Section 1367.004 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.004
. (a) A health care service plan that issues, sells,
renews, or offers a specialized health care service plan contract
covering dental services shall, no later than September 30, 2015, and
each year thereafter, file a report, which shall be known as the MLR
annual report, with the department that is organized by market and
product type and contains the same information required in the 2013
federal Medical Loss Ratio (MLR) Annual Reporting Form (CMS-10418).
(b) The MLR reporting year shall be for the calendar year during
which dental coverage is provided by the plan. All terms used in the
MLR annual report shall have the same meaning as used in the federal
Public Health Service Act (42 U.S.C. Sec. 300gg-18), Part 158
(commencing with Section 158.101) of Title 45 of the Code of Federal
Regulations, and Section 1367.003.
(c) If the director decides to conduct a financial examination, as
described in Section 1382, because the director finds it necessary
to verify the health care service plan's representations in the MLR
annual report, the department shall provide the health care service
plan with a notification 30 days before the commencement of the
financial examination.
(d) The health care service plan shall have 30 days from the date
of notification to electronically submit to the department all
requested records, books, and papers specified in subdivision (a) of
Section 1381. The director may extend the time for a health care
service plan to comply with this subdivision upon a finding of good
cause.
(e) The department shall make available to the public all of the
data provided to the department pursuant to this section.
(f) This section does not apply to a health care service plan
contract issued, sold, renewed, or offered for health care services
or coverage provided in the Medi-Cal program (Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9 of the Welfare and
Institutions Code), the Healthy Families Program (Part 6.2
(commencing with Section 12693) of Division 2 of the Insurance Code),
the Access for Infants and Mothers Program (Part 6.3 (commencing
with Section 12695) of Division 2 of the Insurance Code), the
California Major Risk Medical Insurance Program (Part 6.5 (commencing
with Section 12700) of Division 2 of the Insurance Code), or the
Federal Temporary High Risk Insurance Pool (Part 6.6 (commencing with
Section 12739.5) of Division 2 of the Insurance Code), to the extent
consistent with the federal Patient Protection and Affordable Care
Act (Public Law 111-148).
(g) It is the intent of the Legislature that the data reported
pursuant to this section be considered by the Legislature in adopting
a medical loss ratio standard for health care service plans that
cover dental services that would take effect no later than January 1,
2018.
(h) Until January 1, 2018, the director may issue guidance to
health care service plans subject to this section regarding
compliance with this section. This guidance shall not be subject to
the Administrative Procedure Act (Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code). Any guidance issued pursuant to this subdivision shall be
effective only until the director adopts regulations pursuant to the
Administrative Procedure Act. The department shall consult with the
Department of Insurance in issuing guidance pursuant to this
subdivision.