SECTIONS 10850-10856 - California Statutes

INSURANCE CODE

SECTION 10850-10856

10850. (a) In order to be eligible to be a participating carrier, a
carrier shall demonstrate the following operating characteristics
satisfactory to the board:
(1) Be licensed and approved as a carrier and in good standing
with the appropriate regulatory authority.
(2) The ability to provide data required by the board, including
information on enrollee satisfaction based on standard surveys, as
may be prescribed, and to meet reasonable satisfaction measures as
may be established.
(3) The ability to provide standard data elements in a manner
prescribed by the board.
(4) All other criteria established by the board.
(b) Carriers that contract with or employ health care providers
shall have mechanisms to accomplish all of the following in a manner
satisfactory to the purchasing alliance, provided that the
requirements of the alliance do not conflict with the carrier's
licensing requirements:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(c) In evaluating which carriers may participate in the purchasing
alliance, the board shall consider all of the following:
(1) Minimum geographic service and participation requirements,
maximum thresholds for premium rates, and standards for determining
whether a carrier operates efficiently.
(2) The ability of a carrier to provide services within the
purchasing alliance service regions.
(3) Pricing and the competitiveness of each bid from a carrier.

10851. Every participating carrier shall:
(a) Meet the standards established by the board pursuant to this
chapter.
(b) Provide any data required by the board.
(c) Comply with, all applicable laws and regulations that regulate
health care coverage or medical benefits provided to employers,
including, with respect to coverage that is provided to small
employers, Chapter 8 (commencing with Section 10700) for insurers and
Article 3.1 (commencing with Section 1357) of Chapter 2.2 of
Division 2 of the Health and Safety Code for health care service
plans. However, a carrier contracting to participate in a purchasing
alliance shall be deemed to be in compliance with the requirements
for small employers of subdivision (a) of Section 1357.03 of the
Health and Safety Code and of subdivisions (b) and (c) of Section
10705 for a benefit plan design offered through the purchasing
alliance in those service regions in which the carrier participates
in the purchasing alliance and the benefit plan design is offered
exclusively through the purchasing alliance.
(d) Comply with all rules and regulations regarding the
application of risk adjustment factors to standard risk rates for
small employers as specified in subdivisions (a) and (b) of Section
1357.12 of the Health and Safety Code and subdivisions (a) and (b) of
Section 10714 of this code. A participating carrier shall also
comply with the requirements that coverage be issued to small
employers on a guaranteed issue basis as is specified in subdivision
(a) of Section 1357.03 of the Health and Safety Code and subdivision
(b) of Section 10705 of this code for small employers.
(e) All participating medical carriers shall, in determining small
employer rates for health benefit plans offered through a purchasing
alliance, use the six service regions established by this chapter in
determining risk categories for standard employee risk rates.
(f) Enroll and disenroll individuals as directed by the purchasing
alliance or its designee.
(g) Comply with any other requirement established by the board
pursuant to this chapter.

10853. In contracts with participating carriers, the purchasing
alliance may establish performance standards for specific contractual
elements and penalties for failure to fulfill specific contractual
obligations.

10854. Nothing in this chapter shall prohibit a participating
carrier from contracting with particular health care providers or
types, classes, or categories of health care providers or setting
reimbursement methodology.

10855. In the event the participating carrier elects to terminate
its participating agreement with a purchasing alliance, the
participating carrier shall do both of the following:
(a) Provide advance notice of its decision to the board.
(b) Provide notice of the decision at least 180 days prior to the
nonrenewal of any health benefit plan or ancillary benefit plan to
employers or small employers and enrollees.
A participating carrier that elects not to renew a health benefit
plan with a purchasing alliance shall be prohibited from writing new
business through the purchasing alliance for a period of three years
from the date of the notice to the purchasing alliance or until the
purchasing alliance, with the concurrence of the commissioner,
invites the former participating carrier to renew participation,
whichever is sooner.

10856. Nothing in this article shall be construed to limit the
existing regulatory authority of the Department of Managed Health
Care to regulate health care service plans or of the Department of
Insurance to regulate disability or life insurers or hospital service
plans. None of the requirements of this article shall conflict with
the participating carrier's licensing requirements.