California Health and Safety Code 1357.16 – (a) Health care service plans may enter into contractual …
(a) Health care service plans may enter into contractual agreements with qualified associations, as defined in subdivision (b), under which these qualified associations may assume responsibility for performing specific administrative services, as defined in this section, for qualified association members. Health care service plans that enter into agreements with qualified associations for assumption of administrative services shall establish uniform definitions for the administrative services that may be provided by a qualified association or its third-party administrator. The health care service plan shall permit all qualified associations to assume one or more of these functions when the health care service plan determines the qualified association demonstrates the administrative capacity to assume these functions.
For the purposes of this section, administrative services provided by qualified associations or their third-party administrators shall be services pertaining to eligibility determination, enrollment, premium collection, sales, or claims administration on a per-claim basis that would otherwise be provided directly by the health care service plan or through a third-party administrator on a commission basis or an agent or solicitor workforce on a commission basis.
Terms Used In California Health and Safety Code 1357.16
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- department: means State Department of Health Services. See California Health and Safety Code 20
- Director: means "State Director of Health Services. See California Health and Safety Code 21
- Person: means any person, individual, firm, association, organization, partnership, business trust, foundation, labor organization, corporation, limited liability company, public agency, or political subdivision of the state. See California Health and Safety Code 1345
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
- Small employer: means either of the following:
California Health and Safety Code 1357
- Solicitor: means any person who engages in the acts defined in subdivision ( l). See California Health and Safety Code 1345
Each health care service plan that enters into an agreement with any qualified association for the provision of administrative services shall offer all qualified associations with which it contracts the same premium discounts for performing those services the health care service plan has permitted the qualified association or its third-party administrator to assume. The health care service plan shall apply these uniform discounts to the health care service plan’s risk adjusted employee risk rates after the health plan has determined the qualified association’s risk adjusted employee risk rates pursuant to Section 1357.12. The health care service plan shall report to the Department of Managed Health Care its schedule of discount for each administrative service.
In no instance may a health care service plan provide discounts to qualified associations that are in any way intended to, or materially result in, a reduction in premium charges to the qualified association due to the health status of the membership of the qualified association. In addition to any other remedies available to the director to enforce this chapter, the director may declare a contract between a health care service plan and a qualified association for administrative services pursuant to this section null and void if the director determines any discounts provided to the qualified association are intended to, or materially result in, a reduction in premium charges to the qualified association due to the health status of the membership of the qualified association.
(b) For the purposes of this section, a qualified association is a nonprofit corporation comprised of a group of individuals or employers who associate based solely on participation in a specified profession or industry, that conforms to all of the following requirements:
(1) It accepts for membership any individual or small employer meeting its membership criteria.
(2) It does not condition membership directly or indirectly on the health or claims history of any person.
(3) It uses membership dues solely for and in consideration of the membership and membership benefits, except that the amount of the dues shall not depend on whether the member applies for or purchases insurance offered by the association.
(4) It is organized and maintained in good faith for purposes unrelated to insurance.
(5) It existed on January 1, 1972, and has been in continuous existence since that date.
(6) It has a constitution and bylaws or other analogous governing documents that provide for election of the governing board of the association by its members.
(7) It offered, marketed, or sold health coverage to its members for 20 continuous years prior to January 1, 1993.
(8) It agrees to offer only to association members any plan contract.
(9) It agrees to include any member choosing to enroll in the plan contract offered by the association, provided that the member agrees to make required premium payments.
(10) It complies with all provisions of this article.
(11) It had at least 10,000 enrollees covered by association sponsored plans immediately prior to enactment of Chapter 1128 of the Statutes of 1992.
(12) It applies any administrative cost at an equal rate to all members purchasing coverage through the qualified association.
(c) A qualified association shall comply with Section 1357.52.
(Amended by Stats. 2012, Ch. 728, Sec. 82. (SB 71) Effective January 1, 2013.)