ARTICLE 5. Standards for Prepaid Health Plans

Article 5 added by Stats. 1974, Ch. 983.

§§ 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…