1399.825. As used in this article:
(a) "Child" means any individual under 19 years of age.
(b) "Individual grandfathered plan coverage" means health care
coverage in which an individual was enrolled on March 23, 2010,
consistent with Section 1251 of PPACA and any rules or regulations
adopted pursuant to that law.
(c) "Initial open enrollment period" means the open enrollment
period beginning on January 1, 2011, and ending 60 days thereafter.
(d) "Late enrollee" means a child without coverage who did not
enroll in a health care service plan contract during an open
enrollment period because of any of the following:
(1) The child lost dependent coverage due to termination or change
in employment status of the child or the person through whom the
child was covered; cessation of an employer's contribution toward an
employee or dependent's coverage; death of the person through whom
the child was covered as a dependent; legal separation; divorce; loss
of coverage under the Healthy Families Program, the Access for
Infants and Mothers Program, or the Medi-Cal program; or adoption of
the child.
(2) The child became a resident of California during a month that
was not the child's birth month.
(3) The child is born as a resident of California and did not
enroll in the month of birth.
(4) The child is mandated to be covered pursuant to a valid state
or federal court order.
(e) "Open enrollment period" means the annual open enrollment
period, subsequent to the initial open enrollment period, applicable
to each individual child that is the month of the child's birth date.
(f) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any
subsequent rules or regulations issued pursuant to that law.
(g) "Preexisting condition exclusion" means, with respect to
coverage, a limitation or exclusion of benefits relating to a
condition based on the fact that the condition was present before the
date of enrollment of the coverage, whether or not any medical
advice, diagnosis, care, or treatment was recommended or received
before that date.
(h) "Responsible party for a child" means an adult having custody
of the child or with responsibility for the financial needs of the
child, including the responsibility to provide health care coverage.
(i) "Standard risk rate" means the lowest rate that can be offered
for a child with the same benefit plan, effective date, age,
geographic region, and family status.
1399.826. (a) (1) During each open enrollment period, every health
care service plan offering plan contracts in the individual market,
other than individual grandfathered plan coverage, shall offer to the
responsible party for a child coverage for the child that does not
exclude or limit coverage due to any preexisting condition of the
child.
(b) A health care service plan offering coverage in the individual
market shall not reject an application for a health care service
plan contract from a child or filed on behalf of a child by the
responsible party during an open enrollment period or from a late
enrollee during a period no longer than 63 days from the qualifying
event listed in subdivision (d) of Section 1399.825.
(c) Except to the extent permitted by federal law, rules,
regulations, or guidance issued by the relevant federal agency, a
health care service plan shall not condition the issuance or offering
of individual coverage on any of the following factors:
(1) Health status.
(2) Medical condition, including physical and mental illnesses.
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability, including conditions arising out of
acts of domestic violence.
(8) Disability.
(9) Any other health status-related factor as determined by
department.
This subdivision shall not apply to a contract providing
individual grandfathered plan coverage.
(d) When a responsible party for a child submits a premium
payment, based on the quoted premium charges, and that payment is
delivered or postmarked, whichever occurs earlier, within the first
15 days of the month, coverage under the plan contract shall become
effective no later than the first day of the following month. When
that payment is neither delivered nor postmarked until after the 15th
day of the month, coverage shall become effective no later than the
first day of the second month following delivery or postmark of the
payment.
(e) A health care service plan offering coverage in the individual
market shall not reject the request of a responsible party for a
child to include that child as a dependent on an existing health care
service plan contract that includes dependent coverage during an
open enrollment period.
(f) Nothing in this article shall be construed to prohibit a
health care service plan offering coverage in the individual market
from establishing rules for eligibility for coverage and offering
coverage pursuant to those rules for children and individuals based
on factors otherwise authorized under federal and state law for
health plan contracts in addition to those offered on a guaranteed
issue basis during an open enrollment period to children or late
enrollees pursuant to this article. However, a health care service
plan, other than a plan providing individual grandfathered plan
coverage, shall not impose a preexisting condition provision on
coverage, including dependent coverage, offered to a child.
(g) Nothing in this article shall be construed to require a plan
to establish a new service area or to offer health coverage on a
statewide basis, outside of the plan's existing service area.
(h) Nothing in this article shall be construed to prevent a health
care service plan from offering coverage to a family member of an
enrollee in grandfathered health plan coverage consistent with
Section 1251 of PPACA.
1399.827. This article shall not apply to health care service plan
contracts for coverage of Medicare services pursuant to contracts
with the United States government, Medicare supplement contracts,
Medi-Cal contracts with the State Department of Health Care Services,
plan contracts offered under the Healthy Families Program, long-term
care coverage, or specialized health care service plan contracts.
1399.828. (a) Upon the effective date of this article, a health
care service plan shall fairly and affirmatively offer, market, and
sell all of the plan's health care service plan contracts that are
offered and sold to a child or the responsible party for a child in
each service area in which the plan provides or arranges for the
provision of health care services during any open enrollment period,
to late enrollees, and during any other period in which state or
federal law, rules, regulations, or guidance expressly provide that a
health care service plan shall not condition offer or acceptance of
coverage on any preexisting condition.
(b) No health care service plan or solicitor shall, directly or
indirectly, engage in the following activities:
(1) Encourage or direct a child or responsible party for a child
to refrain from filing an application for coverage with a plan
because of the health status, claims experience, industry,
occupation, or geographic location, provided that the location is
within the plan's approved service area, of the child.
(2) Encourage or direct a child or responsible party for a child
to seek coverage from another plan because of the health status,
claims experience, industry, occupation, or geographic location,
provided that the location is within the plan's approved service
area, of the child.
(c) A health care service plan shall not, directly or indirectly,
enter into any contract, agreement, or arrangement with a solicitor
that provides for or results in the compensation paid to a solicitor
for the sale of a health care service plan contract to be varied
because of the health status, claims experience, industry,
occupation, or geographic location of the child. This subdivision
does not apply to a compensation arrangement that provides
compensation to a solicitor on the basis of percentage of premium,
provided that the percentage shall not vary because of the health
status, claims experience, industry, occupation, or geographic area
of the child.
1399.829. (a) A health care service plan may use the following
characteristics of an eligible child for purposes of establishing the
rate of the plan contract for that child, where consistent with
federal regulations under PPACA: age, geographic region, and family
composition, plus the health care service plan contract selected by
the child or the responsible party for the child.
(b) From the effective date of this article to December 31, 2013,
inclusive, rates for a child applying for coverage shall be subject
to the following limitations:
(1) During any open enrollment period or for late enrollees, the
rate for any child due to health status shall not be more than two
times the standard risk rate for a child.
(2) The rate for a child shall be subject to a 20-percent
surcharge above the highest allowable rate on a child applying for
coverage who is not a late enrollee and who failed to maintain
coverage with any health care service plan or health insurer for the
90-day period prior to the date of the child's application. The
surcharge shall apply for the 12-month period following the effective
date of the child's coverage.
(3) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may rate a child based on health status during any period other than
an open enrollment period if the child is not a late enrollee.
(4) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may condition an offer or acceptance of coverage on any preexisting
condition or other health status-related factor for a period other
than an open enrollment period and for a child who is not a late
enrollee.
(c) For any individual health care service plan contract issued,
sold, or renewed prior to December 31, 2013, the health plan shall
provide to a child or responsible party for a child a notice that
states the following:
"Please consider your options carefully before failing to maintain
or renew coverage for a child for whom you are responsible. If you
attempt to obtain new individual coverage for that child, the premium
for the same coverage may be higher than the premium you pay now."
(d) A child who applied for coverage between September 23, 2010,
and the end of the initial open enrollment period shall be deemed to
have maintained coverage during that period.
(e) Effective January 1, 2014, except for individual grandfathered
health plan coverage, the rate for any child shall be identical to
the standard risk rate.
(f) Health care service plans may require documentation from
applicants relating to their coverage history.
1399.832. No health care service plan shall be required to offer a
health care service plan contract or accept applications for the
contract pursuant to this article in the case of any of the
following:
(a) To a child, if the child who is to be covered by the plan
contract does not work or reside within the plan's approved service
areas.
(b) (1) Within a specific service area or portion of a service
area, if the plan reasonably anticipates and demonstrates to the
satisfaction of the director that it will not have sufficient health
care delivery resources to ensure that health care services will be
available and accessible to the child because of its obligations to
existing enrollees.
(2) A health care service plan that cannot offer a health care
service plan contract to individuals or children because it is
lacking in sufficient health care delivery resources within a service
area or a portion of a service area may not offer a contract in the
area in which the plan is not offering coverage to individuals to new
employer groups until the plan notifies the director that it has the
ability to deliver services to individuals, and certifies to the
director that from the date of the notice it will enroll all
individuals requesting coverage in that area from the plan.
(3) Nothing in this article shall be construed to limit the
director's authority to develop and implement a plan of
rehabilitation for a health care service plan whose financial
viability or organizational and administrative capacity has become
impaired.
1399.833. The director may require a health care service plan to
discontinue the offering of contracts or acceptance of applications
from any individual or child or responsible party for a child upon a
determination by the director that the plan does not have sufficient
financial viability or organizational and administrative capacity to
ensure the delivery of health care services to its enrollees. In
determining whether the conditions of this section have been met, the
director shall consider, but not be limited to, the plan's
compliance with the requirements of Section 1367, Article 6
(commencing with Section 1375.1), and the rules adopted under those
provisions.
1399.834. (a) All health care service plan contracts offered to a
child or on behalf of a child to a responsible party for a child
shall conform to the requirements of Sections 1366.3, 1365, and
1373.6 and shall be renewable at the option of the enrollee or
responsible party for a child on behalf of the enrollee except as
permitted to be canceled, rescinded, or not renewed pursuant to
Section 1365.
(b) Any plan that ceases to offer for sale new individual health
care service plan contracts pursuant to Section 1365 shall continue
to be governed by this article with respect to business conducted
under this article.
(c) Except as authorized under Section 1399.833, a plan that, as
of the effective date of this article, does not write new health care
service plan contracts for children in this state or that, after the
effective date of this article, ceases to write new health care
service plan contracts for children in this state shall be prohibited
from offering for sale new individual health care service plan
contracts in this state for a period of five years from the date of
notice to the director.
1399.835. On or before July 1, 2011, the director may issue
guidance to health plans regarding compliance with this article and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The guidance shall only
be effective until the director and the Insurance Commissioner adopt
joint regulations pursuant to the Administrative Procedure Act.
1399.825. As used in this article:
(a) "Child" means any individual under 19 years of age.
(b) "Individual grandfathered plan coverage" means health care
coverage in which an individual was enrolled on March 23, 2010,
consistent with Section 1251 of PPACA and any rules or regulations
adopted pursuant to that law.
(c) "Initial open enrollment period" means the open enrollment
period beginning on January 1, 2011, and ending 60 days thereafter.
(d) "Late enrollee" means a child without coverage who did not
enroll in a health care service plan contract during an open
enrollment period because of any of the following:
(1) The child lost dependent coverage due to termination or change
in employment status of the child or the person through whom the
child was covered; cessation of an employer's contribution toward an
employee or dependent's coverage; death of the person through whom
the child was covered as a dependent; legal separation; divorce; loss
of coverage under the Healthy Families Program, the Access for
Infants and Mothers Program, or the Medi-Cal program; or adoption of
the child.
(2) The child became a resident of California during a month that
was not the child's birth month.
(3) The child is born as a resident of California and did not
enroll in the month of birth.
(4) The child is mandated to be covered pursuant to a valid state
or federal court order.
(e) "Open enrollment period" means the annual open enrollment
period, subsequent to the initial open enrollment period, applicable
to each individual child that is the month of the child's birth date.
(f) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any
subsequent rules or regulations issued pursuant to that law.
(g) "Preexisting condition exclusion" means, with respect to
coverage, a limitation or exclusion of benefits relating to a
condition based on the fact that the condition was present before the
date of enrollment of the coverage, whether or not any medical
advice, diagnosis, care, or treatment was recommended or received
before that date.
(h) "Responsible party for a child" means an adult having custody
of the child or with responsibility for the financial needs of the
child, including the responsibility to provide health care coverage.
(i) "Standard risk rate" means the lowest rate that can be offered
for a child with the same benefit plan, effective date, age,
geographic region, and family status.
1399.826. (a) (1) During each open enrollment period, every health
care service plan offering plan contracts in the individual market,
other than individual grandfathered plan coverage, shall offer to the
responsible party for a child coverage for the child that does not
exclude or limit coverage due to any preexisting condition of the
child.
(b) A health care service plan offering coverage in the individual
market shall not reject an application for a health care service
plan contract from a child or filed on behalf of a child by the
responsible party during an open enrollment period or from a late
enrollee during a period no longer than 63 days from the qualifying
event listed in subdivision (d) of Section 1399.825.
(c) Except to the extent permitted by federal law, rules,
regulations, or guidance issued by the relevant federal agency, a
health care service plan shall not condition the issuance or offering
of individual coverage on any of the following factors:
(1) Health status.
(2) Medical condition, including physical and mental illnesses.
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability, including conditions arising out of
acts of domestic violence.
(8) Disability.
(9) Any other health status-related factor as determined by
department.
This subdivision shall not apply to a contract providing
individual grandfathered plan coverage.
(d) When a responsible party for a child submits a premium
payment, based on the quoted premium charges, and that payment is
delivered or postmarked, whichever occurs earlier, within the first
15 days of the month, coverage under the plan contract shall become
effective no later than the first day of the following month. When
that payment is neither delivered nor postmarked until after the 15th
day of the month, coverage shall become effective no later than the
first day of the second month following delivery or postmark of the
payment.
(e) A health care service plan offering coverage in the individual
market shall not reject the request of a responsible party for a
child to include that child as a dependent on an existing health care
service plan contract that includes dependent coverage during an
open enrollment period.
(f) Nothing in this article shall be construed to prohibit a
health care service plan offering coverage in the individual market
from establishing rules for eligibility for coverage and offering
coverage pursuant to those rules for children and individuals based
on factors otherwise authorized under federal and state law for
health plan contracts in addition to those offered on a guaranteed
issue basis during an open enrollment period to children or late
enrollees pursuant to this article. However, a health care service
plan, other than a plan providing individual grandfathered plan
coverage, shall not impose a preexisting condition provision on
coverage, including dependent coverage, offered to a child.
(g) Nothing in this article shall be construed to require a plan
to establish a new service area or to offer health coverage on a
statewide basis, outside of the plan's existing service area.
(h) Nothing in this article shall be construed to prevent a health
care service plan from offering coverage to a family member of an
enrollee in grandfathered health plan coverage consistent with
Section 1251 of PPACA.
1399.827. This article shall not apply to health care service plan
contracts for coverage of Medicare services pursuant to contracts
with the United States government, Medicare supplement contracts,
Medi-Cal contracts with the State Department of Health Care Services,
plan contracts offered under the Healthy Families Program, long-term
care coverage, or specialized health care service plan contracts.
1399.828. (a) Upon the effective date of this article, a health
care service plan shall fairly and affirmatively offer, market, and
sell all of the plan's health care service plan contracts that are
offered and sold to a child or the responsible party for a child in
each service area in which the plan provides or arranges for the
provision of health care services during any open enrollment period,
to late enrollees, and during any other period in which state or
federal law, rules, regulations, or guidance expressly provide that a
health care service plan shall not condition offer or acceptance of
coverage on any preexisting condition.
(b) No health care service plan or solicitor shall, directly or
indirectly, engage in the following activities:
(1) Encourage or direct a child or responsible party for a child
to refrain from filing an application for coverage with a plan
because of the health status, claims experience, industry,
occupation, or geographic location, provided that the location is
within the plan's approved service area, of the child.
(2) Encourage or direct a child or responsible party for a child
to seek coverage from another plan because of the health status,
claims experience, industry, occupation, or geographic location,
provided that the location is within the plan's approved service
area, of the child.
(c) A health care service plan shall not, directly or indirectly,
enter into any contract, agreement, or arrangement with a solicitor
that provides for or results in the compensation paid to a solicitor
for the sale of a health care service plan contract to be varied
because of the health status, claims experience, industry,
occupation, or geographic location of the child. This subdivision
does not apply to a compensation arrangement that provides
compensation to a solicitor on the basis of percentage of premium,
provided that the percentage shall not vary because of the health
status, claims experience, industry, occupation, or geographic area
of the child.
1399.829. (a) A health care service plan may use the following
characteristics of an eligible child for purposes of establishing the
rate of the plan contract for that child, where consistent with
federal regulations under PPACA: age, geographic region, and family
composition, plus the health care service plan contract selected by
the child or the responsible party for the child.
(b) From the effective date of this article to December 31, 2013,
inclusive, rates for a child applying for coverage shall be subject
to the following limitations:
(1) During any open enrollment period or for late enrollees, the
rate for any child due to health status shall not be more than two
times the standard risk rate for a child.
(2) The rate for a child shall be subject to a 20-percent
surcharge above the highest allowable rate on a child applying for
coverage who is not a late enrollee and who failed to maintain
coverage with any health care service plan or health insurer for the
90-day period prior to the date of the child's application. The
surcharge shall apply for the 12-month period following the effective
date of the child's coverage.
(3) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may rate a child based on health status during any period other than
an open enrollment period if the child is not a late enrollee.
(4) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may condition an offer or acceptance of coverage on any preexisting
condition or other health status-related factor for a period other
than an open enrollment period and for a child who is not a late
enrollee.
(c) For any individual health care service plan contract issued,
sold, or renewed prior to December 31, 2013, the health plan shall
provide to a child or responsible party for a child a notice that
states the following:
"Please consider your options carefully before failing to maintain
or renew coverage for a child for whom you are responsible. If you
attempt to obtain new individual coverage for that child, the premium
for the same coverage may be higher than the premium you pay now."
(d) A child who applied for coverage between September 23, 2010,
and the end of the initial open enrollment period shall be deemed to
have maintained coverage during that period.
(e) Effective January 1, 2014, except for individual grandfathered
health plan coverage, the rate for any child shall be identical to
the standard risk rate.
(f) Health care service plans may require documentation from
applicants relating to their coverage history.
1399.832. No health care service plan shall be required to offer a
health care service plan contract or accept applications for the
contract pursuant to this article in the case of any of the
following:
(a) To a child, if the child who is to be covered by the plan
contract does not work or reside within the plan's approved service
areas.
(b) (1) Within a specific service area or portion of a service
area, if the plan reasonably anticipates and demonstrates to the
satisfaction of the director that it will not have sufficient health
care delivery resources to ensure that health care services will be
available and accessible to the child because of its obligations to
existing enrollees.
(2) A health care service plan that cannot offer a health care
service plan contract to individuals or children because it is
lacking in sufficient health care delivery resources within a service
area or a portion of a service area may not offer a contract in the
area in which the plan is not offering coverage to individuals to new
employer groups until the plan notifies the director that it has the
ability to deliver services to individuals, and certifies to the
director that from the date of the notice it will enroll all
individuals requesting coverage in that area from the plan.
(3) Nothing in this article shall be construed to limit the
director's authority to develop and implement a plan of
rehabilitation for a health care service plan whose financial
viability or organizational and administrative capacity has become
impaired.
1399.833. The director may require a health care service plan to
discontinue the offering of contracts or acceptance of applications
from any individual or child or responsible party for a child upon a
determination by the director that the plan does not have sufficient
financial viability or organizational and administrative capacity to
ensure the delivery of health care services to its enrollees. In
determining whether the conditions of this section have been met, the
director shall consider, but not be limited to, the plan's
compliance with the requirements of Section 1367, Article 6
(commencing with Section 1375.1), and the rules adopted under those
provisions.
1399.834. (a) All health care service plan contracts offered to a
child or on behalf of a child to a responsible party for a child
shall conform to the requirements of Sections 1366.3, 1365, and
1373.6 and shall be renewable at the option of the enrollee or
responsible party for a child on behalf of the enrollee except as
permitted to be canceled, rescinded, or not renewed pursuant to
Section 1365.
(b) Any plan that ceases to offer for sale new individual health
care service plan contracts pursuant to Section 1365 shall continue
to be governed by this article with respect to business conducted
under this article.
(c) Except as authorized under Section 1399.833, a plan that, as
of the effective date of this article, does not write new health care
service plan contracts for children in this state or that, after the
effective date of this article, ceases to write new health care
service plan contracts for children in this state shall be prohibited
from offering for sale new individual health care service plan
contracts in this state for a period of five years from the date of
notice to the director.
1399.835. On or before July 1, 2011, the director may issue
guidance to health plans regarding compliance with this article and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The guidance shall only
be effective until the director and the Insurance Commissioner adopt
joint regulations pursuant to the Administrative Procedure Act.
1399.825. As used in this article:
(a) "Child" means any individual under 19 years of age.
(b) "Individual grandfathered plan coverage" means health care
coverage in which an individual was enrolled on March 23, 2010,
consistent with Section 1251 of PPACA and any rules or regulations
adopted pursuant to that law.
(c) "Initial open enrollment period" means the open enrollment
period beginning on January 1, 2011, and ending 60 days thereafter.
(d) "Late enrollee" means a child without coverage who did not
enroll in a health care service plan contract during an open
enrollment period because of any of the following:
(1) The child lost dependent coverage due to termination or change
in employment status of the child or the person through whom the
child was covered; cessation of an employer's contribution toward an
employee or dependent's coverage; death of the person through whom
the child was covered as a dependent; legal separation; divorce; loss
of coverage under the Healthy Families Program, the Access for
Infants and Mothers Program, or the Medi-Cal program; or adoption of
the child.
(2) The child became a resident of California during a month that
was not the child's birth month.
(3) The child is born as a resident of California and did not
enroll in the month of birth.
(4) The child is mandated to be covered pursuant to a valid state
or federal court order.
(e) "Open enrollment period" means the annual open enrollment
period, subsequent to the initial open enrollment period, applicable
to each individual child that is the month of the child's birth date.
(f) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any
subsequent rules or regulations issued pursuant to that law.
(g) "Preexisting condition exclusion" means, with respect to
coverage, a limitation or exclusion of benefits relating to a
condition based on the fact that the condition was present before the
date of enrollment of the coverage, whether or not any medical
advice, diagnosis, care, or treatment was recommended or received
before that date.
(h) "Responsible party for a child" means an adult having custody
of the child or with responsibility for the financial needs of the
child, including the responsibility to provide health care coverage.
(i) "Standard risk rate" means the lowest rate that can be offered
for a child with the same benefit plan, effective date, age,
geographic region, and family status.
1399.826. (a) (1) During each open enrollment period, every health
care service plan offering plan contracts in the individual market,
other than individual grandfathered plan coverage, shall offer to the
responsible party for a child coverage for the child that does not
exclude or limit coverage due to any preexisting condition of the
child.
(b) A health care service plan offering coverage in the individual
market shall not reject an application for a health care service
plan contract from a child or filed on behalf of a child by the
responsible party during an open enrollment period or from a late
enrollee during a period no longer than 63 days from the qualifying
event listed in subdivision (d) of Section 1399.825.
(c) Except to the extent permitted by federal law, rules,
regulations, or guidance issued by the relevant federal agency, a
health care service plan shall not condition the issuance or offering
of individual coverage on any of the following factors:
(1) Health status.
(2) Medical condition, including physical and mental illnesses.
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability, including conditions arising out of
acts of domestic violence.
(8) Disability.
(9) Any other health status-related factor as determined by
department.
This subdivision shall not apply to a contract providing
individual grandfathered plan coverage.
(d) When a responsible party for a child submits a premium
payment, based on the quoted premium charges, and that payment is
delivered or postmarked, whichever occurs earlier, within the first
15 days of the month, coverage under the plan contract shall become
effective no later than the first day of the following month. When
that payment is neither delivered nor postmarked until after the 15th
day of the month, coverage shall become effective no later than the
first day of the second month following delivery or postmark of the
payment.
(e) A health care service plan offering coverage in the individual
market shall not reject the request of a responsible party for a
child to include that child as a dependent on an existing health care
service plan contract that includes dependent coverage during an
open enrollment period.
(f) Nothing in this article shall be construed to prohibit a
health care service plan offering coverage in the individual market
from establishing rules for eligibility for coverage and offering
coverage pursuant to those rules for children and individuals based
on factors otherwise authorized under federal and state law for
health plan contracts in addition to those offered on a guaranteed
issue basis during an open enrollment period to children or late
enrollees pursuant to this article. However, a health care service
plan, other than a plan providing individual grandfathered plan
coverage, shall not impose a preexisting condition provision on
coverage, including dependent coverage, offered to a child.
(g) Nothing in this article shall be construed to require a plan
to establish a new service area or to offer health coverage on a
statewide basis, outside of the plan's existing service area.
(h) Nothing in this article shall be construed to prevent a health
care service plan from offering coverage to a family member of an
enrollee in grandfathered health plan coverage consistent with
Section 1251 of PPACA.
1399.827. This article shall not apply to health care service plan
contracts for coverage of Medicare services pursuant to contracts
with the United States government, Medicare supplement contracts,
Medi-Cal contracts with the State Department of Health Care Services,
plan contracts offered under the Healthy Families Program, long-term
care coverage, or specialized health care service plan contracts.
1399.828. (a) Upon the effective date of this article, a health
care service plan shall fairly and affirmatively offer, market, and
sell all of the plan's health care service plan contracts that are
offered and sold to a child or the responsible party for a child in
each service area in which the plan provides or arranges for the
provision of health care services during any open enrollment period,
to late enrollees, and during any other period in which state or
federal law, rules, regulations, or guidance expressly provide that a
health care service plan shall not condition offer or acceptance of
coverage on any preexisting condition.
(b) No health care service plan or solicitor shall, directly or
indirectly, engage in the following activities:
(1) Encourage or direct a child or responsible party for a child
to refrain from filing an application for coverage with a plan
because of the health status, claims experience, industry,
occupation, or geographic location, provided that the location is
within the plan's approved service area, of the child.
(2) Encourage or direct a child or responsible party for a child
to seek coverage from another plan because of the health status,
claims experience, industry, occupation, or geographic location,
provided that the location is within the plan's approved service
area, of the child.
(c) A health care service plan shall not, directly or indirectly,
enter into any contract, agreement, or arrangement with a solicitor
that provides for or results in the compensation paid to a solicitor
for the sale of a health care service plan contract to be varied
because of the health status, claims experience, industry,
occupation, or geographic location of the child. This subdivision
does not apply to a compensation arrangement that provides
compensation to a solicitor on the basis of percentage of premium,
provided that the percentage shall not vary because of the health
status, claims experience, industry, occupation, or geographic area
of the child.
1399.829. (a) A health care service plan may use the following
characteristics of an eligible child for purposes of establishing the
rate of the plan contract for that child, where consistent with
federal regulations under PPACA: age, geographic region, and family
composition, plus the health care service plan contract selected by
the child or the responsible party for the child.
(b) From the effective date of this article to December 31, 2013,
inclusive, rates for a child applying for coverage shall be subject
to the following limitations:
(1) During any open enrollment period or for late enrollees, the
rate for any child due to health status shall not be more than two
times the standard risk rate for a child.
(2) The rate for a child shall be subject to a 20-percent
surcharge above the highest allowable rate on a child applying for
coverage who is not a late enrollee and who failed to maintain
coverage with any health care service plan or health insurer for the
90-day period prior to the date of the child's application. The
surcharge shall apply for the 12-month period following the effective
date of the child's coverage.
(3) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may rate a child based on health status during any period other than
an open enrollment period if the child is not a late enrollee.
(4) If expressly permitted under PPACA and any rules, regulations,
or guidance issued pursuant to that act, a health care service plan
may condition an offer or acceptance of coverage on any preexisting
condition or other health status-related factor for a period other
than an open enrollment period and for a child who is not a late
enrollee.
(c) For any individual health care service plan contract issued,
sold, or renewed prior to December 31, 2013, the health plan shall
provide to a child or responsible party for a child a notice that
states the following:
"Please consider your options carefully before failing to maintain
or renew coverage for a child for whom you are responsible. If you
attempt to obtain new individual coverage for that child, the premium
for the same coverage may be higher than the premium you pay now."
(d) A child who applied for coverage between September 23, 2010,
and the end of the initial open enrollment period shall be deemed to
have maintained coverage during that period.
(e) Effective January 1, 2014, except for individual grandfathered
health plan coverage, the rate for any child shall be identical to
the standard risk rate.
(f) Health care service plans may require documentation from
applicants relating to their coverage history.
1399.832. No health care service plan shall be required to offer a
health care service plan contract or accept applications for the
contract pursuant to this article in the case of any of the
following:
(a) To a child, if the child who is to be covered by the plan
contract does not work or reside within the plan's approved service
areas.
(b) (1) Within a specific service area or portion of a service
area, if the plan reasonably anticipates and demonstrates to the
satisfaction of the director that it will not have sufficient health
care delivery resources to ensure that health care services will be
available and accessible to the child because of its obligations to
existing enrollees.
(2) A health care service plan that cannot offer a health care
service plan contract to individuals or children because it is
lacking in sufficient health care delivery resources within a service
area or a portion of a service area may not offer a contract in the
area in which the plan is not offering coverage to individuals to new
employer groups until the plan notifies the director that it has the
ability to deliver services to individuals, and certifies to the
director that from the date of the notice it will enroll all
individuals requesting coverage in that area from the plan.
(3) Nothing in this article shall be construed to limit the
director's authority to develop and implement a plan of
rehabilitation for a health care service plan whose financial
viability or organizational and administrative capacity has become
impaired.
1399.833. The director may require a health care service plan to
discontinue the offering of contracts or acceptance of applications
from any individual or child or responsible party for a child upon a
determination by the director that the plan does not have sufficient
financial viability or organizational and administrative capacity to
ensure the delivery of health care services to its enrollees. In
determining whether the conditions of this section have been met, the
director shall consider, but not be limited to, the plan's
compliance with the requirements of Section 1367, Article 6
(commencing with Section 1375.1), and the rules adopted under those
provisions.
1399.834. (a) All health care service plan contracts offered to a
child or on behalf of a child to a responsible party for a child
shall conform to the requirements of Sections 1366.3, 1365, and
1373.6 and shall be renewable at the option of the enrollee or
responsible party for a child on behalf of the enrollee except as
permitted to be canceled, rescinded, or not renewed pursuant to
Section 1365.
(b) Any plan that ceases to offer for sale new individual health
care service plan contracts pursuant to Section 1365 shall continue
to be governed by this article with respect to business conducted
under this article.
(c) Except as authorized under Section 1399.833, a plan that, as
of the effective date of this article, does not write new health care
service plan contracts for children in this state or that, after the
effective date of this article, ceases to write new health care
service plan contracts for children in this state shall be prohibited
from offering for sale new individual health care service plan
contracts in this state for a period of five years from the date of
notice to the director.
1399.835. On or before July 1, 2011, the director may issue
guidance to health plans regarding compliance with this article and
that guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The guidance shall only
be effective until the director and the Insurance Commissioner adopt
joint regulations pursuant to the Administrative Procedure Act.
