§ 56500. Application and Proposal Information.

(a) Each applicant for a PCCM contract shall submit to the Department an application containing, but not limited to, the following information:

(1) A statement as to the optional services that will be selected in addition to the mandatory services required of PCCM plans.

(2) A brief description of any existing health care delivery system including information covering the scope and availability of services currently provided to Medi-Cal beneficiaries by the applicant.

(3) A description of the proposed PCCM plan health care delivery system. If the services are a duplicate of those described in (2), a signed statement declaring that the health care delivery system will be the same will satisfy this requirement.

(4) A U.S. Postal Zip Code map with the proposed service area outlined in red.

(5) A separate list of all service area Zip codes in numerical order.

(6) A general area map of the service area that has all service sites distinctly identified and clearly listed on a legend.

(7) An array of the Medi-Cal population in the service area by PCCM plan eligible Medi-Cal Aid categories.

(8) A breakdown of the applicant's current patient population by private pay, insurance and Medi-Cal.

(9) A history of any experience the applicant has in providing care to patients through medical systems such as preferred provider organizations, industrial practice, prepaid health plans, PCCM plans, or any structured medical care delivery system that would demonstrate the ability to function as a PCCM plan.

(b) Each PCCM contract applicant approved by the Department shall submit a proposal containing, but not limited to, the following information:

(1) A description of the administrative structure which includes:

(A) An organization chart with the identification and functional description of each organizational unit, including corporate and medical management personnel.

(B) Complete background information for corporate and medical management personnel.

(C) Job descriptions for corporate and medical management personnel.

(D) A completed disclosure statement pursuant to section 56600.

(2) If applicable, a corporate structure chart identifying and displaying the relationships between the proposed PCCM plan and its parent company, affiliates, subsidiaries, and any principal subcontractors.

(3) For each provider of health care services included in the PCCM plan, provide the following:

(A) Full name.

(B) Business address.

(C) Professional license number including the expiration date, where applicable; medical specialty including any certifying board, where applicable; and Medi-Cal provider number.

(D) Days and hours of operation for each provider.

(E) If an individual provider serves more than one site, list the days and hours of service for each site.

(4) A complete description of the procedures for internal and external referrals.

(5) A complete description of the system for providing or arranging for the provision of emergency services.

(6) Descriptions of the following medical administrative procedures:

(A) The proposed quality assurance, peer review, and utilization review programs.

(B) The proposed medical record system.

(C) The proposed provider grievance and complaint process.

(D) The procedures for provision of health education services.

(E) Proposed protocols for handling and disposing of infectious waste.

(7) Proposed protocols for medical care which includes age specific preventive health services.

(8) A description of the following proposed administrative procedures:

(A) Office procedures for missed appointment follow-up and the handling of emergency telephone calls.

(B) Marketing plan.

(C) Standard subcontract format.

(D) Tort liability protocols/procedures.

(E) The system for prompt reimbursement of nonplan providers for capitated services rendered to PCCM plan members.

(F) The system for complying with PCCM contract quarterly utilization and financial reporting requirements.

(9) A description of the following membership services:

(A) Enrollment procedures.

(B) The Statement of Understanding to be signed by each member.

(C) Member complaint process including a sample of the disposition notice, complaint log, and any related printed materials .

(D) The PCCM plan service guide.

(10) A listing and brief description of any existing government contract which involves current medical operations.

(11) A written statement that the PCCM plan will or will not accept the option of a risk limit.

(12) A description of activities that must be completed prior to contract implementation such as hiring staff, printing marketing materials and enrolling members.

(13) The following financial information:

(A) Detailed financial plan demonstrating the availability and sources of sufficient funds to cover operating costs for the first year of operation.

(B) Current income statement.

(C) Balance Sheet.

(D) Statement of Changes in Financial Position.

(E) A detailed cash flow budget, including all written assumptions, estimates and projections, demonstrating the availability and sources of funds to meet the obligations under the prospective contract. Projections shall include enrollment, income and expenses on a month-by-month basis for two years. Supporting budgets for affiliates shall be provided when the organization relies upon affiliates to provide services under the prospective contract.

(F) A projected calculation of tangible net equity.

(G) Certified financial statements, presented on a combined basis with all affiliates, as of the applicant's fiscal or calendar year end. No additional disclosures are required when the applicant's submission is within 90 calendar days after the end of the applicant's fiscal year. Unaudited financial statements to the most current quarter end shall also be submitted if the applicant's submission occurs prior to or more than 90 calendar days after the close of the applicant's fiscal year. Unaudited statements shall be prepared on a combined basis.

(H) A listing of all proposed subcontracts between the PCCM plan and affiliates.

(I) Proof of adequate professional liability insurance coverage.

(c) Each PCCM contract applicant approved by the Department shall submit the following certifications:

(1) A signed statement as to the willingness and ability of the applicant to revise policies or procedures as necessary or required by the Department.

(2) A signed statement as to the willingness and ability of the applicant to enroll members regardless of their race, creed, color, religion, age, sex, physical or mental handicap, sexual orientation, marital status, national origin or ancestry, and without reference to preexisting medical conditions other than those specifically excluded from converge under the PCCM contract.

(3) A signed statement to the effect that the applicant will not engage in selective enrollment marketing activities.

(4) A written statement that the applicant will maintain and operate a system which ensures the provision of or arrangement for CHDP services in close proximity to the primary care service site for eligible members.

HISTORY

1. New section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-9-90.

2. New section refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 11-6-90.

3. Request to readopt section on an emergency basis pursuant to Government Code section 11346.1 granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 11-6-90 order transmitted to OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).

5. New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or emergency language will be repealed by operation of law on the following day.

6. Certificate of Compliance as to 3-25-91 order including amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92, No. 1).

Note

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Section 14088.16, Welfare and Institutions Code.