reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15855.

15855. The department shall review each funding proposal submitted by an applicant in accordance with the criteria described in Section 15854 and based on that criteria, approve or reject the proposal.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15857.

15857. Each health care service plan, specialized health care service plan, and health insurer that contracts to provide health care benefits under this chapter shall be licensed by the Department of Managed Health Care or the Department of Insurance, or be a Medi-Cal managed care plan.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15858.

15858. (a) The department shall administer the provisions of this chapter and may do all of the following:
(1) Administer the expenditure of moneys from the fund.
(2) (A) Issue rules and regulations as necessary.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this chapter and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature pursuant to Section 9795 of the Government Code on a semiannual basis until regulations have been adopted.
(3) Enter into contracts.
(4)  Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed by this chapter.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15859.

15859. All expenses incurred by the department in administering this chapter, including, but not limited to, expenses for developing standards and processes to implement any of the provisions of this chapter, evaluating applications, or processing or granting appeals growing out of any of the provisions of this chapter, shall be paid from the fund or directly by applicants, except that the department may accept funding from a not-for-profit group or foundation, or from a governmental entity providing grants for health-related activities, to administer this chapter.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15860.

15860. Nothing in this chapter creates a right or an entitlement to the provision of health insurance coverage or health care benefits. Except as provided in Section 15850.5, no costs shall accrue to the state for the provision of these services. The state shall not be liable beyond the assets of the fund for any obligation incurred or liabilities sustained by applicants in the operation of the fund or of the projects authorized by this chapter.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15861.

15861. To the extent necessary to obtain federal financial participation for projects approved pursuant to this chapter, the department shall apply for one or more waivers or shall file state plan amendments pursuant to the federal State Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) to allow a county agency, local initiative, or county organized health system to apply for matching funds through the federal State Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) using local funds for the state matching funds.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15862.

15862. (a) The provisions of this chapter shall be implemented only if all of the following conditions are met:
(1) Federal financial participation is available for this purpose.
(2) Federal participation is approved.
(3) The department determines that federal funds under Title XXI of the Social Security Act remain available after providing funds for all current enrollees and eligible children that are likely to enroll in the optional targeted low-income children group and, to the extent funded through the federal Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code), the Medi-Cal Access program and Medi-Cal program, as determined by a Department of Finance estimate.
(4) Funds are appropriated specifically for this purpose.
(b) The department may accept funding necessary for the preparation of the federal waiver applications or state plan amendments described in Section 15861 from a not-for-profit group or foundation, but only to the extent that the funding may be eligible for federal financial participation.
(Amended by Stats. 2015, Ch. 303, Sec. 625. (AB 731) Effective January 1, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15863.

15863. The state shall be held harmless for any federal disallowance resulting from this chapter and any other expenses or liabilities, including, but not limited to, the cost of processing or granting appeals, unless the department is acting pursuant to Section 15850.5. An applicant receiving supplemental reimbursement pursuant to this chapter shall be liable for any reduced federal financial participation, and any other expenses or liabilities, including, but not limited to, the costs of processing or granting appeals, resulting from the implementation of this chapter with respect to that applicant. The state may recoup any federal disallowance from the applicant for which it can be held harmless.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 3 - County Children s Health Initiative Program › Section 15864.

15864. This chapter shall become operative on July 1, 2014.
(Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Note: This section prescribes a delayed operative date (July 1, 2014) for Chapter 3, commencing with Section 15850.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 1 - General › Section 15870.

15870. For the purposes of this chapter, the following terms have the following meanings:
(a) “Applicant” means an individual who applies for major risk medical coverage through the program.
(b) “Department” means the State Department of Health Care Services.
(c) “Exchange” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code.
(d) “Fund” means the Major Risk Medical Insurance Fund, from which the department may authorize expenditures to pay for medically necessary services which exceed subscribers’ contributions, and for administration of the program.
(e) “Major risk medical coverage” means the payment for medically necessary services provided by institutional and professional providers.
(f) “Participating health plan” means either of the following entities that contracts with the department to administer major risk medical coverage to program subscribers:
(1) A private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner.
(2) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.
(g) “Plan rates” means the total monthly amount charged by a participating health plan for a category of risk.
(h) “Program” means the California Major Risk Medical Insurance Program.
(i) “Subscriber” means an individual who is eligible for and receives major risk medical coverage through the program, and includes a member of a federally recognized California Indian tribe.
(j) “Subscriber contribution” means the portion of participating health plan rates paid by the subscriber, or paid on behalf of the subscriber by a federally recognized California Indian tribal government. If a federally recognized California Indian tribal government makes a contribution on behalf of a member of the tribe, the tribal government shall ensure that the subscriber is made aware of all the health plan options available in the county where the member resides.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 1 - General › Section 15872.

15872. The California Major Risk Medical Insurance Program is hereby established within, and shall be administered by, the department.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 1 - General › Section 15872.5.

15872.5. This chapter shall become operative on July 1, 2014.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Note: This section prescribes a delayed operative date (July 1, 2014) for Chapter 4, comprising Sections 15870 to 15895.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 2 - Powers and Duties › Section 15873.

15873. The department shall have the authority:
(a) To establish eligibility criteria, notwithstanding Section 15884, and determine the eligibility of applicants.
(b) To determine the major risk medical coverage to be provided to program subscribers.
(c) To research and assess the needs of persons not adequately covered by existing private and public health care delivery systems and promote means of assuring the availability of adequate health care services.
(d) To approve subscriber contributions, and plan rates, and establish program contribution amounts.
(e) To provide major risk medical coverage for subscribers or to contract with a participating health plan or plans or other vendor to provide or administer major risk medical coverage for subscribers.
(f) To authorize expenditures from the fund to pay program expenses which exceed subscriber contributions.
(g) To contract for administration of the program or any portion thereof with any public agency, including any agency of state government, or with any private entity.
(h) (1) To issue rules and regulations to carry out the purposes of this chapter.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature pursuant to Section 9795 of the Government Code on a semiannual basis until regulations have been adopted.
(i) To authorize expenditures from the fund or from other moneys appropriated in the annual Budget Act for purposes relating to Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.
(j) To exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed upon it under this chapter.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 2 - Powers and Duties › Section 15876.

15876. Plan rates for major risk medical benefits approved for the program shall not be excessive, inadequate, or unfairly discriminatory, but shall be adequate to pay anticipated costs of claims or services and administration.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 3 - Policies Issued by the Department › Section 15878.

15878. The department may place a lien on compensation or benefits recovered or recoverable by a subscriber from any party or parties responsible for the compensation or benefits for which benefits have been provided under a policy issued under this article or Article 4 (commencing with Section 15881).
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 3 - Policies Issued by the Department › Section 15879.

15879. Except as provided in Article 3.5 (commencing with Section 14124.70) of Chapter 7 of Part 3, benefits received under this article or Article 4 (commencing with Section 15881) are in excess of and secondary to, any other form of health benefits coverage.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 3 - Policies Issued by the Department › Section 15880.

15880. Benefits under this article or Article 4 (commencing with Section 15881) shall be subject to required subscriber copayments and deductibles as the department may authorize. Any authorized copayments shall not exceed 25 percent and any authorized deductible shall not exceed an annual household deductible amount of five hundred dollars ($500). However, health plans not utilizing a deductible may be authorized to charge an office visit copayment of up to twenty-five dollars ($25). If the department contracts with participating health plans pursuant to Article 4 (commencing with Section 15881), copayments or deductibles shall be authorized in a manner consistent with the basic method of operation of the participating health plans. The aggregate amount of deductible and copayments payable annually under this section shall not exceed two thousand five hundred dollars ($2,500) for an individual and four thousand dollars ($4,000) for a family.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 4 - Participating Health Plans › Section 15881.

15881. The department shall provide coverage through participating health plans and may contract for the processing of applications, the enrollment of subscribers, and activities necessary to administer the program. A contract entered into pursuant to this chapter 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 department shall not be required to specify the amounts encumbered for each contract but may allocate funds to each contract based on projected and actual subscriber enrollments in a total amount not to exceed revenue available for the program.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 4 - Participating Health Plans › Section 15882.

15882. The department may provide or purchase stop-loss coverage under which the program and participating health plans share the risk for health plan expenses which exceed plan rates.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 4 - Participating Health Plans › Section 15883.

15883. The department shall withdraw its approval of any participating health benefits plan for noncompliance with program standards, nonpayment of claims, or other good cause shown. Approval shall not be withdrawn except after reasonable notice to the health plan, program subscribers enrolled in the plan, physicians or organizations of physicians offering services through the plan, and all interested parties.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15884.

15884. (a) Each resident of the state meeting the eligibility criteria of this section and who is unable to secure adequate private health coverage is eligible to apply for major risk medical coverage through the program. For these purposes, “resident” includes a member of a federally recognized California Indian tribe.
(b) To be eligible for enrollment in the program, an applicant shall have been rejected for health care coverage by at least one private health plan. An applicant shall be deemed to have been rejected if the only private health coverage that the applicant could secure would do one of the following:
(1) Impose substantial waivers that the department determines would leave a subscriber without adequate coverage for medically necessary services.
(2) Afford limited coverage that the department determines would leave the subscriber without adequate coverage for medically necessary services.
(3) Afford coverage only at an excessive price, which the department determines is significantly above standard average individual coverage rates.
(c) Rejection for policies or certificates of specified disease or policies or certificates of hospital confinement indemnity, as described in Section 10198.61 of the Insurance Code, shall not be deemed to be rejection for the purposes of eligibility for enrollment.
(d) The department may permit dependents of eligible subscribers to enroll in major risk medical coverage through the program if the department determines the enrollment can be carried out in an actuarially and administratively sound manner.
(e) Notwithstanding the provisions of this section, the department shall prescribe a period of time during which a resident is ineligible to apply for major risk medical coverage through the program if the resident either voluntarily disenrolls from, or was terminated for nonpayment of the premium from, a private health plan after enrolling in that private health plan pursuant to either Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15884.5.

15884.5. (a) It shall constitute unfair competition for purposes of Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions Code for an insurer, an insurance agent or broker, or an administrator, as defined in Section 1759 of the Insurance Code, to refer an individual employee, or his or her dependents, to the program, or arrange for an individual employee, or his or her dependents, to apply to the program, for the purpose of separating that employee, or his or her dependents, from group health coverage provided in connection with the employees employment.
(b) It shall constitute an unfair labor practice contrary to public policy and enforceable under Section 95 of the Labor Code for any employer to refer an individual employee, or his or her dependents, to the program, or to arrange for an individual employee, or his or her dependents, to apply to the program, for the purpose of separating that employee, or his or her dependents, from group health coverage provided in connection with the employee’s employment.
(c) As used in this section, “group health coverage” includes any nonprofit hospital service plan, health care service plan, self-insured employee welfare benefit plan, or disability insurance providing medical or hospital benefits.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15885.

15885. The department may permit the exclusion of coverage or benefits for charges or expenses incurred by a subscriber during the first six months of enrollment in the program for any condition for which, during the six months immediately preceding enrollment in the program medical advice, diagnosis, care, or treatment was recommended or received as to the condition during that period.
However, the exclusion from coverage of this section shall be waived to the extent to which the subscriber was covered under any creditable coverage, as defined in Section 10900 of the Insurance Code, that was terminated, provided the subscriber has applied for enrollment in the program not later than 63 days following termination of the prior coverage, or within 180 days of termination of coverage if the subscriber lost his or her previous creditable coverage because the subscriber’s employment ended, the availability of health coverage offered through employment or sponsored by an employer terminated, or an employer’s contribution toward health coverage terminated. The exclusion from coverage of this section shall also be waived as to any condition of a subscriber previously receiving coverage under a plan of another state similar to the program established by this chapter if the subscriber was eligible for benefits under that other-state coverage for the condition. The department may establish alternative mechanisms applicable to enrollment in participating health plans. These mechanisms may include, but are not limited to, a postenrollment waiting period.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15885.5.

15885.5. If more than one participating health plan is offered, the department shall make available to applicants eligible to enroll in the program sufficient information to make an informed choice among the various types of participating health plans. Each applicant shall be issued an appropriate document setting forth or summarizing the services to which an enrollee is entitled, procedures for obtaining major risk medical coverage, a list of contracting health plans and providers, and a summary of grievance procedures.
(Amended by Stats. 2015, Ch. 303, Sec. 626. (AB 731) Effective January 1, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15886.

15886. After the applicant notifies the department in writing of his or her choice of participating health plan, the department shall assist the applicant in enrolling as a subscriber and securing major risk medical coverage for the subscriber and any dependents.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15886.5.

15886.5. A subscriber may request a change in coverage based upon a change in the family status of any dependent, by filing an application within 30 days after the occurrence of the change in family status, or at other times and under conditions as may be prescribed by the department.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15887.

15887. Health coverage secured through the program shall permit a covered dependent of a subscriber to elect to continue the same coverage upon the death of the subscriber, or upon the subscriber becoming eligible for Medicare Part A and Part B.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15887.5.

15887.5. 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 the department.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15888.

15888. If a subscriber is dissatisfied with any action or failure to act which has occurred in connection with a participating plan’s coverage, the subscriber shall have the right to appeal to the department and shall be accorded an opportunity for a fair hearing. Hearings may be conducted, insofar as practicable, pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 5 - Subscriber Eligibility and Enrollment › Section 15888.5.

15888.5. Subscribers and their dependents who become eligible for Medicare Part A and Part B, excluding those on Medicare solely because of end-stage renal disease, shall not be enrolled, or continue to be enrolled, in major risk medical coverage afforded by this chapter.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 6 - Plan Rates and Compensation from the Fund › Section 15890.

15890. Upon enrollment as a subscriber in the program, the subscriber shall be responsible for payment of the subscriber contribution. Termination of coverage by a participating health plan for nonpayment of the subscriber contribution shall be governed by the same laws and regulations by which the participating health plan is regulated as to all its subscribers and enrollees.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 6 - Plan Rates and Compensation from the Fund › Section 15890.5.

15890.5. Each health plan contracting with the department pursuant to Article 4 (commencing with Section 15881) shall submit annually to the department rates which it estimates are sufficient to cover the cost of providing major risk medical coverage to its subscribers. The rates shall be submitted on the basis of categories of risk which shall be established by the department.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 6 - Plan Rates and Compensation from the Fund › Section 15891.5.

15891.5. A participating health plan may charge subscriber contributions under this article that do not exceed the difference between its plan rate for the category of risk and the program contribution amount for the category of risk.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 7 - Major Risk Medical Insurance Fund › Section 15893.

15893. (a) There is hereby continued in existence in the State Treasury a special fund known as the Major Risk Medical Insurance Fund that is, notwithstanding Section 13340 of the Government Code, continuously appropriated to the department for the purposes specified in Section 15894, Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.
(b) Funds may be deposited in the Major Risk Medical Insurance Fund from one or more of the following accounts in the Cigarette and Tobacco Products Surtax Fund:
(1) The Hospital Services Account.
(2) The Physician Services Account.
(3) The Unallocated Account.
(c) Effective July 1, 2017, the Major Risk Medical Insurance Fund in the State Treasury is abolished and all moneys in the fund shall be transferred to the Health Care Services Plan Fines and Penalties Fund created pursuant to subdivision (d). Any remaining balance, assets, liabilities, and encumbrances of the Major Risk Medical Insurance Fund as of July 1, 2017, shall be transferred to, and become part of, the Health Care Services Plan Fines and Penalties Fund.
(d) There is hereby created in the State Treasury a special fund known as the Health Care Services Plan Fines and Penalties Fund that is, notwithstanding Section 13340 of the Government Code, continuously appropriated to the department for the purposes specified in Section 15894, Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.
(e) Any law that refers to the Major Risk Medical Insurance Fund, including, but not limited to, a reference in this chapter to the Major Risk Medical Insurance Fund or the “fund,” shall be construed to refer to the Health Care Services Plan Fines and Penalties Fund, effective July 1, 2017.
(f) Notwithstanding any other law, the Controller may use the funds in the Health Care Services Plan Fines and Penalties Fund for cash flow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code.
(Amended by Stats. 2017, Ch. 52, Sec. 79. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 7 - Major Risk Medical Insurance Fund › Section 15894.

15894. (a) Except as provided in Section 15894.5, the department shall authorize the expenditure of money in the fund to cover program expenses, including program expenses that exceed subscriber contributions, and to cover expenses relating to Section 10127.16 of the Insurance Code, Section 1373.622 of the Health and Safety Code, and health care services for eligible individuals in the Medi-Cal program. The department shall determine the amount of funds expended for each of these purposes, taking into consideration the requirements of this chapter, Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code. Funds may be expended for health care services for eligible individuals in the Medi-Cal program only after all costs for the administration and delivery of health care services under Section 1373.622 of the Health and Safety Code and Section 10127.16 of the Insurance Code have been fully funded.
(b) Following consultation with a health care service plan or health insurer, if the department and the health care service plan or health insurer have not agreed to a final reconciliation of the amount to be expended from the fund or to be reimbursed to the fund, the department shall give written notice of its determination to the health care service plan or health insurer of the final reconciliation amount, as determined by the department. The health care service plan or health insurer shall remit payment to the department within 60 days of the date of notice from the department. If payment is not received, interest shall accrue in the amount of 7 percent per annum. The department may offset the amount to be reimbursed to the fund against any other payments owed to the health care service plan or health insurer by the department, or may negotiate a payment plan with the health care service plan or health insurer for full payment, and in that case may waive interest accrual as long as payment from the health care service plan or health insurer is made in accordance with the payment plan. This subdivision shall control over any conflict or ambiguity between this subdivision and the provisions of Section 1373.622 of the Health and Safety Code, Section 10127.16 of the Insurance Code, Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code, or this chapter.
(Amended by Stats. 2017, Ch. 52, Sec. 81. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 7 - Major Risk Medical Insurance Fund › Section 15894.5.

15894.5. (a) From money appropriated by the Legislature to the fund, the department may expend sufficient funds to carry out the purposes of this chapter and of Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.
(b) However, the state is not liable beyond the assets of the fund for any obligations incurred, or liabilities sustained, in the operation of the California Major Risk Medical Insurance Program or for the expenditures described in Section 10127.16 of the Insurance Code and Section 1373.622 of the Health and Safety Code.
(Amended by Stats. 2015, Ch. 303, Sec. 627. (AB 731) Effective January 1, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.3 - Health Care Coverage Assistance › CHAPTER 4 - California Major Risk Medical Insurance Program › ARTICLE 7 - Major Risk Medical Insurance Fund › Section 15895.

15895. Any moneys remaining in the fund at the end of any fiscal year may be carried forward to the next succeeding fiscal year.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.5 - HEALTH CARE COVERAGE INITIATIVE › Section 15900.

15900. The Legislature finds and declares the following:
(a) Approximately 21 percent of nonelderly Californians lack health insurance coverage. Many are low-income individuals who are not eligible for existing public health coverage programs.
(b) One hundred eighty million dollars ($180,000,000) in federal funds will be available for three years to reimburse for public expenditures made under a Health Care Coverage Initiative for uninsured individuals. These funds are to be provided pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.
(c) California’s health care safety net system plays an essential role in delivering critical health services to low-income individuals.
(d) Local governments have the unique ability to design health service delivery models that meet the needs of their diverse populations and build on local infrastructures.
(Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.5 - HEALTH CARE COVERAGE INITIATIVE › Section 15901.

15901. (a) There is hereby established the Health Care Coverage Initiative to expand health care coverage to low-income uninsured individuals in California.
(b) The Health Care Coverage Initiative shall operate pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion that became effective September 1, 2005. The initiative shall be implemented only to the extent that federal financial participation is available.
(Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.5 - HEALTH CARE COVERAGE INITIATIVE › Section 15902.

15902. (a) Persons eligible to be served by the Health Care Coverage Initiative are low-income uninsured individuals who are not currently eligible for the Medi-Cal program, Healthy Families Program, or Access for Infants and Mothers program.
(b) Funding for the Health Care Coverage Initiative shall be used to expand health care coverage for eligible uninsured individuals.
(c) Any expansion of health care coverage for uninsured individuals shall not diminish access to health care available for other uninsured individuals, including access through disproportionate share hospitals, county clinics, or community clinics.
(d) Services provided under the Health Care Coverage Initiative shall be available to those eligible uninsured individuals enrolled in a Health Care Coverage program, and nothing in this part shall be construed to create an entitlement program of any kind.
(e) No state General Fund moneys shall be used to fund the Health Care Coverage Initiative, nor to fund any related administrative costs provided to counties.
(Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.5 - HEALTH CARE COVERAGE INITIATIVE › Section 15903.

15903. The Health Care Coverage Initiative shall be designed and implemented to achieve all of the following outcomes:
(a) Expand the number of Californians who have health care coverage.
(b) Strengthen and build upon the local health care safety net system, including disproportionate share hospitals, county clinics, and community clinics.
(c) Improve access to high quality health care and health outcomes for individuals.
(d) Create efficiencies in the delivery of health services that could lead to savings in health care costs.
(e) Provide grounds for long-term sustainability of the programs funded under the initiative.
(f) Implement programs in an expeditious manner in order to meet federal requirements regarding the timing of expenditures.
(Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3.5 - HEALTH CARE COVERAGE INITIATIVE › Section 15905.

15905. Applications submitted to the department shall include, but not be limited to, each of the following:
(a) A description of the proposed Health Care Coverage program, including, but not limited to, all of the following:
(1) Eligibility criteria.
(2) Screening and enrollment processes that include an identification system to demonstrate enrollment into the Health Care Coverage program.
(3) Screening processes to identify individuals who may qualify for enrollment into Medi-Cal, the Healthy Families Program, or the Access for Infants and Mothers Program.
(b) A description of the quality monitoring system to be implemented with the Health Care Coverage program.
(c) A description of the population to be served.
(d) A list of health care providers who have agreed to participate in the Health Care Coverage program.
(e) A description of the organized health care delivery systems to be used for the Health Care Coverage program, including, but not limited to, designation of a medical home and processes used to assign eligible individuals to a primary care provider.
(f) A list of the health benefits to be provided, including the preventive and primary care services and how they will be promoted.
(g) A description of the care management services to be provided, and the providers of those services.
(h) A calculation of the average cost per individual served.
(i) The number of individuals to be served.
(j) The mechanism under which the proposed Health Care Coverage Initiative will make expenditures to, or on behalf of, providers and other entities, including, but not limited to, documentation to support the ability to implement the Health Care Coverage program by September 1, 2007, and to claim the full amount of the allocation for each program year.
(k) A description of the source of the local nonfederal share of funds.
(l) A description of how the proposed Health Care Coverage program will strengthen the local health care safety net system.
(m) A consent form signed by the applicant to provide requested data elements as required per the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.
(n) Use of a reliable medical record system, that may include, but need not be limited to, existing electronic medical records.
(o) A complete description of health care services currently provided to Medi-Cal beneficiaries and a description as to how the proposed Health Care Coverage program will coordinate its Health Care Coverage program with services provided to Medi-Cal beneficiaries.
(Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)