Section 53500 - Application Information(a) Each organization applying to establish a plan, and each plan applying to renew its contract with the State,shall submit to the Department a package containing the following information: (1) A brief history and general description of its organization.(2) A description of its proposed or existing administrative structure, including: (A) The functions and responsibilities of all principals, policymakers, administrator, medical director and other executive officers.(B) An organization chart and functional description of each organizational unit.(3) A list of all principals, policymakers, executive officers, providers of health care services and other key personnel, including the following information:(C) Date and place of birth.(D) Internal Revenue Service employer number, when applicable.(E) License number, medical specialty and Medi-Cal provider number, when applicable.(4) Evidence of a current Knox-Keene license or a license application with related correspondence or a license as a nonprofit hospital service plan issued pursuant to Section 11493(e) and Sections 11501 to 11505 of the Insurance Code.(5) Financial information including: (A) A detailed cash flow budget, including all written assumptions, estimates and projections, demonstrating the availability and sources of funds to meet the obligations under the contract, for the prospective contract period. Supporting budgets for such affiliates must be provided when the contractor relies upon affiliates to provide services under the contract (see Section 53102 for the definition of "affiliate").(B) A projected calculation of tangible net equity.(C) Certified financial statements, presented on a combined basis with all affiliates, as of the contractor's fiscal or calendar year end. No additional disclosures are required when the contractor's submission is within 90 days after the end of the contractor's fiscal year. Unaudited financial statements to the most current quarter end shall also be submitted if the contractor's submission occurs prior to or more than 90 days after the close of the contractor's fiscal year. Unaudited statements shall be prepared on a combined basis.(D) A listing of all subcontracts between the plan and affiliates.(E) Proof of adequate professional liability insurance coverage.(6) A description of the proposed or existing health care delivery system, including information concerning the following: (A) The scope and availability of services to be provided under the proposed contract.(B) The ratios of physicians to the prepaid patient population and primary care physicians to the prepaid patient population.(C) Location and description of all service sites, hospitals, pharmacies, laboratory and X-ray facilities and skilled nursing facilities, with information about the service availability at each location.(D) The availability of services in emergency circumstances.(E) The preventive health care programs offered.(F) The medical record and medical record service system to be used by the plan.(G) A description of the proposed or existing system to set standards for acceptable medical care, evaluate the quality of care provided, including procedures for the establishment and continuous professional review of the standards for acceptable medical care, review of the performance of medical personnel and review of the effectiveness of controls upon the utilization and costs of services.(7) A delineation of the zip codes of the proposed or existing contract service area and the location of the Medi-Cal beneficiary target population within the service area.(8) A description of proposed marketing efforts, with realistic enrollment and marketing cost projections, for both Medi-Cal and private target population enrollment.(9) Copies of all proposed or existing subcontracts related to securing health care services, administrative and management services or any other services necessary to fulfill its contractual obligations, unless the Department already has a current copy of the subcontract on file.(10) A description of the proposed or existing system for promptly reimbursing nonplan providers for emergency services rendered to members.(11) Certification of willingness and ability to enroll members regardless of their race, creed, color, religion, age, sex, national origin, sexual orientation, marital status or ancestry; and without reference to preexisting medical conditions other than those specifically excluded from coverage under the contract.(12) A description of the proposed or existing procedures by which grievances submitted by members are to be promptly processed and resolved.(13) Any other information required by the Department for proper evaluation of the application.Cal. Code Regs. Tit. 22, § 53500
1. Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No. 27).
2. Amendment filed 12-30-81; effective thirtieth day thereafter (Register 82, No. 1).
3. Amendment of subsection (a)(5) filed 9-22-82; effective thirtieth day thereafter (Register 82, No. 39).
4. Amendment filed 10-26-84; effective thirtieth day thereafter (Register 84, No. 43). Note: Authority cited: Section 14312, Welfare and Institutions Code. Reference: Sections 14204 and 14450, Welfare and Institutions Code.
1. Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No. 27).
2. Amendment filed 12-30-81; effective thirtieth day thereafter (Register 82, No. 1).
3. Amendment of subsection (a)(5) filed 9-22-82; effective thirtieth day thereafter (Register 82, No. 39).
4. Amendment filed 10-26-84; effective thirtieth day thereafter (Register 84, No. 43).