Current through Register 2024 Notice Reg. No. 52, December 27, 2024
(a) The time period for annual
reconciliation, reports and payment shall be as follows:
(1) The annual reconciliation reporting and
payment process shall start one year after the end of each reporting period
established in Health and Safety Code Section
1373.62(g)(1)
and Insurance Code 10127.15 (g)(1). These periods are as follows:
September 1, 2003, to December 31, 2003, inclusive,
January 1, 2004, to December 31, 2004, inclusive,
January 1, 2005, to December 31, 2005, inclusive,
January 1, 2006, to December 31, 2006, inclusive,
January 1, 2007, to August 30, 2007,
inclusive.
(2) However, for
the purpose of reconciliation and payment, the January 1, 2007 to August 30,
2007 reporting period shall be extended through December 31, 2007, and shall
include Program Graduates and Program Graduate dependents that remain enrolled
in a Pilot Program health plan's standard benefit plan on September 1, 2007
(the day the Pilot Program becomes inoperative). Pilot Program health plans
with such program graduates or program graduate dependents may continue to
report, and be eligible for reconciliation and payment, one year after the
close of each calendar year until the plan no longer has any remaining program
graduates or program graduate dependents.
(b) In order to qualify for annual
reconciliations, a Pilot Program health plan shall submit an annual report for
each calendar year by December 31 of the following year, starting with a
December 31, 2004 due date for calendar year 2003.
(1) For reconciliations addressing calendar
years 2003 through 2007 inclusive, Pilot Program health plans that submit these
reports by the December 31 due date will be given priority for reconciliation
and any resulting payments. Pilot Program health plans that submit reports
after the established due dates will be reconciled, and any resulting payments
made from available funds, in order of the day of receipt of the
report.
(2) For reconciliations
addressing calendar year 2008 and all subsequent calendar years, a Pilot
Program health plan that submits the required report after the December 31 due
date shall not be entitled to be paid any amount pursuant to this section for
the applicable calendar year and shall refund to the board, within thirty-five
days of notification by the board, any amount previously paid to the plan for
the applicable calendar year pursuant to section
2698.600.
(3) Notwithstanding paragraphs (1) and (2) or
subsection (d), the following rules apply effective January 1, 2014:
(A) The Board shall not provide any payment
to any Pilot Program health plan for health care expenses incurred on or after
January 1, 2014 and shall not provide the aggregate standard monthly
administrative fee for any month after December 2013.
(B) As a condition of receiving payment for a
reporting period pursuant to this section, a Pilot Program health plan shall
provide the Board with a complete, final annual reconciliation report for that
period by the earlier of December 31, 2014 or the date the report is otherwise
due pursuant to paragraphs (1) and (2). If the Board receives a complete, final
reconciliation report for a reporting period by the date required pursuant to
this subparagraph, the Board shall complete reconciliation with the pilot
program health plan for that reporting period within six months of receiving
the report.
(c)
The annual report to be submitted by Pilot Program health plans shall consist
of three parts:
(1) For a Program Graduate
and a Program Graduate dependent enrolled in a Pilot Program standard benefit
plan, an enrollment and program report to be submitted electronically, in a
format to be specified by the Board, for the reporting periods established
above in subsection (a)(1) and (2):
(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 annual reporting period,
and if disenrollment was the result of any of the following:
1. Program Graduate's request;
2. eligibility for Medicare Part A and Part
B;
3. eligibility for other health
insurance;
4. non-payment of
premiums;
5. fraud;
6. death; or
7. other.
(K) Dollar amount of all premiums paid by, or
on behalf of each Program Graduate, and Program Graduate dependent for coverage
in the Pilot Program standard benefit plan during the reporting
period.
(2) A claims
report, to be provided electronically for each program graduate and program
graduate dependent enrolled with the Pilot Program health plan for service
provided and expense payments made during the annual reporting period. The
reporting expense payments shall be limited to expense payments made to
providers of services and shall not include the Pilot Program health plan
administrative expenses, and shall not include incurred but not reported costs.
The report, entitled "Major Risk Medical Insurance Pilot Program Health Plan
and Claims Reporting File Layout and Field Description," dated September, 2003
is hereby incorporated by reference.
(3) 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.
(4) An incomplete report shall be returned
with an explanation to the Pilot Program health plan of the reasons for
incompleteness.
(d)
Except as provided in paragraph (3) of subsection (b), the Board will review
and reconcile each annual complete report within 120 days of receipt to the
Pilot Program health plan of the findings based on the following formula:
one half (aggregate claims plus aggregate standard monthly
administrative fee minus aggregate premiums) minus semiannual interim payments
paid for that reporting period equals Final Payment.
In order to determine an aggregate monthly administrative fee
for individuals in the Pilot Program, the Board will use a weighted average,
weighted by plan population and adjusted by a factor of the number of
dependents in the Program, of the current administrative fees for plans
participating in the Program.
(1) The
Board may make adjustments in determining the final payment to any Pilot
Program health plan as follows:
(A) to delete
any payments for persons who cannot be determined to be a Program Graduate or
Program Graduate dependent during the reporting period,
(B) to delete expenses for services beyond
the date of disenrollment during a reporting period for a Program Graduate or
Program Graduate dependent,
(C) to
delete expenses for services for the Program Graduate or Program Graduate
dependent beyond the date of eligibility for Medicare Part A and Medicare Part
B, and who are not in Medicare solely because of end stage renal
disease,
(D) to delete expenses
that occurred for services outside of the reporting period, and
(E) to delete all expenses beyond the
$200,000 annual and $750,000 lifetime benefit limits for each individual in a
Pilot Program standard benefit plan.
(2) If the current reconciliation indicates
that further payment is owed to the Pilot Program health plan, the payment
shall be made 30 days after notification of the reconciliation results. If the
annual reconciliation indicates that an overpayment has been made through the
semiannual interim payment process, the Pilot Program health plan shall pay the
overpayment to the Board within 35 days after the notification of
reconciliation.
(e) The
annual reconciliation, reporting and payment process shall be subject to review
and/or audit by the Board or its authorized representatives, for a period of
four years after a reconciliation payment by either the Board or a Pilot
Program health plan has been made.
1. New 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 (b), including
redesignation of portion of former subsection (b) as new subsection (b)(1), new
subsection (b)(2) and amendment of subsections (c)(2) and (d) 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).
5. New subsections
(b)(3)-(b)(3)(B) and amendment of subsection (d) filed 12-19-2013 as an
emergency; operative 12-19-2013 (Register 2013, No. 51). A Certificate of
Compliance must be transmitted to OAL by 6-17-2014 or emergency language will
be repealed by operation of law on the following day.
6. Certificate
of Compliance as to 12-19-2013 order transmitted to OAL 5-29-2014 and filed
6-18-2014 (Register 2014, No. 25).
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.
