State Codes and Statutes

Statutes > California > Ins > 12739.5-12739.62

INSURANCE CODE
SECTION 12739.5-12739.62



12739.5.  It is the intent of the Legislature to implement Section
1101 of the federal Patient Protection and Affordable Care Act
(Public Law 111-148) in California to establish a temporary high risk
pool so that access to health coverage for individuals with
preexisting medical conditions can be effectively and promptly
provided by the Managed Risk Medical Insurance Board.



12739.50.  For the purposes of this part, the following terms have
the following meanings:
   (a) "Applicant" means an individual who applies for high risk
medical coverage through the program.
   (b) "Board" means the Managed Risk Medical Insurance Board.
   (c) "Federal temporary high risk pool" is the temporary high risk
health insurance pool program established pursuant to Section 1101 of
the federal Patient Protection and Affordable Care Act (Public Law
111-148).
   (d) "Fund" means the Federal Temporary High Risk Health Insurance
Fund, established in Section 12739.71, from which the board may
authorize expenditures to pay for all of the following:
   (1) Covered, medically necessary services that exceed subscribers'
contributions.
   (2) Administration of the program.
   (3) Marketing and outreach.
   (e) "High risk medical coverage" or "coverage" means payment for
medically necessary services provided by institutional and
professional providers through the program.
   (f) "Participating health plan" means a private insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan, as defined under
subdivision (f) of Section 1345 of the Health and Safety Code, that
contracts with the program to provide or administer high risk medical
coverage to program subscribers.
   (g) "Plan rates" means the total monthly amount charged by a
participating health plan to provide or administer high risk medical
coverage.
   (h) "Program" means the Federal Temporary High Risk Pool through
which the board operates the federal temporary high risk pool in
California.
   (i) "Subscriber" means an eligible individual, as defined in
subsection (d) of Section 1101 of the federal Patient Protection and
Affordable Care Act (Public Law 111-148), who is enrolled in the
program, and includes a member of a federally recognized California
Indian tribe.
   (j) "Subscriber contribution" means the premium for high risk
medical coverage paid by the subscriber or, if authorized by the
federal government, paid on behalf of the subscriber by a federally
recognized California Indian tribal government. If a federally
recognized California Indian tribal government makes a contribution
on behalf of a member of the tribe, the tribal government shall
ensure that the subscriber is made aware of all the health coverage
options, including participating health plans, available in the
county where the member resides.


12739.51.  The Federal Temporary High Risk Pool is hereby created in
the California Health and Human Services Agency. The program shall
be managed by the board.



12739.52.  The board shall have the authority to do all of the
following, consistent with Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148):
   (a) Enter into an agreement with the federal Department of Health
and Human Services to administer the federal temporary high risk pool
as provided in Section 12739.53.
   (b) Determine eligibility criteria and enrollment and
disenrollment criteria and processes, including processes for waiting
lists, enrollment limits, disenrollments, and any other limits on
enrollment needed to maintain program expenditures within available
federal funds.
   (c) Determine the participation requirements of applicants,
subscribers, and participating health plans, third-party
administrators, and other contractors.
   (d) Determine when subscribers' coverage begins and ends.
   (e) Provide for the processing of applications and the enrollment
of subscribers.
   (f) Determine the high risk medical coverage to be provided to
subscribers, including the scope of benefits and subscriber cost
sharing.
   (g) Establish subscriber contributions and plan rates.
   (h) (1) Provide high risk medical coverage for subscribers through
contracts with participating health plans or third-party
administrators to provide or administer the coverage. A contract
between the board and a participating health plan may provide that
the contracting health plan assumes full or partial risk for the cost
of covered health services or that the contracting health plan
undertakes to provide only administrative services for the state's
self-insured high risk medical coverage. A contract between the board
and a third-party administrator may provide that the third-party
administrator undertakes to provide only administrative services for
the state's self-insured high risk medical coverage. The board may
provide or purchase stop-loss coverage under which the program and
participating health plans or stop-loss insurers share the risk for
health plan expenses that exceed plan rates.
   (2) Nothing in paragraph (1) shall be construed to alter the
rights of a participating health plan under existing law if the board
is unable to continue payment to the plan in accordance with the
terms of the plan's contract with the board.
   (i) Authorize expenditures from the fund to pay program expenses
that exceed subscriber contributions.
   (j) Contract for administration of the program or any portion of
the program with any public agency, including any agency of state
government, or with any private entity.
   (k) If, and to the extent, permitted by federal law and by the
federal Department of Health and Human Services, align program
administration with the administration of the Major Risk Medical
Insurance Program established pursuant to Part 6.5 (commencing with
Section 12700) to ensure coordination and administrative efficiency.
   (l) Sue and be sued.
   (m) Employ necessary staff.
   (n) Refer potential violations of state and federal law by
participating health plans and other entities and persons to the
appropriate regulatory agencies.
   (o) Subject to the approval of the Department of Finance, obtain
loans from the General Fund for all necessary and reasonable expenses
related to the administration of the fund and the program. The board
shall repay principal and interest, using the pooled money
investment account rate of interest, to the General Fund no later
than July 1, 2014.
   (p) (1) Issue rules and regulations to carry out the purposes of
this part. The adoption and readoption of regulations to implement
this part shall be deemed to be an emergency that calls for immediate
action to avoid serious harm to the public peace, health, 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 the board describe facts showing the need for
immediate action and from review by the Office of Administrative Law.
   (2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the board
shall, without taking any regulatory action, initially implement this
section pursuant to the agreement with the federal Department of
Health and Human Services described in subdivision (a) of Section
12739.53. Thereafter, the board shall adopt any necessary regulations
in accordance with the requirements of Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code and with paragraph (1) of this subdivision.
   (q) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon the
board under this part, including the powers and responsibilities
necessary to enter into an agreement with, and comply with the
requirements of, the federal Department of Health and Human Services
as described in subdivision (a) of Section 12739.53.




12739.53.  (a) The board shall, consistent with Section 1101 of the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and State and federal law and contingent on the agreement of
the federal Department of Health and Human Services and receipt of
sufficient federal funding, enter into an agreement with the federal
Department of Health and Human Services to administer the federal
temporary high risk pool in California.
   (b) If the federal Department of Health and Human Services and the
state enter into an agreement to administer the federal temporary
high risk pool, the board shall do all of the following:
   (1) Administer the program pursuant to that agreement.
   (2) Begin providing coverage in the program on the date
established pursuant to the agreement with the federal Department of
Health and Human Services.
   (3) Establish the scope and content of high risk medical coverage.
   (4) Determine reasonable minimum standards for participating
health plans, third-party administrators, and other contractors.
   (5) Determine the time, manner, method, and procedures for
withdrawing program approval from a plan, third-party administrator,
or other contractor, or limiting enrollment of subscribers in a plan.
   (6) Research and assess the needs of persons without adequate
health coverage and promote means of ensuring the availability of
adequate health care services.
   (7) Administer the program to ensure the following:
   (A) That the program subsidy amount does not exceed amounts
transferred to the fund pursuant to this part.
   (B) That the aggregate amount spent for high risk medical coverage
and program administration does not exceed the federal funds
available to the state for this purpose and that no state funds are
spent for the purposes of this part.
   (8) Maintain enrollment and expenditures to ensure that
expenditures do not exceed amounts available in the fund and that no
state funds are spent for purposes of this part. If sufficient funds
are not available to cover the estimated cost of program
expenditures, the board shall institute appropriate measures to limit
enrollment.
   (9) In adopting benefit and eligibility standards, be guided by
the needs and welfare of persons unable to secure adequate health
coverage for themselves and their dependents and by prevailing
practices among private health plans.
   (10) As required by the federal Department of Health and Human
Services, implement procedures to provide for the transition of
subscribers into qualified health plans offered through an exchange
or exchanges to be established pursuant to the federal Patient
Protection and Affordable Care Act (Public Law 111-148).
   (11) Post on the board's Internet Web site the monthly progress
reports submitted to the federal Department of Health and Human
Services. In addition, the board shall provide notice of any
anticipated waiting lists or disenrollments due to insufficient
funding to the public, by making that notice available as part of its
board meetings, and concurrently to the Legislature.
   (12) Develop and implement a plan for marketing and outreach.
   (c) There shall not be any liability in a private capacity on the
part of the board or any member of the board, or any officer or
employee of the board for or on account of any act performed or
obligation entered into in an official capacity, when done in good
faith, without intent to defraud, and in connection with the
administration, management, or conduct of this part or affairs
related to this part.



12739.54.  (a) Plan rates for high risk medical benefits approved
for the program shall not be excessive, inadequate, or unfairly
discriminatory, but shall be adequate to pay anticipated costs of
claims or services and administration.
   (b) As a condition of reimbursement, participating health plans or
third-party administrators shall submit claims to the board within
18 months following the date of service. The board may vary the time
limit established in this subdivision if necessary to administer the
reimbursement or reconciliation processes established by the board or
to meet the requirements of the state's agreement with the federal
Department of Health and Human Services described in subdivision (a)
of Section 12739.53.



12739.55.  The program may place a lien on compensation or benefits
recovered or recoverable by a subscriber from any party or parties
responsible for the compensation or benefits for which benefits have
been provided pursuant to this part.



12739.56.  Except as provided in Article 3.5 (commencing with
Section 14124.70) of Chapter 7 of Part 3 of Division 9 of the Welfare
and Institutions Code, benefits received under this part are in
excess of, and secondary to, any other form of health benefits
coverage.



12739.57.  The board shall provide coverage pursuant to this part
through participating health plans or through provider networks using
a third-party administrator and may contract for the processing of
applications, the enrollment of subscribers, and all activities
necessary to administer the program. Any contract entered into
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
projected and actual subscriber enrollments in a total amount not to
exceed revenue available for the program.



12739.58.  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 program.



12739.59.  (a) Program decisions concerning an applicant's or
subscriber's eligibility or eligibility date may be appealed to the
board, according to procedures to be established by the board.
   (b) Coverage determinations may be appealed to the board,
according to procedures established by the board. If permitted by the
federal Department of Health and Human Services, the board shall not
be required to provide an appeal concerning a coverage determination
if the subject of the appeal is within the jurisdiction of the
Department of Managed Health Care pursuant to the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) and its
implementing regulations or within the jurisdiction of the Department
of Insurance pursuant to the Insurance Code and its implementing
regulations.
   (c) Hearings shall be conducted according to the requirements of
the federal Department of Health and Human Services and, insofar as
practicable and not inconsistent with those requirements, pursuant to
the provisions of Chapter 5 (commencing with Section 11500) of Part
1 of Division 3 of Title 2 of the Government Code.



12739.60.  Upon enrollment as a subscriber in the program, the
subscriber shall be responsible for payment of the subscriber
contribution.


12739.61.  The board shall cease to provide coverage through the
program on January 1, 2014, and at that time shall cease to operate
the program except as required to complete payments to, or payment
reconciliations with, participating health plans or other
contractors, process appeals, or conduct other necessary transition
activities, including, but not limited to, transition of subscribers
into an exchange or exchanges established pursuant to the federal
Patient Protection and Affordable Care Act (Public Law 111-148).



12739.62.  This part shall remain in effect only until January 1,
2020, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2020, deletes or extends
that date.

State Codes and Statutes

Statutes > California > Ins > 12739.5-12739.62

INSURANCE CODE
SECTION 12739.5-12739.62



12739.5.  It is the intent of the Legislature to implement Section
1101 of the federal Patient Protection and Affordable Care Act
(Public Law 111-148) in California to establish a temporary high risk
pool so that access to health coverage for individuals with
preexisting medical conditions can be effectively and promptly
provided by the Managed Risk Medical Insurance Board.



12739.50.  For the purposes of this part, the following terms have
the following meanings:
   (a) "Applicant" means an individual who applies for high risk
medical coverage through the program.
   (b) "Board" means the Managed Risk Medical Insurance Board.
   (c) "Federal temporary high risk pool" is the temporary high risk
health insurance pool program established pursuant to Section 1101 of
the federal Patient Protection and Affordable Care Act (Public Law
111-148).
   (d) "Fund" means the Federal Temporary High Risk Health Insurance
Fund, established in Section 12739.71, from which the board may
authorize expenditures to pay for all of the following:
   (1) Covered, medically necessary services that exceed subscribers'
contributions.
   (2) Administration of the program.
   (3) Marketing and outreach.
   (e) "High risk medical coverage" or "coverage" means payment for
medically necessary services provided by institutional and
professional providers through the program.
   (f) "Participating health plan" means a private insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan, as defined under
subdivision (f) of Section 1345 of the Health and Safety Code, that
contracts with the program to provide or administer high risk medical
coverage to program subscribers.
   (g) "Plan rates" means the total monthly amount charged by a
participating health plan to provide or administer high risk medical
coverage.
   (h) "Program" means the Federal Temporary High Risk Pool through
which the board operates the federal temporary high risk pool in
California.
   (i) "Subscriber" means an eligible individual, as defined in
subsection (d) of Section 1101 of the federal Patient Protection and
Affordable Care Act (Public Law 111-148), who is enrolled in the
program, and includes a member of a federally recognized California
Indian tribe.
   (j) "Subscriber contribution" means the premium for high risk
medical coverage paid by the subscriber or, if authorized by the
federal government, paid on behalf of the subscriber by a federally
recognized California Indian tribal government. If a federally
recognized California Indian tribal government makes a contribution
on behalf of a member of the tribe, the tribal government shall
ensure that the subscriber is made aware of all the health coverage
options, including participating health plans, available in the
county where the member resides.


12739.51.  The Federal Temporary High Risk Pool is hereby created in
the California Health and Human Services Agency. The program shall
be managed by the board.



12739.52.  The board shall have the authority to do all of the
following, consistent with Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148):
   (a) Enter into an agreement with the federal Department of Health
and Human Services to administer the federal temporary high risk pool
as provided in Section 12739.53.
   (b) Determine eligibility criteria and enrollment and
disenrollment criteria and processes, including processes for waiting
lists, enrollment limits, disenrollments, and any other limits on
enrollment needed to maintain program expenditures within available
federal funds.
   (c) Determine the participation requirements of applicants,
subscribers, and participating health plans, third-party
administrators, and other contractors.
   (d) Determine when subscribers' coverage begins and ends.
   (e) Provide for the processing of applications and the enrollment
of subscribers.
   (f) Determine the high risk medical coverage to be provided to
subscribers, including the scope of benefits and subscriber cost
sharing.
   (g) Establish subscriber contributions and plan rates.
   (h) (1) Provide high risk medical coverage for subscribers through
contracts with participating health plans or third-party
administrators to provide or administer the coverage. A contract
between the board and a participating health plan may provide that
the contracting health plan assumes full or partial risk for the cost
of covered health services or that the contracting health plan
undertakes to provide only administrative services for the state's
self-insured high risk medical coverage. A contract between the board
and a third-party administrator may provide that the third-party
administrator undertakes to provide only administrative services for
the state's self-insured high risk medical coverage. The board may
provide or purchase stop-loss coverage under which the program and
participating health plans or stop-loss insurers share the risk for
health plan expenses that exceed plan rates.
   (2) Nothing in paragraph (1) shall be construed to alter the
rights of a participating health plan under existing law if the board
is unable to continue payment to the plan in accordance with the
terms of the plan's contract with the board.
   (i) Authorize expenditures from the fund to pay program expenses
that exceed subscriber contributions.
   (j) Contract for administration of the program or any portion of
the program with any public agency, including any agency of state
government, or with any private entity.
   (k) If, and to the extent, permitted by federal law and by the
federal Department of Health and Human Services, align program
administration with the administration of the Major Risk Medical
Insurance Program established pursuant to Part 6.5 (commencing with
Section 12700) to ensure coordination and administrative efficiency.
   (l) Sue and be sued.
   (m) Employ necessary staff.
   (n) Refer potential violations of state and federal law by
participating health plans and other entities and persons to the
appropriate regulatory agencies.
   (o) Subject to the approval of the Department of Finance, obtain
loans from the General Fund for all necessary and reasonable expenses
related to the administration of the fund and the program. The board
shall repay principal and interest, using the pooled money
investment account rate of interest, to the General Fund no later
than July 1, 2014.
   (p) (1) Issue rules and regulations to carry out the purposes of
this part. The adoption and readoption of regulations to implement
this part shall be deemed to be an emergency that calls for immediate
action to avoid serious harm to the public peace, health, 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 the board describe facts showing the need for
immediate action and from review by the Office of Administrative Law.
   (2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the board
shall, without taking any regulatory action, initially implement this
section pursuant to the agreement with the federal Department of
Health and Human Services described in subdivision (a) of Section
12739.53. Thereafter, the board shall adopt any necessary regulations
in accordance with the requirements of Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code and with paragraph (1) of this subdivision.
   (q) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon the
board under this part, including the powers and responsibilities
necessary to enter into an agreement with, and comply with the
requirements of, the federal Department of Health and Human Services
as described in subdivision (a) of Section 12739.53.




12739.53.  (a) The board shall, consistent with Section 1101 of the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and State and federal law and contingent on the agreement of
the federal Department of Health and Human Services and receipt of
sufficient federal funding, enter into an agreement with the federal
Department of Health and Human Services to administer the federal
temporary high risk pool in California.
   (b) If the federal Department of Health and Human Services and the
state enter into an agreement to administer the federal temporary
high risk pool, the board shall do all of the following:
   (1) Administer the program pursuant to that agreement.
   (2) Begin providing coverage in the program on the date
established pursuant to the agreement with the federal Department of
Health and Human Services.
   (3) Establish the scope and content of high risk medical coverage.
   (4) Determine reasonable minimum standards for participating
health plans, third-party administrators, and other contractors.
   (5) Determine the time, manner, method, and procedures for
withdrawing program approval from a plan, third-party administrator,
or other contractor, or limiting enrollment of subscribers in a plan.
   (6) Research and assess the needs of persons without adequate
health coverage and promote means of ensuring the availability of
adequate health care services.
   (7) Administer the program to ensure the following:
   (A) That the program subsidy amount does not exceed amounts
transferred to the fund pursuant to this part.
   (B) That the aggregate amount spent for high risk medical coverage
and program administration does not exceed the federal funds
available to the state for this purpose and that no state funds are
spent for the purposes of this part.
   (8) Maintain enrollment and expenditures to ensure that
expenditures do not exceed amounts available in the fund and that no
state funds are spent for purposes of this part. If sufficient funds
are not available to cover the estimated cost of program
expenditures, the board shall institute appropriate measures to limit
enrollment.
   (9) In adopting benefit and eligibility standards, be guided by
the needs and welfare of persons unable to secure adequate health
coverage for themselves and their dependents and by prevailing
practices among private health plans.
   (10) As required by the federal Department of Health and Human
Services, implement procedures to provide for the transition of
subscribers into qualified health plans offered through an exchange
or exchanges to be established pursuant to the federal Patient
Protection and Affordable Care Act (Public Law 111-148).
   (11) Post on the board's Internet Web site the monthly progress
reports submitted to the federal Department of Health and Human
Services. In addition, the board shall provide notice of any
anticipated waiting lists or disenrollments due to insufficient
funding to the public, by making that notice available as part of its
board meetings, and concurrently to the Legislature.
   (12) Develop and implement a plan for marketing and outreach.
   (c) There shall not be any liability in a private capacity on the
part of the board or any member of the board, or any officer or
employee of the board for or on account of any act performed or
obligation entered into in an official capacity, when done in good
faith, without intent to defraud, and in connection with the
administration, management, or conduct of this part or affairs
related to this part.



12739.54.  (a) Plan rates for high risk medical benefits approved
for the program shall not be excessive, inadequate, or unfairly
discriminatory, but shall be adequate to pay anticipated costs of
claims or services and administration.
   (b) As a condition of reimbursement, participating health plans or
third-party administrators shall submit claims to the board within
18 months following the date of service. The board may vary the time
limit established in this subdivision if necessary to administer the
reimbursement or reconciliation processes established by the board or
to meet the requirements of the state's agreement with the federal
Department of Health and Human Services described in subdivision (a)
of Section 12739.53.



12739.55.  The program may place a lien on compensation or benefits
recovered or recoverable by a subscriber from any party or parties
responsible for the compensation or benefits for which benefits have
been provided pursuant to this part.



12739.56.  Except as provided in Article 3.5 (commencing with
Section 14124.70) of Chapter 7 of Part 3 of Division 9 of the Welfare
and Institutions Code, benefits received under this part are in
excess of, and secondary to, any other form of health benefits
coverage.



12739.57.  The board shall provide coverage pursuant to this part
through participating health plans or through provider networks using
a third-party administrator and may contract for the processing of
applications, the enrollment of subscribers, and all activities
necessary to administer the program. Any contract entered into
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
projected and actual subscriber enrollments in a total amount not to
exceed revenue available for the program.



12739.58.  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 program.



12739.59.  (a) Program decisions concerning an applicant's or
subscriber's eligibility or eligibility date may be appealed to the
board, according to procedures to be established by the board.
   (b) Coverage determinations may be appealed to the board,
according to procedures established by the board. If permitted by the
federal Department of Health and Human Services, the board shall not
be required to provide an appeal concerning a coverage determination
if the subject of the appeal is within the jurisdiction of the
Department of Managed Health Care pursuant to the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) and its
implementing regulations or within the jurisdiction of the Department
of Insurance pursuant to the Insurance Code and its implementing
regulations.
   (c) Hearings shall be conducted according to the requirements of
the federal Department of Health and Human Services and, insofar as
practicable and not inconsistent with those requirements, pursuant to
the provisions of Chapter 5 (commencing with Section 11500) of Part
1 of Division 3 of Title 2 of the Government Code.



12739.60.  Upon enrollment as a subscriber in the program, the
subscriber shall be responsible for payment of the subscriber
contribution.


12739.61.  The board shall cease to provide coverage through the
program on January 1, 2014, and at that time shall cease to operate
the program except as required to complete payments to, or payment
reconciliations with, participating health plans or other
contractors, process appeals, or conduct other necessary transition
activities, including, but not limited to, transition of subscribers
into an exchange or exchanges established pursuant to the federal
Patient Protection and Affordable Care Act (Public Law 111-148).



12739.62.  This part shall remain in effect only until January 1,
2020, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2020, deletes or extends
that date.


State Codes and Statutes

State Codes and Statutes

Statutes > California > Ins > 12739.5-12739.62

INSURANCE CODE
SECTION 12739.5-12739.62



12739.5.  It is the intent of the Legislature to implement Section
1101 of the federal Patient Protection and Affordable Care Act
(Public Law 111-148) in California to establish a temporary high risk
pool so that access to health coverage for individuals with
preexisting medical conditions can be effectively and promptly
provided by the Managed Risk Medical Insurance Board.



12739.50.  For the purposes of this part, the following terms have
the following meanings:
   (a) "Applicant" means an individual who applies for high risk
medical coverage through the program.
   (b) "Board" means the Managed Risk Medical Insurance Board.
   (c) "Federal temporary high risk pool" is the temporary high risk
health insurance pool program established pursuant to Section 1101 of
the federal Patient Protection and Affordable Care Act (Public Law
111-148).
   (d) "Fund" means the Federal Temporary High Risk Health Insurance
Fund, established in Section 12739.71, from which the board may
authorize expenditures to pay for all of the following:
   (1) Covered, medically necessary services that exceed subscribers'
contributions.
   (2) Administration of the program.
   (3) Marketing and outreach.
   (e) "High risk medical coverage" or "coverage" means payment for
medically necessary services provided by institutional and
professional providers through the program.
   (f) "Participating health plan" means a private insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan, as defined under
subdivision (f) of Section 1345 of the Health and Safety Code, that
contracts with the program to provide or administer high risk medical
coverage to program subscribers.
   (g) "Plan rates" means the total monthly amount charged by a
participating health plan to provide or administer high risk medical
coverage.
   (h) "Program" means the Federal Temporary High Risk Pool through
which the board operates the federal temporary high risk pool in
California.
   (i) "Subscriber" means an eligible individual, as defined in
subsection (d) of Section 1101 of the federal Patient Protection and
Affordable Care Act (Public Law 111-148), who is enrolled in the
program, and includes a member of a federally recognized California
Indian tribe.
   (j) "Subscriber contribution" means the premium for high risk
medical coverage paid by the subscriber or, if authorized by the
federal government, paid on behalf of the subscriber by a federally
recognized California Indian tribal government. If a federally
recognized California Indian tribal government makes a contribution
on behalf of a member of the tribe, the tribal government shall
ensure that the subscriber is made aware of all the health coverage
options, including participating health plans, available in the
county where the member resides.


12739.51.  The Federal Temporary High Risk Pool is hereby created in
the California Health and Human Services Agency. The program shall
be managed by the board.



12739.52.  The board shall have the authority to do all of the
following, consistent with Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148):
   (a) Enter into an agreement with the federal Department of Health
and Human Services to administer the federal temporary high risk pool
as provided in Section 12739.53.
   (b) Determine eligibility criteria and enrollment and
disenrollment criteria and processes, including processes for waiting
lists, enrollment limits, disenrollments, and any other limits on
enrollment needed to maintain program expenditures within available
federal funds.
   (c) Determine the participation requirements of applicants,
subscribers, and participating health plans, third-party
administrators, and other contractors.
   (d) Determine when subscribers' coverage begins and ends.
   (e) Provide for the processing of applications and the enrollment
of subscribers.
   (f) Determine the high risk medical coverage to be provided to
subscribers, including the scope of benefits and subscriber cost
sharing.
   (g) Establish subscriber contributions and plan rates.
   (h) (1) Provide high risk medical coverage for subscribers through
contracts with participating health plans or third-party
administrators to provide or administer the coverage. A contract
between the board and a participating health plan may provide that
the contracting health plan assumes full or partial risk for the cost
of covered health services or that the contracting health plan
undertakes to provide only administrative services for the state's
self-insured high risk medical coverage. A contract between the board
and a third-party administrator may provide that the third-party
administrator undertakes to provide only administrative services for
the state's self-insured high risk medical coverage. The board may
provide or purchase stop-loss coverage under which the program and
participating health plans or stop-loss insurers share the risk for
health plan expenses that exceed plan rates.
   (2) Nothing in paragraph (1) shall be construed to alter the
rights of a participating health plan under existing law if the board
is unable to continue payment to the plan in accordance with the
terms of the plan's contract with the board.
   (i) Authorize expenditures from the fund to pay program expenses
that exceed subscriber contributions.
   (j) Contract for administration of the program or any portion of
the program with any public agency, including any agency of state
government, or with any private entity.
   (k) If, and to the extent, permitted by federal law and by the
federal Department of Health and Human Services, align program
administration with the administration of the Major Risk Medical
Insurance Program established pursuant to Part 6.5 (commencing with
Section 12700) to ensure coordination and administrative efficiency.
   (l) Sue and be sued.
   (m) Employ necessary staff.
   (n) Refer potential violations of state and federal law by
participating health plans and other entities and persons to the
appropriate regulatory agencies.
   (o) Subject to the approval of the Department of Finance, obtain
loans from the General Fund for all necessary and reasonable expenses
related to the administration of the fund and the program. The board
shall repay principal and interest, using the pooled money
investment account rate of interest, to the General Fund no later
than July 1, 2014.
   (p) (1) Issue rules and regulations to carry out the purposes of
this part. The adoption and readoption of regulations to implement
this part shall be deemed to be an emergency that calls for immediate
action to avoid serious harm to the public peace, health, 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 the board describe facts showing the need for
immediate action and from review by the Office of Administrative Law.
   (2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the board
shall, without taking any regulatory action, initially implement this
section pursuant to the agreement with the federal Department of
Health and Human Services described in subdivision (a) of Section
12739.53. Thereafter, the board shall adopt any necessary regulations
in accordance with the requirements of Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code and with paragraph (1) of this subdivision.
   (q) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon the
board under this part, including the powers and responsibilities
necessary to enter into an agreement with, and comply with the
requirements of, the federal Department of Health and Human Services
as described in subdivision (a) of Section 12739.53.




12739.53.  (a) The board shall, consistent with Section 1101 of the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and State and federal law and contingent on the agreement of
the federal Department of Health and Human Services and receipt of
sufficient federal funding, enter into an agreement with the federal
Department of Health and Human Services to administer the federal
temporary high risk pool in California.
   (b) If the federal Department of Health and Human Services and the
state enter into an agreement to administer the federal temporary
high risk pool, the board shall do all of the following:
   (1) Administer the program pursuant to that agreement.
   (2) Begin providing coverage in the program on the date
established pursuant to the agreement with the federal Department of
Health and Human Services.
   (3) Establish the scope and content of high risk medical coverage.
   (4) Determine reasonable minimum standards for participating
health plans, third-party administrators, and other contractors.
   (5) Determine the time, manner, method, and procedures for
withdrawing program approval from a plan, third-party administrator,
or other contractor, or limiting enrollment of subscribers in a plan.
   (6) Research and assess the needs of persons without adequate
health coverage and promote means of ensuring the availability of
adequate health care services.
   (7) Administer the program to ensure the following:
   (A) That the program subsidy amount does not exceed amounts
transferred to the fund pursuant to this part.
   (B) That the aggregate amount spent for high risk medical coverage
and program administration does not exceed the federal funds
available to the state for this purpose and that no state funds are
spent for the purposes of this part.
   (8) Maintain enrollment and expenditures to ensure that
expenditures do not exceed amounts available in the fund and that no
state funds are spent for purposes of this part. If sufficient funds
are not available to cover the estimated cost of program
expenditures, the board shall institute appropriate measures to limit
enrollment.
   (9) In adopting benefit and eligibility standards, be guided by
the needs and welfare of persons unable to secure adequate health
coverage for themselves and their dependents and by prevailing
practices among private health plans.
   (10) As required by the federal Department of Health and Human
Services, implement procedures to provide for the transition of
subscribers into qualified health plans offered through an exchange
or exchanges to be established pursuant to the federal Patient
Protection and Affordable Care Act (Public Law 111-148).
   (11) Post on the board's Internet Web site the monthly progress
reports submitted to the federal Department of Health and Human
Services. In addition, the board shall provide notice of any
anticipated waiting lists or disenrollments due to insufficient
funding to the public, by making that notice available as part of its
board meetings, and concurrently to the Legislature.
   (12) Develop and implement a plan for marketing and outreach.
   (c) There shall not be any liability in a private capacity on the
part of the board or any member of the board, or any officer or
employee of the board for or on account of any act performed or
obligation entered into in an official capacity, when done in good
faith, without intent to defraud, and in connection with the
administration, management, or conduct of this part or affairs
related to this part.



12739.54.  (a) Plan rates for high risk medical benefits approved
for the program shall not be excessive, inadequate, or unfairly
discriminatory, but shall be adequate to pay anticipated costs of
claims or services and administration.
   (b) As a condition of reimbursement, participating health plans or
third-party administrators shall submit claims to the board within
18 months following the date of service. The board may vary the time
limit established in this subdivision if necessary to administer the
reimbursement or reconciliation processes established by the board or
to meet the requirements of the state's agreement with the federal
Department of Health and Human Services described in subdivision (a)
of Section 12739.53.



12739.55.  The program may place a lien on compensation or benefits
recovered or recoverable by a subscriber from any party or parties
responsible for the compensation or benefits for which benefits have
been provided pursuant to this part.



12739.56.  Except as provided in Article 3.5 (commencing with
Section 14124.70) of Chapter 7 of Part 3 of Division 9 of the Welfare
and Institutions Code, benefits received under this part are in
excess of, and secondary to, any other form of health benefits
coverage.



12739.57.  The board shall provide coverage pursuant to this part
through participating health plans or through provider networks using
a third-party administrator and may contract for the processing of
applications, the enrollment of subscribers, and all activities
necessary to administer the program. Any contract entered into
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
projected and actual subscriber enrollments in a total amount not to
exceed revenue available for the program.



12739.58.  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 program.



12739.59.  (a) Program decisions concerning an applicant's or
subscriber's eligibility or eligibility date may be appealed to the
board, according to procedures to be established by the board.
   (b) Coverage determinations may be appealed to the board,
according to procedures established by the board. If permitted by the
federal Department of Health and Human Services, the board shall not
be required to provide an appeal concerning a coverage determination
if the subject of the appeal is within the jurisdiction of the
Department of Managed Health Care pursuant to the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) and its
implementing regulations or within the jurisdiction of the Department
of Insurance pursuant to the Insurance Code and its implementing
regulations.
   (c) Hearings shall be conducted according to the requirements of
the federal Department of Health and Human Services and, insofar as
practicable and not inconsistent with those requirements, pursuant to
the provisions of Chapter 5 (commencing with Section 11500) of Part
1 of Division 3 of Title 2 of the Government Code.



12739.60.  Upon enrollment as a subscriber in the program, the
subscriber shall be responsible for payment of the subscriber
contribution.


12739.61.  The board shall cease to provide coverage through the
program on January 1, 2014, and at that time shall cease to operate
the program except as required to complete payments to, or payment
reconciliations with, participating health plans or other
contractors, process appeals, or conduct other necessary transition
activities, including, but not limited to, transition of subscribers
into an exchange or exchanges established pursuant to the federal
Patient Protection and Affordable Care Act (Public Law 111-148).



12739.62.  This part shall remain in effect only until January 1,
2020, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2020, deletes or extends
that date.