California Health and Safety Code § 1358.10

(a) (1) This section shall apply to Medicare Select contracts, as defined in this section. (2) A contract shall not be advertised as a Medicare Select contract unless it meets the requirements of this section. (b) For the purposes of this section: (1) “Complaint” means any dissatisfaction expressed by an individual concerning a Medicare Select issuer or its network providers. (2) “Grievance” means dissatisfaction expressed in writing by an individual covered by a Medicare Select contract with the administration, claims practices, or provision of services concerning a Medicare Select issuer or its network providers. (3) “Medicare Select issuer” means an issuer offering, or seeking to offer, a Medicare Select contract. (4) “Medicare Select contract” means a Medicare supplement contract that contains restricted network provisions. (5) “Network provider” means a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits covered under a Medicare Select contract. “Provider network” means a grouping of network providers. (6) “Restricted network provision” means any provision which conditions the payment of benefits, in whole or in part, on the use of network providers. (7) “Service area” means the geographic area approved by the director within which an issuer is authorized to offer a Medicare Select contract. (c) The director may authorize an issuer to offer a Medicare Select contract pursuant to Section 4358 of the federal Omnibus Budget Reconciliation Act (OBRA) of 1990 if the director finds that the issuer’s Medicare Select contracts are in compliance with this chapter and if the director finds that the issuer has satisfied all of the requirements of this section. (d) A Medicare Select issuer shall not issue a Medicare Select contract in this state until its plan of operation has been approved by the director. (e) A Medicare Select issuer shall file a proposed plan of operation with the director in a format prescribed by the director. The plan of operation shall contain at least the following information: (1) Evidence that all covered services that are subject to restricted network provisions are available and accessible through network providers, including a demonstration of all of the following: (A) That services can be provided by network providers with reasonable promptness with respect to geographic location, hours of operation, and afterhour care. The hours of operation and availability of afterhour care shall reflect usual practice in the local area. Geographic availability shall reflect the usual travel times within the community. (B) That the number of network providers in the service area is sufficient, with respect to current and expected enrollees, as to either of the following: (i) To deliver adequately all services that are subject to a restricted network provision. (ii) To make appropriate referrals. (C) There are written agreements with network providers describing specific responsibilities. (D) Emergency care is available 24 hours per day and seven days per week. (E) In the case of covered services that are subject to a restricted network provision and are provided on a prepaid basis, that there are written agreements with network providers prohibiting the providers from billing or otherwise seeking reimbursement from or recourse against any individual covered under a Medicare Select contract. This subparagraph shall not apply to supplemental charges or coinsurance amounts as stated in the Medicare Select contract. (2) A statement or map providing a clear description of the service area. (3) A description of the grievance procedure to be utilized. (4) A description of the quality assurance program, including all of the following: (A) The formal organizational structure. (B) The written criteria for selection, retention, and removal of network providers. (C) The procedures for evaluating quality o

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