California Health and Safety Code 1374.69 – At least 20 business days prior to offering a point-of-service plan …
At least 20 business days prior to offering a point-of-service plan contract, a health care service plan shall file a notice of material modification in accordance with Section 1352. The notice of material modification shall include, but not be limited to, provisions specifying how the health care service plan shall accomplish all of the following:
(a) Design the benefit levels and conditions of coverage for in-network coverage and services and out-of-network point-of-service utilization.
Terms Used In California Health and Safety Code 1374.69
- Contract: A legal written agreement that becomes binding when signed.
- Director: means "State Director of Health Services. See California Health and Safety Code 21
- Enrollee: means a person who is enrolled in a plan and who is a recipient of services from the plan. See California Health and Safety Code 1345
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
(b) Provide or arrange for the provision of adequate systems to do all of the following:
(1) Process and pay claims for all out-of-network coverage and services.
(2) Generate accurate financial and utilization data and reports on a timely basis, so that it and any authorized regulatory agency can evaluate the health care service plan’s experience with point-of-service plan contracts and monitor compliance with point-of-service plan contract projections established by the health care service plan and regulatory requirements.
(3) Track and monitor the quality of health care obtained out-of-network by plan enrollees to the extent reasonable and possible.
(4) Respond promptly to enrollee grievances and complaints, written or oral, including those regarding services obtained out-of-network.
(5) Meet the requirements for a point-of-service plan contract set forth in this section and any additional requirements that may be required by the director.
(c) Comply initially and on an ongoing basis with the requirements of this article.
(d) This section shall become operative July 1, 1995.
(Amended by Stats. 1999, Ch. 525, Sec. 120. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)