reglab/statecodes huggingface dataset:
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12670.

12670. It is the intent of the Legislature to ensure that persons covered by a group policy, who become ineligible for that coverage have access to benefits pursuant to this part by requiring employers, employee organizations, and other entities that provide that coverage to their employees or members to also make available conversion policies for those persons and to ensure that insurers as herein defined offer conversion policies. The conversion policy shall be the most popular preferred provider organization product offered to residents of this state under the provisions of the federal Health Insurance Portability and Accountability Act of 1996. In addition, it is the intent of the Legislature to encourage the continuation of group health coverage by requiring the entities herein defined to make available continuation benefits for widows, widowers, divorced spouses, and dependents who were covered by the group policy on the date of termination of coverage.
(Amended by Stats. 2002, Ch. 799, Sec. 1. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12672.

12672. (a) Any group policy issued, amended, or renewed in this state on or after January 1, 1983, which provides insurance for employees or members on an expense-incurred or service basis, other than for a specific disease or for accidental injuries only, shall contain a provision that an employee or member whose coverage under the group policy has been terminated for any reason except as provided in this part, shall be entitled to have a converted policy issued to him or her by the insurer under whose group policy he or she was covered, without evidence of insurability, subject to the terms and conditions of this part.
(b) (1) This section shall be inoperative on January 1, 2014.
(2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91), this section shall become operative on the date of that repeal or amendment.
(3) For purposes of this subdivision, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.
(Amended by Stats. 2013, Ch. 441, Sec. 23. (AB 1180) Effective October 1, 2013. Inoperative, by its own provisions, on January 1, 2014, subject to condition for resuming operation.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12673.

12673. Conversion coverage shall be required to be made available to an employee or member unless such coverage under the group policy terminates for one or more of the following reasons:
(a) The group policy or the policyholder’s participation in the group policy terminates and the insurance is replaced by similar coverage under another group policy within 60 days of the date of termination of the group coverage or the policyholder’s participation.
(b) The employee or member has failed to make any required payment of the premium or contribution when due.
(c) The employee or member had not been continuously covered during the three-month period immediately preceding the employee’s or member’s termination of coverage.
(Amended by Stats. 1982, Ch. 1186, Sec. 5.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12674.

12674. A converted policy shall be issued effective on the day following the termination of coverage under the group policy if written application and the first premium payment for the conversion policy are made to the insurer not later than 31 days after the termination of insurance, unless such requirements are waived in writing by the insurer.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12675.

12675. The premium for the conversion coverage shall be determined in accordance with the insurer’s rates applicable to the age and class of risk of each person to be covered and to the type and amount of coverage provided.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12676.

12676. The conversion coverage shall cover the employee or member and his or her dependents who were covered by the group policy on the date of termination of coverage. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12677.

12677. The insurer shall not be required to issue a converted policy covering any person if such person is entitled to be covered by Medicare.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12678.

12678. The insurer shall not be required to issue a converted policy covering any person if any of the following exists:
(a) The person is covered for similar benefits by another individual policy.
(b) The person is covered or is eligible to be covered for similar benefits by another group policy.
(c) The person is covered or is eligible to be covered for similar benefits under any arrangement of coverage for persons in a group whether insured or uninsured.
(Amended by Stats. 2002, Ch. 799, Sec. 3. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12679.

12679. A converted policy may provide that the insurer may at any time request information from any person covered thereunder as to whether he or she is covered for the similar benefits described in Section 12678. The converted policy shall provide that as of any premium due date the insurer may refuse to renew the policy or the coverage of any insured person for the following reasons only:
(a) Failure of the individual covered by the converted policy to provide the requested information.
(b) Fraud or material misrepresentation by the individual covered by the converted policy in applying for any benefits under the converted policy.
(c) Eligibility of the individual covered by the converted policy for coverage under Medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy. As used in this section, “state or federal law” does not include Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or Title XIX of the United States Social Security Act.
(d) Nonpayment of premium.
(e) Coverage of the individual for similar benefits under another individual policy.
(f) Eligibility of the individual covered by the converted policy for coverage under any arrangement for coverage for persons in a group whether insured or uninsured.
(g) Other reasons approved by the Insurance Commissioner.
(Amended by Stats. 1982, Ch. 1186, Sec. 7.5.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12680.

12680. If conversion coverage is issued and benefits are also provided to a person under Section 12678, the insurer may limit the conversion benefits provided or available for such person so that such conversion benefits together with benefits provided or available from the sources referred to in Section 12678 shall not exceed 100 percent of the charges for covered benefits. Priority of any coverages involved shall be determined by the effective dates, the earlier one being first.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12681.

12681. An insurer shall not be required to issue a converted policy providing benefits in excess of those provided under the group policy from which conversion is made.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12682.

12682. The converted policy shall not exclude, as a preexisting condition, any condition covered by the group policy. The converted policy may provide for a reduction of its benefits by the amount of any such benefits payable under the group policy after the individual’s insurance terminates thereunder. The converted policy may also provide that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual’s coverage under the group policy remained in effect.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12683.

12683. Subject to the provisions and conditions of this part, if the group policy from which conversion is made covers the employee or member for basic hospital or surgical expense, the employee or member shall be entitled to obtain a converted policy providing at least the following minimum benefits:
(a) Plan A.
(1) Hospital room and board daily expense benefits up to two hundred dollars ($200) for a duration of 70 days.
(2) Miscellaneous hospital expense benefits up to an amount of 10 times the hospital room and board daily expense benefits.
(3) Surgical expense benefits according to a surgical procedures schedule consistent with those customarily offered by the insurer under a group or individual health insurance policy and providing a maximum benefit of four thousand eight hundred dollars ($4,800).
(b) Plan B—75 percent of the dollar amounts of Plan A.
(c) Plan C—50 percent of the dollar amounts of Plan A.
(d) The maximum dollar amount for Plan A’s hospital room and board daily expense and surgical benefit may be redetermined by the Insurance Commissioner as to conversion coverage issued subsequent to that redetermination. The redetermination shall not be made more often than once in three years. The maximum dollar amount redetermined by the commissioner for hospital room and board shall not exceed 80 percent of the average semiprivate room rate then charged in the state.
(e) Covered expenses under this section shall include benefits for expense incurred by the employee, member, or spouse in connection with pregnancy, provided that:
(1) The pregnancy commenced while covered under the group policy from which conversion was made.
(2) The expense is of a type which would have been covered under such group policy.
(3) The conversion policy is in force when the expense is incurred.
(Amended by Stats. 1993, Ch. 1210, Sec. 10. Effective January 1, 1994.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12684.

12684. Subject to the provisions and conditions of this part, if the group policy from which conversion is made provides the employee or member with major medical or comprehensive medical insurance, the employee or member shall be entitled to obtain a converted policy providing comprehensive medical coverage providing at least the following benefits:
(a) A payment per covered person for all covered medical expenses incurred during the person’s lifetime equal to one hundred thousand dollars ($100,000); provided, however, that for treatment of mental illness payment may be limited to ten thousand dollars ($10,000) during the person’s lifetime.
(b) Payment of benefits at the rate of 75 percent of covered medical expenses; provided, however, that if coverage is provided for expenses incurred for outpatient treatment of mental illness, payment of benefits may be at the rate of 50 percent of such covered expenses, and the insurer may limit the amount of covered expense for each outpatient visit and the amount of benefits payable for expenses incurred during each calendar year for that outpatient treatment.
(c) A cash deductible for each benefit period at the option of the insured of two hundred dollars ($200), five hundred dollars ($500), or one thousand dollars ($1,000), but not less than the cash deductible which applied to the insured under the group policy which entitles him or her to a converted policy.
(d) Covered medical expenses shall include the charges for a semiprivate hospital room and board, but need not exceed the lesser of two hundred dollars ($200) per day or the hospital’s most common charge for a semiprivate room, covered expenses for intensive care shall be at least two and one-half times the covered hospital room and board charge. The maximum dollar amount for hospital room and board daily covered expense may be redetermined by the commissioner as to conversion coverage issued after the redetermination. That redetermination shall not be made more often than once in three years. The maximum dollar amount redetermined by the commissioner shall not exceed the average semiprivate room rate then charged in the state.
(e) Covered expenses under this section shall include benefits for expense incurred by the employee, member, or spouse in connection with pregnancy, provided that:
(1) The pregnancy commenced while covered under the group policy from which conversion was made.
(2) The expense is of a type which would have been covered under such group policy.
(3) The conversion policy is in force when the expense is incurred.
(f) Covered expense under this section need not include expense for dental or vision care, or other optional benefits not normally offered by the insurer under a major medical or comprehensive medical expense plan.
(Amended by Stats. 1993, Ch. 1210, Sec. 11. Effective January 1, 1994.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12685.

12685. The insurer may, at its option, offer alternative plans for group health conversion in addition to those required by this part.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12686.

12686. (a) In the event coverage would be continued under a group policy on an employee or member following his or her retirement prior to the time he or she is or could be covered by Medicare, the employee or member may elect, in lieu of the continuation of group insurance, to have the same conversion rights as would apply had that coverage terminated at retirement by reason of termination of employment or membership.
(b) The converted policy may provide for reduction or termination of coverage of any person upon his or her eligibility for coverage under Medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy. As used in this section, “state or federal law” does not include Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or Title XIX of the United States Social Security Act.
(c) Subject to the conditions set forth herein, the conversion coverage shall also be available to:
(1) A covered dependent spouse and such children whose coverage terminates under the group policy by reason of the death of the employee or member, or a covered dependent spouse in the event such person ceases to be a qualified family member by reason of the termination of the marriage.
(2) A child, solely with respect to himself or herself, whose coverage terminates because the child ceases to be a qualified family member under the group policy.
(d) If the benefit levels required in Section 12683 or Section 12684 exceed the benefit levels provided under the group policy, the converted policy may offer benefits which are substantially similar to those provided under the group policy in lieu of those required in Section 12683 or Section 12684.
(e) The insurer may elect to provide conversion coverage through a group insurance policy issued for that purpose in lieu of an individual policy.
(f) An insurer required by this part to provide conversion coverage may provide such coverage through one or more other insurers authorized to provide disability insurance coverage in this state.
(Amended by Stats. 1982, Ch. 1186, Sec. 10.5.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12687.

12687. Notwithstanding any other provision in this part, whenever an employee or member chooses among two or more conversion policies, such choice shall be made within 31 days from the last date when the employee or member was eligible for benefits under a group policy from which conversion is available.
(Amended by Stats. 1982, Ch. 1186, Sec. 11.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12688.

12688. Notwithstanding any provision in this part to the contrary, a hospital service corporation or any insurer which customarily offers individual conversion coverage on a service basis may, in lieu of the expense incurred conversion coverage provided in Sections 12683 and 12684, make available conversion coverage on a service basis which complies with the intent of this part as approved by the commissioner.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12689.

12689. A notification of the conversion coverage shall be included in each certificate of coverage or other legally required document explaining coverage; provided, however, that it shall be the sole responsibility of the policyholder to notify its employees or members of the availability, terms and conditions of conversion coverage which responsibility shall be satisfied by notification within 15 days of termination of group coverage. Group coverage shall not be deemed terminated until the expiration of any continuation of the group coverage. For purposes of this part, the policyholder shall not be deemed to be the agent of the insurer for purposes of notification of the availability, terms and conditions of conversion coverage.
(Amended by Stats. 1984, Ch. 914, first Sec. 5.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12690.

12690. Nothing in this part shall prohibit insurers from establishing one or more pools from which the converted policies provided for on this part may be issued.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12691.

12691. A converted policy which is delivered in a jurisdiction other than this state may be in a form which could be delivered in such jurisdiction as a converted policy had the group policy been issued in such jurisdiction.
(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12692.

12692. On and after January 1, 1985, every insurer and nonprofit hospital service plan issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer to group policyholders a continuation benefit which, if selected, shall have a duration of at least 90 days and which shall be offered consecutively to any federal requirement for continuation benefits. The terms and conditions shall include continuation benefit coverage for widows, widowers, divorced or legally separated spouses, spouses of covered employees becoming entitled to benefits under Title XVIII of the Social Security Act, and their dependents, including dependent children who cease to be dependent children under the plan, who were covered by the group contract on the date of termination of coverage. However, any existing provisions of law regarding termination of a dependent child status shall not be affected by this section.
The continuation of coverage shall be available only under the following conditions:
(a) Those eligible remain within the State of California, although the departure of a dependent child to another state shall not invalidate the continuation provisions for any other family members.
(b) Those eligible do not marry or remarry, although the marriage of any dependent child shall not invalidate the continuation provisions for other family members.
(c) Those eligible are not eligible for any comparable state, federal, or private group medical plan, although the eligibility of any dependent child shall not invalidate the continuation provisions for other family members.
(d) Those eligible do not find employment with an employer that has a group plan of its own, even if the plan is less substantive, although the entry into such an employee plan by a dependent child shall not invalidate the continuation provisions for other family members.
(e) The group policy is not terminated or the employer’s participation in the group policy is not terminated.
(f) Those eligible do not knowingly furnish incorrect information or otherwise improperly obtain the benefits of the plan.
(g) The continuing individual shall pay the premium amount in the manner specified in the group policy for both his or her share of the premium and the group policyholder’s share, if any.
(h) Eligible persons under this section shall be notified in the same manner required for conversion notification pursuant to Section 12689. Every insurer shall communicate the availability of such coverage to all group policyholders and to all prospective group policyholders with whom they are negotiating.
(Amended by Stats. 1988, Ch. 960, Sec. 2.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.1 - HEALTH DISABILITY INSURANCE CONVERSION › Section 12692.5.

12692.5. Notwithstanding any other provision of this part, Sections 12672, 12673, 12674, 12675, 12676, 12677, 12678, 12679, 12680, 12681, 12682, 12683, 12684, 12685, 12686, 12687, 12688, 12689, 12690, 12691, and 12692 shall not apply to a group policy that is issued, amended, or renewed on or after September 1, 2003.
(Added by Stats. 2002, Ch. 799, Sec. 4. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 1 - Purpose › Section 12693.

12693. The Legislature declares all of the following:
(a) Approximately 1.6 million California children, 17 percent of children ages 17 and under, have no health insurance. One in four California children, which is 2.3 million, rely on Medi-Cal for insurance coverage, while just over half of the state’s children, 53 percent, have employment-based coverage through a parent.
(b) Most uninsured California children come from low-income families, with nearly 75 percent of uninsured children (1.2 million) living in families with incomes below 200 percent of the federal poverty level. Children whose families earn incomes between 100 and 200 percent of the federal poverty level, an estimated 580,000 children, are among the most vulnerable of populations. Their families make too much money to generally qualify for free Medi-Cal, are employed in working class jobs that typically do not offer insurance, and cannot afford private health insurance. In short, affordability remains a major barrier to obtaining coverage.
(c) Notwithstanding the generally good health of children, health insurance coverage is important to ensure that they receive the health care that is essential to monitor their growth, nutrition, and development and to address potential health problems early.
(d) Lack of insurance coverage for children results in reduced access to medical services, resulting in restricted access to primary and preventive care and increased reliance on emergency rooms and hospitals for treatment. Timely treatment for infectious and chronic diseases can prevent more serious medical conditions in children of all ages.
(e) When a child is seriously ill or injured, the costs of needed medical care can force families into financial ruin.
(f) That by July 1, 1998, there shall be in place a program providing access to health coverage to all children residing in households with family incomes below 200 percent of the federal poverty level.
(g) It is the intent of the Legislature that the program comply with the requirements of Title XXI of the Social Security Act, also know as the State Children’s Health Insurance Program.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.01.

12693.01. For purposes of this part, the definitions contained in this chapter shall govern the construction of this part, unless the context requires otherwise.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.02.

12693.02. (a) “Applicant” means a person over the age of 18 years who is a natural or adoptive parent; a legal guardian; or a caretaker relative, foster parent, or stepparent with whom the child resides, who applies for coverage under the program on behalf of a child.
(b) “Applicant” also means any of the following:
(1) A person 18 years of age who is applying on his or her own behalf for coverage under the program.
(2) A person who is under 18 years of age and is an emancipated minor who is applying on his or her own behalf for coverage under the program.
(3) A minor who is not living in the home of a natural or adoptive parent, a legal guardian, or a caretaker relative, foster parent or stepparent, who is applying on his or her own behalf for coverage under the program.
(4) A minor who applies for coverage under the program on behalf of his or her child.
(Amended by Stats. 1999, Ch. 146, Sec. 11. Effective July 22, 1999.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.03.

12693.03. “Board” means the Managed Risk Medical Insurance Board.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.04.

12693.04. “Child” means a person who is under 19 years of age who is eligible for the program pursuant to Chapter 9 (commencing with Section 12693.70).
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.045.

12693.045. “Community provider plan” means that participating health plan in each geographic area that has been designated by the board as having the highest percentage of traditional and safety net providers in its provider network.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.05.

12693.05. “County organized health system” means a health care organization that contracts with the State Department of Health Services to provide comprehensive health care to all eligible Medi-Cal beneficiaries residing in the county, and that is operated directly by a public entity established by a county government pursuant to Section 14087.51 or 14087.54 of the Welfare and Institutions Code, or Chapter 3 (commencing with Section 101675) of Part 4 of Division 101 of the Health and Safety Code.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.06.

12693.06. “Family contribution” means the cost to an applicant to enable herself or himself or an eligible child or children to enroll in and participate in the program. Family contribution does not include copayments for insured services. The family contribution may be paid by a family contribution sponsor pursuant to Section 12693.17.
(Amended by Stats. 1999, Ch. 146, Sec. 12. Effective July 22, 1999.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.065.

12693.065. “Family value package” means the combination of participating health, dental, and vision plans available to subscribers in each geographic area offering the lowest prices to the program. The board may define the family value package to include not only the combination of participating health, dental, and vision plans offering the absolute lowest price to the program but also the combination of health, dental, and vision plans within a fixed percentage or dollar amount of the absolute lowest price.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.07.

12693.07. “Fund” means the Healthy Families Fund.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.08.

12693.08. “Local initiative” means a prepaid health plan that is organized by, or designated by, a county government or county governments, or organized by stakeholders, of a region designated by the department to provide comprehensive health care to eligible Medi-Cal beneficiaries. The entities established pursuant to the following sections of the Welfare and Institutions Code are local initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.09.

12693.09. “Participating dental plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal dental services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the board to provide coverage to program subscribers:
(a) A dental insurer holding a valid outstanding certificate of authority from the commissioner.
(b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.10.

12693.10. “Participating health plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal health care services under insurance policies or contracts, medical and hospital service arrangements, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contracts with the board to provide coverage to program subscribers:
(a) A private health insurer holding a valid outstanding certificate of authority from the commissioner.
(b) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.
(c) A county organized health system.
(d) A local initiative.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.105.

12693.105. A health care service plan, as defined in subdivision (b) of Section 12693.10, shall include a plan operating as a geographic managed care plan.
(Added by Stats. 1997, Ch. 625, Sec. 2. Effective October 3, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.11.

12693.11. “Participating vision care plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal vision services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the board to provide coverage to program subscribers:
(a) A vision insurer holding a valid outstanding certificate of authority from the commissioner.
(b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.12.

12693.12. “Program” means the Healthy Families Program, which includes a purchasing pool providing health coverage for children in families without access to affordable employer based dependent coverage and a purchasing credit mechanism through which families with access to employer based dependent coverage can receive financial assistance with the cost of dependent coverage for children.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.13.

12693.13. “Purchasing credit member” means an applicant 18 years of age or a child who is eligible for and participates in the purchasing credit component of the program.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.14.

12693.14. “Subscriber” means an applicant 18 years of age or a child who is eligible for and participates in the purchasing pool component of the program.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.15.

12693.15. “Supplemental coverage” means coverage purchased by the program from (a) a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner, or (b) a health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code to bring the coverage available to purchasing credit members into at least 95 percent actuarial equivalence with the coverage provided to subscribers through the purchasing pool component of the program. The coverage shall provide for any necessary adjustment of the cost-sharing levels charged to purchasing credit members to be equivalent to those charged to subscribers through the purchasing pool component of the program. Subscriber costs and benefits for the purchasing credit members shall be at least 95 percent actuarially equivalent to subscriber costs and benefits in the purchasing pool component.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.16.

12693.16. “Geographic managed care plan” means an entity that is operating pursuant to a contract entered into under Article 2.91 (commencing with Section 14089) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.
(Added by Stats. 1997, Ch. 625, Sec. 3. Effective October 3, 1997.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 2 - Definitions › Section 12693.17.

12693.17. “Family contribution sponsor” means a person or entity that pays the family contribution on behalf of an applicant for any period of 12 consecutive months and, notwithstanding Section 12693.70, if the sponsor is paying for the initial 12 months of eligibility, the payment for 12 months is made with the application.
(Amended by Stats. 2002, Ch. 1161, Sec. 18. Effective September 30, 2002.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 3 - Creation of Program and Powers of the Board › Section 12693.20.

12693.20. The Healthy Families Program is hereby created and shall be administered by the Managed Risk Medical Insurance Board.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 3 - Creation of Program and Powers of the Board › Section 12693.21.

12693.21. The board may do all of the following consistent with the standards in this part:
(a) Determine eligibility criteria for the program.
(b) Determine the participation requirements of applicants, subscribers, purchasing credit members, and participating health, dental, and vision plans.
(c) Determine when subscribers’ coverage begins and the extent and scope of coverage.
(d) Determine family contribution amount schedules and collect the contributions.
(e) Determine who may be a family contribution sponsor and provide a mechanism for sponsorship.
(f) Provide or make available subsidized coverage through participating health, dental, and vision plans, in a purchasing pool, which may include the use of a purchasing credit mechanism, through supplemental coverage, or through coordination with other state programs.
(g) Provide for the processing of applications, the enrollment of subscribers, and the distribution of purchasing credits.
(h) Determine and approve the benefit designs and copayments required by health, dental, or vision plans participating in the purchasing pool component program.
(i) Approve those health plans eligible to receive purchasing credits.
(j) Enter into contracts.
(k) Sue and be sued.
(l) Employ necessary staff.
(m) Authorize expenditures from the fund to pay program expenses that exceed subscriber contributions, and to administer the program as necessary.
(n) Maintain enrollment and expenditures to ensure that expenditures do not exceed amounts available in the Healthy Families Fund and if sufficient funds are not available to cover the estimated cost of program expenditures, the board shall institute appropriate measures to limit enrollment.
(o) Issue rules and regulations, as necessary. Until January 1, 2000, any rules and regulations issued pursuant to this subdivision may be adopted as emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The adoption of these regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare. The regulations shall become effective immediately upon filing with the Secretary of State.
(p) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed by this part.
(q) Notwithstanding any other provision of law, on and after January 1, 2011, impose any sanction on, and provide notice and a hearing to, participating health, dental, and vision plans consistent with Section 403 of the federal Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111-3) by applying subsection (e) of Section 1932 of the federal Social Security Act.
(Amended by Stats. 2010, Ch. 717, Sec. 26. (SB 853) Effective October 19, 2010.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 3 - Creation of Program and Powers of the Board › Section 12693.22.

12693.22. During the 2009–10 and 2010–11 fiscal years, the adoption and readoption of regulations to modify health, dental, and vision benefits or otherwise modify program requirements and operations consistent with the provisions of this part 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 facts showing the need for immediate action and from review by the Office of Administrative Law.
(Added by Stats. 2009, Ch. 157, Sec. 2. (AB 1422) Effective September 22, 2009.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 3 - Creation of Program and Powers of the Board › Section 12693.23.

12693.23. Until July 1, 2012, the adoption and readoption of regulations to implement subdivision (q) of Section 12693.21, subdivision (b) of Section 12693.26, or subdivision (l) of Section 56.30 of the Civil Code, or any provision of the federal Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111-3) not addressed by those sections, shall be deemed to be an emergency and necessary for the immediate preservation of the 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 facts showing the need for immediate action and from review by the Office of Administrative Law.
(Added by Stats. 2010, Ch. 717, Sec. 27. (SB 853) Effective October 19, 2010.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.25.

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.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.26.

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.
(Amended by Stats. 2010, Ch. 717, Sec. 28. (SB 853) Effective October 19, 2010.)