§ 53840. Two-Plan Model Requirements.

Each plan in a designated region shall:

(a) Obtain or maintain a license to operate as a Knox-Keene health care service plan, and meet all requirements set forth in Chapter 2.2 (commencing with Section 1340 of the Health and Safety Code) and related applicable regulatory requirements throughout the term of the contract between the plan and the department.

(b) Comply with all applicable federal and state statutory, regulatory, and administrative requirements, including, but not limited to, those organizational and administrative requirements contained in the Social Security Act and the Code of Federal Regulations.

(c) Comply with all standards, requirements and responsibilities stipulated and agreed to in the contract between the plan and the department including but not limited to:

(1) Organization.

(2) Legal Capacity.

(3) Administration/Staffing.

(4) Management Information System.

(5) Reporting Requirements.

(6) Quality Improvement System.

(7) Provider Network and Geographic Access, including a documented system for monitoring access to care.

(8) Scope of Services including preventive services for adults and all required CHDP and EPSDT services.

(9) Medical Standards/Health Education.

(10) Marketing and Enrollment.

(11) Member Services/Grievance System.

(12) Cultural and Linguistic Services Requirements.

(13) Financial Solvency.

HISTORY

1. New article 5 (sections 53840 and 53845) and section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3 and 14087.4, Welfare and Institutions Code.