California Code of Regulations
Title 10 - Investment
Chapter 5.5 - Major Risk Medical Insurance Board
Article 6 - Pilot Program Payments
Section 2698.600 - Semiannual Interim Payment and Reporting Procedures for Pilot Program Health Plans

Universal Citation: 10 CA Code of Regs 2698.600

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The semiannual interim payment process for Pilot Program payment shall occur starting at the end of the first reporting period, September 1, 2003 through December 31, 2003, and on June 30 and December 31 of each year thereafter, as long as there are Program Graduates or Program Graduate dependents enrolled. In order to qualify for a semiannual interim payment a Pilot Program health plan shall submit a semiannual interim enrollment report no later than 90 days after the semiannual reporting period as established above in this section. If a Pilot Program health plan does not submit a semiannual interim enrollment report by the end of the 90 day period, the plan will not receive an interim payment for that period.

(b) The semiannual interim enrollment report shall be submitted for each program graduate enrolled in the Pilot Program standard benefit plan during the semiannual interim period, and consist of:

(1) A signed certification that all program graduates for whom the Pilot Program health plan has made claim are enrolled in a Pilot Program standard benefit plan.

(2) The following information, to be submitted electronically, in a format specified by the Board, which consists of the following elements for each Program Graduate enrolled in the Pilot Program standard benefit plan during the semiannual interim period:
(A) The Program Graduate's unique identification number,

(B) The Pilot Program health plan's own identification number for the Program Graduate,

(C) The Program Graduate's full name,

(D) The Program Graduate's home address including house or unit number, street, city, county, state, and zip code,

(E) The name of each Program Graduate dependent who is covered under the Pilot Program at the same time as the program graduate,

(F) The date of birth of each Program Graduate and Program Graduate dependent,

(G) The Program Graduate's and any Program Graduate dependent's date of disenrollment from the Program, as indicated on the Certificate of Program Completion,

(H) The Program Graduate's and any Program Graduate dependent's date of enrollment in the Pilot Program health plan,

(I) The Program Graduate's and any Program Graduate dependent's date of enrollment in the Pilot Program health plan, when transferred from one Pilot Program health plan to another.

(J) The Program Graduate's and any Program Graduate dependent's date of disenrollment in the Pilot Program health plan, if disenrollment has occurred during the interim semiannual reporting period.

(3) The semiannual interim enrollment report shall include an estimate, adjusted for incurred but not reported (IBNR) costs, of the amount expended for program graduates and program graduate dependents, and the total amount of premium payments received to the Pilot Program health plan during the reporting period.

(c) The Board will issue an interim payment no later then 45 days after receipt of a valid semiannual interim payment report, consisting of all the elements as stated above in subsection (b). The payment will be determined using the following formula for each individual:

the most recent average premium as established by the Board during its semiannual determination of estimated enrollment times one half (the absolute value of the prior calendar year loss ratio minus 110 percent)

(d) The semiannual interim payment reporting process shall be subject to review and/or audit by the Board or its authorized representative in order to verify Program Graduates, and Program Graduate dependents, enrollment through a Pilot Program health plan in the Pilot Program standard benefit plan, for a period of four years after an interim payment has been made.

1. New article 6 (sections 2698.600-2698.604) and section filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).
3. Amendment of subsection (c) filed 12-3-2009 as an emergency; operative 12-3-2009 (Register 2009, No. 49). A Certificate of Compliance must be transmitted to OAL by 6-1-2010 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 12-3-2009 order transmitted to OAL 5-28-2010 and filed 7-12-2010 (Register 2010, No. 29).

Note: Authority cited: Section 1373.62, Health and Safety Code; and Sections 10127.15, 12711 and 12712, Insurance Code. Reference: Sections 1373.62 and 1373.622, Health and Safety Code; and Sections 10127.15, 12711 and 12712, Insurance Code.

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