Cal. Code Regs. Tit. 22, § 53886 - Health Care Options Presentation

(a) The Health Care Options Program shall provide, in each designated region, a presentation of plan options to each new and continuing eligible beneficiary who meets the mandatory enrollment criteria specified in section 53845 and to any eligible beneficiary who meets the voluntary enrollment criteria specified in section 53845 and requests a presentation. For non-English or limited English speaking beneficiaries, presentations shall be made in the beneficiary's preferred language. Reasonable accommodations shall be made for persons who are blind, deaf or hearing impaired. At the department's discretion, the presentation may be in person or by mail. The department shall ensure that any eligible beneficiary requesting a face-to-face presentation is provided the opportunity to have such presentation at the earliest possible time and in the most convenient location possible, or is given the opportunity to speak with a telephone representative provided by the Health Care Options Program for assistance in making a plan selection.

(b) The health care options presentation shall include, at a minimum, the following information:

(1) The names of each plan.

(2) Each plan's service area.

(3) The name, address, telephone number, and specialty, if any, of each primary and specialty care provider or clinic participating in each plan. Providers participating in each plan will be listed alphabetically by last name and grouped by geographic area.

(4) The process for selecting or changing a primary care provider and an explanation that beneficiaries have the right to select a primary care clinic as their primary care provider and to change their primary care provider at any time.

(5) Services covered by each plan.

(6) Procedures for accessing and receiving health care services from each plan.

(7) Hospitals used by each plan.

(8) Any features or additional services, including cultural and linguistic services, provided by each plan, pursuant to the contract.

(9) An explanation that a beneficary eligible for voluntary enrollment may submit a request for disenrollment from the plan at any time, in accordance with the provisions of section 53891.

(c) For eligible beneficiaries for whom plan enrollment is mandatory, the following additional information shall be provided:

(1) An explanation that an exemption from plan enrollment exists for American Indians, members of American Indian households, and others eligible to receive health care services through an Indian Health Service facility, as specified in section 53887(a)(1).

(2) An explanation that an exemption from plan enrollment may be obtained for individuals with complex medical conditions, as specified in section 53887(a)(2), and how to request such an exemption.

(3) An explanation that if beneficiaries do not select a plan within 30 days, they will be assigned to a plan.

(4) An explanation that beneficiaries have the right to disenroll from a plan and reenroll in the competing plan at any time, in accordance with section 53891.

(d) The Health Care Options Program shall provide assistance to eligible beneficiaries in enrollment/disenrollment, as needed.

(e) Prior to either requesting enrollment by signing a written request or being assigned to a plan in a designated region in accordance with section 53883, each eligible beneficiary shall be informed in writing by the department or the Health Care Options Program of at least the following:

(1) There will be a 15 to 45 day processing time between the date of application or assignment and the effective date of enrollment in a plan.

(2) Until plan enrollment is effective, the beneficiary may receive Medi-Cal covered health care services from any Medi-Cal provider licensed to provide the services.

(3) An explanation of the process for requesting exemption from plan enrollment for the reasons specified in section 53887.

(f) In the event disenrollment from a plan is restricted pursuant to section 53891(b) during the second through sixth month of enrollment, the Health Care Options Program shall inform beneficiaries of the conditions of disenrollment.

Notes

Cal. Code Regs. Tit. 22, § 53886

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
2. Repealer of section and NOTE and new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of section and NOTE filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14016.5, 14087.3, 14087.305 and 14087.4, Welfare and Institutions Code.

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
3. Amendment of section and Note filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).