DMHC Updates ICE Annual Conference November 8, 2005   Rick Martin Provider Oversight California Department of Managed Health Care

SB 260 Implementation Revised regulations retroactive to July 1, 2005 Confidentiality Web-based financial statement filing process Filing timeliness - first quarterly filing due November 15 Grading Criteria CAP process External party responsibilities

Grading Criteria Claims timeliness IBNR methodology Positive TNE Positive Working Capital Cash Ratio January 1, 2006 - 0.60 July 1, 2006 - 0.65 January 1, 2007 - 0.75

Corrective Action Plans Identifies the Grading Criteria the RBO failed to meet and the amount by which it failed to meet it Identifies all Plans contracted with RBO Describes specific actions the RBO will take to correct the deficiency Time frame for completing the corrective action

AB 1455 Implementation Provider Complaint Unit – current statistics Revisions to reporting formats Reasonable & Customary reimbursement Independent/Alternative Dispute Resolution Process

AB 1455 - Quarterly Reporting Changes Reporting on five additional Emerging Claims Payment Deficiencies Failures effective October 1, 2005 1300.71(a)(8)(T) 1300.71(b)(1) – 90 days (contracted) & 180 days (non contracted) 1300.71(a)(8)(H) 1300.71(a)(8)(I) Additional changes required effective October 1, 2006 Reporting Paid or Adjusted claims Reporting Emergency Room Claims

AB 1455 – Annual Reporting Changes Changes are the same as Quarterly requirements Additional changes (effective October 1, 2005) Disclosures of Emerging Claim Payment Deficiencies for Health Care Service Plans are in a ‘Yes’ or ‘No’ format Disclosures of Emerging Claim Payment Deficiencies for payors are based on the Health Plan’s audit of the payor. Provide Dispute Resolution changes (effective October 1, 2005) Break out contracted and non-contracted claims payment/billing disputes Separate the total number of claims payment/billing disputes by ‘Type’ of provider (I.e. professional, institutional, other).

New Regulations Regulations currently in formal rule making process Prescription Drug Benefits and C0-Payments – 1300.42.7 Conflict of Interest Code – 1000 Public Meeting and Hearing – 1002.4 Regulations under development Timely Access to Health Care Services (General Access) – 1300.67.2, 1300.67.2.2, 1300.67.2.3 Access to Language Assistance (including Waiting Room Notices Repeal) – 1300.42.7, 1300.67.8(f) Centers of Excellence – TBD Rural Critical Access – 1300.67.2.1 Mental Health Parity – 1300.74.72

Initiatives DMHC web-site redesign New licensing efiling system Streamlining licensing review