1351.2
. (a) If a prepaid health plan operating lawfully under the
laws of Mexico elects to operate a health care service plan in this
state, the prepaid health plan shall apply for licensure as a health
care service plan under this chapter by filing an application for
licensure in the form prescribed by the department and verified by an
authorized representative of the applicant. The prepaid health plan
shall be subject to the provisions of this chapter, and the rules
adopted by the director thereunder, as determined by the director to
be applicable. The application shall be accompanied by the fee
prescribed by subdivision (a) of Section 1356 and shall demonstrate
compliance with the following requirements:
(1) The prepaid health plan is constituted and operating lawfully
under the laws of Mexico and, if required by Mexican law, is
authorized as an Insurance Institution Specializing in Health by the
Mexican Insurance Commission. If the Mexican Insurance Commission
determines that the prepaid health plan is not required to be
authorized as an Insurance Institution Specializing in Health under
the laws of Mexico, the applicant shall obtain written verification
from the Mexican Insurance Commission stating that the applicant is
not required to be authorized as an Insurance Institution
Specializing in Health in Mexico. A Mexican prepaid health plan that
is not required to be an Insurance Institution Specializing in Health
shall obtain written verification from the Mexican Ministry of
Health that the prepaid health plan and its provider network are
operating in full compliance of Mexican law.
(2) The prepaid health plan offers and sells in this state only
employer-sponsored group plan contracts exclusively for the benefit
of Mexican nationals legally employed in the County of San Diego or
the County of Imperial, and for the benefit of their dependents
regardless of nationality, that pay for, reimburse the cost of, or
arrange for the provision or delivery of health care services that
are to be provided or delivered wholly in Mexico, except for the
provision or delivery of those health care services set forth in
paragraph (4).
(3) Solicitation of plan contracts in this state is made only
through insurance brokers and agents licensed in this state or a
third-party administrator licensed in this state, each of which is
authorized to offer and sell plan group contracts.
(4) Group contracts provide, through a contract of insurance
between the prepaid health plan and an insurer admitted in this
state, for the reimbursement of emergency and urgent care services
provided out of area as required by subdivision (h) of Section 1345.
(5) All advertising, solicitation material, disclosure statements,
evidences of coverage, and contracts are in compliance with the
appropriate provisions of this chapter and the rules or orders of the
director. The director shall require that each of these documents
contain a legend in 10-point type, in both English and Spanish,
declaring that the health care service plan contract provided by the
prepaid health plan may be limited as to benefits, rights, and
remedies under state and federal law.
(6) All funds received by the prepaid health plan from a
subscriber are deposited in an account of a bank organized under the
laws of this state or in an account of a national bank located in
this state.
(7) The prepaid health plan maintains a tangible net equity as
required by this chapter and the rules of the director, as calculated
under United States generally accepted accounting principles, in the
amount of a least one million dollars ($1,000,000). In lieu of an
amount in excess of the minimum tangible net equity of one million
dollars ($1,000,000), the prepaid health plan may demonstrate a
reasonable acceptable alternative reimbursement arrangement that the
director may in his or her discretion accept. The prepaid health plan
shall also maintain a fidelity bond and a surety bond as required by
Section 1376 and the rules of the director.
(8) The prepaid health plan agrees to make all of its books and
records, including the books and records of health care providers in
Mexico, available to the director in the form and at the time and
place requested by the director. Books and records shall be made
available to the director no later than 24 hours from the date of the
request.
(9) The prepaid health plan files a consent to service of process
with the director and agrees to be subject to the laws of this state
and the United States in any investigation, examination, dispute, or
other matter arising from the advertising, solicitation, or offer and
sale of a plan contract, or the management or provision of health
care services in this state or throughout the United States. The
prepaid health plan shall agree to notify the director, immediately
and in no case later than one business day, if it is subject to any
investigation, examination, or administrative or legal action
relating to the prepaid health plan or the operations of the prepaid
health plan initiated by the government of Mexico or the government
of any state of Mexico against the prepaid health plan or any
officer, director, security holder, or contractor owning 10 percent
or more of the securities of the prepaid health plan. The prepaid
health plan shall agree that in the event of conflict of laws in any
action arising out of the license, the laws of California and the
United States shall apply.
(10) The prepaid health plan agrees that disputes arising from the
group contracts involving group contractholders and providers of
health care services in the United States shall be subject to the
jurisdiction of the courts of this state and the United States.
(11) The prepaid health plan shall employ or designate a medical
director who holds an unrestricted license to practice medicine in
this state issued pursuant to Section 2050 of the Business and
Professions Code or pursuant to the Osteopathic Act for health care
services set forth in paragraph (4). For health care services that
are to be provided or delivered wholly in Mexico, the prepaid health
plan may employ or designate a medical director operating under the
laws of Mexico.
(b) The prepaid health plan shall pay the application processing
fee and other fees and assessments set forth in Section 1356. The
director, by order, may designate provisions of this chapter and
rules adopted thereunder that need not be applied to a prepaid health
plan licensed under the laws of Mexico when consistent with the
intent and purpose of this chapter, and in the public interest.
(c) If the plan ceases to operate legally in Mexico, the director
shall immediately deliver written notice to the health care service
plan that it is not in compliance with the provisions of this
section. If this occurs, a health care service plan shall do all of
the following:
(1) Provide the director with written proof that the prepaid
health plan has complied with the laws of Mexico not later than 45
days after the date the written notice is received by the health care
service plan.
(2) If, by the 45th day, the health care service plan is unable to
provide written confirmation that it is in full compliance with
Mexican law, the director shall notify the health care service plan
in writing that it is prohibited from accepting any new enrollees or
subscribers. The health care service plan shall be given an
additional 180 days to comply with Mexican law or to become a
licensed health care service plan.
(3) If, at the end of the 180-day notice period in paragraph (2),
the health care service plan has not complied with the laws of Mexico
or California, the director shall issue an order that the health
care service plan cease and desist operations in California.