California Code of Regulations Title 28 - Managed Health Care
California Code of Regulations – Title 28: Managed Health Care
Title 28 of the California Code of Regulations (CCR) governs Managed Health Care and is primarily administered by the California Department of Managed Health Care (DMHC). It sets the rules and requirements for health care service plans, such as Health Maintenance Organizations (HMOs) and other managed care organizations operating in the state.
Purpose of Title 28
Title 28 supports the enforcement of the Knox-Keene Health Care Service Plan Act of 1975, ensuring that health care service plans:
Provide adequate medical care
Operate fairly and efficiently
Are financially sound
Handle enrollee grievances appropriately
Key Areas Covered
Some of the major topics and regulatory requirements in Title 28 include:
1. Licensing of Health Care Service Plans
Rules for initial and ongoing licensing
Requirements for out-of-state plans offering services in California
2. Financial Requirements
Minimum net equity standards
Tangible net equity and working capital requirements
Reporting and audit obligations
3. Grievance and Appeals Processes
Procedures health plans must follow to handle member complaints
Timelines and documentation standards
4. Disclosure and Marketing
Standards for plan disclosures, such as Evidence of Coverage (EOC)
Rules on advertising and marketing to ensure accuracy and fairness
5. Provider Contracts and Networks
Requirements for network adequacy (e.g., timely access to care)
Contracts with physicians and hospitals
Continuity of care for enrollees
6. Utilization Review and Medical Necessity
Standards and timelines for utilization review decisions
Appeals of medical necessity determinations
7. Timely Access to Care Regulations
Maximum wait times for appointments with primary care, specialists, mental health providers, etc.
8. Mental Health Parity and Telehealth
Requirements for equal treatment of mental and physical health conditions
Standards for telehealth services
Where to Access Title 28
You can find the full text of Title 28 of the CCR here:
DMHC Regulations Portal: https://www.dmhc.ca.gov
Westlaw’s California Regulations Database: https://govt.westlaw.com/calregs
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