reglab/statecodes huggingface dataset:
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.27.

12693.27. (a) The board shall develop a purchasing credit mechanism to enable applicants with access to affordable and comprehensive employer-sponsored dependent coverage to have an eligible child enrolled in the employer’s health plan. Children enrolled in the purchasing credit mechanism may receive dental and vision benefits through the purchasing pool component of the program.
(b) In order to be eligible for a purchasing credit, the employer shall make a meaningful contribution toward the cost of coverage for an employee’s dependents for whom an application is made for a purchasing credit. An employer’s contribution, including any increases or decreases in the contribution made after the effective date of this part, may not vary among employees based on wage base or job classification.
(c) The board shall adopt appropriate mechanisms to recoup purchasing credit expenditures from an employer plan when the employees or dependents on behalf of whose coverage the payments are made are no longer enrolled in that plan.
(d) An employer utilizing a purchasing credit arrangement and a participating health plan receiving a purchasing credit must use 100 percent of the funds for the purchase of coverage for purchasing credit members including dependent coverage.
(e) A participating plan shall not assess the board for any portion of late fees, returned checks, or other fees in connection with an employer with group coverage who is also participating in the purchasing credit arrangement.
(f) An applicant may begin coverage for dependents using a purchasing credit arrangement at any time. Purchasing credit members enrolling in employer-sponsored coverage shall not be considered late enrollees for the purposes of subdivision (d) of Section 1357 and subdivision (b) of Section 1357.50 of the Health and Safety Code, and subdivision (b) of Section 10198.6 and subdivision (l) of Section 10700.
(g) Under no circumstances shall the employee’s share of cost, including, deductibles, copayments, and coinsurance, for dependent coverage, including any supplemental coverage necessary to meet the 95 percent actuarial standard established in Section 12693.15 be more than that required as the employee’s share of premium if the employee’s children were enrolled in the purchasing pool component of the program.
(h) The board may limit participation in the purchasing credit program to those employers that provide employee health benefits through participation in public or private purchasing cooperatives.
(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 12693.271.

12693.271. (a) The Legislature finds and declares that the state faces a fiscal crisis that requires unprecedented measures to reduce General Fund expenditures.
(b) Notwithstanding any other provision of law, beginning the first day of the fifth month following the enactment of the 2008–09 Budget Act, the rates for the participating health, dental, and vision plans shall be set by reducing the rates that were in effect on July 1, 2007, by 5 percent, and by adjusting the July 1, 2007, rates downward to account for any reduction in the actuarial value of the benefits provided to subscribers as of the first day of the fifth month following the enactment of the 2008–09 Budget Act, associated with annual limitations on dental benefits. This requirement does not preclude the board from making other downward adjustments that it deems appropriate as a result of its annual rate negotiation process.
(Added by Stats. 2008, Ch. 758, Sec. 16. Effective September 30, 2008.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.28.

12693.28. The program shall be administered without regard to gender, gender identity, gender expression, race, creed, color, sexual orientation, health status, disability, or occupation.
(Amended by Stats. 2011, Ch. 719, Sec. 28. (AB 887) Effective January 1, 2012.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.29.

12693.29. (a) The board shall use appropriate and efficient means to notify families of the availability of health coverage from the program.
(b) The State Department of Health Services in conjunction with the board shall conduct a community outreach and education campaign in accordance with Section 14067 of the Welfare and Institutions Code to assist in notifying families of the availability of health coverage for their children.
(c) The board shall use appropriate materials, which may include brochures, pamphlets, fliers, posters, and other promotional items, to notify families of the availability of coverage through the program.
(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 12693.30.

12693.30. (a) The board shall assure that written enrollment information issued or provided by the program is available to program subscribers and applicants in each of the languages identified pursuant to Chapter 17.5 (commencing with Section 7290) of Division 7 of Title 1 of the Government Code.
(b) The board shall assure that phone services provided to program subscribers and applicants by the program are available in all of the languages identified pursuant to Chapter 17.5 (commencing with Sec. 7290) of Division 7 of Title 1 of the Government Code.
(c) The board shall assure that interpreter services are available between subscribers and contracting plans. The board shall assure that subscribers are provided information within provider network directories of available linguistically diverse providers.
(d) The board shall assure that participating health, dental, and vision plans provide documentation on how they provide linguistically and culturally appropriate services, including marketing materials, to subscribers.
(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 12693.31.

12693.31. No participating health, dental, or vision plan shall, in an area served by the program, directly, or through an employee, agent, or contractor, provide an applicant, or a child with any marketing material relating to benefits or rates provided under the program unless the material has been both reviewed and approved by the board.
(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 12693.326.

12693.326. Notwithstanding any other provision of this part, a new subscriber in the program shall be allowed to switch his or her choice of plans once within the first three months of coverage for any reason.
(Amended by Stats. 2004, Ch. 234, Sec. 3. Effective January 1, 2005.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.33.

12693.33. To the extent feasible and permissible under federal law and with receipt of necessary federal approvals, the State Department of Health Services and the board shall develop a joint Medi-Cal and program application and enrollment form for children. The department shall seek any federal approval necessary to implement a combined application form.
(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 12693.34.

12693.34. (a) The board may establish geographic areas within which participating health, dental, and vision plans may offer coverage to subscribers.
(b) Nothing in this section shall restrict a county organized health system or a local initiative from providing service to program subscribers in their licensed geographic service area.
(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 12693.35.

12693.35. Participating health, dental, and vision plans shall have, but need not be limited to, all of the following operating characteristics satisfactory to the board in consultation with the plan’s licensing or regulatory oversight agency:
(a) Strong financial condition, including the ability to assume the risk of providing and paying for covered services. A participating plan may utilize reinsurance, provider risk sharing, and other appropriate mechanisms to share a portion of the risk.
(b) Adequate administrative management.
(c) A satisfactory grievance procedure.
(d) Participating plans that contract with or employ health care providers shall have mechanisms to accomplish all of the following, in a manner satisfactory to the board:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(e) (1) Before the effective date of the contract, the participating health plan shall have devised a system for identifying in a simple and clear fashion both in its own records and in the medical records of subscribers the fact that the services provided are provided under the program.
(2) Throughout the duration of the contract, the plan shall use the system described in paragraph (1).
(f) Plans licensed by the Department of Managed Health Care shall be deemed to meet the requirements of subdivisions (a) to (d), inclusive, of this section.
(Amended by Stats. 2015, Ch. 190, Sec. 67. (AB 1517) Effective January 1, 2016.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.36.

12693.36. (a) Notwithstanding any other provision of law, the board shall not be subject to licensure or regulation by the Department of Insurance or the Department of Managed Health Care, as the case may be.
(b) Participating health, dental, and vision plans that contract with the program and are regulated by either the Insurance Commissioner or the Department of Managed Health Care shall be licensed and in good standing with their respective licensing agencies. In their application to the program, those entities shall provide assurance of their standing with the appropriate licensing entity.
(Amended by Stats. 2005, Ch. 80, Sec. 4. Effective July 19, 2005.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.37.

12693.37. (a) The board shall contract with a broad range of health plans in an area, if available, to ensure that subscribers have a choice from among a reasonable number and types of competing health plans. The board shall develop and make available objective criteria for health plan selection and provide adequate notice of the application process to permit all health plans a reasonable and fair opportunity to participate. The criteria and application process shall allow participating health plans to comply with their state and federal licensing and regulatory obligations, except as otherwise provided in this chapter. Health plan selection shall be based on the criteria developed by the board.
(b) (1) In its selection of participating plans the board shall take all reasonable steps to assure the range of choices available to each applicant, other than a purchasing credit member, shall include plans that include in their provider networks and have signed contracts with traditional and safety net providers.
(2) Participating health plans shall be required to submit to the board on an annual basis a report summarizing their provider network. The report shall provide, as available, information on the provider network as it relates to:
(A) Geographic access for the subscribers.
(B) Linguistic services.
(C) The ethnic composition of providers.
(D) The number of subscribers who selected traditional and safety net providers.
(c) (1) The board shall not rely solely on the Department of Managed Health Care’s determination of a health plan network’s adequacy or geographic access to providers in the awarding of contracts under this part. The board shall collect and review demographic, census, and other data to provide to prospective local initiatives, health plans, or specialized health plans, as defined in this act, specific provider contracting target areas with significant numbers of uninsured children in low-income families. The board shall give priority to those plans, on a county-by-county basis, that demonstrate that they have included in their prospective plan networks significant numbers of providers in these geographic areas.
(2) Targeted contracting areas are those ZIP Codes or groups of ZIP Codes or census tracts or groups of census tracts that have a percentage of uninsured children in low-income families greater than the overall percentage of uninsured children in low-income families in that county.
(d) In each geographic area, the board shall designate a community provider plan that is the participating health plan which has the highest percentage of traditional and safety net providers in its network. Subscribers selecting such a plan shall be given a family contribution discount as described in Section 12693.43.
(e) The board shall establish reasonable limits on health plan administrative costs.
(Amended by Stats. 2000, Ch. 857, Sec. 75. Effective January 1, 2001.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.38.

12693.38. (a) The board shall contract with a sufficient number of dental and vision plans to assure that dental and vision benefits are available to all subscribers. The board shall develop and make available objective criteria for dental and vision plan selection and provide adequate notice of the application process to permit all dental and vision plans a reasonable and fair opportunity to participate. The criteria and application process shall allow participating dental and vision plans to comply with their state and federal licensing and regulatory obligations, except as otherwise provided in this part. Dental and vision plan selection shall be based on the criteria developed by the board.
(b) Participating dental plans shall be required to submit to the board on an annual basis a report summarizing their provider network. The report shall provide, as available, information on the provider network as it relates to each of the following:
(1) Geographic access for the subscribers.
(2) Linguistic services.
(3) The ethnic composition of providers.
(c) The board shall establish reasonable limits on dental plan administrative costs.
(Amended by Stats. 1998, Ch. 285, Sec. 1. Effective August 13, 1998.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.39.

12693.39. The board shall establish a process for determining which employer-sponsored health plans are eligible to receive a purchasing credit issued by the program. The process shall assure that the benefits, copayments, coinsurance, and deductibles are no less than 95 percent actuarially equivalent to those provided to program subscribers enrolled in the purchasing pool.
(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 12693.40.

12693.40. The board shall contract with health plans to provide coverage supplemental to that provided by an applicant’s or applicant’s spouse’s employer-sponsored health plan for the purchasing credit member, if the employer-sponsored plan’s benefits are not 95 percent actuarially equivalent to those provided to subscribers. If supplemental coverage is available and provided, the plan may then, notwithstanding Section 12693.39, become eligible to receive purchasing credits.
(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 12693.41.

12693.41. (a) The board shall consult and coordinate with the State Department of Health Services in implementing a preenrollment program into the Healthy Families Program or the Medi-Cal program pursuant to subdivision (b) of Section 14011.7 of the Welfare and Institutions Code. The board shall accept the followup application provided for in Section 14011.7 of the Welfare and Institutions Code as an application for the Healthy Families Program. Preenrollment shall be administered by the State Department of Health Services to provide full-scope benefits pursuant to Medi-Cal program requirements, at no cost to the applicant.
(b) The board may use the state fiscal intermediary for medicaid to process the eligibility determinations and payments required pursuant to Section 14011.7 of the Welfare and Institutions Code.
(c) The board shall be exempt from the requirements of Chapter 7 (commencing with Section 11700) of Division 3 of Title 2 of the Government Code and Chapter 3 (commencing with Section 12100) of Part 2 of Division 2 of the Public Contract Code as those requirements apply to the use of processing services by the state fiscal intermediary.
(d) The board may adopt emergency regulations to implement preenrollment into the Healthy Families Program or the Medi-Cal program pursuant to Section 14011.7 of the Welfare and Institutions Code. The emergency regulations shall include, but not be limited to, regulations that implement any changes in rules relating to eligibility, enrollment, and disenrollment in the programs pursuant to Sections 12693.45 and 12693.70. The initial adoption of emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, and general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and one readoption of those regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations and each shall remain in effect for no more than 180 days.
(e) This section shall become operative on April 1, 2003.
(Repealed (in Sec. 19) and added by Stats. 2002, Ch. 1161, Sec. 20. Effective September 30, 2002. Section operative April 1, 2003, by its own provisions.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.42.

12693.42. Any purchasing credit issued by the board, or a contractor acting on behalf of the board, pursuant to this part shall have an overall cost to the program no greater than the cost to the program to enroll the subscriber in the lowest cost plan available to the subscriber through the purchasing pool. Administrative costs and the cost to the program of any supplemental product shall be included in the calculation of the cost of the purchasing credit program and deducted from the amount of the purchasing credit.
(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 12693.44.

12693.44. (a) The board shall establish family contribution amounts for purchasing credit members that are equivalent to the amounts charged to subscribers participating in the purchasing pool portion of the program. Purchasing credit members shall not be required to pay family contribution amounts greater than the cost to the applicant if the purchasing credit members were enrolled in the purchasing pool component of the program. When calculating the cost to the applicant to participate in the purchasing pool, the family contribution discounts provided in subdivisions (c), (d), and (e) of Section 12693.34 shall not be considered. Purchasing credit members shall be eligible for dental and vision coverage through the purchasing pool at no additional premium charge.
(b) The family contribution amounts paid on behalf of a purchasing credit member may be paid directly to the applicant’s employer through a payroll deduction or other mechanism.
(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 12693.45.

12693.45. (a) After two consecutive months of nonpayment of family contributions by an applicant, and a reasonable written notice period of no less than 30 days is provided to the applicant, subscribers or purchasing credit members may be disenrolled for an applicant’s failure to pay family contributions. The board may impose or contract for collection actions to collect unpaid family contributions.
(b) Subject to any additional requirements of federal law, disenrollments shall be effective at the end of the second consecutive month of nonpayment.
(Amended by Stats. 2002, Ch. 1161, Sec. 22. Effective September 30, 2002.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.46.

12693.46. The board may prohibit applicants who drop coverage after enrolling in the pool from reenrollment in the program for up to six months.
(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 12693.47.

12693.47. The program may place a lien on compensation or benefits, recovered or recoverable by a subscriber or applicant from any party or parties responsible for the compensation or benefits for which benefits have been provided under a policy issued under this part.
(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 12693.48.

12693.48. The board may adjust payments made to a participating health plan if the board finds that the plan has a significantly disproportionate share of high- or low-risk subscribers. Prior to making this finding, the program shall obtain validated data from participating health plans. Reporting requirements shall be administratively compatible with the methods of operation of the health plans. Any adjustments to payments shall utilize demographic and other factors which are actuarially related to risk.
(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 12693.49.

12693.49. (a) When an applicant is dissatisfied with any action or inaction of a participating plan in which a subscriber is enrolled through the purchasing pool, the applicant shall first attempt to resolve the dispute with the participating plan according to its established policies and procedures.
(b) The board shall assure that all participating health, dental, and vision plans make subscribers aware of the regulatory oversight available to the applicant by the participating health, dental, or vision plan’s licensing or state oversight entity.
(c) The board shall assure that all participating health, dental, and vision plans report to the board, at least once a year, the number and types of benefit grievances filed by applicants on behalf of subscribers in the program. This information shall be available to applicants upon request in a format determined by the board.
(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 12693.50.

12693.50. (a) The board shall consult and coordinate with the State Department of Health Services to implement the Medi-Cal to Healthy Families Accelerated Enrollment program pursuant to Section 14011.65 of the Welfare and Institutions Code.
(b) The state shall seek approval of any amendments to the state plan, necessary to implement Section 14011.65 of the Welfare and Institutions Code in accordance with Title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.). Notwithstanding any other provision of law, only when all necessary federal approvals have been obtained shall Section 14011.65 of the Welfare and Institutions Code be implemented.
(c) The board may adopt emergency regulations to implement the provision of accelerated eligibility benefits pursuant to this section and as described under Section 14011.65 of the Welfare and Institutions Code. The emergency regulations shall include, but not be limited to, regulations that implement any changes in rules relating to program eligibility, enrollment, and disenrollment. The initial adoption of emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, and general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and one readoption of those regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations, and each shall remain in effect for no more than 180 days.
(Added by Stats. 2005, Ch. 80, Sec. 4.5. Effective July 19, 2005.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.51.

12693.51. (a) A transfer of enrollment from one participating health plan to another may be made by a subscriber at times and under conditions as may be prescribed by regulations of the board.
(b) The board shall provide for the transfer of coverage of any subscriber to another participating plan (1) if a contract with any participating plan under which the subscriber receives coverage is canceled or not renewed and (2) at least once a year upon request in a manner as determined by the board, and (3) if a subscriber moves to an area that the current health plan does not serve.
(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 12693.515.

12693.515. (a) Effective July 1, 2004, any subscriber who affirmatively selects, or is assigned by default to, a federally qualified health center, as defined by Section 1396(d)(l)(2) of Title 42 of the United States Code, a rural health clinic, as defined by Section 1396(d)(l)(1) of Title 42 of the United States Code, or a primary care clinic that is licensed under Section 1204 of the Health and Safety Code, or is exempt from licensure under subdivision (h) of Section 1206 of the Health and Safety Code, shall be deemed to have been assigned directly to the federally qualified health center, the rural health clinic, or the primary care clinic, and not to any individual provider who performs services on behalf of the federally qualified health center, the rural health clinic, or the primary care clinic.
(b) (1) When a subscriber is assigned, from any source, to a physician who is an employee of a federally qualified health center, a rural health clinic, or a primary care clinic, the assignment shall constitute an assignment to that federally qualified health center, rural health clinic, or primary care clinic for purposes of the subscriber’s health care coverage.
(2) When a subscriber is assigned, from any source, to a dentist who is an employee of a federally qualified health center, a rural health clinic, or a primary care clinic, the assignment shall constitute an assignment to that federally qualified health center, rural health clinic, or primary care clinic for purposes of the subscriber’s dental coverage.
(3) When a subscriber is assigned, from any source, to an optometrist who is an employee of a federally qualified health center, a rural health clinic, or a primary care clinic, the assignment shall constitute an assignment to that federally qualified health center, rural health clinic, or primary care clinic for purposes of the subscriber’s vision coverage.
(c) This section shall not limit any rights a subscriber may have to select an available primary care physician within a health care service plan’s service area pursuant to Section 1373.3 of the Health and Safety Code.
(Added by Stats. 2003, Ch. 139, Sec. 1. Effective January 1, 2004.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 4 - Administration › Section 12693.52.

12693.52. The board may negotiate or arrange for stop-loss insurance coverage that limits the program’s fiscal responsibility for the total costs of health services provided to program subscribers, or arrange for participating health plans to share or assure the financial risk for a portion of the total cost of health care services to program subscribers, or both.
(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 12693.53.

12693.53. The board shall develop and utilize appropriate cost containment measures to maximize the coverage offered under the program. Those measures may include limiting the expenditure of state funds for this purpose to the price to the state for the lowest cost plan contracting with the program and creation of program rules that restrict the ability of employers or applicants to drop existing coverage in order to qualify children for the program.
(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 12693.54.

12693.54. A contract entered pursuant to this part shall be exempt from any provision of law relating to competitive bidding, and shall be exempt from the review or approval of any division of the Department of General Services. The board shall not be required to specify the amounts encumbered for each contract, but may allocate funds to each contract based on the projected or actual subscriber enrollments to a total amount not to exceed the amount appropriate for the program including family contributions.
(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 12693.55.

12693.55. (a) A health care provider who is furnished documentation of a person’s enrollment in the program shall not seek reimbursement nor attempt to obtain payment for any covered services provided to that person other than from the participating health plan covering that person or from other entities that the board enters into contracts or interagency agreements with to provide or pay for benefits under this part pursuant to Section 12693.26.
(b) The provisions of subdivision (a) do not apply to any copayments required under this part for the covered services provided to the person.
(c) For purposes of this section, “health care provider” means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services.
(Amended by Stats. 2011, Ch. 29, Sec. 1. (AB 102) Effective June 29, 2011.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 5 - Health Benefits and Copayments › Section 12693.60.

12693.60. (a) Coverage provided to subscribers shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act. Except as otherwise provided in this part, the covered health benefits provided to subscribers shall be equivalent to those provided to state employees through the Public Employees’ Retirement System for the most recent plan year preceding the applicable program plan year, except that the plans may provide a mechanism for inpatient hospital care provided under the mental health benefit through which applicants may agree to a treatment plan in which each inpatient day may be substituted for two residential treatment days or three day treatment program days.
(b) The adoption and readoption, by the Managed Risk Medical Insurance Board, of regulations to implement the changes made to this section by the act that added this subdivision, shall be deemed to be an emergency and necessary 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 it describe facts showing the need for immediate action and from review by the Office of Administrative Law.
(Amended by Stats. 2011, Ch. 3, Sec. 1.5. (AB 97) Effective March 24, 2011.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 5 - Health Benefits and Copayments › Section 12693.61.

12693.61. The following provisions apply for subscribers who have been identified by the participating health plans as potentially seriously emotionally disturbed.
(a) Participating plans, to the extent feasible, including plans receiving purchasing credits shall develop memoranda of understanding, consistent with criteria established by the board in consultation with the State Department of Health Care Services, for referral of subscribers who are seriously emotionally disturbed to a county mental health department. This referral does not relieve a participating plan from providing the mental health coverage specified in its contract, including assessment of, and development of, a treatment plan for serious emotional disturbance. Plans may contract with county mental health departments to provide for all, or a portion of, the services provided under the program’s mental health benefit.
(b) The board shall establish an accounting process under which counties providing services to subscribers who have been determined to be seriously emotionally disturbed pursuant to Section 5600.3 of the Welfare and Institutions Code can claim federal reimbursement for the services. The board shall reimburse counties pursuant to the rates set by the State Department of Health Care Services in accordance with Sections 5705, 14705.7, 14705, 14708, 14711, and 14718 of the Welfare and Institutions Code. The actual amount reimbursed by the board shall be the federal share of the cost of the subscriber.
(c) This section shall only become operative with federal approval of the State Child Health Plan and the approval of federal financial participation.
(d) Counties choosing to enter into a memorandum of understanding pursuant to subdivision (a) shall provide the nonfederal share of cost for the subscriber.
(Amended by Stats. 2012, Ch. 34, Sec. 38. (SB 1009) Effective June 27, 2012. Section conditionally operative as provided in subd. (c).)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 5 - Health Benefits and Copayments › Section 12693.62.

12693.62. Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under the program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, a participating plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children’s Services Program for the particular subscriber for the treatment of a California Children’s Services Program eligible medical condition. Participating plans shall refer a child who they reasonably suspect of having a medical condition that is eligible for services under the California Children’s Services Program to the California Children’s Services Program. The California Children’s Services Program shall provide case management and authorization of services if the child is found to be medically eligible for the California Children’s Services Program. Diagnosis and treatment services that are authorized by the California Children’s Services Program shall be performed by paneled providers for that program and approved special care centers of that program in accordance with treatment plans approved by the California Children’s Services Program. All other services provided under the participating plan shall be available to the subscriber.
(Amended by Stats. 1999, Ch. 146, Sec. 17. Effective July 22, 1999.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 6 - Dental Benefits and Copayments › Section 12693.63.

12693.63. (a) The board shall determine the dental benefits to be provided to subscribers by the program. These benefits shall be consistent with those provided to state employees through the Department of Personnel Administration, the predecessor to the Department of Human Resources, on July 1, 1997, except that orthodontia shall only be a benefit when it is determined to be medically necessary.
(b) The board shall establish the required subscriber copayment levels for dental benefits. The copayment levels established by the board shall, to the extent possible, reflect the copayment levels provided to state employees through the Department of Personnel Administration, the predecessor to the Department of Human Resources, on July 1, 1997, except that no copayment shall be charged for medically necessary orthodontia services. There shall be no subscriber copayments for preventive and diagnostic services, including, but not limited to, examinations, teeth cleaning, X-rays, topical fluoride treatments, space maintainers, and sealants.
(c) No deductible shall be charged to subscribers for dental benefits.
(d) (1) The board may establish a cap on the amount of dental coverage provided to a subscriber in a given benefit year effective on and after the first day of the fifth month following enactment of the 2008–09 Budget Act. This dental coverage cap shall not be lower than one thousand five hundred dollars ($1,500) per subscriber per benefit year.
(2) The board may adopt, and may only one-time readopt, regulations to implement paragraph (1). The adoption and one-time readoption of a regulation authorized by this paragraph is deemed to address an emergency, for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted for this purpose from the requirements of subdivision (b) of Section 11346.1 of the Government Code.
(Amended by Stats. 2018, Ch. 903, Sec. 18. (SB 1504) Effective January 1, 2019.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 6 - Dental Benefits and Copayments › Section 12693.64.

12693.64. Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under the program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, a participating plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children’s Services Program for the particular subscriber for the treatment of a California Children’s Services Program eligible medical condition. All other services provided under the participating plan shall be available to the subscriber.
(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 7 - Vision Benefits and Copayments › Section 12693.65.

12693.65. (a) Vision benefits shall be provided to subscribers and shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act.
(b) The covered benefits shall be equivalent to those provided to state employees through the Department of Human Resources, except for tinted lenses and also photochromatic lenses, unless otherwise deemed medically necessary.
(c) The board shall establish the required subscriber copayment levels for vision benefits consistent with the limitations of Section 2103 of Title XXI of the Social Security Act. The copayment levels established by the board shall, to the extent possible, reflect the copayment levels provided to state employees through the Department of Human Resources.
(d) From March 1, 2011, to June 30, 2012, inclusive, the adoption and readoption, by the board, of regulations to modify vision benefits pursuant to this section, including, but not limited to, restriction of providers through which covered vision benefits may be obtained, restriction of benefits for services from nonparticipating providers, or restriction of products and materials provided as benefits pursuant to this section, shall be deemed to be an emergency and necessary 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 it describe facts showing the need for immediate action and from review by the Office of Administrative Law.
(Amended by Stats. 2012, Ch. 665, Sec. 174. (SB 1308) Effective January 1, 2013.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 7 - Vision Benefits and Copayments › Section 12693.66.

12693.66. Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under the program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, a participating plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children’s Services Program for the particular subscriber for the treatment of a California Children’s Services Program eligible medical condition. All other services provided under the participating plan shall be available to the subscriber.
(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 8 - Linkages with Public Programs › Section 12693.68.

12693.68. The board shall encourage all plans, including those receiving purchasing credits, that provide services under the program to have viable protocols for screening and referring children needing supplemental services outside of the scope of the screening, preventive, and medically necessary and therapeutic services covered by the contract to public programs providing such supplemental services for which they may be eligible, as well as for coordination of care between the plan and the public programs. The public programs for which plans may be required to develop screening, referral, and care coordination protocols may include the California Children’s Services Program, the regional centers, county mental health programs, substance use disorder programs administered by the State Department of Health Care Services, and programs administered by local education agencies.
(Amended by Stats. 2013, Ch. 22, Sec. 75. (AB 75) Effective June 27, 2013. Operative July 1, 2013, by Sec. 110 of Ch. 22.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 8 - Linkages with Public Programs › Section 12693.69.

12693.69. A child enrolled in the Healthy Families Program who has a medical condition that is eligible for services pursuant to the California Children’s Services Program, and whose family is not financially eligible for the California Children’s Services Program, shall have the medically necessary treatment services for their California Children’s Services Program eligible medical condition authorized and paid for by the California Children’s Services Program. County expenditures for the payment of services for the child shall be waived and these expenditures shall be paid for by the state from Title XXI funds that are applicable and state general funds.
(Added by Stats. 1999, Ch. 146, Sec. 18. Effective July 22, 1999.)
2023 California Code › Insurance Code - INS › DIVISION 2 - CLASSES OF INSURANCE › PART 6.2 - HEALTHY FAMILIES › CHAPTER 9 - Eligibility › Section 12693.71.

12693.71. (a) The board shall monitor applications to determine whether employers and employees have dropped employer-sponsored dependent coverage in order to participate in the program.
(b) The board may disapprove an application if it is determined that the children to be covered under the application were covered by an employer-sponsored insurance within the last three months.
(c) If the board imposes the limitation identified in subdivision (b) or (d), it shall also establish exceptions to this limitation in cases where prior coverage ended due to reasons unrelated to the availability of the program. This shall include, but not be limited to:
(1) Loss of employment due to factors other than voluntary termination.
(2) Change to a new employer that does not provide an option for dependent coverage.
(3) Change of address so that no employer sponsored coverage is available.
(4) Discontinuation of health benefits to all employees of the applicant’s employer.
(5) Expiration of COBRA coverage period.
(6) Coverage provided pursuant to an exemption authorized under subdivision (i) of Section 1367 of the Health and Safety Code.
(d) If the board determines, based on evidence gathered during a reasonable period of program operation, that a substantial share of funds expended for the program are providing health coverage for children that have discontinued employer-based coverage in order to enter the program or if required by the federal government for state plan approval, the board may take actions to increase the three-month time limit specified in subdivision (b), to such a time limit that cannot exceed six months.
(Added by Stats. 1997, Ch. 623, Sec. 2. Effective January 1, 1998.)