California Code of Regulations Title 28 - Managed Health Care
California Code of Regulations – Title 28
Managed Health Care
Overview
Title 28 of the California Code of Regulations (CCR) sets the rules for managed health care plans operating in California. It is enforced by the Department of Managed Health Care (DMHC). The regulations ensure that health plans provide timely, adequate, and quality care to enrollees while protecting consumer rights.
Title 28 covers health maintenance organizations (HMOs), preferred provider organizations (PPOs) regulated by DMHC, and other managed care entities.
1. Scope and Purpose
Protects enrollees’ rights and ensures access to medically necessary care.
Establishes standards for plan operations, contracts, and marketing practices.
Ensures financial solvency and responsible governance of managed care plans.
Provides regulatory oversight, including audits, investigations, and enforcement.
2. Organizational Requirements
Managed care plans must comply with rules regarding:
Licensing and registration with the DMHC.
Corporate governance, including board responsibilities and conflict-of-interest policies.
Financial reporting to demonstrate solvency and proper use of funds.
Grievance and appeal procedures for members.
3. Consumer Protections
Plans must provide clear member rights information.
Enrollees have the right to:
Access care without unreasonable delay
Receive information about coverage, benefits, and providers
File complaints and appeals
Plans must maintain confidentiality of medical and personal information.
Plans are required to provide language assistance and culturally competent care for diverse populations.
4. Provider Network Standards
Plans must maintain adequate networks of providers to serve members geographically and clinically.
Minimum standards for:
Provider-to-member ratios
Appointment wait times
Geographic accessibility of primary and specialty care
Plans are responsible for credentialing providers and monitoring their quality of care.
5. Medical Management and Quality Assurance
Plans must have utilization management systems for reviewing care appropriateness.
Must maintain quality improvement programs, including:
Performance measurement
Clinical practice guidelines
Member satisfaction assessments
Plans must provide continuity of care, including in the event of plan changes or provider network modifications.
6. Financial and Reporting Requirements
Plans must submit annual financial reports to DMHC.
Must maintain reserves to meet claims obligations.
Subject to audits and corrective actions if financial or operational deficiencies are found.
7. Marketing and Disclosure
Marketing materials must be accurate, clear, and non-misleading.
Plans must disclose:
Benefits, limitations, and exclusions
Cost-sharing requirements
Provider network and grievance procedures
8. Enforcement and Penalties
DMHC has authority to:
Conduct investigations and audits
Issue fines, corrective orders, or license suspensions
Plans are accountable for non-compliance with regulations.
9. Emergency Preparedness
Plans must have disaster recovery and emergency response plans to maintain continuity of care during emergencies.
Purpose
Title 28 ensures that managed health care plans operate safely, ethically, and in the best interest of enrollees, balancing accessibility, quality, and financial integrity.
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