California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 6 - Appeals on Cancellation › Section 1300.65 - Cancellations, Rescissions, and Nonrenewals of an Enrollment or Subscription

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Definitions
The terms used in Health and Safety Code sections
					 1365
					 and
					 1389.21,
					 as well as the terms used in this Article, are defined as follows:
(1) "APTC enrollee" means an individual, an
				  enrollee or a subscriber in the individual market who is currently a recipient
				  of advance payments of the premium tax credit ("APTC") pursuant to the federal
				  Patient Protection and Affordable Care Act ("PPACA") at section
				  1401 (26 U.S.C. §
												36B).
(2) "Billed for the charge" means the
				  enrollee, subscriber, or group contract holder was sent a bill that provides,
				  at a minimum, an accurate itemization of the premium amount(s) due, the due
				  date(s), and the period(s) of time covered by the premium(s). The bill shall
				  also include the following statement in at least 12-point font:
Your health plan is billing you for the cost of your health
					 coverage. You must pay all amounts listed in this bill by the due date. If you
					 do not pay this amount by the due date, your health coverage can be cancelled.
					 You will receive a grace period before your plan can cancel your coverage for
					 not paying the amount due. You can file a complaint with your plan and with the
					 California Department of Managed Health Care if you think there is a mistake.
					 Learn more about your health care rights and responsibilities in your plan
					 Evidence of Coverage.
(3)
				  "Cancelled," "not renewed" or "nonrenewal" means termination of coverage
				  initiated by the plan during or at the conclusion of the contract term, but
				  does not include the following:
(A) Voluntary
				  termination at the request of the enrollee or subscriber.
(B) Termination for failure to satisfy any
				  statutory or regulatory eligibility requirements under federal or state
				  law.
(C) Exhaustion of any
				  time-limited coverage provided by federal or state law, including, but not
				  limited to, continuation coverage under the federal Consolidated Omnibus Budget
				  Reconciliation Act of 1985 (section
				  4980B of Title 26 of the United
				  States Code, sections
				  1161 et seq. of Title 29 of the
				  United States Code, and section
				  300 bb of Title 42 of the United
				  States Code) or Cal-COBRA (Health and Safety Code sections
				  1366.20
				  through
				  1366.29).
(D) Prospective termination for failure to
				  satisfy eligibility requirements under a group plan contract, as follows:
(i) Time-based employment requirements,
				  including, but not limited to, a reduction in work hours;
(ii) Marital or registered domestic partner
				  status;
(iii) Attainment of
				  limiting age by dependent child;
(iv) Group participation requirements;
				  or
(v) Service-area
				  requirements.
(4) "Contractholder" or "contract holder"
				  means the enrollee, subscriber, group, association or employer with which the
				  plan has contracted to provide health services.
(5) "Enrollee" means a person who is enrolled
				  in a plan and who is a recipient of services from the plan, as that term is
				  defined in Health and Safety Code section
				  1345(c).
(6) "Enrollment," "subscription," or
				  "contract" means "plan contract," as that term is defined in Health and Safety
				  Code section
				  1345(r).
(7) "Exchange" or "Covered California" means
				  the California Health Benefit Exchange established in Title 22 (commencing with
				  section 100500) of the Government
				  Code.
(8) "Federal grace period"
				  means the period of three consecutive months a QHP Issuer must provide to an
				  APTC enrollee, before terminating the APTC enrollee's health care coverage for
				  nonpayment of premiums.
(9) "Grace
				  period" means the period of at least 30 consecutive days beginning the day the
				  Notice of Start of Grace Period is dated.
(10) "Grievance" means a written or oral
				  expression of dissatisfaction to the plan or the Director regarding the plan
				  and/or provider, including a written or oral expression of dissatisfaction by
				  an enrollee, subscriber, or group contract holder who believes their plan
				  contract, enrollment or subscription has been or will be improperly cancelled,
				  rescinded or not renewed. The right to request a review by filing a complaint
				  authorized under Health and Safety Code section
				  1365(b)
				  shall be handled as an expedited grievance pursuant to the requirements of
				  Health and Safety Code sections
				  1368
				  and
				  1368.01,
				  and California Code of Regulations, title 28, sections
				  1300.68 and
				  1300.68.01.
(11) "Group contract holder" means a group,
				  association, or employer that contracts with a plan to provide health care
				  services to members or employees.
(12) "Individual" means enrollee or
				  subscriber as defined in Health and Safety Code section
				  1345(c) and
				  (p), respectively.
(13) "Non-Suspension QHP Issuer" means a
				  health care service plan that does not pend claims for services given to the
				  APTC enrollee in the second and third months of the federal grace period. A
				  Non-Suspension QHP Issuer shall provide coverage to the APTC enrollee as
				  required by the plan contract during the 3-month federal grace
				  period.
(14) "Nonpayment of
				  Premiums" means failure of the enrollee, subscriber, or group contract holder
				  to pay any premium, or portion of premium, by the due date after having been
				  billed for the charge.
(15) "Notice
				  of Cancellation, Rescission or Nonrenewal" means notice sent by the plan to the
				  enrollee, subscriber, or group contract holder that the plan contract will be
				  cancelled, rescinded or not renewed for any reason other than nonpayment of
				  premiums as permitted under California Code of Regulations, title 28, sections
				  1300.65.1 or
				  1300.89.21, or Health and Safety
				  Code sections
				  1365
				  or
				  1389.21.
(16) "Notice of End of Coverage" means the
				  notice sent to the enrollee, subscriber, or group contract holder notifying the
				  recipient that the enrollee's coverage has been cancelled.
(17) "Notice of Start of Federal Grace
				  Period" means notice sent by the plan to the enrollee or subscriber that the
				  plan contract will be terminated unless the premium amount due is received by
				  the plan no later than the last day of the Federal Grace Period.
(18) "Notice of Start of Grace Period" means
				  the notice sent by the plan to the enrollee, subscriber, or group contract
				  holder that the plan contract will be terminated unless the premium amount due
				  is received by the plan no later than the last day of the Grace
				  Period.
(19) "Outstanding premium"
				  means the total premium amounts that have been billed to the enrollee,
				  subscriber or group contract holder and are past due.
(20) "Plan" means a "health care service
				  plan" or "specialized health care service plan," as those terms are defined in
				  Health and Safety Code section
				  1345(f).
(21) "Premium payment threshold policy" means
				  a plan's policy to consider an enrollee, subscriber, or group contract holder
				  to have paid all amounts due if the enrollee, subscriber, or group contract
				  holder pays an amount sufficient to maintain a percentage of total premium owed
				  equal to or greater than a level prescribed by the plan, provided that the
				  level is reasonable and that the level and policy are applied in a uniform
				  manner to all enrollees, subscribers, contract holders, and group contract
				  holders.
(22) "QHP Issuer" means,
				  for the purposes of this Article, a plan licensed under the provisions of the
				  Act and certified by the Exchange to market individual and/or small group
				  products on the Exchange. Any of the requirements contained in California Code
				  of Regulations, title 28, sections
				  1300.65,
				  1300.65.1,
				  1300.65.2, and
				  1300.65.3 that are delegated by a
				  QHP Issuer to a delegated group shall also apply to that delegated
				  group.
(23) "Qualified Health Plan"
				  or "QHP" means a plan contract certified to be offered through the
				  Exchange.
(24) "Rescission" or
				  "rescind" means retroactive cancellation of coverage as defined in California
				  Code of Regulations, title 28, section
				  1300.89.21.
(25) "Small employer" has the same meaning as
				  defined in Health and Safety Code sections
				  1357(
l
),
				  1357.500(k) and 1357.600(k).
(26)
				  "Suspension QHP Issuer" means a health care service plan that pends claims for
				  services rendered to the enrollee in the second and third months of the federal
				  grace period, pursuant to Title 45 of the Code of Federal Regulations, section
				  156.270.