CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 1249Introduced by Assembly Member MaienscheinFebruary 21, 2019 An act to amend Section 1343 of the Health and Safety Code, relating to health care service plans. LEGISLATIVE COUNSEL'S DIGESTAB 1249, as introduced, Maienschein. Health care service plans: regulations: exemptions. Existing federal law defines a voluntary employees beneficiary association as an organization comprised of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate.This bill would additionally require the director to exempt from the requirements of the act, for a period of at least 5 years, a contract to provide health care services between a voluntary employees beneficiary association, as defined, and a provider that utilizes risk-based or global risk payment, if the contract meets certain conditions, including that the purpose of the contract is to demonstrate cost savings compared to a fee-for-service reimbursement model.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1343 of the Health and Safety Code is amended to read:1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 1249Introduced by Assembly Member MaienscheinFebruary 21, 2019 An act to amend Section 1343 of the Health and Safety Code, relating to health care service plans. LEGISLATIVE COUNSEL'S DIGESTAB 1249, as introduced, Maienschein. Health care service plans: regulations: exemptions. Existing federal law defines a voluntary employees beneficiary association as an organization comprised of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate.This bill would additionally require the director to exempt from the requirements of the act, for a period of at least 5 years, a contract to provide health care services between a voluntary employees beneficiary association, as defined, and a provider that utilizes risk-based or global risk payment, if the contract meets certain conditions, including that the purpose of the contract is to demonstrate cost savings compared to a fee-for-service reimbursement model.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION
Assembly Bill No. 1249
Introduced by Assembly Member MaienscheinFebruary 21, 2019
Introduced by Assembly Member Maienschein
February 21, 2019
An act to amend Section 1343 of the Health and Safety Code, relating to health care service plans.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 1249, as introduced, Maienschein. Health care service plans: regulations: exemptions.
Existing federal law defines a voluntary employees beneficiary association as an organization comprised of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate.This bill would additionally require the director to exempt from the requirements of the act, for a period of at least 5 years, a contract to provide health care services between a voluntary employees beneficiary association, as defined, and a provider that utilizes risk-based or global risk payment, if the contract meets certain conditions, including that the purpose of the contract is to demonstrate cost savings compared to a fee-for-service reimbursement model.
Existing federal law defines a voluntary employees beneficiary association as an organization comprised of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate.
This bill would additionally require the director to exempt from the requirements of the act, for a period of at least 5 years, a contract to provide health care services between a voluntary employees beneficiary association, as defined, and a provider that utilizes risk-based or global risk payment, if the contract meets certain conditions, including that the purpose of the contract is to demonstrate cost savings compared to a fee-for-service reimbursement model.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1343 of the Health and Safety Code is amended to read:1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1343 of the Health and Safety Code is amended to read:1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
SECTION 1. Section 1343 of the Health and Safety Code is amended to read:
### SECTION 1.
1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.(3) The term of the contract does not exceed five years from the date of approval by the director.(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis. (e)(f) This chapter shall not apply to:(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.(3) A person who does all of the following:(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).(C) Has obtained a certificate of authority from the State Department of Social Services.(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.(5) The California Small Group Reinsurance Fund.
1343. (a) This chapter shall apply to health care service plans and specialized health care service plan contracts as defined in subdivisions (f) and (o) of Section 1345.
(b) The director may by the adoption of rules or the issuance of orders deemed necessary and appropriate, either unconditionally or upon specified terms and conditions or for specified periods, exempt from this chapter any class of persons or plan contracts if the director finds the action to be in the public interest and not detrimental to the protection of subscribers, enrollees, or persons regulated under this chapter, and that the regulation of the persons or plan contracts is not essential to the purposes of this chapter.
(c) The director, upon request of the Director of Health Care Services, shall exempt from this chapter any county-operated pilot program contracting with the State Department of Health Care Services pursuant to Article 7 (commencing with Section 14490) of Chapter 8 of Part 3 of Division 9 of the Welfare and Institutions Code. The director may exempt noncounty-operated pilot programs upon request of the Director of Health Care Services. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.
(d) Upon the request of the Director of Health Care Services, the director may exempt from this chapter any mental health plan contractor or any capitated rate contract under Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9 of the Welfare and Institutions Code. Those exemptions may be subject to conditions the Director of Health Care Services deems appropriate.
(e) The director, upon application, shall exempt from this chapter, for a period of at least five years from the date the exemption is granted, a contract to provide health care services executed between a voluntary employees beneficiary association, as defined in Section 501(c)(9) of the Internal Revenue Code, and a provider that utilizes risk-based or global risk payment, if all of the following criteria are met:
(1) The purpose of the contract is to demonstrate the control of costs for health care services when compared against a sole fee-for-service provider reimbursement model.
(2) The parties to the contract agree to collect and report information regarding the comparative cost savings when compared to fee-for-service payment and performance measurements for clinical patient outcomes.
(3) The term of the contract does not exceed five years from the date of approval by the director.
(4) The participating providers under the contract are currently registered with the department as a risk-bearing organization, limited licensee, or restricted licensee, and agree to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.
(e)
(f) This chapter shall not apply to:
(1) A person organized and operating pursuant to a certificate issued by the Insurance Commissioner unless the entity is directly providing the health care service through those entity-owned or contracting health facilities and providers, in which case this chapter shall apply to the insurers plan and to the insurer.
(2) A plan directly operated by a bona fide public or private institution of higher learning which that directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.
(3) A person who does all of the following:
(A) Promises to provide care for life or for more than one year in return for a transfer of consideration from, or on behalf of, a person 60 years of age or older.
(B) Has obtained a written license pursuant to Chapter 2 (commencing with Section 1250) or Chapter 3.2 (commencing with Section 1569).
(C) Has obtained a certificate of authority from the State Department of Social Services.
(4) The Major Risk Medical Insurance Board when engaging in activities under Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of the Insurance Code, Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code, and Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code.
(5) The California Small Group Reinsurance Fund.