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Frequently Asked Questions

Table of Contents

How do I know if I need to be licensed by the Department of Managed Health Care?

Your first step is to review the laws and regulations that pertain to licensure. This information is available in the Knox Keene Act (KKA) and the California Code of Regulations (CCR). You may wish to seek outside counsel to assist with the requirements. Specific sections include: KKA 1345(f)(1), KKA 1349 to 1356.1 and CCR 1300.51 to 1300.51.3.

Where can I find the Knox Keene Act and California Code of Regulations?

Laws and Regulations Relating to Health Care Plans in California are also available by clicking the following link: Laws. Specific sections that pertain to licensure KKA 1345(f)(1), KKA 1349 to 1356.1 and CCR 1300.51 to 1300.51.3. You may also purchase a hardcopy of the law for $14.50 by calling 916-324-8176.

How much does it cost to get licensed?

The cost can vary, however, the amount is not to exceed twenty-five thousand dollars ($25,000). See section 1356 of the KKA pertaining to fees.

Who do I talk to if I have questions?

After reviewing the sections of the law and you have further questions please contact the Department's Licensing Division for more information (916-324-9046).

How long does it take to get licensed?

The timeframe can vary, however, it helps if the Plan is actively involved with the Department with scheduling pre-filing conferences, submitting their requirement documents in a timely fashion.

What happens with the fines assessed against a health plan?

The fines assessed are deposited into the Managed Care Fund, which is used to operate the DMHC, including important consumer services such as the Help Center.

Does the enrollee get the money?

The DMHC does not represent the enrollee in enforcement actions against a health plan. Thus, the enrollee does not receive any portion of the fines. The investigation is not a substitute for civil litigation or any remedies an enrollee may seek against their health plan.

As a Health Care Service Plan, am I Required to File Reports under SB 260?

Every plan that contracts with a risk-bearing organization shall submit a quarterly survey listing all its contracting organizations, including their names, addresses, contact persons, telephone numbers, and number of enrollees assigned to the organization as of the last day of the quarter being reported and not more than forty five (45) days after the close of each subsequent calendar quarter

Along with the quarterly report, every plan shall submit an annual survey report due by May 15 of each year, containing the specific information as required under §1300.75.4.3.

As a Health Care Service Plan, What are My Reporting Obligations Under AB 1455?

Within 60 days of the close of each calendar quarter, the plan shall disclose to the Department (A) any emerging patterns of claims payment deficiencies; (B) whether any of its claims processing organizations or capitated providers failed to timely and accurately reimburse 95% of its claims (including the payment of interest and penalties); (C) the corrective action that has been undertaken over the preceding two quarters.

Within 15 days of the close of each calendar year, beginning with the 2004 calendar year, the plan shall submit to the Director, as part of the Annual Plan Claims Payment and Dispute Resolution Mechanism Report information disclosing the claims payment compliance status of the plan and each of its claims processing organizations and capitated providers. The Annual Plan Claims Payment and Dispute Resolution Mechanism Report for 2004 shall include claims payment and dispute resolution data received from October 1, 2003 through September 30, 2004. Each subsequent Annual Plan Claims Payment and Dispute Resolution Mechanism Report shall include claims payment and dispute resolution data received for the last calendar quarter of the year preceding the reporting year and the first three calendar quarters for the reporting year.


Last revised: July 18, 2006