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REVISED 12-6-02

DEPARTMENT OF MANAGED HEALTH CARE PROPOSED REGULATIONS: FINANCIAL EXAMINATIONS

Section 1300.49.2 Exemptions.

New CCR Title 28, section 1300.49.2

For purposes of section 1349.2(a)(7) of the Act, "fiscally sound operation" means an

operation maintaining a positive unrestricted fund balance; maintaining cash and cash

equivalents sufficient to meet current obligations when they become due; and is issued a

report, certificate, or opinion by an independent certified public accountant that is

unqualified, and without reservation regarding future financial viability concerns.

NOTE: Authority cited: section 1344, Health and Safety Code. Reference: section 1349.2, Health and Safety Code.

Section 1300.75.1 Fiscal Soundness, Insurance, and Other Arrangements.

Amend section 1300.75.1(a)(1) and (a)(2). Add new subsections (a)(4) and (a)(5).

(a) A plan shall demonstrate fiscal soundness and assumption of full financial risk as

follows:

(1) Demonstrate through its history of operations and through projections (which

shall be supported by a statement as to the facts and assumptions upon which they are

based) that the plans arrangements for health care services and the schedule of its rates

and charges are financially sound, and provide for the achievement and maintenance of a

positive cash flow including provisions for sufficient to timely reimburse providers and

enrollees for all claims and for retirement of existing and proposed indebtedness.

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(2) Demonstrate that its working capital, cash, and cash generated by operations is are

adequate, including provisions for contingencies.

(3) Demonstrate an approach to the risk of insolvency which allows for the

continuation of benefits for the duration of the contract period for which payment has

been made, the continuation of benefits to subscribers and enrollees who are confined on

the date of insolvency in an in-patient facility until their discharge, and payments to

unaffiliated providers for services rendered.

(4) Demonstrate that transactions with the plans shareholders or any affiliates will

not jeopardize the financial soundness of the plan by executing undertakings that meet

the following minimum requirements:

(A) A plan will not declare or pay dividends, distribute or upstream cash, assets or

property where such actions would result in noncompliance with the tangible net equity

requirements of section 1300.76. Additionally, a plan shall not permit the distribution of

cash, assets, or property that would result in insufficient working capital or cash flow

necessary to provide for the retirement of existing or proposed indebtedness as it comes

due, or adversely affects the ability of the plan to provide health care services required by

the Act or these regulations.

(B) A plan shall file a written Notice of Material Modification pursuant to Health and

Safety Code section 1352 and obtain prior approval of the Department for any loans or

credit agreements entered into by the plan with shareholders or affiliates where the plan:

cosigns or guarantees any portion of the loan or credit agreement, permits any portion of

an existing loan or credit agreement to be assumed by the plan, or pledges plan assets or

capital stock in support of the loan or credit agreement.

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(C) A plan shall provide written notice of undertakings within the meaning of (A) and

(B) to all current and future holders of any loans or credit agreements, or any shareholder

or plan affiliates to the extent that plan assets or stock are involved in such loans or credit

agreements to ensure that satisfaction of any obligations under such instruments is

subordinated to the plans obligations under the Act and these regulations.

(5) Ensure that each contracting provider has the administrative and financial

capacity to meet its contractual obligations.

(b) As a part of its program pursuant to subsection (a), a plan may obtain insurance or

make other arrangements:

(1) For the cost of providing to any member covered health care services the aggregate

value of which exceeds $5,000 in any year;

(2) For the cost of covered health care services provided to its members other than

through the plan because medical necessity required the ir provision of the health care

services before they services could be secured through the plan; and

(3) For not more than 90 percent of the amount by which its costs for any of its fiscal

years exceed 115 percent of its income for such fiscal year.

(c) In passing upon a plan's showing pursuant to this section, the Director will consider

all relevant factors, including but not limited to:

(1) The method of compensating providers and the terms of provider contracts, especially

as to the obligations of providers to subscribers and enrollees in the event of plan

insolvency.

(2) The methods by which the plan controls and monitors the utilization of health care

services.

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(3) The administrative expenses (actual and projected) of the plan and especially as to

new or expanding plans, the fiscal soundness of its program to acquire and service an

expanded subscriber population.

NOTE: Authority cited: Ssection 1344, Health and Safety Code. Reference: Ssection 1375.1, Health and Safety Code.

Section 1300.76 Plan Tangible Net Equity Requirement.

Amend section 1300.76

(a) Except as provided in subsection (b) or (c), each All full service health care

service plans licensed pursuant to the provisions of the Act shall, at al times, have and

maintain at all times a tangible net equity at least equal to the greater of:

(1) $1 million; or

(2) the sum of two four percent of the first $150 million of annualized premium

revenues plus one two percent of annualized premium revenues in excess of $150

million; or

(3) an amount equal to the sum of:

(A) eight twelve percent of the first $150 million of annualized health care

expenditures except those paid on a capitated basis, or managed hospital payment basis,

or per diem basis; plus

(B) four six percent of the annualized health care expenditures, except those paid on

a capitated basis, or managed hospital payment basis, or per diem basis, which are in

excess of $150 million; plus

(C) four six percent of annualized hospital expenditures paid on a managed hospital

payment basis or per diem basis.

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(b) Except as provided in subsection (c), each All specialized health care service

plans licensed pursuant to the provisions of the Act and which only offers specialized

health care service contracts shall, at all times, have and maintain at all times a tangible

net equity at least equal to the greater of:

(1) $50,000 $200,000; or

(2) the sum of two four percent of the first $7,500,000 $7.5 million of annua lized

premium revenues plus one two percent of annualized premium revenues in excess of

$7,500,000 $7.5 million; or

(3) an amount equal to the sum of:

(A) eight twelve percent of the first $7,500,000 $7.5 million of annualized health care

expenditures, except those paid on a capitated, or managed hospital payment, basis or per

diem basis; plus

(B) four six percent of the annualized health care expenditures, except those paid on

a capitated basis, or managed hospital payment basis or per diem basis, which are in

excess of $7,500,000; $7.5 million plus

(C) four six percent of annualized hospital expenditures paid on a managed hospital

payment basis or per diem basis.

(c) Each plan pursuant to the provisions of the Act prior to the effective date of this

section must maintain a minimum tangible net equity of:

(1) 20 percent of the amount required by subsection (a) or (b), as applicable within 6

months of the effective date of this section.

(2) 36 percent of the amount required by subsection (a) or (b), as applicable within 12

months of the effective date of this section.

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(3) 52 percent of the amount required by subsection (a) or (b), as applicable within 18

months of the effective date of this section.

(4) 68 percent of the amount required by subsection (a) or (b), as applicable within 24

months of the effective date of this section.

(5) 84 percent of the amount required by subsection (a) or (b), as applicable within 30

months of the effective date of this section.

(6) 100 percent of the amount required by subsection (a) or (b), as applicable within

36 months of the effective date of this section.

(d) The Director may extend the time periods noted in subsection (c) if the Director

determines that such extension is in the best interests of the plan and its enrollees and it

will not cause the plan to operate in a manner that may be hazardous to its enrollees.

(e)(c) All licensed health plans shall meet and maintain the tangible net equity

requirements specified in subsections (a) and (b) on or before July 1, 2003.

(d) For the purpose of this