Cal. Code Regs. tit. 10 § 2698.602

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2698.602 - Annual Reconciliation Reporting and Payment Process for Pilot Program Health Plans

(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.

Cal. Code Regs. Tit. 10, § 2698.602

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.