reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.84 - Procedure for Correction of Incorrect Information Deposited in a Claims Analysis Bureau

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any
				  person who believes that any insurance claims information maintained by a
				  Claims Analysis Bureau is incorrect may request in writing that the CAB
				  investigate whether or not the information is correct.
(b) Within 30 days from the date of receipt
				  of a written request pursuant to subsection
				  2698.84(a), a CAB
				  shall either:
(1) Correct, amend or delete
				  the portion of the insurance claims information in dispute; or
(2) Notify the individual of:
(A) The CAB's refusal to make such
				  correction, amendment or deletion.
(B) The reasons for the refusal.
(C) The individual's right to file a
				  statement as provided in subdivision (d).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.85 - Examination by the Insurance Commissioner of Insurance Claims Information Transmitted to Claims Analysis Bureau

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Commissioner may perform an
				  examination of any insurance claims information transmitted to any CAB the
				  Commissioner may deem necessary and shall have access to all non-privileged
				  reports, working papers, correspondence, or other documents, including audit
				  reports and audit working papers relating to the insurer's receipt, compilation
				  and transmission of insurance claims information.
(b) The expenses of any examination of
				  insurance claims information conducted pursuant to subsection
				  2698.85 (a) shall
				  be borne by the organization that is the subject of the examination.
1. New
					 section filed 5-19-97; operative 6-18-97 (Register 97, No. 21).
2.
					 Repealer and new section filed 12-26-2006; operative 1-25-2006 (Register 2006,
					 No. 52).
3. Change without regulatory effect amending subsection (a)
					 filed 7-14-2021 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2021, No. 29). Filing deadline specified in Government
					 Code section
					 11349.3(a)
					 extended 60 calendar days pursuant to Executive Order
					 N-40-20.
Note: Authority cited, 1875.18(d)(2), Insurance Code.
						Reference: Sections
						736 and
						1875.18,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.86 - Public Records Act Requests and Subpoenas Seeking Insurance Claims Information from Claims Analysis Bureaus

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Claims Analysis Bureau shall not
				  release any insurance claims information in response to a Public Records Act
				  Request.
(b) A Claims Analysis
				  Bureau shall not release any insurance claims information received pursuant to
				  the provisions of California Insurance Code 1875.18 to public inspection until
				  such time as the release of the information is required in connection with a
				  criminal or civil proceeding.
1. New
					 section filed 5-19-97; operative 6-18-97 (Register 97, No. 21).
2.
					 Repealer and new section filed 12-26-2006; operative 1-25-2006 (Register 2006,
					 No. 52).
Note: Authority cited: Section
						1875.18(d)(2),
						Insurance Code. Reference: Sections
						1875.16 and
						1875.18,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.87 - Security Procedures Applicable to Information Deposited to a Claims Analysis Bureau

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Every CAB shall establish and adopt administrative policies and procedures and
				  physical controls to: prevent the unauthorized access to its system of records;
				  to prevent unauthorized disclosure of records; and to prevent physical damage
				  to or destruction of records. At a minimum the administrative policies and
				  procedures and physical controls shall require that:
(1) records are protected from public
				  view;
(2) the area in which records
				  are kept is supervised during business hours to prevent unauthorized persons
				  from having access to them;
(3)
				  records are inaccessible to unauthorized persons outside of business
				  hours;
(4) records are not
				  disclosed to unauthorized persons or under unauthorized circumstances in either
				  oral or written form; and,
(5)
				  direct access to records is restricted to only those individuals who must have
				  direct access to records in order to perform their duties.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.88 - Immunity from Defamation, Invasion of Privacy or Negligence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Claims Analysis Bureau or any person
				  employed therein that provides insurance claims information to any other person
				  or entity pursuant to California Insurance Code Section
				  1875.18
				  shall have the same immunity provided under California Insurance Code Section
				  791.21 to
				  any person that discloses personal or privileged information; however, this
				  subsection does not provide immunity for disclosing or furnishing false
				  information with malice or willful intent to injure any person.
1. New
					 section filed 12-26-2006; operative 1-25-2006 (Register 2006, No.
					 52).
Note: Authority cited: Sections
						1875.18(d)(2),
						Insurance Code. Reference: Section
						1875.18(c)(2) and
						(d)(2), Insurance
						Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.89 - Penalties

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				  Commissioner may suspend or revoke the license of any CAB if the CAB fails to
				  comply with any provisions of this subchapter.
(b) The Commissioner shall conduct any
				  proceeding to suspend or revoke any license granted to a CAB in accordance with
				  the Administrative Procedures Act, Chapter 5(commencing with Section
				  11500) of Part 1 of Division 3 of
				  Title 2 of the Government Code.
(c)
				  Penalties for noncompliance are cumulative and shall be in addition to any
				  other penalties or remedies provided by the Insurance Code.
1. New
					 section filed 12-26-2006; operative 1-25-2006 (Register 2006, No.
					 52).
Note: Authority cited: Section
						1875.18,
						Insurance Code. Reference: Sections
						1875.18,
						12921 and
						12926,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 6 - Law Enforcement Access to Insurance Claims Information › Section 2698.89.1 - Effective Date

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				  regulations set forth in this subchapter shall become effective upon filing
				  with the Secretary of State.
(b)
				  All persons or entities subject to the regulations set forth in this subchapter
				  shall have until July 1, 2007 to fully comply with the provisions of this
				  subchapter.
1. New
					 section filed 12-26-2006; operative 1-25-2006 (Register 2006, No.
					 52).
2. Amendment of NOTE filed 12-19-2007; operative 1-18-2008
					 (Register 2007, No. 51).
Note: Authority cited: Section
						1875.18,
						Insurance Code. Reference: Section
						1875.18,
						Insurance Code
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 7 - Direct Repair Programs and Auto Body Repair Labor Rate Surveys › Section 2698.90 - Direct Repair Programs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As
				  used in this Article, a "Direct Repair Program" includes any program under
				  which an insurer refers, suggests, or recommends an auto body repair facility
				  to insureds or claimants and the insurer has a formal agreement, whether
				  written or otherwise, with the repair facility to provide auto body repair
				  services to such insureds or claimants.
(b) Auto body repair shops reporting a denial
				  to participate in an insurer's Direct Repair Program pursuant to Insurance Code
				  section
				  758 shall
				  make such reports to the Market Conduct Division/Field Claims Bureau of the
				  Department of Insurance.
1. New
					 article 7 (sections
					 2698.90-2698.91) and section filed
					 9-25-2002; operative 10-25-2002 (Register 2002, No.
					 39).
Note: Authority cited: Sections
						758,
						12921 and
						12926,
						Insurance Code. Reference: Section
						758,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.95 - Annual Fee

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
				  admitted disability insurer, as provided for by Insurance Code section
				  1872.85,
				  shall pay an annual fee of twenty cents ($.20) for each person in this state
				  that is covered by an individual or group disability insurance policy during
				  each calendar year or any part thereof. Such assessment shall also be paid by
				  any other entity, doing business in this state, which is liable for any loss
				  due to health insurance fraud.
(b)
				  Insurers shall report to the Commissioner by December 31 of each calendar year
				  on the number of persons in this state that are covered by an individual or
				  group disability policy.
(c) The
				  annual fee shall be payable upon presentation of an invoice by the
				  Commissioner. Payment of the annual fee shall be considered delinquent if not
				  paid by the insurer within forty-five (45) days of the invoice date and any
				  amount not paid within this period shall be charged a late fee in accordance
				  with Insurance Code section
				  12995.
1. New
					 article 8 (section
					 2698.95) and section filed
					 8-31-2004; operative 8-31-2004 pursuant to Government Code section
					 11343.4
					 (Register 2004, No. 36).
2. Amendment of article heading, new
					 subsection (b), subsection relettering and amendment of NOTE filed 11-3-2005;
					 operative 12-3-2005 (Register 2005, No. 44).
3. Amendment of
					 subsection (a) filed 5-20-2013; operative 7-1-2013 (Register 2013, No.
					 21).
4. Change without regulatory effect amending subsection (a),
					 repealing subsection (b), relettering subsections and amending newly designated
					 subsection (b) filed 1-2-2015 pursuant to title 1, section
					 100, subdivision (a)(6),
					 California Code of Regulations (Register 2015, No.
					 1).
Note: Authority cited: Section
						1872.85,
						Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al.
						(1989) 48 Cal.3d 805, 824. Reference: Sections
						1872.85 and
						12995,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.95.1 - Authority and Purpose

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
These regulations are promulgated pursuant to authority
					 granted to the Insurance Commissioner under the provisions of Insurance Code
					 section
					 1872.85.
					 The purpose of these regulations is to set forth the intended and allowable use
					 of funds to be distributed to district attorneys for purposes of enhanced
					 investigation and prosecution of disability insurance fraud cases, including an
					 application process and subsequent reporting requirements.
1. New
					 section filed 11-3-2005; operative 12-3-2005 (Register 2005, No.
					 44).
Note: Authority cited: Section
						1872.85,
						Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al.
						(1989) 48 Cal.3d 805 and 824. Reference: Section
						1872.85,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.95.11 - Determination and Criteria for Award of Grants

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Pursuant to Insurance Code section
				  1872.85(b) and
				  (c), the Commissioner shall distribute funds
				  under this program to district attorneys who are able to show a likely positive
				  outcome that will enhance the prosecution of disability insurance fraud in
				  their jurisdiction. In order to obtain funds under this program, a district
				  attorney must submit an application pursuant to Insurance Code section
				  1872.85(b).
(b) In determining to award a grant under
				  this program, the Commissioner shall consider the information provided in an
				  application and may consider the recommendations and advice of the Fraud
				  Division.
(c) Priority shall be
				  given to those grant applications which, in the determination of the
				  Commissioner, have the potential to have the greatest impact on disability
				  insurance fraud activity.
1. New
					 section filed 11-3-2005; operative 12-3-2005 (Register 2005, No.
					 44).
Note: Authority cited: Section
						1872.85,
						Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al.
						(1989) 48 Cal.3d 805 and 824. Reference: Section
						1872.85,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.96 - Application Procedure and Contents

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Request for Application (RFA) shall be
				  distributed annually to each county district attorney in the state. The
				  Commissioner shall designate a date for the submission of an application
				  requesting grant funding under this program. Notice of the date for submission
				  shall be mailed to each district attorney at least 30 days before the date set
				  for submission of an application. Applications received after the date set for
				  submission will not be considered for funding.
(b) An application shall include:
(1) a "county plan" as more specifically
				  described in section
				  2698.97.1.
(2) a "budget proposal" as more specifically
				  described in section
				  2698.98.
(3) a list of program contacts for the
				  applicant that shall include the name, position, business address, telephone,
				  email address and fax number for each individual.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.97 - Funding Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Funding of a grant shall be in the form of a grant award agreement. Each
				  applicant whose application has been approved for grant funding shall submit an
				  enabling resolution by the county Board of Supervisors approving and
				  authorizing execution of a grant award agreement.
(b) Distribution of grant award funds shall
				  be on a quarterly basis. Funding and dates of distribution shall be contingent
				  upon the adoption of an annual State Budget Act and the collection of
				  assessments. The duration of a grant, otherwise known as a funding cycle, shall
				  be one fiscal year.
(c) Within 60
				  days after the end of each funding cycle, a grantee shall provide the
				  Department with an estimate of any unexpended and/or unencumbered funds. A
				  grantee who has undertaken investigations and prosecutions which will
				  carry-over into a subsequent funding cycle may carry-over into the subsequent
				  funding cycle distributed but unused funds not exceeding twenty-five percent
				  (25%) of the total funding award, provided that the grantee files a written
				  plan, at the end of the funding cycle, which specifies and justifies to the
				  Commissioner how those funds will be used. In the event that, due to
				  extenuating circumstances, distributed funds exceeding twenty-five percent
				  (25%) of the previous total funding award are unused, the Commissioner may
				  consider and approve requests for carry-over of the unused funds to the extent
				  that the grantee provides justification.
1. New
					 section filed 11-3-2005; operative 12-3-2005 (Register 2005, No.
					 44).
Note: Authority cited: Section
						1872.85,
						Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al.
						(1989) 48 Cal.3d 805 and 824. Reference: Section
						1872.85,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.97.1 - County Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A county plan shall include the following elements:
(a) Problem Statement: A description of the
				  disability insurance fraud problem in the county, including how it arose, why
				  it is important, its unique aspects, if any, and what is needed to resolve the
				  problem, including supporting data, evidence, or indicators of fraudulent
				  activity related to disability insurance.
(b) Supporting data may include the following
				  items:
(1) A narrative description of the
				  disability insurance fraud activity in the county, including any supporting
				  data, evidence or indicators of fraudulent related activity.
(2) A description of the general criminal
				  activity, based upon the most recent California Crime Index Annual Report by
				  the California Attorney General.
(3) Population density, based upon the most
				  recent report compiled by the California Department of Finance, Demographic
				  Research Unit.
(4) Disability
				  insurance claims frequency.
(5)
				  Number of disability fraud suspected fraudulent claims reported to the Division
				  during a 36-month period immediately preceding the submission of the
				  application.
(6) Evidence of prior
				  and current disability insurance fraud activity.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.98 - Budget Proposal

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The proposed budget forms the basis for program management
					 and audit and must be presented in line-item detail and cover a one year
					 program period from July through June of each fiscal year. Annual budget levels
					 shall be included in the Request for Application (RFA). The budget may include
					 a line item for an independent audit to be completed at the end of each annual
					 program period or as specified in the RFA. The district attorney's budget shall
					 include the following:
(a) Salaries
				  and benefits computed at the county salary and benefit schedule. A current copy
				  of the pertinent schedule shall be submitted with the proposed
				  budget.
(b) Operation support
				  costs.
(1) Estimated costs shall be listed by
				  line item.
(2) Itemized costs shall
				  conform to county policy regarding appropriateness of expenses.
(3) Allowable costs are those costs incurred
				  in direct support of local program activities, including program related
				  travel, equipment costs proportional to program-related use of the equipment,
				  facilities cost, expert witness fees and audits.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 8 - Disability Insurance Fraud Assessment Grant Program › Section 2698.98.1 - District Attorney Reporting and Commissioner's Audit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each district attorney receiving funds pursuant to
					 Insurance Code section
					 1872.85
					 shall submit an annual report to the Commissioner regarding the local program
					 and its accomplishments. Failure to submit the annual report shall affect
					 subsequent funding decisions. The report shall include the following
					 items:
(a) An Expenditure Report,
				  which shall include information for the following:
(1) Personnel: salaries and
				  benefits.
(2) Operations costs
				  breakdown.
(3) Explanation of any
				  significant variances from the county's application as
				  approved.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 11 - Governing Procedure for Hearings [Renumbered] › Article 1 - Governing Procedure for Hearings [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
				  subchapter 11 (article 1), article 1 (sections
				  2698.99.10 -
				  2698.99.13) and section filed
				  3-20-2003; operative 4-19-2003 (Register 2003, No. 12).
2. Change
				  without regulatory effect renumbering former subchapter 11, article 1 (sections
				  2698.99.10 -
				  2698.99.13) to subchapter 4.5,
				  article 1 (sections
				  2615-2615.3) filed 6-3-2003
				  pursuant to section
				  100, title 1, California Code of
				  Regulations (Register 2003, No. 23).
Note: Authority cited: Sections
					 11400.20
					 and
					 11415.10,
					 Government Code. Reference: Section
					 21.5,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 1 - Definitions › Section 2698.100 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For the purpose of this part:
(a) "Appellant" means an applicant,
				subscriber, enrolled dependent, or dependent subscriber who has filed an appeal
				with the program.
(b) "Applicant"
				means an individual who has filed an application for major risk medical
				coverage with the program.
(c)
				"Authorized Representative" means any person or entity who has been designated,
				in writing, by the appellant to act on his/her behalf or individuals who have
				appropriate power of attorney or legal conservatorship.
(d) "Board" means the Managed Risk Medical
				Insurance Board.
(e) "Certificate
				of Program Completion" means a certificate issued by the Program to persons
				leaving the Program after 36 consecutive months of coverage.
(f) "Coverage" means the payment by the
				program or other health plan or insurer for medically necessary services
				provided by institutional and professional providers.
(g) "Creditable coverage" means:
(1) Any individual or group policy, contract
				or program, that is written or administered by a disability insurer, health
				care service plan, fraternal benefits society, self-insured employer plan, or
				any other entity, in this state or elsewhere, and that arranges or provides
				medical, hospital and surgical coverage not designed to supplement other
				private or governmental plans. The term includes continuation or conversion
				coverage but does not include accident only, credit, disability income,
				Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
				supplement, Medicare supplement, long-term care, dental, vision, coverage
				issued as a supplement to liability insurance, insurance arising out of a
				workers' compensation or similar law, automobile medical payment insurance, or
				insurance under which benefits are payable with or without regard to fault and
				that is statutorily required to be contained in any liability insurance policy
				or equivalent self-insurance.
(2)
				The federal Medicare program pursuant to Title XVIII of the Social Security
				Act.
(3) The Medicaid program
				pursuant to Title XIX of the Social Security Act.
(4) Any other publicly sponsored program,
				provided in this state or elsewhere of medical, hospital and surgical
				care.
(5) 10 U.S.C.A. Chapter 55
				(commencing with Section
				1071) Civilian Health and Medical
				Program of the Uniformed Services (CHAMPUS).
(6) A medical care program of the Indian
				Health Service or of a tribal organization.
(7) A state health benefits risk
				pool.
(8) A health plan offered
				under 5 U.S.C.A. Chapter 89 (commencing with Section
				8901)(FEHBP).
(9) A public health plan as defined in
				federal regulations authorized by Section
				2701(c)(1)
				(
l
) of the Public Health Service Act, as amended by
				Public Law
				104-191.
(10) A health benefit plan under Section
				5(e) of the Peace
				Corps Act (22 U.S.C.A.
				2504(e)).
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 1 - Definitions › Section 2698.102 - Terms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For the purposes of this part:
(a) "Tenses and Number." The present tense
				includes the past and future, and the future the present; the singular includes
				the plural and the plural the singular.
(b) "Time." Whenever in this chapter a time
				is stated in which an act is to be done, the time is computed by excluding the
				first day and including the last day. If the last day is a holiday it is also
				excluded.
1. New section
				  filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32).
				  Amendments to remain in effect for 180 days pursuant to section
				  21, chapter 794, Statutes of 2002
				  (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004
				  or emergency language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 8-4-2003 order transmitted
				  to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No.
				  10).
Note: Authority cited: Sections
					 12711 and
					 12712,
					 Insurance Code. Reference: Sections
					 12711 and
					 12712,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.200 - Basis of Eligibility

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				All eligibility requirements contained herein shall be applied without regard
				to sex, race, creed, color, sexual orientation, health status, national origin,
				occupation, or occupational history of the individual applying for the
				program.
(b) To be eligible for the
				program, an applicant shall meet the requirements of either (1) or (2):
(1) Meet all of the following requirements;
(A) Be a resident of the State of California;
				and
(B) Not be eligible for Part A
				and Part B of Medicare, except those applicants on Medicare solely because of
				end-stage renal disease; and
(C)
				Not be eligible to purchase any health insurance for continuation of benefits
				under the provisions of Health and Safety Code section
				1366.20
				et. seq., or under the provisions of Insurance Code section
				10128.50
				et. seq. or have exhausted any health insurance for continuation of benefits
				under the provisions of 29 US Code 1161 et. seq.; and
(D) Be unable to secure adequate private
				coverage. An individual shall be deemed unable to secure adequate private
				health coverage if the individual within the previous 12 months:
1. Has been denied individual coverage;
				or
2. Has been involuntarily
				terminated from health insurance coverage for reasons other than nonpayment of
				premium or fraud; or
3. Has been
				offered an individual, not a group, health insurance premium rate in excess of
				the subscriber rate for the individual's first choice participating health
				plan.
(E) Clauses 2 and 3
				of subparagraph (D) shall not apply to applications received on and after
				January 1, 2014.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.201 - Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Board shall
				establish an application review process which assures timely action on
				applications. The program shall complete the application review process within
				30 days of the receipt of the application and payment of the initial subscriber
				contribution.
(b) To apply for the
				program an individual shall submit:
(1) all
				information, documentation, and declarations necessary to determine program
				eligibility as set forth in subsection (d) of this section, and
(2) a check or money order for an amount
				equal to the initial subscriber contribution for the individual's first choice
				participating health plan.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.202 - Determination of Eligibility

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Upon receipt of a complete application
				the program shall determine an applicant's eligibility based upon the criteria
				specified in section
				2698.200.
(b)
(1)
				Applicants determined ineligible shall be notified in writing by the program,
				except as in (2) below. The notice shall include the reason for the
				determination of ineligibility and an explanation of the appeal process. The
				applicant's initial subscriber contribution shall be refunded.
(2) If an applicant is determined to be
				currently ineligible, but the applicant has documented pursuant to section
				2698.201(d)(2)(U)
				that he/she will become eligible, the applicant shall be notified that the
				application will be held until the eligibility date specified, and on that date
				the applicant will be determined eligible. The applicant's initial subscriber
				contribution shall not be refunded, unless the applicant's eligibility date is
				more than 60 days from the date of the notification.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.203 - Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Providing
				neither of the circumstances specified in section
				2698.202(d)
				exists, applicants determined eligible for the program shall be enrolled in an
				available participating health plan of the applicant's choice in the
				applicant's county of residence.
(b) If an applicant applied to have
				dependents covered, dependents shall also be enrolled in the subscriber's
				participating health plan.
(c) The
				date on which the coverage shall begin, subject to the provisions of section
				2698.303, shall be the first day
				of the month following enrollment.
(d) An applicant shall be notified in writing
				by the program of enrollment with a participating health plan, the beginning
				date of coverage by the participating health plan, and of any pre-existing
				condition exclusion period or post-enrollment waiting period. The notice shall
				caution the applicant about discontinuing any existing coverage until full
				coverage by the participating health plan has begun.
1. New section
				  filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A
				  Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-20-90 order transmitted
				  to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3.
				  Editorial correction of subsection (d) (Register 95, No. 13).
4.
				  Amendment of section and NOTE filed 8-4-2003 as an emergency; operative
				  8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days
				  pursuant to section
				  21, chapter 794, Statutes of 2002
				  (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004
				  or emergency language will be repealed by operation of law on the following
				  day.
5. Certificate of Compliance as to 8-4-2003 order transmitted
				  to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No.
				  10).
Note: Authority cited: Sections
					 10127.15,
					 12711,
					 12712 and
					 12712.5,
					 Insurance Code. Reference: Sections
					 12711,
					 12725 and
					 12728,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.204 - Disenrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Disenrollment
				shall occur when:
(1) The subscriber requests
				in writing to be disenrolled or that an enrolled dependent be
				disenrolled.
(2) The enrolled
				dependent requests in writing to be disenrolled.
(3) The dependent subscriber requests in
				writing to be disenrolled.
(4) The
				subscriber or dependent subscriber fails to make subscriber contributions in
				accordance with section
				2698.403.
(5) The subscriber, enrolled dependent or
				dependent subscriber no longer meets the residency requirement.
(6) The subscriber, enrolled dependent or
				dependent subscriber has notified the program in writing of his/her eligibility
				for Part A and Part B of Medicare or the program becomes aware of his/her
				eligibility for Part A and Part B of Medicare, except subscribers, enrolled
				dependents or dependent subscribers on Medicare solely because of end-stage
				renal disease.
(7) The subscriber,
				enrolled dependent or dependent subscriber has been enrolled in the program for
				a period of 36 consecutive months from his/her respective start of coverage
				date.
(A) If the subscriber, enrolled
				dependent or dependent subscriber was initially subject to a post-enrollment
				waiting period, the length of that post-enrollment waiting period shall not be
				calculated as part of his/her 36 consecutive months of enrollment.
(B) If the subscriber, enrolled dependent or
				dependent subscriber was initially subject to a pre-existing condition
				exclusion period, the length of that pre-existing condition exclusion period
				shall be calculated as a part of his/her 36 consecutive months of
				enrollment.
(8) The
				subscriber, enrolled dependent or dependent subscriber has committed an act of
				fraud to circumvent the statutes or regulations of the program.
(9) Death of a subscriber, enrolled dependent
				or dependent subscriber.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.205 - Continuation of Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				If a subscriber is disenrolled pursuant to section
				2698.204(a)(5) or
				2698.204(a)(6)
				2698.204(a)(7) or 2698.204(a)(9), an enrolled dependent shall be eligible for
				continued coverage in the program as a dependent subscriber for as long as
				he/she continues to meet the requirements of section
				2698.200(c).
(b) If an enrolled dependent loses his or her
				dependent status due to divorce from the subscriber, the enrolled dependent
				shall be eligible for continued coverage in the program as a dependent
				subscriber for as long as he/she continues to meet the requirements of section
				2698.200(c).
(c) An enrolled dependent that remains
				eligible pursuant to this section shall become a dependent subscriber and be
				subject to section
				2698.204(a)(7),
				but shall not be required to demonstrate independent eligibility for the
				program.
1. New section
				  filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A
				  Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-20-90 order transmitted
				  to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3.
				  Amendment filed 12-19-91 as an emergency; operative 12-19-91 (Register 92, No.
				  19). A Certificate of Compliance must be transmitted to OAL 4-17-92 or
				  emergency language will be repealed by operation of law on the following
				  day.
4. Certificate of Compliance as to 12-19-91 order transmitted
				  to OAL 4-8-92 and filed 5-12-92 (Register 92, No. 23).
5. Repealer
				  and new section filed 8-4-2003 as an emergency; operative 8-4-2003 (Register
				  2003, No. 32). Amendments to remain in effect for 180 days pursuant to section
				  21, chapter 794, Statutes of 2002
				  (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004
				  or emergency language will be repealed by operation of law on the following
				  day.
6. Certificate of Compliance as to 8-4-2003 order transmitted
				  to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No.
				  10).
Note: Authority cited: Sections
					 12711,
					 12712 and
					 12712.5,
					 Insurance Code. Reference: Section
					 12730,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.206 - Dependent Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
(1) Dependents may be enrolled:
(A) Within sixty (60) days of the date the
				individual became the subscriber's dependent; or
(B) Within sixty (60) days of the termination
				of a dependent's other health care coverage.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.207 - Transfer of Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				A subscriber and enrolled dependents, if any, or a dependent subscriber shall
				be transferred from one participating health plan to another if any of the
				following occurs:
(1) The subscriber or
				dependent subscriber so requests, in writing, during an open enrollment period
				established by the Board. The program shall inform each subscriber or dependent
				subscriber of each open enrollment period.
(2) The subscriber or dependent subscriber so
				requests, in writing, because the subscriber or dependent subscriber has moved
				and no longer resides in an area served by the participating health plan in
				which the subscriber or dependent subscriber is enrolled, and there is at least
				one participating health plan serving the area in which the subscriber or
				dependent subscriber now resides that is accepting new enrollees.
(3) The subscriber or dependent subscriber or
				the participating health plan so requests, in writing, because of failure to
				establish a satisfactory subscriber-plan relationship and the executive
				director determines that the transfer is in the best interests of the program,
				and there is at least one participating health plan serving the area in which
				the subscriber or dependent subscriber resides that is accepting new
				enrollees.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 2 - Eligibility, Application, and Enrollment › Section 2698.208 - Payment to Insurance Agents and Brokers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If authorized by the board, the program
				shall pay an insurance agent as defined in section
				31 of the
				Insurance Code or broker as defined in section
				33 of the
				Insurance Code for assisting an individual in completing the application form,
				if the following conditions are met:
(1) The
				individual is enrolled as a result of the application;
(2) The agent or broker requests such payment
				in writing; and
(3) Such request
				accompanies the application and includes the name, license number, tax
				identification number or social security number, telephone number, and fax
				number (if available), signature, and address of the agent or
				broker.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 3 - Minimum Scope of Benefits › Section 2698.300 - Deductible and Copayment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Benefits shall be subject to such
				required copayments and deductibles as the Board may authorize subject to the
				following limits:
(1) The copayment shall not
				exceed 25 percent of the cost of covered services.
(2) Notwithstanding the provision contained
				in subsection (1), the Board may authorize health plans not utilizing a
				deductible to charge an office visit copayment of up to twenty-five dollars
				($25).
(3) The deductible shall not
				exceed $500 annually for a household, which consists of a subscriber and any
				enrolled dependents or of a dependent subscriber.
(4) The sum of the copayment and deductible
				shall not exceed $2,500 annually for a subscriber or dependent subscriber or
				$4,000 annually for a subscriber and enrolled dependents.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 3 - Minimum Scope of Benefits › Section 2698.301 - Minimum Scope of Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				The basic minimum scope of benefits offered by participating health plans to
				subscribers, dependent subscribers and enrolled dependents must comply with all
				requirements of the Knox-Keene Health Care Service Plan Act of 1975 including
				amendments as well as its applicable regulations, and shall include all of the
				benefits and services listed in this section. Except as required by the
				applicable statute and regulations, no other benefits shall be permitted to be
				offered by a participating health plan unless specifically provided for in the
				program contract with the participating health plan. The basic minimum scope of
				benefits shall be as follows:
(1) Hospital
				inpatient care in a hospital licensed pursuant to subdivision (a) of section
				1250
				of the Health and Safety Code, including all of the following benefits and
				services:
(A) Semi-private room, including
				meals and general nursing services; and private room and special diets when
				prescribed as medically necessary.
(B) Hospital services, including use of
				operating room and related facilities, intensive care unit and services, labor
				and delivery room, and anesthesia.
(C) Drugs, medications, and parenteral
				solutions administered while an inpatient.
(D) Dressings, casts, equipment, oxygen
				services, and radiation therapy.
(E) Respiratory and physical
				therapy.
(F) Diagnostic laboratory
				and x-ray services.
(G) Special
				duty nursing as medically necessary.
(H) Administration of blood and blood
				products.
(I) Other diagnostic,
				therapeutic or rehabilitative services (including occupational, physical and
				speech therapy) as appropriate.
(J)
				Medically necessary inpatient alcohol and substance abuse
				detoxification.
(K) General
				anesthesia and associated facility charges in connection with dental procedures
				rendered in a hospital, when the clinical status or underlying medical
				condition of a subscriber, enrolled dependent or dependent subscriber requires
				dental procedures that ordinarily would not require general anesthesia to be
				rendered in a hospital. This benefit is only available to subscribers, enrolled
				dependents or dependent subscribers under seven years of age; the
				developmentally disabled, regardless of age; and subscribers, enrolled
				dependents or dependent subscribers whose health is compromised and for whom
				general anesthesia is medically necessary, regardless of age.
Nothing in this section shall require a participating health
				  plan to cover any charges for the dental procedure itself, including, but not
				  limited to, the professional fee of the dentist.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 3 - Minimum Scope of Benefits › Section 2698.302 - Excluded Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				Plans offered under this program shall exclude the following benefits unless
				specifically provided for in the program contract with the participating health
				plan:
(1) Services that are not medically
				necessary. "Medically necessary" as applied to the diagnosis or treatment of
				illness is an article or service that is not investigational and is necessary
				because:
(A) It is appropriate and is
				provided in accordance with accepted medical standards in the state of
				California, and could not be omitted without adversely affecting the patient's
				condition or the quality of medical care rendered; and
(B) As to inpatient care, it could not have
				been provided in a physician's office, in the outpatient department of a
				hospital, or in a lesser facility without adversely affecting the patient's
				condition or the quality of medical care rendered; and
(C) If the proposed article or service is not
				commonly used, its application or proposed application has been preceded by a
				thorough review and application of conventional therapies; and
(D) The service or article has been
				demonstrated to be of significantly greater therapeutic value than other, less
				expensive, services or articles.