12693.25. The board may use a purchasing pool model, issuance of
purchasing credits, supplemental coverage, or other means as
appropriate to meet the purposes of this part.
12693.26. (a) The board shall establish a purchasing pool for
coverage of program subscribers to enable applicants without access
to affordable and comprehensive employer-sponsored dependent coverage
to provide their eligible children with health, dental, and vision
benefits. The board shall negotiate separate contracts with
participating health, dental, and vision plans for each of the
benefit packages described in Chapters 5 (commencing with Section
12693.60), 6 (commencing with Section 12693.63), and 7 (commencing
with Section 12693.65).
(b) Notwithstanding any other provision of law, on and after
January 1, 2011, the board may negotiate contracts with entities that
are not participating health, dental, or vision plans, including,
but not limited to, interagency agreements with the State Department
of Health Care Services, to provide or pay for benefits to
subscribers under this part, if necessary for any of the following
purposes:
(1) To comply with Section 403 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying paragraph (4) of subsection (a) of Section 1932 of the
federal Social Security Act.
(2) To comply with Section 503 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying subsection (bb) of Section 1902 of the federal Social
Security Act.
(3) To ensure that subscribers have adequate access to benefits
under this part.
(c) Any interagency agreement entered into by a state agency with
the board pursuant to subdivision (b), and any other contract or
contract amendment necessary to implement that agreement, shall be
exempt from any provision of law relating to competitive bidding and
from the review or approval of any division of the Department of
General Services in the same manner as contracts entered into by the
board are exempt pursuant to Section 12693.54.
12693.27. (a) The board shall develop a purchasing credit mechanism
to enable applicants with access to affordable and comprehensive
employer-sponsored dependent coverage to have an eligible child
enrolled in the employer's health plan. Children enrolled in the
purchasing credit mechanism may receive dental and vision benefits
through the purchasing pool component of the program.
(b) In order to be eligible for a purchasing credit, the employer
shall make a meaningful contribution toward the cost of coverage for
an employee's dependents for whom an application is made for a
purchasing credit. An employer's contribution, including any
increases or decreases in the contribution made after the effective
date of this part, may not vary among employees based on wage base or
job classification.
(c) The board shall adopt appropriate mechanisms to recoup
purchasing credit expenditures from an employer plan when the
employees or dependents on behalf of whose coverage the payments are
made are no longer enrolled in that plan.
(d) An employer utilizing a purchasing credit arrangement and a
participating health plan receiving a purchasing credit must use 100
percent of the funds for the purchase of coverage for purchasing
credit members including dependent coverage.
(e) A participating plan shall not assess the board for any
portion of late fees, returned checks, or other fees in connection
with an employer with group coverage who is also participating in the
purchasing credit arrangement.
(f) An applicant may begin coverage for dependents using a
purchasing credit arrangement at any time. Purchasing credit members
enrolling in employer-sponsored coverage shall not be considered late
enrollees for the purposes of subdivision (d) of Section 1357 and
subdivision (b) of Section 1357.50 of the Health and Safety Code, and
subdivision (b) of Section 10198.6 and subdivision (l) of Section
10700.
(g) Under no circumstances shall the employee's share of cost,
including, deductibles, copayments, and coinsurance, for dependent
coverage, including any supplemental coverage necessary to meet the
95 percent actuarial standard established in Section 12693.15 be more
than that required as the employee's share of premium if the
employee's children were enrolled in the purchasing pool component of
the program.
(h) The board may limit participation in the purchasing credit
program to those employers that provide employee health benefits
through participation in public or private purchasing cooperatives.
12693.271. (a) The Legislature finds and declares that the state
faces a fiscal crisis that requires unprecedented measures to reduce
General Fund expenditures.
(b) Notwithstanding any other provision of law, beginning the
first day of the fifth month following the enactment of the 2008-09
Budget Act, the rates for the participating health, dental, and
vision plans shall be set by reducing the rates that were in effect
on July 1, 2007, by 5 percent, and by adjusting the July 1, 2007,
rates downward to account for any reduction in the actuarial value of
the benefits provided to subscribers as of the first day of the
fifth month following the enactment of the 2008-09 Budget Act,
associated with annual limitations on dental benefits. This
requirement does not preclude the board from making other downward
adjustments that it deems appropriate as a result of its annual rate
negotiation process.
12693.28. The program shall be administered without regard to
gender, race, creed, color, sexual orientation, health status,
disability, or occupation.
12693.29. (a) The board shall use appropriate and efficient means
to notify families of the availability of health coverage from the
program.
(b) The State Department of Health Services in conjunction with
the board shall conduct a community outreach and education campaign
in accordance with Section 14067 of the Welfare and Institutions Code
to assist in notifying families of the availability of health
coverage for their children.
(c) The board shall use appropriate materials, which may include
brochures, pamphlets, fliers, posters, and other promotional items,
to notify families of the availability of coverage through the
program.
12693.30. (a) The board shall assure that written enrollment
information issued or provided by the program is available to program
subscribers and applicants in each of the languages identified
pursuant to Chapter 17.5 (commencing with Section 7290) of Division 7
of Title 1 of the Government Code.
(b) The board shall assure that phone services provided to program
subscribers and applicants by the program are available in all of
the languages identified pursuant to Chapter 17.5 (commencing with
Sec. 7290) of Division 7 of Title 1 of the Government Code.
(c) The board shall assure that interpreter services are available
between subscribers and contracting plans. The board shall assure
that subscribers are provided information within provider network
directories of available linguistically diverse providers.
(d) The board shall assure that participating health, dental, and
vision plans provide documentation on how they provide linguistically
and culturally appropriate services, including marketing materials,
to subscribers.
12693.31. No participating health, dental, or vision plan shall, in
an area served by the program, directly, or through an employee,
agent, or contractor, provide an applicant, or a child with any
marketing material relating to benefits or rates provided under the
program unless the material has been both reviewed and approved by
the board.
12693.32. (a) The board may pay designated individuals or
organizations an application assistance fee, if the individual or
organization assists an applicant to complete the program
application, and the applicant is enrolled in the program as a result
of the application.
(b) The board may establish the list of eligible individuals, or
categories of individuals and organizations, the amount of the
application assistance payment, and rules necessary to assure the
integrity of the payment process.
(c) The board, as part of its community outreach and education
campaign, may include community-based face-to-face initiatives to
educate potentially eligible applicants about the program and to
assist potential applicants in the application process. Those
entities undertaking outreach efforts shall not include as part of
their responsibilities the selection of a health plan and provider
for the applicant. Participating plans shall be prohibited from
directly, indirectly, or through their agents conducting in-person,
door-to-door, mail, or telephone solicitation of applicants for
enrollment except through employers with employees eligible to
participate in the purchasing credit mechanism. However, information
approved by the board on the providers and plans available to
prospective subscribers in their geographic areas shall be
distributed through any door-to-door activities for potentially
eligible applicants and their children.
(d) (1) All assistance offered to an individual applying to the
program shall be free of charge. Except as provided in subdivision
(a) or by a regulation adopted by the board, no individual or
organization offering or providing assistance to an applicant to
complete the program application shall solicit or receive any fee or
remuneration from the applicant or subscriber for offering or
providing that service.
(2) A person who violates this subdivision or a regulation adopted
by the board pursuant to this subdivision, shall be assessed a civil
penalty of five hundred dollars ($500) for each violation. For this
purpose, a violation occurs each day a solicitation is published on
an Internet Web site or is otherwise circulated to the public. This
penalty is in addition to any other remedy or penalty provided by
law. All penalties collected under this paragraph shall be deposited
in the State Treasury to the credit of the Healthy Families Fund.
(3) A civil or administrative action brought under this article at
the request of the board may be brought by the Attorney General in
the name of the people of the State of California in a court of
competent jurisdiction, or in a hearing through the Office of
Administrative Hearings conducted in accordance with Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, except that when a civil action is to be filed
in small claims court, the board may bring the action. The action
shall be filed within three years of the date the board discovered
the facts indicating a violation of this subdivision.
12693.325. (a) (1) Notwithstanding any provision of this chapter, a
participating health, dental, or vision plan that is licensed and in
good standing as required by subdivision (b) of Section 12693.36 may
provide application assistance directly to an applicant acting on
behalf of an eligible person who telephones, writes, or contacts the
plan in person at the plan's place of business, or at a community
public awareness event that is open to all participating plans in the
county, or at any other site approved by the board, and who requests
application assistance.
(2) A participating health, dental, or vision plan may also
provide application assistance directly to an applicant only under
the following conditions:
(A) The assistance is provided upon referral from a government
agency, school, or school district.
(B) The applicant has authorized the government agency, school, or
school district to allow a health, dental, or vision plan to contact
the applicant with additional information on enrolling in free or
low-cost health care.
(C) The State Department of Health Care Services approves the
applicant authorization form in consultation with the board.
(D) The plan may not actively solicit referrals and may not
provide compensation for the referrals.
(E) If a family is already enrolled in a health plan, the plan
that contacts the family cannot encourage the family to change health
plans.
(F) The board amends its marketing guidelines to require that when
a government agency, school, or school district requests assistance
from a participating health, dental, or vision plan to provide
application assistance, that all plans in the area shall be invited
to participate.
(G) The plan abides by the board's marketing guidelines.
(b) A participating health, dental, or vision plan may provide
application assistance to an applicant who is acting on behalf of an
eligible or potentially eligible child in any of the following
situations:
(1) The child is enrolled in a Medi-Cal managed care plan and the
participating plan becomes aware that the child's eligibility status
has or will change and that the child will no longer be eligible for
Medi-Cal. In those instances, the plan shall inform the applicant of
the differences in benefits and requirements between the Healthy
Families Program and the Medi-Cal program.
(2) The child is enrolled in a Healthy Families Program managed
care plan and the participating plan becomes aware that the child's
eligibility status has changed or will change and that the child will
no longer be eligible for the Healthy Families Program. When it
appears a child may be eligible for Medi-Cal benefits, the plan shall
inform the applicant of the differences in benefits and requirements
between the Medi-Cal program and the Healthy Families Program.
(3) The participating plan provides employer-sponsored coverage
through an employer and an employee of that employer who is the
parent or legal guardian of the eligible or potentially eligible
child.
(4) The child and his or her family are participating through the
participating plan in COBRA continuation coverage or other group
continuation coverage required by either state or federal law and the
group continuation coverage will expire within 60 days, or has
expired within the past 60 days.
(5) The child's family, but not the child, is participating
through the participating plan in COBRA continuation coverage or
other group continuation coverage required by either state or federal
law, and the group continuation coverage will expire within 60 days,
or has expired within the past 60 days.
(c) A participating health, dental, or vision plan employee or
other representative that provides application assistance shall
complete a certified application assistant training class approved by
the State Department of Health Care Services in consultation with
the board. The employee or other representative shall in all cases
inform an applicant verbally of his or her relationship with the
participating health plan. In the case of an in-person contact, the
employee or other representative shall provide in writing to the
applicant the nature of his or her relationship with the
participating health plan and obtain written acknowledgment from the
applicant that the information was provided.
(d) A participating health, dental, or vision plan that provides
application assistance may not do any of the following:
(1) Directly, indirectly, or through its agents, conduct
door-to-door marketing or telephone solicitation.
(2) Directly, indirectly, or through its agents, select a health
plan or provider for a potential applicant. Instead, the plan shall
inform a potential applicant of the choice of plans available within
the applicant's county of residence and specifically name those plans
and provide the most recent version of the program handbook.
(3) Directly, indirectly, or through its agents, conduct mail or
in-person solicitation of applicants for enrollment, except as
specified in subdivision (b), using materials approved by the board.
(e) A participating health, dental, or vision plan that provides
application assistance pursuant to this section is not eligible for
an application assistance fee otherwise available pursuant to Section
12693.32, and may not sponsor a person eligible for the program by
paying his or her family contribution amounts or copayments, and may
not offer applicants any inducements to enroll, including, but not
limited to, gifts or monetary payments.
(f) A participating health, dental, or vision plan may assist
applicants acting on behalf of subscribers who are enrolled with the
participating plan in completing the program's annual eligibility
review package in order to allow those applicants to retain health
care coverage.
(g) Each participating health, dental, or vision plan shall submit
to the board a plan for application assistance. All scripts and
materials to be used during application assistance sessions shall be
approved by the board and the State Department of Health Care
Services.
(h) Each participating health, dental, or vision plan shall
provide each applicant with the toll-free telephone number for the
Healthy Families Program.
(i) When deemed appropriate by the board, the board may refer a
participating health, dental, or vision plan to the Department of
Managed Health Care or the State Department of Health Care Services,
as applicable, for the review or investigation of its application
assistance practices.
(j) The board shall evaluate the impact of the changes required by
this section and shall provide a biennial report to the Legislature
on or before March 1 of every other year. To prepare these reports,
the State Department of Health Care Services, in cooperation with the
board, shall code all the application packets used by a managed care
plan to record the number of applications received that originated
from managed care plans. The number of applications received that
originated from managed care plans shall also be reported on the
board's Web site. In addition, the board shall periodically survey
those families assisted by plans to determine if the plans are
meeting the requirements of this section, and if families are being
given ample information about the choice of health, dental, or vision
plans available to them.
(k) Nothing in this section shall be seen as mitigating a
participating health, dental, or vision plan's responsibility to
comply with all federal and state laws, including, but not limited
to, Section 1320a-7b of Title 42 of the United States Code.
12693.326. Notwithstanding any other provision of this part, a new
subscriber in the program shall be allowed to switch his or her
choice of plans once within the first three months of coverage for
any reason.
12693.33. To the extent feasible and permissible under federal law
and with receipt of necessary federal approvals, the State Department
of Health Services and the board shall develop a joint Medi-Cal and
program application and enrollment form for children. The department
shall seek any federal approval necessary to implement a combined
application form.
12693.34. (a) The board may establish geographic areas within which
participating health, dental, and vision plans may offer coverage to
subscribers.
(b) Nothing in this section shall restrict a county organized
health system or a local initiative from providing service to program
subscribers in their licensed geographic service area.
12693.35. Participating health, dental, and vision plans shall
have, but need not be limited to, all of the following operating
characteristics satisfactory to the board in consultation with the
plan's licensing or regulatory oversight agency:
(a) Strong financial condition, including the ability to assume
the risk of providing and paying for covered services. A
participating plan may utilize reinsurance, provider risk sharing,
and other appropriate mechanisms to share a portion of the risk.
(b) Adequate administrative management.
(c) A satisfactory grievance procedure.
(d) Participating plans that contract with or employ health care
providers shall have mechanisms to accomplish all of the following,
in a manner satisfactory to the board:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(e) (1) Before the effective date of the contract, the
participating health plan shall have devised a system for identifying
in a simple and clear fashion both in its own records and in the
medical records of subscribers the fact that the services provided
are provided under the program.
(2) Throughout the duration of the contract, the plan shall use
the system described in paragraph (1).
(f) Plans licensed by the Department of Corporations shall be
deemed to meet the requirements of subdivisions (a) to (d),
inclusive, of this section.
12693.36. (a) Notwithstanding any other provision of law, the board
shall not be subject to licensure or regulation by the Department of
Insurance or the Department of Managed Health Care, as the case may
be.
(b) Participating health, dental, and vision plans that contract
with the program and are regulated by either the Insurance
Commissioner or the Department of Managed Health Care shall be
licensed and in good standing with their respective licensing
agencies. In their application to the program, those entities shall
provide assurance of their standing with the appropriate licensing
entity.
12693.37. (a) The board shall contract with a broad range of health
plans in an area, if available, to ensure that subscribers have a
choice from among a reasonable number and types of competing health
plans. The board shall develop and make available objective criteria
for health plan selection and provide adequate notice of the
application process to permit all health plans a reasonable and fair
opportunity to participate. The criteria and application process
shall allow participating health plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this chapter. Health plan selection shall be based on the
criteria developed by the board.
(b) (1) In its selection of participating plans the board shall
take all reasonable steps to assure the range of choices available to
each applicant, other than a purchasing credit member, shall include
plans that include in their provider networks and have signed
contracts with traditional and safety net providers.
(2) Participating health plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to:
(A) Geographic access for the subscribers.
(B) Linguistic services.
(C) The ethnic composition of providers.
(D) The number of subscribers who selected traditional and safety
net providers.
(c) (1) The board shall not rely solely on the Department of
Managed Health Care's determination of a health plan network's
adequacy or geographic access to providers in the awarding of
contracts under this part. The board shall collect and review
demographic, census, and other data to provide to prospective local
initiatives, health plans, or specialized health plans, as defined in
this act, specific provider contracting target areas with
significant numbers of uninsured children in low-income families. The
board shall give priority to those plans, on a county-by-county
basis, that demonstrate that they have included in their prospective
plan networks significant numbers of providers in these geographic
areas.
(2) Targeted contracting areas are those ZIP Codes or groups of
ZIP Codes or census tracts or groups of census tracts that have a
percentage of uninsured children in low-income families greater than
the overall percentage of uninsured children in low-income families
in that county.
(d) In each geographic area, the board shall designate a community
provider plan that is the participating health plan which has the
highest percentage of traditional and safety net providers in its
network. Subscribers selecting such a plan shall be given a family
contribution discount as described in Section 12693.43.
(e) The board shall establish reasonable limits on health plan
administrative costs.
12693.38. (a) The board shall contract with a sufficient number of
dental and vision plans to assure that dental and vision benefits are
available to all subscribers. The board shall develop and make
available objective criteria for dental and vision plan selection and
provide adequate notice of the application process to permit all
dental and vision plans a reasonable and fair opportunity to
participate. The criteria and application process shall allow
participating dental and vision plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this part. Dental and vision plan selection shall be
based on the criteria developed by the board.
(b) Participating dental plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to each of the following:
(1) Geographic access for the subscribers.
(2) Linguistic services.
(3) The ethnic composition of providers.
(c) The board shall establish reasonable limits on dental plan
administrative costs.
12693.39. The board shall establish a process for determining which
employer-sponsored health plans are eligible to receive a purchasing
credit issued by the program. The process shall assure that the
benefits, copayments, coinsurance, and deductibles are no less than
95 percent actuarially equivalent to those provided to program
subscribers enrolled in the purchasing pool.
12693.40. The board shall contract with health plans to provide
coverage supplemental to that provided by an applicant's or applicant'
s spouse's employer-sponsored health plan for the purchasing credit
member, if the employer-sponsored plan's benefits are not 95 percent
actuarially equivalent to those provided to subscribers. If
supplemental coverage is available and provided, the plan may then,
notwithstanding Section 12693.39, become eligible to receive
purchasing credits.
12693.41. (a) The board shall consult and coordinate with the State
Department of Health Services in implementing a preenrollment
program into the Healthy Families Program or the Medi-Cal program
pursuant to subdivision (b) of Section 14011.7 of the Welfare and
Institutions Code. The board shall accept the followup application
provided for in Section 14011.7 of the Welfare and Institutions Code
as an application for the Healthy Families Program. Preenrollment
shall be administered by the State Department of Health Services to
provide full-scope benefits pursuant to Medi-Cal program
requirements, at no cost to the applicant.
(b) The board may use the state fiscal intermediary for medicaid
to process the eligibility determinations and payments required
pursuant to Section 14011.7 of the Welfare and Institutions Code.
(c) The board shall be exempt from the requirements of Chapter 7
(commencing with Section 11700) of Division 3 of Title 2 of the
Government Code and Chapter 3 (commencing with Section 12100) of Part
2 of Division 2 of the Public Contract Code as those requirements
apply to the use of processing services by the state fiscal
intermediary.
(d) The board may adopt emergency regulations to implement
preenrollment into the Healthy Families Program or the Medi-Cal
program pursuant to Section 14011.7 of the Welfare and Institutions
Code. The emergency regulations shall include, but not be limited to,
regulations that implement any changes in rules relating to
eligibility, enrollment, and disenrollment in the programs pursuant
to Sections 12693.45 and 12693.70. The initial adoption of emergency
regulations and one readoption of the initial regulations shall be
deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety, and general
welfare. Initial emergency regulations and the first readoption of
those regulations shall be exempt from review by the Office of
Administrative Law. The initial emergency regulations and one
readoption of those regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and publication in the California Code of
Regulations and each shall remain in effect for no more than 180
days.
(e) This section shall become operative on April 1, 2003.
12693.42. Any purchasing credit issued by the board, or a
contractor acting on behalf of the board, pursuant to this part shall
have an overall cost to the program no greater than the cost to the
program to enroll the subscriber in the lowest cost plan available to
the subscriber through the purchasing pool. Administrative costs and
the cost to the program of any supplemental product shall be
included in the calculation of the cost of the purchasing credit
program and deducted from the amount of the purchasing credit.
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost Family Value
Package in a given geographic area.
(b) In each geographic area, the board shall designate one or more
Family Value Packages for which the required total family
contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with annual household incomes up to and including 150
percent of the federal poverty level.
(2) (A) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be twelve dollars ($12) per child with a
maximum required contribution of thirty-six dollars ($36) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be sixteen dollars ($16) per child with a
maximum required contribution of forty-eight dollars ($48) per month
per family.
(3) (A) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with annual household income to
which subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be seventeen dollars ($17) per child with a
maximum required contribution of fifty-one dollars ($51) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-four dollars ($24) per child with a
maximum required contribution of seventy-two dollars ($72) per month
per family.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost Family Value Package
may be offered to and selected by applicants. However, the cost to
the program of those combinations that exceeds the price to the
program of the highest cost Family Value Package shall be paid by the
applicant as part of the family contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with annual household incomes up to and
including 150 percent of the federal poverty level.
(2) (A) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be nine dollars ($9) per child with a
maximum required contribution of twenty-seven dollars ($27) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be thirteen dollars ($13) per child with a
maximum required contribution of thirty-nine dollars ($39) per month
per family.
(3) (A) On and after July 1, 2005, twelve dollars ($12) per child
with a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with annual household income to which
subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be fourteen dollars ($14) per child with a
maximum required contribution of forty-two dollars ($42) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-one dollars ($21) per child with a
maximum required contribution of sixty-three dollars ($63) per month
per family.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purpose of
subdivision (e) of Section 11346.1 of the Government code, the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative law, is hereby extended to 180 days.
(i) The board may adopt, and may only one-time readopt,
regulations to implement the changes to this section that are
effective the first day of the fifth month following the enactment of
the 2008-09 Budget Act. The adoption and one-time readoption of a
regulation authorized by this section is deemed to address an
emergency, for purposes of Sections 11346.1 and 11349.6 of the
Government Code, and the board is hereby exempted for this purpose
from the requirements of subdivision (b) of Section 11346.1 of the
Government Code.
(j) The program shall provide prior notice to any applicant for a
subscriber whose premium will increase as a result of amendments made
to this section by the act that added this subdivision and shall
provide the applicant with an opportunity to demonstrate that, based
on reduced family income, the subscriber is subject to a lower
premium pursuant to this section.
12693.44. (a) The board shall establish family contribution amounts
for purchasing credit members that are equivalent to the amounts
charged to subscribers participating in the purchasing pool portion
of the program. Purchasing credit members shall not be required to
pay family contribution amounts greater than the cost to the
applicant if the purchasing credit members were enrolled in the
purchasing pool component of the program. When calculating the cost
to the applicant to participate in the purchasing pool, the family
contribution discounts provided in subdivisions (c), (d), and (e) of
Section 12693.34 shall not be considered. Purchasing credit members
shall be eligible for dental and vision coverage through the
purchasing pool at no additional premium charge.
(b) The family contribution amounts paid on behalf of a purchasing
credit member may be paid directly to the applicant's employer
through a payroll deduction or other mechanism.
12693.45. (a) After two consecutive months of nonpayment of family
contributions by an applicant, and a reasonable written notice period
of no less than 30 days is provided to the applicant, subscribers or
purchasing credit members may be disenrolled for an applicant's
failure to pay family contributions. The board may impose or contract
for collection actions to collect unpaid family contributions.
(b) Subject to any additional requirements of federal law,
disenrollments shall be effective at the end of the second
consecutive month of nonpayment.
12693.46. The board may prohibit applicants who drop coverage after
enrolling in the pool from reenrollment in the program for up to six
months.
12693.47. The program may place a lien on compensation or benefits,
recovered or recoverable by a subscriber or applicant from any party
or parties responsible for the compensation or benefits for which
benefits have been provided under a policy issued under this part.
12693.48. The board may adjust payments made to a participating
health plan if the board finds that the plan has a significantly
disproportionate share of high- or low-risk subscribers. Prior to
making this finding, the program shall obtain validated data from
participating health plans. Reporting requirements shall be
administratively compatible with the methods of operation of the
health plans. Any adjustments to payments shall utilize demographic
and other factors which are actuarially related to risk.
12693.49. (a) When an applicant is dissatisfied with any action or
inaction of a participating plan in which a subscriber is enrolled
through the purchasing pool, the applicant shall first attempt to
resolve the dispute with the participating plan according to its
established policies and procedures.
(b) The board shall assure that all participating health, dental,
and vision plans make subscribers aware of the regulatory oversight
available to the applicant by the participating health, dental, or
vision plan's licensing or state oversight entity.
(c) The board shall assure that all participating health, dental,
and vision plans report to the board, at least once a year, the
number and types of benefit grievances filed by applicants on behalf
of subscribers in the program. This information shall be available to
applicants upon request in a format determined by the board.
12693.50. (a) The board shall consult and coordinate with the State
Department of Health Services to implement the Medi-Cal to Healthy
Families Accelerated Enrollment program pursuant to Section 14011.65
of the Welfare and Institutions Code.
(b) The state shall seek approval of any amendments to the state
plan, necessary to implement Section 14011.65 of the Welfare and
Institutions Code in accordance with Title XXI of the Social Security
Act (42 U.S.C. 1397aa et seq.). Notwithstanding any other provision
of law, only when all necessary federal approvals have been obtained
shall Section 14011.65 of the Welfare and Institutions Code be
implemented.
(c) The board may adopt emergency regulations to implement the
provision of accelerated eligibility benefits pursuant to this
section and as described under Section 14011.65 of the Welfare and
Institutions Code. The emergency regulations shall include, but not
be limited to, regulations that implement any changes in rules
relating to program eligibility, enrollment, and disenrollment. The
initial adoption of emergency regulations and one readoption of the
initial regulations shall be deemed to be an emergency and necessary
for the immediate preservation of the public peace, health and
safety, and general welfare. Initial emergency regulations and the
first readoption of those regulations shall be exempt from review by
the Office of Administrative Law. The initial emergency regulations
and one readoption of those regulations authorized by this section
shall be submitted to the Office of Administrative Law for filing
with the Secretary of State and publication in the California Code of
Regulations, and each shall remain in effect for no more than 180
days.
12693.51. (a) A transfer of enrollment from one participating
health plan to another may be made by a subscriber at times and under
conditions as may be prescribed by regulations of the board.
(b) The board shall provide for the transfer of coverage of any
subscriber to another participating plan (1) if a contract with any
participating plan under which the subscriber receives coverage is
canceled or not renewed and (2) at least once a year upon request in
a manner as determined by the board, and (3) if a subscriber moves to
an area that the current health plan does not serve.
12693.515. (a) Effective July 1, 2004, any subscriber who
affirmatively selects, or is assigned by default to, a federally
qualified health center, as defined by Section 1396(d)(l)(2) of Title
42 of the United States Code, a rural health clinic, as defined by
Section 1396(d)(l)(1) of Title 42 of the United States Code, or a
primary care clinic that is licensed under Section 1204 of the Health
and Safety Code, or is exempt from licensure under subdivision (h)
of Section 1206 of the Health and Safety Code, shall be deemed to
have been assigned directly to the federally qualified health center,
the rural health clinic, or the primary care clinic, and not to any
individual provider who performs services on behalf of the federally
qualified health center, the rural health clinic, or the primary care
clinic.
(b) (1) When a subscriber is assigned, from any source, to a
physician who is an employee of a federally qualified health center,
a rural health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's health care coverage.
(2) When a subscriber is assigned, from any source, to a dentist
who is an employee of a federally qualified health center, a rural
health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's dental coverage.
(3) When a subscriber is assigned, from any source, to an
optometrist who is an employee of a federally qualified health
center, a rural health clinic, or a primary care clinic, the
assignment shall constitute an assignment to that federally qualified
health center, rural health clinic, or primary care clinic for
purposes of the subscriber's vision coverage.
(c) This section shall not limit any rights a subscriber may have
to select an available primary care physician within a health care
service plan's service area pursuant to Section 1373.3 of the Health
and Safety Code.
12693.52. The board may negotiate or arrange for stop-loss
insurance coverage that limits the program's fiscal responsibility
for the total costs of health services provided to program
subscribers, or arrange for participating health plans to share or
assure the financial risk for a portion of the total cost of health
care services to program subscribers, or both.
12693.53. The board shall develop and utilize appropriate cost
containment measures to maximize the coverage offered under the
program. Those measures may include limiting the expenditure of state
funds for this purpose to the price to the state for the lowest cost
plan contracting with the program and creation of program rules that
restrict the ability of employers or applicants to drop existing
coverage in order to qualify children for the program.
12693.54. A contract entered pursuant to this part shall be exempt
from any provision of law relating to competitive bidding, and shall
be exempt from the review or approval of any division of the
Department of General Services. The board shall not be required to
specify the amounts encumbered for each contract, but may allocate
funds to each contract based on the projected or actual subscriber
enrollments to a total amount not to exceed the amount appropriate
for the program including family contributions.
12693.55. (a) A health care provider who is furnished documentation
of a person's enrollment in the program shall not seek reimbursement
nor attempt to obtain payment for any covered services provided to
that person other than from the participating health plan covering
that person.
(b) The provisions of subdivision (a) do not apply to any
copayments required for the covered services provided to the person
under his or her participating health plan.
(c) For purposes of this section, "health care provider" means any
professional person, organization, health facility, or other person
or institution licensed by the state to deliver or furnish health
care services.
12693.25. The board may use a purchasing pool model, issuance of
purchasing credits, supplemental coverage, or other means as
appropriate to meet the purposes of this part.
12693.26. (a) The board shall establish a purchasing pool for
coverage of program subscribers to enable applicants without access
to affordable and comprehensive employer-sponsored dependent coverage
to provide their eligible children with health, dental, and vision
benefits. The board shall negotiate separate contracts with
participating health, dental, and vision plans for each of the
benefit packages described in Chapters 5 (commencing with Section
12693.60), 6 (commencing with Section 12693.63), and 7 (commencing
with Section 12693.65).
(b) Notwithstanding any other provision of law, on and after
January 1, 2011, the board may negotiate contracts with entities that
are not participating health, dental, or vision plans, including,
but not limited to, interagency agreements with the State Department
of Health Care Services, to provide or pay for benefits to
subscribers under this part, if necessary for any of the following
purposes:
(1) To comply with Section 403 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying paragraph (4) of subsection (a) of Section 1932 of the
federal Social Security Act.
(2) To comply with Section 503 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying subsection (bb) of Section 1902 of the federal Social
Security Act.
(3) To ensure that subscribers have adequate access to benefits
under this part.
(c) Any interagency agreement entered into by a state agency with
the board pursuant to subdivision (b), and any other contract or
contract amendment necessary to implement that agreement, shall be
exempt from any provision of law relating to competitive bidding and
from the review or approval of any division of the Department of
General Services in the same manner as contracts entered into by the
board are exempt pursuant to Section 12693.54.
12693.27. (a) The board shall develop a purchasing credit mechanism
to enable applicants with access to affordable and comprehensive
employer-sponsored dependent coverage to have an eligible child
enrolled in the employer's health plan. Children enrolled in the
purchasing credit mechanism may receive dental and vision benefits
through the purchasing pool component of the program.
(b) In order to be eligible for a purchasing credit, the employer
shall make a meaningful contribution toward the cost of coverage for
an employee's dependents for whom an application is made for a
purchasing credit. An employer's contribution, including any
increases or decreases in the contribution made after the effective
date of this part, may not vary among employees based on wage base or
job classification.
(c) The board shall adopt appropriate mechanisms to recoup
purchasing credit expenditures from an employer plan when the
employees or dependents on behalf of whose coverage the payments are
made are no longer enrolled in that plan.
(d) An employer utilizing a purchasing credit arrangement and a
participating health plan receiving a purchasing credit must use 100
percent of the funds for the purchase of coverage for purchasing
credit members including dependent coverage.
(e) A participating plan shall not assess the board for any
portion of late fees, returned checks, or other fees in connection
with an employer with group coverage who is also participating in the
purchasing credit arrangement.
(f) An applicant may begin coverage for dependents using a
purchasing credit arrangement at any time. Purchasing credit members
enrolling in employer-sponsored coverage shall not be considered late
enrollees for the purposes of subdivision (d) of Section 1357 and
subdivision (b) of Section 1357.50 of the Health and Safety Code, and
subdivision (b) of Section 10198.6 and subdivision (l) of Section
10700.
(g) Under no circumstances shall the employee's share of cost,
including, deductibles, copayments, and coinsurance, for dependent
coverage, including any supplemental coverage necessary to meet the
95 percent actuarial standard established in Section 12693.15 be more
than that required as the employee's share of premium if the
employee's children were enrolled in the purchasing pool component of
the program.
(h) The board may limit participation in the purchasing credit
program to those employers that provide employee health benefits
through participation in public or private purchasing cooperatives.
12693.271. (a) The Legislature finds and declares that the state
faces a fiscal crisis that requires unprecedented measures to reduce
General Fund expenditures.
(b) Notwithstanding any other provision of law, beginning the
first day of the fifth month following the enactment of the 2008-09
Budget Act, the rates for the participating health, dental, and
vision plans shall be set by reducing the rates that were in effect
on July 1, 2007, by 5 percent, and by adjusting the July 1, 2007,
rates downward to account for any reduction in the actuarial value of
the benefits provided to subscribers as of the first day of the
fifth month following the enactment of the 2008-09 Budget Act,
associated with annual limitations on dental benefits. This
requirement does not preclude the board from making other downward
adjustments that it deems appropriate as a result of its annual rate
negotiation process.
12693.28. The program shall be administered without regard to
gender, race, creed, color, sexual orientation, health status,
disability, or occupation.
12693.29. (a) The board shall use appropriate and efficient means
to notify families of the availability of health coverage from the
program.
(b) The State Department of Health Services in conjunction with
the board shall conduct a community outreach and education campaign
in accordance with Section 14067 of the Welfare and Institutions Code
to assist in notifying families of the availability of health
coverage for their children.
(c) The board shall use appropriate materials, which may include
brochures, pamphlets, fliers, posters, and other promotional items,
to notify families of the availability of coverage through the
program.
12693.30. (a) The board shall assure that written enrollment
information issued or provided by the program is available to program
subscribers and applicants in each of the languages identified
pursuant to Chapter 17.5 (commencing with Section 7290) of Division 7
of Title 1 of the Government Code.
(b) The board shall assure that phone services provided to program
subscribers and applicants by the program are available in all of
the languages identified pursuant to Chapter 17.5 (commencing with
Sec. 7290) of Division 7 of Title 1 of the Government Code.
(c) The board shall assure that interpreter services are available
between subscribers and contracting plans. The board shall assure
that subscribers are provided information within provider network
directories of available linguistically diverse providers.
(d) The board shall assure that participating health, dental, and
vision plans provide documentation on how they provide linguistically
and culturally appropriate services, including marketing materials,
to subscribers.
12693.31. No participating health, dental, or vision plan shall, in
an area served by the program, directly, or through an employee,
agent, or contractor, provide an applicant, or a child with any
marketing material relating to benefits or rates provided under the
program unless the material has been both reviewed and approved by
the board.
12693.32. (a) The board may pay designated individuals or
organizations an application assistance fee, if the individual or
organization assists an applicant to complete the program
application, and the applicant is enrolled in the program as a result
of the application.
(b) The board may establish the list of eligible individuals, or
categories of individuals and organizations, the amount of the
application assistance payment, and rules necessary to assure the
integrity of the payment process.
(c) The board, as part of its community outreach and education
campaign, may include community-based face-to-face initiatives to
educate potentially eligible applicants about the program and to
assist potential applicants in the application process. Those
entities undertaking outreach efforts shall not include as part of
their responsibilities the selection of a health plan and provider
for the applicant. Participating plans shall be prohibited from
directly, indirectly, or through their agents conducting in-person,
door-to-door, mail, or telephone solicitation of applicants for
enrollment except through employers with employees eligible to
participate in the purchasing credit mechanism. However, information
approved by the board on the providers and plans available to
prospective subscribers in their geographic areas shall be
distributed through any door-to-door activities for potentially
eligible applicants and their children.
(d) (1) All assistance offered to an individual applying to the
program shall be free of charge. Except as provided in subdivision
(a) or by a regulation adopted by the board, no individual or
organization offering or providing assistance to an applicant to
complete the program application shall solicit or receive any fee or
remuneration from the applicant or subscriber for offering or
providing that service.
(2) A person who violates this subdivision or a regulation adopted
by the board pursuant to this subdivision, shall be assessed a civil
penalty of five hundred dollars ($500) for each violation. For this
purpose, a violation occurs each day a solicitation is published on
an Internet Web site or is otherwise circulated to the public. This
penalty is in addition to any other remedy or penalty provided by
law. All penalties collected under this paragraph shall be deposited
in the State Treasury to the credit of the Healthy Families Fund.
(3) A civil or administrative action brought under this article at
the request of the board may be brought by the Attorney General in
the name of the people of the State of California in a court of
competent jurisdiction, or in a hearing through the Office of
Administrative Hearings conducted in accordance with Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, except that when a civil action is to be filed
in small claims court, the board may bring the action. The action
shall be filed within three years of the date the board discovered
the facts indicating a violation of this subdivision.
12693.325. (a) (1) Notwithstanding any provision of this chapter, a
participating health, dental, or vision plan that is licensed and in
good standing as required by subdivision (b) of Section 12693.36 may
provide application assistance directly to an applicant acting on
behalf of an eligible person who telephones, writes, or contacts the
plan in person at the plan's place of business, or at a community
public awareness event that is open to all participating plans in the
county, or at any other site approved by the board, and who requests
application assistance.
(2) A participating health, dental, or vision plan may also
provide application assistance directly to an applicant only under
the following conditions:
(A) The assistance is provided upon referral from a government
agency, school, or school district.
(B) The applicant has authorized the government agency, school, or
school district to allow a health, dental, or vision plan to contact
the applicant with additional information on enrolling in free or
low-cost health care.
(C) The State Department of Health Care Services approves the
applicant authorization form in consultation with the board.
(D) The plan may not actively solicit referrals and may not
provide compensation for the referrals.
(E) If a family is already enrolled in a health plan, the plan
that contacts the family cannot encourage the family to change health
plans.
(F) The board amends its marketing guidelines to require that when
a government agency, school, or school district requests assistance
from a participating health, dental, or vision plan to provide
application assistance, that all plans in the area shall be invited
to participate.
(G) The plan abides by the board's marketing guidelines.
(b) A participating health, dental, or vision plan may provide
application assistance to an applicant who is acting on behalf of an
eligible or potentially eligible child in any of the following
situations:
(1) The child is enrolled in a Medi-Cal managed care plan and the
participating plan becomes aware that the child's eligibility status
has or will change and that the child will no longer be eligible for
Medi-Cal. In those instances, the plan shall inform the applicant of
the differences in benefits and requirements between the Healthy
Families Program and the Medi-Cal program.
(2) The child is enrolled in a Healthy Families Program managed
care plan and the participating plan becomes aware that the child's
eligibility status has changed or will change and that the child will
no longer be eligible for the Healthy Families Program. When it
appears a child may be eligible for Medi-Cal benefits, the plan shall
inform the applicant of the differences in benefits and requirements
between the Medi-Cal program and the Healthy Families Program.
(3) The participating plan provides employer-sponsored coverage
through an employer and an employee of that employer who is the
parent or legal guardian of the eligible or potentially eligible
child.
(4) The child and his or her family are participating through the
participating plan in COBRA continuation coverage or other group
continuation coverage required by either state or federal law and the
group continuation coverage will expire within 60 days, or has
expired within the past 60 days.
(5) The child's family, but not the child, is participating
through the participating plan in COBRA continuation coverage or
other group continuation coverage required by either state or federal
law, and the group continuation coverage will expire within 60 days,
or has expired within the past 60 days.
(c) A participating health, dental, or vision plan employee or
other representative that provides application assistance shall
complete a certified application assistant training class approved by
the State Department of Health Care Services in consultation with
the board. The employee or other representative shall in all cases
inform an applicant verbally of his or her relationship with the
participating health plan. In the case of an in-person contact, the
employee or other representative shall provide in writing to the
applicant the nature of his or her relationship with the
participating health plan and obtain written acknowledgment from the
applicant that the information was provided.
(d) A participating health, dental, or vision plan that provides
application assistance may not do any of the following:
(1) Directly, indirectly, or through its agents, conduct
door-to-door marketing or telephone solicitation.
(2) Directly, indirectly, or through its agents, select a health
plan or provider for a potential applicant. Instead, the plan shall
inform a potential applicant of the choice of plans available within
the applicant's county of residence and specifically name those plans
and provide the most recent version of the program handbook.
(3) Directly, indirectly, or through its agents, conduct mail or
in-person solicitation of applicants for enrollment, except as
specified in subdivision (b), using materials approved by the board.
(e) A participating health, dental, or vision plan that provides
application assistance pursuant to this section is not eligible for
an application assistance fee otherwise available pursuant to Section
12693.32, and may not sponsor a person eligible for the program by
paying his or her family contribution amounts or copayments, and may
not offer applicants any inducements to enroll, including, but not
limited to, gifts or monetary payments.
(f) A participating health, dental, or vision plan may assist
applicants acting on behalf of subscribers who are enrolled with the
participating plan in completing the program's annual eligibility
review package in order to allow those applicants to retain health
care coverage.
(g) Each participating health, dental, or vision plan shall submit
to the board a plan for application assistance. All scripts and
materials to be used during application assistance sessions shall be
approved by the board and the State Department of Health Care
Services.
(h) Each participating health, dental, or vision plan shall
provide each applicant with the toll-free telephone number for the
Healthy Families Program.
(i) When deemed appropriate by the board, the board may refer a
participating health, dental, or vision plan to the Department of
Managed Health Care or the State Department of Health Care Services,
as applicable, for the review or investigation of its application
assistance practices.
(j) The board shall evaluate the impact of the changes required by
this section and shall provide a biennial report to the Legislature
on or before March 1 of every other year. To prepare these reports,
the State Department of Health Care Services, in cooperation with the
board, shall code all the application packets used by a managed care
plan to record the number of applications received that originated
from managed care plans. The number of applications received that
originated from managed care plans shall also be reported on the
board's Web site. In addition, the board shall periodically survey
those families assisted by plans to determine if the plans are
meeting the requirements of this section, and if families are being
given ample information about the choice of health, dental, or vision
plans available to them.
(k) Nothing in this section shall be seen as mitigating a
participating health, dental, or vision plan's responsibility to
comply with all federal and state laws, including, but not limited
to, Section 1320a-7b of Title 42 of the United States Code.
12693.326. Notwithstanding any other provision of this part, a new
subscriber in the program shall be allowed to switch his or her
choice of plans once within the first three months of coverage for
any reason.
12693.33. To the extent feasible and permissible under federal law
and with receipt of necessary federal approvals, the State Department
of Health Services and the board shall develop a joint Medi-Cal and
program application and enrollment form for children. The department
shall seek any federal approval necessary to implement a combined
application form.
12693.34. (a) The board may establish geographic areas within which
participating health, dental, and vision plans may offer coverage to
subscribers.
(b) Nothing in this section shall restrict a county organized
health system or a local initiative from providing service to program
subscribers in their licensed geographic service area.
12693.35. Participating health, dental, and vision plans shall
have, but need not be limited to, all of the following operating
characteristics satisfactory to the board in consultation with the
plan's licensing or regulatory oversight agency:
(a) Strong financial condition, including the ability to assume
the risk of providing and paying for covered services. A
participating plan may utilize reinsurance, provider risk sharing,
and other appropriate mechanisms to share a portion of the risk.
(b) Adequate administrative management.
(c) A satisfactory grievance procedure.
(d) Participating plans that contract with or employ health care
providers shall have mechanisms to accomplish all of the following,
in a manner satisfactory to the board:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(e) (1) Before the effective date of the contract, the
participating health plan shall have devised a system for identifying
in a simple and clear fashion both in its own records and in the
medical records of subscribers the fact that the services provided
are provided under the program.
(2) Throughout the duration of the contract, the plan shall use
the system described in paragraph (1).
(f) Plans licensed by the Department of Corporations shall be
deemed to meet the requirements of subdivisions (a) to (d),
inclusive, of this section.
12693.36. (a) Notwithstanding any other provision of law, the board
shall not be subject to licensure or regulation by the Department of
Insurance or the Department of Managed Health Care, as the case may
be.
(b) Participating health, dental, and vision plans that contract
with the program and are regulated by either the Insurance
Commissioner or the Department of Managed Health Care shall be
licensed and in good standing with their respective licensing
agencies. In their application to the program, those entities shall
provide assurance of their standing with the appropriate licensing
entity.
12693.37. (a) The board shall contract with a broad range of health
plans in an area, if available, to ensure that subscribers have a
choice from among a reasonable number and types of competing health
plans. The board shall develop and make available objective criteria
for health plan selection and provide adequate notice of the
application process to permit all health plans a reasonable and fair
opportunity to participate. The criteria and application process
shall allow participating health plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this chapter. Health plan selection shall be based on the
criteria developed by the board.
(b) (1) In its selection of participating plans the board shall
take all reasonable steps to assure the range of choices available to
each applicant, other than a purchasing credit member, shall include
plans that include in their provider networks and have signed
contracts with traditional and safety net providers.
(2) Participating health plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to:
(A) Geographic access for the subscribers.
(B) Linguistic services.
(C) The ethnic composition of providers.
(D) The number of subscribers who selected traditional and safety
net providers.
(c) (1) The board shall not rely solely on the Department of
Managed Health Care's determination of a health plan network's
adequacy or geographic access to providers in the awarding of
contracts under this part. The board shall collect and review
demographic, census, and other data to provide to prospective local
initiatives, health plans, or specialized health plans, as defined in
this act, specific provider contracting target areas with
significant numbers of uninsured children in low-income families. The
board shall give priority to those plans, on a county-by-county
basis, that demonstrate that they have included in their prospective
plan networks significant numbers of providers in these geographic
areas.
(2) Targeted contracting areas are those ZIP Codes or groups of
ZIP Codes or census tracts or groups of census tracts that have a
percentage of uninsured children in low-income families greater than
the overall percentage of uninsured children in low-income families
in that county.
(d) In each geographic area, the board shall designate a community
provider plan that is the participating health plan which has the
highest percentage of traditional and safety net providers in its
network. Subscribers selecting such a plan shall be given a family
contribution discount as described in Section 12693.43.
(e) The board shall establish reasonable limits on health plan
administrative costs.
12693.38. (a) The board shall contract with a sufficient number of
dental and vision plans to assure that dental and vision benefits are
available to all subscribers. The board shall develop and make
available objective criteria for dental and vision plan selection and
provide adequate notice of the application process to permit all
dental and vision plans a reasonable and fair opportunity to
participate. The criteria and application process shall allow
participating dental and vision plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this part. Dental and vision plan selection shall be
based on the criteria developed by the board.
(b) Participating dental plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to each of the following:
(1) Geographic access for the subscribers.
(2) Linguistic services.
(3) The ethnic composition of providers.
(c) The board shall establish reasonable limits on dental plan
administrative costs.
12693.39. The board shall establish a process for determining which
employer-sponsored health plans are eligible to receive a purchasing
credit issued by the program. The process shall assure that the
benefits, copayments, coinsurance, and deductibles are no less than
95 percent actuarially equivalent to those provided to program
subscribers enrolled in the purchasing pool.
12693.40. The board shall contract with health plans to provide
coverage supplemental to that provided by an applicant's or applicant'
s spouse's employer-sponsored health plan for the purchasing credit
member, if the employer-sponsored plan's benefits are not 95 percent
actuarially equivalent to those provided to subscribers. If
supplemental coverage is available and provided, the plan may then,
notwithstanding Section 12693.39, become eligible to receive
purchasing credits.
12693.41. (a) The board shall consult and coordinate with the State
Department of Health Services in implementing a preenrollment
program into the Healthy Families Program or the Medi-Cal program
pursuant to subdivision (b) of Section 14011.7 of the Welfare and
Institutions Code. The board shall accept the followup application
provided for in Section 14011.7 of the Welfare and Institutions Code
as an application for the Healthy Families Program. Preenrollment
shall be administered by the State Department of Health Services to
provide full-scope benefits pursuant to Medi-Cal program
requirements, at no cost to the applicant.
(b) The board may use the state fiscal intermediary for medicaid
to process the eligibility determinations and payments required
pursuant to Section 14011.7 of the Welfare and Institutions Code.
(c) The board shall be exempt from the requirements of Chapter 7
(commencing with Section 11700) of Division 3 of Title 2 of the
Government Code and Chapter 3 (commencing with Section 12100) of Part
2 of Division 2 of the Public Contract Code as those requirements
apply to the use of processing services by the state fiscal
intermediary.
(d) The board may adopt emergency regulations to implement
preenrollment into the Healthy Families Program or the Medi-Cal
program pursuant to Section 14011.7 of the Welfare and Institutions
Code. The emergency regulations shall include, but not be limited to,
regulations that implement any changes in rules relating to
eligibility, enrollment, and disenrollment in the programs pursuant
to Sections 12693.45 and 12693.70. The initial adoption of emergency
regulations and one readoption of the initial regulations shall be
deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety, and general
welfare. Initial emergency regulations and the first readoption of
those regulations shall be exempt from review by the Office of
Administrative Law. The initial emergency regulations and one
readoption of those regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and publication in the California Code of
Regulations and each shall remain in effect for no more than 180
days.
(e) This section shall become operative on April 1, 2003.
12693.42. Any purchasing credit issued by the board, or a
contractor acting on behalf of the board, pursuant to this part shall
have an overall cost to the program no greater than the cost to the
program to enroll the subscriber in the lowest cost plan available to
the subscriber through the purchasing pool. Administrative costs and
the cost to the program of any supplemental product shall be
included in the calculation of the cost of the purchasing credit
program and deducted from the amount of the purchasing credit.
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost Family Value
Package in a given geographic area.
(b) In each geographic area, the board shall designate one or more
Family Value Packages for which the required total family
contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with annual household incomes up to and including 150
percent of the federal poverty level.
(2) (A) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be twelve dollars ($12) per child with a
maximum required contribution of thirty-six dollars ($36) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be sixteen dollars ($16) per child with a
maximum required contribution of forty-eight dollars ($48) per month
per family.
(3) (A) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with annual household income to
which subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be seventeen dollars ($17) per child with a
maximum required contribution of fifty-one dollars ($51) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-four dollars ($24) per child with a
maximum required contribution of seventy-two dollars ($72) per month
per family.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost Family Value Package
may be offered to and selected by applicants. However, the cost to
the program of those combinations that exceeds the price to the
program of the highest cost Family Value Package shall be paid by the
applicant as part of the family contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with annual household incomes up to and
including 150 percent of the federal poverty level.
(2) (A) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be nine dollars ($9) per child with a
maximum required contribution of twenty-seven dollars ($27) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be thirteen dollars ($13) per child with a
maximum required contribution of thirty-nine dollars ($39) per month
per family.
(3) (A) On and after July 1, 2005, twelve dollars ($12) per child
with a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with annual household income to which
subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be fourteen dollars ($14) per child with a
maximum required contribution of forty-two dollars ($42) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-one dollars ($21) per child with a
maximum required contribution of sixty-three dollars ($63) per month
per family.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purpose of
subdivision (e) of Section 11346.1 of the Government code, the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative law, is hereby extended to 180 days.
(i) The board may adopt, and may only one-time readopt,
regulations to implement the changes to this section that are
effective the first day of the fifth month following the enactment of
the 2008-09 Budget Act. The adoption and one-time readoption of a
regulation authorized by this section is deemed to address an
emergency, for purposes of Sections 11346.1 and 11349.6 of the
Government Code, and the board is hereby exempted for this purpose
from the requirements of subdivision (b) of Section 11346.1 of the
Government Code.
(j) The program shall provide prior notice to any applicant for a
subscriber whose premium will increase as a result of amendments made
to this section by the act that added this subdivision and shall
provide the applicant with an opportunity to demonstrate that, based
on reduced family income, the subscriber is subject to a lower
premium pursuant to this section.
12693.44. (a) The board shall establish family contribution amounts
for purchasing credit members that are equivalent to the amounts
charged to subscribers participating in the purchasing pool portion
of the program. Purchasing credit members shall not be required to
pay family contribution amounts greater than the cost to the
applicant if the purchasing credit members were enrolled in the
purchasing pool component of the program. When calculating the cost
to the applicant to participate in the purchasing pool, the family
contribution discounts provided in subdivisions (c), (d), and (e) of
Section 12693.34 shall not be considered. Purchasing credit members
shall be eligible for dental and vision coverage through the
purchasing pool at no additional premium charge.
(b) The family contribution amounts paid on behalf of a purchasing
credit member may be paid directly to the applicant's employer
through a payroll deduction or other mechanism.
12693.45. (a) After two consecutive months of nonpayment of family
contributions by an applicant, and a reasonable written notice period
of no less than 30 days is provided to the applicant, subscribers or
purchasing credit members may be disenrolled for an applicant's
failure to pay family contributions. The board may impose or contract
for collection actions to collect unpaid family contributions.
(b) Subject to any additional requirements of federal law,
disenrollments shall be effective at the end of the second
consecutive month of nonpayment.
12693.46. The board may prohibit applicants who drop coverage after
enrolling in the pool from reenrollment in the program for up to six
months.
12693.47. The program may place a lien on compensation or benefits,
recovered or recoverable by a subscriber or applicant from any party
or parties responsible for the compensation or benefits for which
benefits have been provided under a policy issued under this part.
12693.48. The board may adjust payments made to a participating
health plan if the board finds that the plan has a significantly
disproportionate share of high- or low-risk subscribers. Prior to
making this finding, the program shall obtain validated data from
participating health plans. Reporting requirements shall be
administratively compatible with the methods of operation of the
health plans. Any adjustments to payments shall utilize demographic
and other factors which are actuarially related to risk.
12693.49. (a) When an applicant is dissatisfied with any action or
inaction of a participating plan in which a subscriber is enrolled
through the purchasing pool, the applicant shall first attempt to
resolve the dispute with the participating plan according to its
established policies and procedures.
(b) The board shall assure that all participating health, dental,
and vision plans make subscribers aware of the regulatory oversight
available to the applicant by the participating health, dental, or
vision plan's licensing or state oversight entity.
(c) The board shall assure that all participating health, dental,
and vision plans report to the board, at least once a year, the
number and types of benefit grievances filed by applicants on behalf
of subscribers in the program. This information shall be available to
applicants upon request in a format determined by the board.
12693.50. (a) The board shall consult and coordinate with the State
Department of Health Services to implement the Medi-Cal to Healthy
Families Accelerated Enrollment program pursuant to Section 14011.65
of the Welfare and Institutions Code.
(b) The state shall seek approval of any amendments to the state
plan, necessary to implement Section 14011.65 of the Welfare and
Institutions Code in accordance with Title XXI of the Social Security
Act (42 U.S.C. 1397aa et seq.). Notwithstanding any other provision
of law, only when all necessary federal approvals have been obtained
shall Section 14011.65 of the Welfare and Institutions Code be
implemented.
(c) The board may adopt emergency regulations to implement the
provision of accelerated eligibility benefits pursuant to this
section and as described under Section 14011.65 of the Welfare and
Institutions Code. The emergency regulations shall include, but not
be limited to, regulations that implement any changes in rules
relating to program eligibility, enrollment, and disenrollment. The
initial adoption of emergency regulations and one readoption of the
initial regulations shall be deemed to be an emergency and necessary
for the immediate preservation of the public peace, health and
safety, and general welfare. Initial emergency regulations and the
first readoption of those regulations shall be exempt from review by
the Office of Administrative Law. The initial emergency regulations
and one readoption of those regulations authorized by this section
shall be submitted to the Office of Administrative Law for filing
with the Secretary of State and publication in the California Code of
Regulations, and each shall remain in effect for no more than 180
days.
12693.51. (a) A transfer of enrollment from one participating
health plan to another may be made by a subscriber at times and under
conditions as may be prescribed by regulations of the board.
(b) The board shall provide for the transfer of coverage of any
subscriber to another participating plan (1) if a contract with any
participating plan under which the subscriber receives coverage is
canceled or not renewed and (2) at least once a year upon request in
a manner as determined by the board, and (3) if a subscriber moves to
an area that the current health plan does not serve.
12693.515. (a) Effective July 1, 2004, any subscriber who
affirmatively selects, or is assigned by default to, a federally
qualified health center, as defined by Section 1396(d)(l)(2) of Title
42 of the United States Code, a rural health clinic, as defined by
Section 1396(d)(l)(1) of Title 42 of the United States Code, or a
primary care clinic that is licensed under Section 1204 of the Health
and Safety Code, or is exempt from licensure under subdivision (h)
of Section 1206 of the Health and Safety Code, shall be deemed to
have been assigned directly to the federally qualified health center,
the rural health clinic, or the primary care clinic, and not to any
individual provider who performs services on behalf of the federally
qualified health center, the rural health clinic, or the primary care
clinic.
(b) (1) When a subscriber is assigned, from any source, to a
physician who is an employee of a federally qualified health center,
a rural health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's health care coverage.
(2) When a subscriber is assigned, from any source, to a dentist
who is an employee of a federally qualified health center, a rural
health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's dental coverage.
(3) When a subscriber is assigned, from any source, to an
optometrist who is an employee of a federally qualified health
center, a rural health clinic, or a primary care clinic, the
assignment shall constitute an assignment to that federally qualified
health center, rural health clinic, or primary care clinic for
purposes of the subscriber's vision coverage.
(c) This section shall not limit any rights a subscriber may have
to select an available primary care physician within a health care
service plan's service area pursuant to Section 1373.3 of the Health
and Safety Code.
12693.52. The board may negotiate or arrange for stop-loss
insurance coverage that limits the program's fiscal responsibility
for the total costs of health services provided to program
subscribers, or arrange for participating health plans to share or
assure the financial risk for a portion of the total cost of health
care services to program subscribers, or both.
12693.53. The board shall develop and utilize appropriate cost
containment measures to maximize the coverage offered under the
program. Those measures may include limiting the expenditure of state
funds for this purpose to the price to the state for the lowest cost
plan contracting with the program and creation of program rules that
restrict the ability of employers or applicants to drop existing
coverage in order to qualify children for the program.
12693.54. A contract entered pursuant to this part shall be exempt
from any provision of law relating to competitive bidding, and shall
be exempt from the review or approval of any division of the
Department of General Services. The board shall not be required to
specify the amounts encumbered for each contract, but may allocate
funds to each contract based on the projected or actual subscriber
enrollments to a total amount not to exceed the amount appropriate
for the program including family contributions.
12693.55. (a) A health care provider who is furnished documentation
of a person's enrollment in the program shall not seek reimbursement
nor attempt to obtain payment for any covered services provided to
that person other than from the participating health plan covering
that person.
(b) The provisions of subdivision (a) do not apply to any
copayments required for the covered services provided to the person
under his or her participating health plan.
(c) For purposes of this section, "health care provider" means any
professional person, organization, health facility, or other person
or institution licensed by the state to deliver or furnish health
care services.
12693.25. The board may use a purchasing pool model, issuance of
purchasing credits, supplemental coverage, or other means as
appropriate to meet the purposes of this part.
12693.26. (a) The board shall establish a purchasing pool for
coverage of program subscribers to enable applicants without access
to affordable and comprehensive employer-sponsored dependent coverage
to provide their eligible children with health, dental, and vision
benefits. The board shall negotiate separate contracts with
participating health, dental, and vision plans for each of the
benefit packages described in Chapters 5 (commencing with Section
12693.60), 6 (commencing with Section 12693.63), and 7 (commencing
with Section 12693.65).
(b) Notwithstanding any other provision of law, on and after
January 1, 2011, the board may negotiate contracts with entities that
are not participating health, dental, or vision plans, including,
but not limited to, interagency agreements with the State Department
of Health Care Services, to provide or pay for benefits to
subscribers under this part, if necessary for any of the following
purposes:
(1) To comply with Section 403 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying paragraph (4) of subsection (a) of Section 1932 of the
federal Social Security Act.
(2) To comply with Section 503 of the federal Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by
applying subsection (bb) of Section 1902 of the federal Social
Security Act.
(3) To ensure that subscribers have adequate access to benefits
under this part.
(c) Any interagency agreement entered into by a state agency with
the board pursuant to subdivision (b), and any other contract or
contract amendment necessary to implement that agreement, shall be
exempt from any provision of law relating to competitive bidding and
from the review or approval of any division of the Department of
General Services in the same manner as contracts entered into by the
board are exempt pursuant to Section 12693.54.
12693.27. (a) The board shall develop a purchasing credit mechanism
to enable applicants with access to affordable and comprehensive
employer-sponsored dependent coverage to have an eligible child
enrolled in the employer's health plan. Children enrolled in the
purchasing credit mechanism may receive dental and vision benefits
through the purchasing pool component of the program.
(b) In order to be eligible for a purchasing credit, the employer
shall make a meaningful contribution toward the cost of coverage for
an employee's dependents for whom an application is made for a
purchasing credit. An employer's contribution, including any
increases or decreases in the contribution made after the effective
date of this part, may not vary among employees based on wage base or
job classification.
(c) The board shall adopt appropriate mechanisms to recoup
purchasing credit expenditures from an employer plan when the
employees or dependents on behalf of whose coverage the payments are
made are no longer enrolled in that plan.
(d) An employer utilizing a purchasing credit arrangement and a
participating health plan receiving a purchasing credit must use 100
percent of the funds for the purchase of coverage for purchasing
credit members including dependent coverage.
(e) A participating plan shall not assess the board for any
portion of late fees, returned checks, or other fees in connection
with an employer with group coverage who is also participating in the
purchasing credit arrangement.
(f) An applicant may begin coverage for dependents using a
purchasing credit arrangement at any time. Purchasing credit members
enrolling in employer-sponsored coverage shall not be considered late
enrollees for the purposes of subdivision (d) of Section 1357 and
subdivision (b) of Section 1357.50 of the Health and Safety Code, and
subdivision (b) of Section 10198.6 and subdivision (l) of Section
10700.
(g) Under no circumstances shall the employee's share of cost,
including, deductibles, copayments, and coinsurance, for dependent
coverage, including any supplemental coverage necessary to meet the
95 percent actuarial standard established in Section 12693.15 be more
than that required as the employee's share of premium if the
employee's children were enrolled in the purchasing pool component of
the program.
(h) The board may limit participation in the purchasing credit
program to those employers that provide employee health benefits
through participation in public or private purchasing cooperatives.
12693.271. (a) The Legislature finds and declares that the state
faces a fiscal crisis that requires unprecedented measures to reduce
General Fund expenditures.
(b) Notwithstanding any other provision of law, beginning the
first day of the fifth month following the enactment of the 2008-09
Budget Act, the rates for the participating health, dental, and
vision plans shall be set by reducing the rates that were in effect
on July 1, 2007, by 5 percent, and by adjusting the July 1, 2007,
rates downward to account for any reduction in the actuarial value of
the benefits provided to subscribers as of the first day of the
fifth month following the enactment of the 2008-09 Budget Act,
associated with annual limitations on dental benefits. This
requirement does not preclude the board from making other downward
adjustments that it deems appropriate as a result of its annual rate
negotiation process.
12693.28. The program shall be administered without regard to
gender, race, creed, color, sexual orientation, health status,
disability, or occupation.
12693.29. (a) The board shall use appropriate and efficient means
to notify families of the availability of health coverage from the
program.
(b) The State Department of Health Services in conjunction with
the board shall conduct a community outreach and education campaign
in accordance with Section 14067 of the Welfare and Institutions Code
to assist in notifying families of the availability of health
coverage for their children.
(c) The board shall use appropriate materials, which may include
brochures, pamphlets, fliers, posters, and other promotional items,
to notify families of the availability of coverage through the
program.
12693.30. (a) The board shall assure that written enrollment
information issued or provided by the program is available to program
subscribers and applicants in each of the languages identified
pursuant to Chapter 17.5 (commencing with Section 7290) of Division 7
of Title 1 of the Government Code.
(b) The board shall assure that phone services provided to program
subscribers and applicants by the program are available in all of
the languages identified pursuant to Chapter 17.5 (commencing with
Sec. 7290) of Division 7 of Title 1 of the Government Code.
(c) The board shall assure that interpreter services are available
between subscribers and contracting plans. The board shall assure
that subscribers are provided information within provider network
directories of available linguistically diverse providers.
(d) The board shall assure that participating health, dental, and
vision plans provide documentation on how they provide linguistically
and culturally appropriate services, including marketing materials,
to subscribers.
12693.31. No participating health, dental, or vision plan shall, in
an area served by the program, directly, or through an employee,
agent, or contractor, provide an applicant, or a child with any
marketing material relating to benefits or rates provided under the
program unless the material has been both reviewed and approved by
the board.
12693.32. (a) The board may pay designated individuals or
organizations an application assistance fee, if the individual or
organization assists an applicant to complete the program
application, and the applicant is enrolled in the program as a result
of the application.
(b) The board may establish the list of eligible individuals, or
categories of individuals and organizations, the amount of the
application assistance payment, and rules necessary to assure the
integrity of the payment process.
(c) The board, as part of its community outreach and education
campaign, may include community-based face-to-face initiatives to
educate potentially eligible applicants about the program and to
assist potential applicants in the application process. Those
entities undertaking outreach efforts shall not include as part of
their responsibilities the selection of a health plan and provider
for the applicant. Participating plans shall be prohibited from
directly, indirectly, or through their agents conducting in-person,
door-to-door, mail, or telephone solicitation of applicants for
enrollment except through employers with employees eligible to
participate in the purchasing credit mechanism. However, information
approved by the board on the providers and plans available to
prospective subscribers in their geographic areas shall be
distributed through any door-to-door activities for potentially
eligible applicants and their children.
(d) (1) All assistance offered to an individual applying to the
program shall be free of charge. Except as provided in subdivision
(a) or by a regulation adopted by the board, no individual or
organization offering or providing assistance to an applicant to
complete the program application shall solicit or receive any fee or
remuneration from the applicant or subscriber for offering or
providing that service.
(2) A person who violates this subdivision or a regulation adopted
by the board pursuant to this subdivision, shall be assessed a civil
penalty of five hundred dollars ($500) for each violation. For this
purpose, a violation occurs each day a solicitation is published on
an Internet Web site or is otherwise circulated to the public. This
penalty is in addition to any other remedy or penalty provided by
law. All penalties collected under this paragraph shall be deposited
in the State Treasury to the credit of the Healthy Families Fund.
(3) A civil or administrative action brought under this article at
the request of the board may be brought by the Attorney General in
the name of the people of the State of California in a court of
competent jurisdiction, or in a hearing through the Office of
Administrative Hearings conducted in accordance with Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, except that when a civil action is to be filed
in small claims court, the board may bring the action. The action
shall be filed within three years of the date the board discovered
the facts indicating a violation of this subdivision.
12693.325. (a) (1) Notwithstanding any provision of this chapter, a
participating health, dental, or vision plan that is licensed and in
good standing as required by subdivision (b) of Section 12693.36 may
provide application assistance directly to an applicant acting on
behalf of an eligible person who telephones, writes, or contacts the
plan in person at the plan's place of business, or at a community
public awareness event that is open to all participating plans in the
county, or at any other site approved by the board, and who requests
application assistance.
(2) A participating health, dental, or vision plan may also
provide application assistance directly to an applicant only under
the following conditions:
(A) The assistance is provided upon referral from a government
agency, school, or school district.
(B) The applicant has authorized the government agency, school, or
school district to allow a health, dental, or vision plan to contact
the applicant with additional information on enrolling in free or
low-cost health care.
(C) The State Department of Health Care Services approves the
applicant authorization form in consultation with the board.
(D) The plan may not actively solicit referrals and may not
provide compensation for the referrals.
(E) If a family is already enrolled in a health plan, the plan
that contacts the family cannot encourage the family to change health
plans.
(F) The board amends its marketing guidelines to require that when
a government agency, school, or school district requests assistance
from a participating health, dental, or vision plan to provide
application assistance, that all plans in the area shall be invited
to participate.
(G) The plan abides by the board's marketing guidelines.
(b) A participating health, dental, or vision plan may provide
application assistance to an applicant who is acting on behalf of an
eligible or potentially eligible child in any of the following
situations:
(1) The child is enrolled in a Medi-Cal managed care plan and the
participating plan becomes aware that the child's eligibility status
has or will change and that the child will no longer be eligible for
Medi-Cal. In those instances, the plan shall inform the applicant of
the differences in benefits and requirements between the Healthy
Families Program and the Medi-Cal program.
(2) The child is enrolled in a Healthy Families Program managed
care plan and the participating plan becomes aware that the child's
eligibility status has changed or will change and that the child will
no longer be eligible for the Healthy Families Program. When it
appears a child may be eligible for Medi-Cal benefits, the plan shall
inform the applicant of the differences in benefits and requirements
between the Medi-Cal program and the Healthy Families Program.
(3) The participating plan provides employer-sponsored coverage
through an employer and an employee of that employer who is the
parent or legal guardian of the eligible or potentially eligible
child.
(4) The child and his or her family are participating through the
participating plan in COBRA continuation coverage or other group
continuation coverage required by either state or federal law and the
group continuation coverage will expire within 60 days, or has
expired within the past 60 days.
(5) The child's family, but not the child, is participating
through the participating plan in COBRA continuation coverage or
other group continuation coverage required by either state or federal
law, and the group continuation coverage will expire within 60 days,
or has expired within the past 60 days.
(c) A participating health, dental, or vision plan employee or
other representative that provides application assistance shall
complete a certified application assistant training class approved by
the State Department of Health Care Services in consultation with
the board. The employee or other representative shall in all cases
inform an applicant verbally of his or her relationship with the
participating health plan. In the case of an in-person contact, the
employee or other representative shall provide in writing to the
applicant the nature of his or her relationship with the
participating health plan and obtain written acknowledgment from the
applicant that the information was provided.
(d) A participating health, dental, or vision plan that provides
application assistance may not do any of the following:
(1) Directly, indirectly, or through its agents, conduct
door-to-door marketing or telephone solicitation.
(2) Directly, indirectly, or through its agents, select a health
plan or provider for a potential applicant. Instead, the plan shall
inform a potential applicant of the choice of plans available within
the applicant's county of residence and specifically name those plans
and provide the most recent version of the program handbook.
(3) Directly, indirectly, or through its agents, conduct mail or
in-person solicitation of applicants for enrollment, except as
specified in subdivision (b), using materials approved by the board.
(e) A participating health, dental, or vision plan that provides
application assistance pursuant to this section is not eligible for
an application assistance fee otherwise available pursuant to Section
12693.32, and may not sponsor a person eligible for the program by
paying his or her family contribution amounts or copayments, and may
not offer applicants any inducements to enroll, including, but not
limited to, gifts or monetary payments.
(f) A participating health, dental, or vision plan may assist
applicants acting on behalf of subscribers who are enrolled with the
participating plan in completing the program's annual eligibility
review package in order to allow those applicants to retain health
care coverage.
(g) Each participating health, dental, or vision plan shall submit
to the board a plan for application assistance. All scripts and
materials to be used during application assistance sessions shall be
approved by the board and the State Department of Health Care
Services.
(h) Each participating health, dental, or vision plan shall
provide each applicant with the toll-free telephone number for the
Healthy Families Program.
(i) When deemed appropriate by the board, the board may refer a
participating health, dental, or vision plan to the Department of
Managed Health Care or the State Department of Health Care Services,
as applicable, for the review or investigation of its application
assistance practices.
(j) The board shall evaluate the impact of the changes required by
this section and shall provide a biennial report to the Legislature
on or before March 1 of every other year. To prepare these reports,
the State Department of Health Care Services, in cooperation with the
board, shall code all the application packets used by a managed care
plan to record the number of applications received that originated
from managed care plans. The number of applications received that
originated from managed care plans shall also be reported on the
board's Web site. In addition, the board shall periodically survey
those families assisted by plans to determine if the plans are
meeting the requirements of this section, and if families are being
given ample information about the choice of health, dental, or vision
plans available to them.
(k) Nothing in this section shall be seen as mitigating a
participating health, dental, or vision plan's responsibility to
comply with all federal and state laws, including, but not limited
to, Section 1320a-7b of Title 42 of the United States Code.
12693.326. Notwithstanding any other provision of this part, a new
subscriber in the program shall be allowed to switch his or her
choice of plans once within the first three months of coverage for
any reason.
12693.33. To the extent feasible and permissible under federal law
and with receipt of necessary federal approvals, the State Department
of Health Services and the board shall develop a joint Medi-Cal and
program application and enrollment form for children. The department
shall seek any federal approval necessary to implement a combined
application form.
12693.34. (a) The board may establish geographic areas within which
participating health, dental, and vision plans may offer coverage to
subscribers.
(b) Nothing in this section shall restrict a county organized
health system or a local initiative from providing service to program
subscribers in their licensed geographic service area.
12693.35. Participating health, dental, and vision plans shall
have, but need not be limited to, all of the following operating
characteristics satisfactory to the board in consultation with the
plan's licensing or regulatory oversight agency:
(a) Strong financial condition, including the ability to assume
the risk of providing and paying for covered services. A
participating plan may utilize reinsurance, provider risk sharing,
and other appropriate mechanisms to share a portion of the risk.
(b) Adequate administrative management.
(c) A satisfactory grievance procedure.
(d) Participating plans that contract with or employ health care
providers shall have mechanisms to accomplish all of the following,
in a manner satisfactory to the board:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(e) (1) Before the effective date of the contract, the
participating health plan shall have devised a system for identifying
in a simple and clear fashion both in its own records and in the
medical records of subscribers the fact that the services provided
are provided under the program.
(2) Throughout the duration of the contract, the plan shall use
the system described in paragraph (1).
(f) Plans licensed by the Department of Corporations shall be
deemed to meet the requirements of subdivisions (a) to (d),
inclusive, of this section.
12693.36. (a) Notwithstanding any other provision of law, the board
shall not be subject to licensure or regulation by the Department of
Insurance or the Department of Managed Health Care, as the case may
be.
(b) Participating health, dental, and vision plans that contract
with the program and are regulated by either the Insurance
Commissioner or the Department of Managed Health Care shall be
licensed and in good standing with their respective licensing
agencies. In their application to the program, those entities shall
provide assurance of their standing with the appropriate licensing
entity.
12693.37. (a) The board shall contract with a broad range of health
plans in an area, if available, to ensure that subscribers have a
choice from among a reasonable number and types of competing health
plans. The board shall develop and make available objective criteria
for health plan selection and provide adequate notice of the
application process to permit all health plans a reasonable and fair
opportunity to participate. The criteria and application process
shall allow participating health plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this chapter. Health plan selection shall be based on the
criteria developed by the board.
(b) (1) In its selection of participating plans the board shall
take all reasonable steps to assure the range of choices available to
each applicant, other than a purchasing credit member, shall include
plans that include in their provider networks and have signed
contracts with traditional and safety net providers.
(2) Participating health plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to:
(A) Geographic access for the subscribers.
(B) Linguistic services.
(C) The ethnic composition of providers.
(D) The number of subscribers who selected traditional and safety
net providers.
(c) (1) The board shall not rely solely on the Department of
Managed Health Care's determination of a health plan network's
adequacy or geographic access to providers in the awarding of
contracts under this part. The board shall collect and review
demographic, census, and other data to provide to prospective local
initiatives, health plans, or specialized health plans, as defined in
this act, specific provider contracting target areas with
significant numbers of uninsured children in low-income families. The
board shall give priority to those plans, on a county-by-county
basis, that demonstrate that they have included in their prospective
plan networks significant numbers of providers in these geographic
areas.
(2) Targeted contracting areas are those ZIP Codes or groups of
ZIP Codes or census tracts or groups of census tracts that have a
percentage of uninsured children in low-income families greater than
the overall percentage of uninsured children in low-income families
in that county.
(d) In each geographic area, the board shall designate a community
provider plan that is the participating health plan which has the
highest percentage of traditional and safety net providers in its
network. Subscribers selecting such a plan shall be given a family
contribution discount as described in Section 12693.43.
(e) The board shall establish reasonable limits on health plan
administrative costs.
12693.38. (a) The board shall contract with a sufficient number of
dental and vision plans to assure that dental and vision benefits are
available to all subscribers. The board shall develop and make
available objective criteria for dental and vision plan selection and
provide adequate notice of the application process to permit all
dental and vision plans a reasonable and fair opportunity to
participate. The criteria and application process shall allow
participating dental and vision plans to comply with their state and
federal licensing and regulatory obligations, except as otherwise
provided in this part. Dental and vision plan selection shall be
based on the criteria developed by the board.
(b) Participating dental plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The report shall provide, as available, information on the provider
network as it relates to each of the following:
(1) Geographic access for the subscribers.
(2) Linguistic services.
(3) The ethnic composition of providers.
(c) The board shall establish reasonable limits on dental plan
administrative costs.
12693.39. The board shall establish a process for determining which
employer-sponsored health plans are eligible to receive a purchasing
credit issued by the program. The process shall assure that the
benefits, copayments, coinsurance, and deductibles are no less than
95 percent actuarially equivalent to those provided to program
subscribers enrolled in the purchasing pool.
12693.40. The board shall contract with health plans to provide
coverage supplemental to that provided by an applicant's or applicant'
s spouse's employer-sponsored health plan for the purchasing credit
member, if the employer-sponsored plan's benefits are not 95 percent
actuarially equivalent to those provided to subscribers. If
supplemental coverage is available and provided, the plan may then,
notwithstanding Section 12693.39, become eligible to receive
purchasing credits.
12693.41. (a) The board shall consult and coordinate with the State
Department of Health Services in implementing a preenrollment
program into the Healthy Families Program or the Medi-Cal program
pursuant to subdivision (b) of Section 14011.7 of the Welfare and
Institutions Code. The board shall accept the followup application
provided for in Section 14011.7 of the Welfare and Institutions Code
as an application for the Healthy Families Program. Preenrollment
shall be administered by the State Department of Health Services to
provide full-scope benefits pursuant to Medi-Cal program
requirements, at no cost to the applicant.
(b) The board may use the state fiscal intermediary for medicaid
to process the eligibility determinations and payments required
pursuant to Section 14011.7 of the Welfare and Institutions Code.
(c) The board shall be exempt from the requirements of Chapter 7
(commencing with Section 11700) of Division 3 of Title 2 of the
Government Code and Chapter 3 (commencing with Section 12100) of Part
2 of Division 2 of the Public Contract Code as those requirements
apply to the use of processing services by the state fiscal
intermediary.
(d) The board may adopt emergency regulations to implement
preenrollment into the Healthy Families Program or the Medi-Cal
program pursuant to Section 14011.7 of the Welfare and Institutions
Code. The emergency regulations shall include, but not be limited to,
regulations that implement any changes in rules relating to
eligibility, enrollment, and disenrollment in the programs pursuant
to Sections 12693.45 and 12693.70. The initial adoption of emergency
regulations and one readoption of the initial regulations shall be
deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety, and general
welfare. Initial emergency regulations and the first readoption of
those regulations shall be exempt from review by the Office of
Administrative Law. The initial emergency regulations and one
readoption of those regulations authorized by this section shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and publication in the California Code of
Regulations and each shall remain in effect for no more than 180
days.
(e) This section shall become operative on April 1, 2003.
12693.42. Any purchasing credit issued by the board, or a
contractor acting on behalf of the board, pursuant to this part shall
have an overall cost to the program no greater than the cost to the
program to enroll the subscriber in the lowest cost plan available to
the subscriber through the purchasing pool. Administrative costs and
the cost to the program of any supplemental product shall be
included in the calculation of the cost of the purchasing credit
program and deducted from the amount of the purchasing credit.
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost Family Value
Package in a given geographic area.
(b) In each geographic area, the board shall designate one or more
Family Value Packages for which the required total family
contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with annual household incomes up to and including 150
percent of the federal poverty level.
(2) (A) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be twelve dollars ($12) per child with a
maximum required contribution of thirty-six dollars ($36) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be sixteen dollars ($16) per child with a
maximum required contribution of forty-eight dollars ($48) per month
per family.
(3) (A) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with annual household income to
which subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be seventeen dollars ($17) per child with a
maximum required contribution of fifty-one dollars ($51) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-four dollars ($24) per child with a
maximum required contribution of seventy-two dollars ($72) per month
per family.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost Family Value Package
may be offered to and selected by applicants. However, the cost to
the program of those combinations that exceeds the price to the
program of the highest cost Family Value Package shall be paid by the
applicant as part of the family contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with annual household incomes up to and
including 150 percent of the federal poverty level.
(2) (A) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be nine dollars ($9) per child with a
maximum required contribution of twenty-seven dollars ($27) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be thirteen dollars ($13) per child with a
maximum required contribution of thirty-nine dollars ($39) per month
per family.
(3) (A) On and after July 1, 2005, twelve dollars ($12) per child
with a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with annual household income to which
subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph shall be applicable to the applicant on July
1, 2005, unless subparagraph (B) of paragraph (6) of subdivision (a)
of Section 12693.70 is no longer applicable to the relevant family
income. The program shall provide prior notice to any applicant for
currently enrolled subscribers whose premium will increase on July 1,
2005, pursuant to this subparagraph and, prior to the date the
premium increase takes effect, shall provide that applicant with an
opportunity to demonstrate that subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income.
(B) Commencing the first day of the fifth month following the
enactment of the 2008-09 Budget Act, the family contribution pursuant
to this paragraph shall be fourteen dollars ($14) per child with a
maximum required contribution of forty-two dollars ($42) per month
per family.
(C) Commencing November 1, 2009, the family contribution pursuant
to this paragraph shall be twenty-one dollars ($21) per child with a
maximum required contribution of sixty-three dollars ($63) per month
per family.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purpose of
subdivision (e) of Section 11346.1 of the Government code, the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative law, is hereby extended to 180 days.
(i) The board may adopt, and may only one-time readopt,
regulations to implement the changes to this section that are
effective the first day of the fifth month following the enactment of
the 2008-09 Budget Act. The adoption and one-time readoption of a
regulation authorized by this section is deemed to address an
emergency, for purposes of Sections 11346.1 and 11349.6 of the
Government Code, and the board is hereby exempted for this purpose
from the requirements of subdivision (b) of Section 11346.1 of the
Government Code.
(j) The program shall provide prior notice to any applicant for a
subscriber whose premium will increase as a result of amendments made
to this section by the act that added this subdivision and shall
provide the applicant with an opportunity to demonstrate that, based
on reduced family income, the subscriber is subject to a lower
premium pursuant to this section.
12693.44. (a) The board shall establish family contribution amounts
for purchasing credit members that are equivalent to the amounts
charged to subscribers participating in the purchasing pool portion
of the program. Purchasing credit members shall not be required to
pay family contribution amounts greater than the cost to the
applicant if the purchasing credit members were enrolled in the
purchasing pool component of the program. When calculating the cost
to the applicant to participate in the purchasing pool, the family
contribution discounts provided in subdivisions (c), (d), and (e) of
Section 12693.34 shall not be considered. Purchasing credit members
shall be eligible for dental and vision coverage through the
purchasing pool at no additional premium charge.
(b) The family contribution amounts paid on behalf of a purchasing
credit member may be paid directly to the applicant's employer
through a payroll deduction or other mechanism.
12693.45. (a) After two consecutive months of nonpayment of family
contributions by an applicant, and a reasonable written notice period
of no less than 30 days is provided to the applicant, subscribers or
purchasing credit members may be disenrolled for an applicant's
failure to pay family contributions. The board may impose or contract
for collection actions to collect unpaid family contributions.
(b) Subject to any additional requirements of federal law,
disenrollments shall be effective at the end of the second
consecutive month of nonpayment.
12693.46. The board may prohibit applicants who drop coverage after
enrolling in the pool from reenrollment in the program for up to six
months.
12693.47. The program may place a lien on compensation or benefits,
recovered or recoverable by a subscriber or applicant from any party
or parties responsible for the compensation or benefits for which
benefits have been provided under a policy issued under this part.
12693.48. The board may adjust payments made to a participating
health plan if the board finds that the plan has a significantly
disproportionate share of high- or low-risk subscribers. Prior to
making this finding, the program shall obtain validated data from
participating health plans. Reporting requirements shall be
administratively compatible with the methods of operation of the
health plans. Any adjustments to payments shall utilize demographic
and other factors which are actuarially related to risk.
12693.49. (a) When an applicant is dissatisfied with any action or
inaction of a participating plan in which a subscriber is enrolled
through the purchasing pool, the applicant shall first attempt to
resolve the dispute with the participating plan according to its
established policies and procedures.
(b) The board shall assure that all participating health, dental,
and vision plans make subscribers aware of the regulatory oversight
available to the applicant by the participating health, dental, or
vision plan's licensing or state oversight entity.
(c) The board shall assure that all participating health, dental,
and vision plans report to the board, at least once a year, the
number and types of benefit grievances filed by applicants on behalf
of subscribers in the program. This information shall be available to
applicants upon request in a format determined by the board.
12693.50. (a) The board shall consult and coordinate with the State
Department of Health Services to implement the Medi-Cal to Healthy
Families Accelerated Enrollment program pursuant to Section 14011.65
of the Welfare and Institutions Code.
(b) The state shall seek approval of any amendments to the state
plan, necessary to implement Section 14011.65 of the Welfare and
Institutions Code in accordance with Title XXI of the Social Security
Act (42 U.S.C. 1397aa et seq.). Notwithstanding any other provision
of law, only when all necessary federal approvals have been obtained
shall Section 14011.65 of the Welfare and Institutions Code be
implemented.
(c) The board may adopt emergency regulations to implement the
provision of accelerated eligibility benefits pursuant to this
section and as described under Section 14011.65 of the Welfare and
Institutions Code. The emergency regulations shall include, but not
be limited to, regulations that implement any changes in rules
relating to program eligibility, enrollment, and disenrollment. The
initial adoption of emergency regulations and one readoption of the
initial regulations shall be deemed to be an emergency and necessary
for the immediate preservation of the public peace, health and
safety, and general welfare. Initial emergency regulations and the
first readoption of those regulations shall be exempt from review by
the Office of Administrative Law. The initial emergency regulations
and one readoption of those regulations authorized by this section
shall be submitted to the Office of Administrative Law for filing
with the Secretary of State and publication in the California Code of
Regulations, and each shall remain in effect for no more than 180
days.
12693.51. (a) A transfer of enrollment from one participating
health plan to another may be made by a subscriber at times and under
conditions as may be prescribed by regulations of the board.
(b) The board shall provide for the transfer of coverage of any
subscriber to another participating plan (1) if a contract with any
participating plan under which the subscriber receives coverage is
canceled or not renewed and (2) at least once a year upon request in
a manner as determined by the board, and (3) if a subscriber moves to
an area that the current health plan does not serve.
12693.515. (a) Effective July 1, 2004, any subscriber who
affirmatively selects, or is assigned by default to, a federally
qualified health center, as defined by Section 1396(d)(l)(2) of Title
42 of the United States Code, a rural health clinic, as defined by
Section 1396(d)(l)(1) of Title 42 of the United States Code, or a
primary care clinic that is licensed under Section 1204 of the Health
and Safety Code, or is exempt from licensure under subdivision (h)
of Section 1206 of the Health and Safety Code, shall be deemed to
have been assigned directly to the federally qualified health center,
the rural health clinic, or the primary care clinic, and not to any
individual provider who performs services on behalf of the federally
qualified health center, the rural health clinic, or the primary care
clinic.
(b) (1) When a subscriber is assigned, from any source, to a
physician who is an employee of a federally qualified health center,
a rural health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's health care coverage.
(2) When a subscriber is assigned, from any source, to a dentist
who is an employee of a federally qualified health center, a rural
health clinic, or a primary care clinic, the assignment shall
constitute an assignment to that federally qualified health center,
rural health clinic, or primary care clinic for purposes of the
subscriber's dental coverage.
(3) When a subscriber is assigned, from any source, to an
optometrist who is an employee of a federally qualified health
center, a rural health clinic, or a primary care clinic, the
assignment shall constitute an assignment to that federally qualified
health center, rural health clinic, or primary care clinic for
purposes of the subscriber's vision coverage.
(c) This section shall not limit any rights a subscriber may have
to select an available primary care physician within a health care
service plan's service area pursuant to Section 1373.3 of the Health
and Safety Code.
12693.52. The board may negotiate or arrange for stop-loss
insurance coverage that limits the program's fiscal responsibility
for the total costs of health services provided to program
subscribers, or arrange for participating health plans to share or
assure the financial risk for a portion of the total cost of health
care services to program subscribers, or both.
12693.53. The board shall develop and utilize appropriate cost
containment measures to maximize the coverage offered under the
program. Those measures may include limiting the expenditure of state
funds for this purpose to the price to the state for the lowest cost
plan contracting with the program and creation of program rules that
restrict the ability of employers or applicants to drop existing
coverage in order to qualify children for the program.
12693.54. A contract entered pursuant to this part shall be exempt
from any provision of law relating to competitive bidding, and shall
be exempt from the review or approval of any division of the
Department of General Services. The board shall not be required to
specify the amounts encumbered for each contract, but may allocate
funds to each contract based on the projected or actual subscriber
enrollments to a total amount not to exceed the amount appropriate
for the program including family contributions.
12693.55. (a) A health care provider who is furnished documentation
of a person's enrollment in the program shall not seek reimbursement
nor attempt to obtain payment for any covered services provided to
that person other than from the participating health plan covering
that person.
(b) The provisions of subdivision (a) do not apply to any
copayments required for the covered services provided to the person
under his or her participating health plan.
(c) For purposes of this section, "health care provider" means any
professional person, organization, health facility, or other person
or institution licensed by the state to deliver or furnish health
care services.
