California Welfare and Institutions Code ARTICLE 5 - Standards for Prepaid Health Plans

• Section 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...
• Section 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...
• Section 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.(Amended...
• Section 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...
• Section 14452.
  (a) All subcontracts shall be entered into pursuant to the requirements of the Knox-Keene Health Care Service Plan Act of 1975, or the requirements of Chapter...
• Section 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 vision care...
• Section 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...
• Section 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 health...
• Section 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 paid,...
• Section 14453.
  In compensating directors and officers, the prepaid health plan shall not compensate at a rate substantially greater than the prevailing charge for similar services in...
• Section 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...
• Section 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 received...
• Section 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 reviews shall...
• Section 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 care...
• Section 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 provide...
• Section 14457.
  In addition to the reviews required or authorized by Section 14456, the department shall conduct periodic onsite visits or additional visits after a determination by...
• Section 14458.
  The prepaid health plan shall establish procedures for continuously reviewing the quality of care, performance of medical personnel, the utilization of services and facilities, and...
• Section 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...
• Section 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 component...
• Section 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 shall specify...
• Section 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 managed care plans to monitor...
• Section 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 Legislature with...
• Section 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...
• Section 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...
• Section 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...
• Section 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...
• Section 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 plan contracting...

Last modified: October 22, 2018