initial or renewed contract. The notice shall…
- § 14301 (a) The department shall determine, by actuarial methods, prospective per capita rates of payment for services provided under this chapter for Medi-Cal…
- § 14301.1 (a) For rates established on or after August 1, 2007, the department shall pay capitation rates to health plans participating in the Medi-Cal managed care…
- § 14301.11 (a) Notwithstanding any law, and subject to subdivisions (e) and (f), in order to account for the impacts of the COVID-19 public health emergency on Medi-Cal…
- § 14301.2 (a) The director may defer fee-for-service payments or payments to Medi-Cal managed care health plans contracting with the department pursuant to Article 2.7…
- § 14301.3 The department shall ensure that Medi-Cal managed care plans demonstrate ongoing ability and readiness to perform the obligations set forth in Section…
- § 14301.4 (a) It is the intent of the Legislature, to the extent federal financial participation is not jeopardized and consistent with federal law, that the…
- § 14301.5 (a) (1) To the extent federal financial participation is not jeopardized and consistent with federal law, and subject to the conditions set forth in…
- § 14302 Except as provided in Section 14490, the duration of initial contracts entered into pursuant to this chapter shall be for a maximum of one year and of renewed…
- § 14302.1 (a) (1) Once it is determined that a contract shall be renewed pursuant to this chapter with a prepaid health plan, by the state agency responsible for…
- § 14303 No contract between the department and the prepaid health plan shall be amended without the public notice and if necessary the holding of a public hearing as…
- § 14303.1 The department shall have authority to amend a prepaid health plan contract in accordance with the terms of a merger of a prepaid health plan with another…
- § 14303.2 The department shall have authority to amend a prepaid health plan contract in accordance with the terms of the reorganization of a prepaid health plan or a…
- § 14303.3 The department shall renew a contract unless good cause is shown for nonrenewal.
- § 14304.5 Each prepaid health plan shall provide directly or through subcontractors, not less than the basic scope of health care benefits as defined in Section 14256.…
- § 14305 The department may limit the scope of health care benefits provided by a prepaid health plan under this chapter to exclude the care of illness or injury which…
- § 14308 (a) Each prepaid health plan shall furnish to the director such information and reports as required by Title XIX of the federal Social Security Act. (b) The…
- § 14309 The department shall provide for a continuing study of the quality of care and services resulting from the operation of this chapter and for surveys and…
- § 14311 Prepaid health plans, the services they provide, and the persons receiving these services shall not be subject to the limitations on services set forth in…
- § 14312 The director shall adopt all necessary rules and regulations to carry out the provisions of this chapter. In adopting such rules and regulations, the director…
- § 14314 The director may recover a due and payable overpayment made to a prepaid health plan by means of a repayment agreement executed between such prepaid health…
- § 14315 When it has been determined that a prepaid health plan has received an overpayment which is due and payable, the director may recover such overpayment by…
- § 14316 Notwithstanding any other provisions of law, contracts with plans which are entered into, renewed, or amended pursuant to this article may include one or more…
ARTICLE 4. Enrollment and Disenrollment §§ 14400–14413 · 15 sections
- § 14400 Every prepaid health plan shall have an open enrollment period at least once every year. During the open enrollment period the plan shall accept up to the…
- § 14401 No Medi-Cal beneficiary shall be enrolled in a prepaid health plan prior to the time a contract under this chapter is signed by the department and such prepaid…
- § 14402 The prepaid health plan shall enroll only those Medi-Cal beneficiaries who reside within the contract service area. Prepaid health plans shall use a standard…
- § 14403 No Medi-Cal beneficiary shall be enrolled in more than one prepaid health plan at any time.
- § 14406 (a) Within seven days after the effective date of enrollment, the prepaid health plan shall provide in writing the following information to a new enrollee or…
- § 14407 Enrollment in a prepaid health plan shall be voluntary and a prepaid health plan shall not use false advertising or false statements to induce enrollment. No…
- § 14407.1 (a) A contractor that has entered into a contract with the department under this chapter, or under another Medi-Cal managed care contracting authority, may…
- § 14407.6 (a) Notwithstanding Section 14407.5, the department shall, to the extent permitted by federal law or under federal waivers which the department may obtain,…
- § 14408 (a) Except as otherwise prohibited by law, a contractor that has entered into a contract with the department pursuant to this chapter may make the benefits…
- § 14408.5 A prepaid health plan that contracts with Medi-Cal managed care or contracts with the Healthy Families Program may provide application assistance pursuant to…
- § 14409 (a) No prepaid health plan, marketing representative, or marketing organization shall in any manner misrepresent itself, the plans it represents, or the…
- § 14410 No prepaid health plan or marketing representative shall adopt or utilize any procedure to identify prospective enrollees with medical or psychiatric problems…
- § 14411 (a) No prepaid health plan or marketing organization shall solicit prospective enrollees on county premises for benefits or services available pursuant to this…
- § 14412 (a) The enrollment of a Medi-Cal beneficiary in the prepaid health plan shall not be terminated except for loss of eligibility, for good cause as determined by…
- § 14413 (a) Requests for disenrollment shall be made to an authorized representative of the prepaid health plan or to the department. All requests for disenrollment,…
ARTICLE 5. Standards for Prepaid Health Plans §§ 14450–14464 · 27 sections
- § 14450 (a) No contract between the department and a prepaid health plan shall be approved or renewed unless the providers and the facilities of the prepaid health…
- § 14450.5 (a) No contract between the department and a prepaid health plan that is contracting with, or that is governed, owned, or operated by, a county board of…
- § 14451 Services under a prepaid health plan contract shall be provided in accordance with the requirements of the Knox-Keene Health Care Service Plan Act of 1975.
- § 14451.5 (a) A prepaid health plan contractor may not enter into subcontracts when such an action would remove from the contractor his obligation to bear a significant…
- § 14452 (a) (1) All subcontracts shall be entered into pursuant to the requirements of the Knox-Keene Health Care Service Plan Act of 1975 and federal law. All…
- § 14452.3 Each prepaid health plan shall provide the services of an optometrist and ophthalmologist when the prepaid health plan contract requires the provision of…
- § 14452.4 Where the prepaid health plan agrees to provide dental services such services shall be provided in a manner that does not require the enrollees to receive…
- § 14452.5 Each prepaid health plan shall provide the services of a psychologist and psychiatrist when the prepaid health plan contract requires the provision of mental…
- § 14452.6 Prepaid health plans, or their subcontractors, shall not bill any enrollee for covered benefits provided under this chapter and for which capitation has been…
- § 14453 In compensating directors and officers, the prepaid health plan shall not compensate at a rate substantially greater than the prevailing charge for similar…
- § 14454 (a) The prepaid health plan shall be liable for all in-area and out-of-area emergency services which are required by the contract and rendered by a nonprepaid…
- § 14455 The prepaid health plan shall maintain a complete unit medical record for each enrollee. Enrollee medical records shall also include records of all treatment…
- § 14456 The department shall conduct annual medical audits of each prepaid health plan unless the director determines there is good cause for additional reviews. The…
- § 14456.3 (a) The department shall share with the Department of Managed Health Care its findings from medical audits and monthly provider files of a Medi-Cal managed…
- § 14456.5 (a) For purposes of this section, Medi-Cal managed care plan means any prepaid health plan or Medi-Cal managed care plan contracting with the department to…
- § 14457 (a) In addition to the reviews required or authorized by Section 14456, the department shall conduct periodic onsite visits or additional visits after a…
- § 14458 The prepaid health plan shall establish procedures for continuously reviewing the quality of care, performance of medical personnel, the utilization of…
- § 14459 (a) The prepaid health plan shall maintain financial records and shall have an annual audit or additional audits after a determination by the director of good…
- § 14459.5 (a) As delegated by the federal government, the department has responsibility for monitoring the quality of all Medicaid services provided in the state. A key…
- § 14459.6 (a) The department shall establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. The list…
- § 14459.7 (a) The department shall implement a Management Information System/Decision Support System (MIS/DSS) for the Medi-Cal Program, that shall integrate data from…
- § 14459.8 (a) By no later than March 15, 2013, with annual updates thereafter, the department shall provide the fiscal and appropriate policy committees of the…
- § 14460 A schedule of reviews, visits, and audits shall be jointly established by the Department of Managed Health Care or the Department of Insurance, as the case may…
- § 14461 Upon request by the department, each prepaid health plan shall submit to the department a copy of any financial report submitted to any other public or private…
- § 14462 In accordance with Section 14081.5, the provisions of Section 15459 of the Government Code shall not be applicable to a hospital, whether or not it negotiates…
- § 14463 (a) Except as otherwise provided in this chapter, each prepaid health plan shall be responsible for all of the costs of services rendered under the provisions…
- § 14464 (a) The department may negotiate and establish an individual administrative cost limit in its contracts with each prepaid health plan or Medi-Cal managed care…
ARTICLE 5.3. Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans §§ 14465–14466 · 2 sections
- § 14465 For purposes of this article and Section 14454, “emergency services” shall have the same meaning as that established in Section 1317.1 of the Health and Safety…
- § 14466 The plan shall make a request to the department to temporarily disenroll any enrollee for the month or months in which the patient is hospitalized and remains…
ARTICLE 6. Conflict of Interest §§ 14475–14482 · 8 sections
- § 14475 (a) No prepaid health plan or pilot program contract shall be approved or renewed by the department pursuant to this chapter if any state officer or state…
- § 14476 The chief executive, sole proprietor, or managing partner of each prepaid health plan shall file with the department an annual statement disclosing any…
- § 14477 (a) For purposes of this article, “state officer” means a United States Senator or Member of Congress representing California, the Governor, Lieutenant…
- § 14478 (a) As used in this chapter, “substantial financial interest” means the ownership of common stock, preferred stock, warrants, options, loans, partnership…
- § 14479 (a) No prepaid health plan or pilot program contract shall be approved, renewed or continued by the department if a state officer or state employee is employed…
- § 14480 No prepaid health plan or pilot program contract with an existing or proposed contractor shall be approved or renewed if a state officer or state employee…
- § 14481 No prepaid health plan or pilot program contract shall be approved or renewed if any state officer or state employee receives anything of value for the purpose…
- § 14482 No prepaid health plan shall contract with any subcontractor other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its…
ARTICLE 7. Pilot Programs §§ 14490–14499.6 · 10 sections
- § 14490 In providing benefits under this chapter and Chapter 7 (commencing with Section 14000), the director shall aggressively seek the development of alternative…
- § 14491 The director shall pursue the feasibility of establishing the following as pilot programs: (a) A capitated, risk-assuming contract with one or more regional…
- § 14493 The director shall also consider programs which demonstrate an innovative and economical use of health personnel and are approved pursuant to Article 18…
- § 14494 The director may enter into other contracts under this article which do one or more of the following: (a) Demonstrate an innovative and economical use of…
- § 14495 In establishing pilot programs, the director may do the following: (a) Provide benefits based on class of recipient, class of benefit, geographical area, or…
- § 14495.10 (a) The department shall establish a pilot program to provide continuous skilled nursing care as a benefit of the Medi-Cal program, when those services are…
- § 14496 (a) Alternate methods of payment for a pilot program may include, but shall not be limited to, a prospectively negotiated reimbursement rate, fee-for-service,…
- § 14497 The director shall call a public hearing pursuant to Section 14300 prior to entering into or renewing a pilot program. The director shall make available to the…
- § 14499.5 (a) (1) In carrying out the intent of this article, the director shall contract for the operation of one local pilot program. Special consideration shall be…
- § 14499.6 (a) The Santa Barbara Regional Health Authority may arrange with out-of-county Selective Provider Contracting Program hospitals that have negotiated hospital…
ARTICLE 8. Medi-Cal At-Risk Fiscal Intermediaries §§ 14499.7–14499.77 · 6 sections
- § 14499.7 The department may contract with one or more fiscal intermediaries in order to pay for benefits authorized under this chapter and Chapter 7 (commencing with…
- § 14499.71 For the purposes of this article, “fiscal intermediary” means an entity that agrees to pay for covered services provided to Medi-Cal eligibles in exchange for…
- § 14499.73 A contract entered into under this article shall provide that a fiscal intermediary meets both of the following criteria: (a) The fiscal intermediary shall…
- § 14499.74 In determining the capitated rates to be paid to a fiscal intermediary during the first year of contracting under this article, the department shall utilize an…
- § 14499.75 A fiscal intermediary may contract for the provision of services with any provider who would be eligible to provide services if services were to be provided on…
- § 14499.77 All services, except those specified for exclusion by the department, received by Medi-Cal recipients residing in the geographical area served by the fiscal…