SECTIONS 14400-14413 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14400-14413

14400. Every prepaid health plan shall have an open enrollment
period at least once every year. During the open enrollment period
the plan shall accept up to the limit of its capacity or the limit of
its contract, without restrictions, other than those which may be
required by the director, Medi-Cal beneficiaries who are eligible to
enroll in such plans. Eligible enrollees shall be accepted in the
order in which they apply for enrollment.

14401. No Medi-Cal beneficiary shall be enrolled in a prepaid
health plan prior to the time a contract under this chapter is signed
by the department and such prepaid health plan is approved by the
appropriate state agencies.

14402. The prepaid health plan shall enroll only those Medi-Cal
beneficiaries who reside within the contract service area. Prepaid
health plans shall use a standard application form prescribed by the
department which is readily understandable to the enrollees. A
beneficiary shall be enrolled in the prepaid health plan when the
beneficiary voluntarily signs the enrollment application agreeing to
utilize the health services provided by the prepaid plan and his
eligibility for enrollment in that plan is verified by validation of
the application by the department.
Notwithstanding the provisions of this section requiring voluntary
enrollment, the department may approve the transfer of the enrollees
of one or more prepaid health plans to another prepaid health plan
in accordance with the terms of a merger or reorganization approved
by the department pursuant to the conditions set forth in Sections
14303.1 and 14303.2.

14403. No Medi-Cal beneficiary shall be enrolled in more than one
prepaid health plan at any time.

14406. (a) Within seven days after the effective date of
enrollment, the prepaid health plan shall provide in writing the
following information to a new enrollee or the family unit of the new
enrollee:
(1) An appropriate document identifying the enrollee and
authorizing the services or benefits to which that person is entitled
under the plan subject to verification of eligibility.
(2) A description of all services and benefits provided by the
plan.
(3) An explanation of the procedure for obtaining these services
and benefits, including in the case of medical foundations or
independent practice associations, the address and telephone number
of each primary care physician, dentist, optometrist, psychologist,
and in the case of other plans, the address and telephone number of
each service site and the location of primary care physicians,
dentists, optometrists and psychologists, and in the case of all
prepaid health plans, the address and telephone numbers of each
hospital, pharmacy, and skilled nursing facility where health care
benefits may be obtained. In addition, the explanation shall state
the hours and days where each of these facilities are open and the
services and benefits available.
(4) The location, telephone number, and procedure for securing
24-hour emergency care and an explanation of and procedure for
obtaining out-of-area emergency coverage.
(5) Information setting forth the term of enrollment in the
prepaid health plan including the causes for which an enrollee shall
lose eligibility in the prepaid health plan.
(6) The procedure for processing and resolving any grievance by
enrollees. Such information shall include the name, address, and
telephone number of the person responsible for resolving grievances
or initiating a grievance procedure.
(7) The procedure by which enrollees may request disenrollment.
(8) Any other information essential to the use of the prepaid
health plan as may be required by the department.
(b) The information made available under this section shall be
revised and distributed annually to each enrollee or enrollee's
family unit and whenever there is a change in the services provided
or the location where they may be obtained. Except for a change which
is unforeseeable, all enrollees affected by the change in service or
the location of services shall be notified at least 14 days prior to
such a change.

14407. Enrollment in a prepaid health plan shall be voluntary and a
prepaid health plan shall not use false advertising or false
statements to induce enrollment. No solicitation of enrollees shall
include the granting or offering of any monetary or other valuable
consideration for enrollment.

14407.1. (a) A contractor that has entered into a contract with the
department under this chapter, or under another Medi-Cal managed
care contracting authority, may offer nonmonetary incentives to
promote good health practices by its existing Medi-Cal enrollees.
(b) No Medi-Cal managed care contractor may offer an incentive to
promote good health practices by its Medi-Cal enrollees prior to
written approval by the department. In the absence of other
countervailing considerations, the department shall approve, to the
extent permitted by federal law, the use by health plans of
nonmonetary incentives to enhance health education program efforts to
increase member participation, learning, and motivation to do any of
the following:
(1) Effectively use managed health care services, including
preventive and primary care services, obstetric care, and health
education services.
(2) Modify personal health behaviors, achieving and maintaining
healthy lifestyles and treatment therapies and positive health
outcomes.
(3) Follow self-care regimens and treatment therapies for existing
medical conditions, chronic diseases, or health conditions.
(c) If a contractor is a publicly operated entity, the offering of
a department-approved, nonmonetary incentive to promote good health
practices by enrollees shall not constitute a gift of public funds.
(d) Violations of this section shall be subject to the
requirements and penalties set forth in Sections 14408 and 14409, and
any regulations adopted by the department pursuant to this article.
(e) The department shall develop and publish written guidelines
for the appropriate use of nonmonetary incentives that may be offered
to Medi-Cal enrollees.

14407.6. (a) Notwithstanding Section 14407.5, the department shall,
to the extent permitted by federal law or under federal waivers
which the department may obtain, establish a minimum enrollment
period for Medi-Cal beneficiaries enrolling in managed care plans
under any of the following:
(1) This chapter.
(2) Any of the following provisions of Chapter 7 (commencing with
Section 14000):
(A) Article 2.7 (commencing with Section 14087.3).
(B) Article 2.9 (commencing with Section 14088).
(C) Article 2.91 (commencing with Section 14089).
(b) (1) Except as otherwise required by federal law, disenrollment
during the minimum enrollment period shall only be for good cause.
(2) For purposes of this section, the meaning of "good cause"
shall be as defined in subdivision (b) of Section 14407.8, and shall
include "good cause" as defined by federal laws or regulations
governing Medi-Cal managed care contracting.

14408. (a) Except as otherwise prohibited by law, a contractor that
has entered into a contract with the department pursuant to this
chapter may make the benefits known to potential enrollees by methods
approved by the department.
(b) No prepaid health plan, marketing representative, or marketing
organization shall engage in marketing activities prior to written
submittal to and approval by the department. All marketing
activities, procedures, methods, and places in which any activities
will be conducted shall be explicitly described in a marketing plan
and approved by the department prior to being used by a prepaid
health plan, marketing representative, or marketing organization. The
marketing plan shall be updated and submitted for renewed approval
on an annual basis. The department may approve, disapprove, or
withdraw approval of any marketing activity or procedure. The
department shall require the discontinuance of any marketing activity
or procedure for which the department withdraws approval. The
conduct of activities or procedures not included in an approved
marketing plan shall constitute a violation of this article and be
subject to sanctions in accordance with Section 14409.
The prepaid health plan shall be responsible for all presentations
by its marketing representatives and for their ethical and
professional conduct. The department may withdraw certification for
participation in the program from, and impose marketing sanctions
specified in Section 14409, as applicable, on marketing
representatives.
(c) The marketing plan shall meet the standards established by the
department. The marketing plan shall include, but not be limited to,
an explicit description of the specific marketing activities, the
method of identifying individual enrollments by marketing
representative, and formal measures to monitor performance of
marketing representatives and verify both of the following:
(1) The prepaid health plan's marketing activities and practices
do not violate subdivision (a) of Section 14409.
(2) Beneficiaries receive complete and accurate information about
the benefits and limitations of receiving health care services
through the prepaid plan in a manner that considers the beneficiary's
level of comprehension.
(d) Each time a marketing representative presents information
about the benefits of prepaid health plan enrollment to a beneficiary
in order to encourage the beneficiary to enroll, the marketing
representative shall leave with the beneficiary printed information
identifying the marketing representative by name and prepaid health
plan represented.
(e) All printed or illustrated material prepared by the prepaid
health plan for dissemination to enrollees or to prospective
enrollees shall be submitted to the department prior to
dissemination. The department shall acknowledge receipt of the
printed or illustrated material within five days, and shall approve
or disapprove the material for dissemination within 60 days after the
date of notification that the material has been received. The
department may withdraw approval of the material previously approved
and order its dissemination discontinued. If the department notifies
the prepaid health plan of its disapproval or withdrawal of approval,
the prepaid health plan shall have the right to meet and confer with
the director or his or her designee and demonstrate the purpose and
reasonable basis for the distribution of the material to enrollees
and potential enrollees.
(f) (1) Any form of door-to-door or in-person marketing that
coerces or misleads beneficiaries or selectively enrolls
beneficiaries on the basis of their health status is unlawful. In
addition, on or after July 1, 1996, door-to-door solicitation of
Medi-Cal enrollees shall not be permitted.
(2) On or after July 1, 1996, the health care options presentation
required by Sections 14016.5 and 14016.6 or the health care options
information required by Sections 14087.305 and 14089 shall be fully
operational in counties specified by the director for expansion of
the Medi-Cal managed care program or in counties where prepaid health
plans are contracting with the department pursuant to Sections
14018.7, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96, 14089, and
14089.05. In these counties, on or after July 1, 1996, no enrollment
of beneficiaries by prepaid health plans shall occur during
in-person marketing activities or during health fairs pursuant to
paragraph (5) of subdivision (f). Enrollment shall be exclusively
performed and transmitted pursuant to the program required by
Sections 14016.5, 14016.6, 14087.305, and 14089.
(3) In the event the health care options presentation required by
Sections 14016.5 and 14016.6 is not fully operational or the health
care options information required by Sections 14087.305 and 14089 is
not fully available, as specified in paragraph (2) of subdivision
(f), the department shall perform the enrollment-only functions until
the health care options presentation or information is fully
operational or available.
(4) Nothing in this section shall preclude a prepaid health plan
from responding to inquiries initiated by beneficiaries or potential
beneficiaries.
(5) Until July 1, 1996, a prepaid health plan may participate in
an organized community or neighborhood health fair in a public place
only if two or more prepaid health plans are participating, or if the
plan is invited by the sponsor of the fair. If there are not two or
more prepaid health plans providing services to Medi-Cal
beneficiaries in a prepaid health plan's service area, this
subdivision shall not apply. On or after July 1, 1996, a prepaid
health plan may participate in an organized community or neighborhood
health fair in a public place for marketing purposes.
(g) Any prepaid health plan, marketing representative, or
marketing organization that violates subdivision (f) shall be subject
to the sanctions set forth in subdivision (b) of Section 14409 and
shall be guilty of a misdemeanor and subject to a fine of five
hundred dollars ($500) or imprisonment in a county jail for six
months, or both, for each violation.
(h) The department shall certify each marketing representative
prior to participation in the program in accordance with standards
established by the department. Continuing certification for
participation in the program shall be contingent upon compliance with
this article, as well as guidelines and standards adopted by the
department, and may be withdrawn upon their violation, as determined
by the department. The department may temporarily decertify any
marketing representative when that action is necessary to protect the
public welfare or the interests of the Medi-Cal program. Temporary
decertification shall be effective immediately upon written notice to
the marketing representative and the managed care contractor, and
shall remain in effect until the department has made a determination
on the merits. Temporary decertification shall be canceled unless the
department acts to permanently withdraw certification within 60
days.
(i) No prepaid health plan shall employ in any capacity relating
to the marketing operations of the plan a marketing representative
whose certification has been withdrawn. Marketing representatives
shall not be recertified for participation until the cause for
withdrawal of certification has been corrected to the satisfaction of
the department. Proof of correction shall be the sole responsibility
of the marketing representative.

14408.5. A prepaid health plan that contracts with Medi-Cal managed
care or contracts with the Healthy Families Program may provide
application assistance pursuant to Section 12693.325 of the Insurance
Code during the eligibility redetermination process in order to
allow persons to retain coverage.

14409. (a) No prepaid health plan, marketing representative, or
marketing organization shall in any manner misrepresent itself, the
plans it represents, or the Medi-Cal program or Healthy Families
Program. Violations of this section shall include, but are not
limited to:
(1) False or misleading claims that marketing representatives are
employees or representatives of the state, county, or anyone other
than the prepaid health plan or the organization by whom they are
reimbursed.
(2) False or misleading claims that the prepaid health plan is
recommended or endorsed by any state or county agency, or by any
other organization which has not certified its endorsement in writing
to the prepaid health plan.
(3) False or misleading claims that the state or county recommends
that a Medi-Cal beneficiary enroll in a prepaid health plan.
(4) Claims that a Medi-Cal beneficiary will lose his benefits
under the Medi-Cal program or any other health or welfare benefits to
which he is legally entitled, if he does not enroll in a prepaid
health plan.
(b) Violations of this article or regulations adopted by the
department pursuant to this article shall result in one or more of
the following sanctions that are appropriate to the specific
violation, considering the nature of the offense and frequency of
occurrence within the prepaid health plan:
(1) Revocation of one or more permitted methods of marketing.
(2) Termination of authorization for a plan to provide application
assistance.
(3) Refusal of the department to accept new enrollments for a
period specified by the department.
(4) Refusal of the department to accept enrollments submitted by a
marketing representative or organization.
(5) Forfeiture by the plan of all or part of the capitation
payments for persons enrolled as a result of such violations.
(6) Requirement that the prepaid health plan in violation of this
article personally contact each enrollee enrolled to explain the
nature of the violation and inform the enrollee of his right to
disenroll.
(7) Application of sanctions as provided in Section 14304.
(8) Temporarily withhold capitation payments for beneficiaries
enrolled in violation of this article, or regulations adopted
thereunder, until the prepaid health plan is in substantial
compliance with the statutory and regulatory provisions.
(c) Any marketing representative who violates subdivision (a)
while engaged in door-to-door solicitation is guilty of a
misdemeanor, and shall be subject to a fine of five hundred dollars
($500) or imprisonment in the county jail for six months, or both.

14410. No prepaid health plan or marketing representative shall
adopt or utilize any procedure to identify prospective enrollees with
medical or psychiatric problems in order to exclude them from
enrollment in the prepaid health plan, other than medical conditions
specifically excluded from coverage by the contract.

14411. (a) No prepaid health plan or marketing organization shall
solicit prospective enrollees on county premises for benefits or
services available pursuant to this chapter except under any one of
the following conditions:
(1) Such marketing activities are performed by a county employee
under an agreement between the county and the prepaid health plan,
and all marketing presentations and materials to be used have been
approved by the department.
(2) Such marketing activities are performed by a state employee
under an agreement between the department, county, and the prepaid
health plan, and all marketing presentations and materials to be used
have been approved by the department.
(3) Such marketing activities are performed by a marketing
representative of a prepaid health plan under an agreement between
the county, the prepaid health plan and the department, and all
marketing presentations and materials to be used have been approved
by the department.
(b) No prepaid health plan or marketing organization shall solicit
prospective enrollees on state premises for benefits or services
available pursuant to this chapter, except under any one of the
following conditions:
(1) Such marketing activities are performed by a state employee
under an agreement between the department, the Department of General
Services, and the prepaid health plan, and all marketing
presentations and materials to be used have been approved by the
department.
(2) Such marketing activities are performed by a marketing
representative of a prepaid health plan under an agreement between
the department, the Department of General Services, and the prepaid
health plan, and all marketing presentations and materials to be used
have been approved by the department.

14412. (a) The enrollment of a Medi-Cal beneficiary in the prepaid
health plan shall not be terminated except for loss of eligibility,
for good cause as determined by the department, or at the request of
the beneficiary.
(b) Enrollment shall be terminated at the request of the Medi-Cal
beneficiary, to the extent required by federal law.
(c) Any Medi-Cal beneficiary enrolled in a prepaid health plan who
would remain eligible for Medi-Cal program benefits for three
additional months pursuant to Section 14005.8 shall remain enrolled
in the prepaid health plan and shall not receive a Medi-Cal card
unless disenrollment is requested by the beneficiary, and the request
is submitted in accordance with state and federal law.
(d) It is the intent of the Legislature that the department shall
develop such policies and procedures to maximize continuity of care
for persons enrolled in prepaid health plans and to insure that the
eligibility determination or redetermination process does not
unnecessarily interfere with such enrollment or create gaps in the
delivery of health services.

14413. (a) Requests for disenrollment shall be made to an
authorized representative of the prepaid health plan or to the
department. All requests for disenrollment, except those submitted
pursuant to Sections 14303.1(c), 14303.2(c), or 14409(b)(5), or for
other good cause as determined by the director, shall be processed
through the prepaid health plan's grievance procedure as approved by
the department. Disenrollment requests received by the prepaid health
plan shall be submitted to the department, on standard disenrollment
forms prescribed by the department, within a reasonable time
following the date of such signed request, as determined by the
director, to permit the department to terminate enrollment effective
the beginning of the first calendar month following a full calendar
month after the request is made.
(b) All applications for disenrollment shall be processed by the
department, and where Medi-Cal eligibility continues or Medi-Cal
coverage is extended under Section 14005.8, a Medi-Cal card shall be
issued effective not later than the beginning of the first calendar
month following a full calendar month after the request for
disenrollment is made. Submittal of a request for disenrollment for
processing through the grievance procedure of a prepaid health plan
shall not be deemed to infringe on this entitlement.