Cal. Code Regs. tit. 2 § 599.509

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 599.509 - Minimum Standards for Health Benefits Carriers

A health benefits plan will not be approved by the Board unless the carrier of the plan meets, in addition to the requirements of the Public Employees' Medical and Hospital Care Act, the following additional requirements:

(a) It must be lawfully engaged in the business of supplying health benefits.

(b) It must have, in the judgment of the Board, the financial resources, organizational facilities and experience in the field of health benefits to carry out its obligations under the plan.

In the case of carriers for service benefit plans and indemnity benefit plans, the Board in forming its judgment shall be guided by such factors as the length of time the carrier has been in the prepaid health benefits field, the capacity of the carrier to effectively service claims of enrolled employees and annuitants throughout the State, the general financial stability of the carrier as exhibited by examinations of the State Insurance Commissioner or other regulatory bodies, and the extent to which the carrier underwrites other prepaid health benefits plans in California.

In the case of carriers for group practice prepayment plans, the Board in forming its judgment shall be guided by such factors as the number of physicians practicing in the group, the number of physicians practicing in the group as specialists and their qualifications, the proportion of the group's income which is derived from prepayment as opposed to fee-for-service, the extent to which the group utilizes outside consultants, the extent to which ancillary and other related services, both in and out of the hospital, are available in the group, the stability of the group's finances and organization, and the potential for enrollment of employees and annuitants under the plan as well as the plan's capacity for servicing such potential enrollees including a demonstrated commitment to cost containment, innovative services, effectiveness of utilization review, and success in achieving market penetration.

In the case of carriers for individual practice prepayment plans, the Board in forming its judgment shall be guided by such factors as the number of physicians participating in the plan, the number of physicians practicing as specialists and their qualifications, the extent to which ancillary and other related services, both in and out of the hospital, are covered, the stability of the plan, finances and organization of the plan, the plan's financial responsibility, and the potential for enrollment of employees and annuitants under the plan, as well as the plan's capacity for servicing such potential enrollees including a demonstrated commitment to cost containment, innovative services, effectiveness of utilization review, and success in achieving market penetration.

(c) It must agree to keep such reasonable financial and statistical records and furnish such reasonable financial and statistical reports with respect to the plan as may be requested by the Board, which may include but is not limited to:

(1) Number of persons enrolled under the plan, by employee, annuitant, and family coverage.

(2) Contributions received from such employees and annuitants, and the employer.

(3) Claims incurred on behalf of such employees and annuitants, including health benefits payments made, or services rendered, by employee, annuitant, and family coverage.

(4) Expense and risk or other retention charges.

(5) Reserves established under the plan.

(d) It must agree to permit representatives of the Board to audit and examine its records and accounts which pertain, directly or indirectly, to the plan at such reasonable times and places as may be designated by the Board. However, any privileged medical information relating to any claimant's medical history and record need not be released by the carrier or revealed to the Board or its representatives, to the extent that any patient's identity is revealed. However, such data must be provided in abstract format upon request by the Board.

(e) It must agree to comply with requirements of the Board in the solicitation of enrollment of employees and annuitants and in any advertising concerning or involving participation in the plan.

(f) It must agree to accept, subject to adjustment for error or fraud, in payment of its prepayment charges for health benefits for all employees and annuitants enrolled in its plan, the contribution of each employee and annuitant withheld from the salary or retirement allowance payable to him or her.

Cal. Code Regs. Tit. 2, § 599.509

1. Amendment of subsection (f) filed 11-27-68 as an emergency; effective upon filing (Register 68, No. 45). For prior history, see Register 68, No. 29.
2. Certificate of Compliance--Sec. 11422.1, Gov. Code, filed 2-20-69 (Register 69, No. 8).
3. Amendment filed 6-15-79; designated effective 8-1-79 (Register 79, No. 24).
4. Amendment filed 6-27-80; designated effective 8-1-80 (Register 80, No. 26).
5. Amendment filed 6-9-86; effective thirtieth day thereafter (Register 86, No. 24).
6. Change without regulatory effect amending NOTE filed 10-31-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 44).

Note: Authority cited: Sections 22794 and 22796, Government Code. Reference: Section 22796, Government Code.

1. Amendment of subsection (f) filed 11-27-68 as an emergency; effective upon filing (Register 68, No. 45). For prior history, see Register 68, No. 29.
2. Certificate of Compliance -Sec. 11422.1, Gov. Code, filed 2-20-69 (Register 69, No. 8).
3. Amendment filed 6-15-79; designated effective 8-1-79 (Register 79, No. 24).
4. Amendment filed 6-27-80; designated effective 8-1-80 (Register 80, No. 26).
5. Amendment filed 6-9-86; effective thirtieth day thereafter (Register 86, No. 24).
6. Change without regulatory effect amendingNote filed 10-31-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 44).