reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 3 - Minimum Scope of Benefits › Section 2698.303 - Pre-Existing Condition Exclusion and Post-Enrollment Waiting Period

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Unless a waiver
				is granted pursuant to subsection (c), subscribers and enrolled dependents who
				enroll in a health maintenance organization participating health plan shall be
				subject to a post-enrollment waiting period. The post-enrollment waiting period
				shall apply to all subscribers and enrolled dependents. Subscribers shall not
				be required to pay subscriber contributions during the waiting period. The
				post-enrollment waiting period shall be 3 months unless reduced pursuant to
				subsection (d).
(b) Unless a waiver
				is granted pursuant to subsection (c), subscribers and enrolled dependents who
				enroll in a fee-for-service participating health plan shall be subject to a
				pre-existing condition exclusion period. During the pre-existing condition
				exclusion period no benefits or services related to a pre-existing condition
				shall be covered. Subscribers shall be required to pay subscriber contributions
				during the pre-existing condition exclusion period. The pre-existing condition
				exclusion period shall be 3 months unless reduced pursuant to subsection
				(d).
(c) Waivers or partial waivers
				to the post-enrollment waiting period or pre-existing condition exclusion
				period shall be granted for each individual subscriber or enrolled dependent
				providing any of the following criteria are met:
(1) The subscriber and/or enrolled dependent
				applies for the program within 180 days of the termination of prior creditable
				coverage, and such coverage was terminated due to:
(A) a loss of employment,
(B) the employer stopped offering or
				sponsoring health coverage, or
(C)
				the employer stopped making contributions towards health
				coverage.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 4 - Risk Categories and Subscriber Contributions › Section 2698.400 - Risk Categories

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				The risk categories on which the program and subscriber contributions are to be
				determined shall be the following;
(1) Six
				(6) geographic regions:
(A) Area 1 shall
				include the counties of Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El
				Dorado, Glenn, Humboldt, Inyo, Kings, Lake, Lassen, Mendocino, Modoc, Mono,
				Monterey, Nevada, Placer, Plumas, San Benito, Shasta, Sierra, Siskiyou, Sutter,
				Tehama, Trinity, Tulare, Tuolumne, Yuba, and Yolo.
(B) Area 2 shall include the counties of
				Fresno, Imperial, Kern, Madera, Mariposa, Merced, Napa, Sacramento, San
				Joaquin, San Luis Obispo, Santa Cruz, Solano, Sonoma, and Stanislaus.
(C) Area 3 shall include the counties of
				Alameda, Contra Costa, Marin, San Francisco, San Mateo, and Santa
				Clara.
(D) Area 4 shall include the
				counties of Orange, Santa Barbara, and Ventura.
(E) Area 5 shall include the county of Los
				Angeles.
(F) Area 6 shall include
				the counties of Riverside, San Bernardino, and San Diego.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 4 - Risk Categories and Subscriber Contributions › Section 2698.401 - Determination of Subscriber Contribution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
(1)
				Each participating health plan shall provide an annual estimate of the standard
				average individual rate for the minimum benefits provided for in the contract
				with the participating health plan for each risk category specified in section
				2698.400. Without applying risk
				categories to dependents or dependent subscribers, each participating health
				plan shall also provide an estimate of the standard average rate for covering a
				subscriber in each risk category and the subscriber's dependents as follows:
(A) A subscriber and one dependent;
				and
(B) A subscriber and two or
				more dependents.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 4 - Risk Categories and Subscriber Contributions › Section 2698.403 - Subscriber Contribution Payments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Subscriber contribution payment procedures shall be as
				  follows:
(a) Each month the program
				shall determine the amount of the subscriber contribution in accordance with
				sections 2698.400 and
				2698.401 and notify the subscriber
				or dependent subscriber of the subscriber contribution amount due to the
				program and the due date. The program shall send the notice at least 30 days in
				advance of the due date.
(b) A
				subscriber or dependent subscriber shall submit the subscriber contribution to
				the program each month so that it is received no later than the first of each
				month for that month of coverage.
(c) The obligation to submit the subscriber
				contribution amount required by subsection (b) above is not contingent upon
				receipt of the notice specified in subsection (a). If the subscriber or
				dependent subscriber does not receive the notice specified in subsection (a)
				above, the subscriber or dependent subscriber shall make a good faith effort to
				determine the amount of the subscriber contribution and shall submit a payment
				of that amount by the due date.
(d)
				The subscriber contribution amount shall be calculated based on the
				subscriber's or the dependent subscriber's age as defined in section
				2698.400.
(e) Adjustments to the subscriber
				contribution amount due to a change in the subscriber's or the dependent
				subscriber's age group as defined in section
				2698.400 shall occur on the first
				day of the month following the subscriber's or the dependent subscriber's birth
				date.
(f) The subscriber
				contribution amount for a dependent subscriber shall be adjusted on the first
				of the month following the dependent's divorce, or the subscriber's
				disenrollment from the program. The adjusted subscriber contribution amount
				shall be calculated based on the dependent subscriber's age as defined in
				section 2698.400.
1. New section
				  filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
2. Amendment
				  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.
3. 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: Section
					 12737,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 4 - Risk Categories and Subscriber Contributions › Section 2698.405 - Overdue Payments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				subscriber or dependent subscriber whose subscriber contribution is not paid in
				full for any reason by the due date shall be considered to be
				overdue.
(b) The program shall
				notify the subscriber or dependent subscriber of the overdue subscriber
				contribution payment amount and the potential for disenrollment from the
				program on the 10th day following the due date when the current month's premium
				is paid before the next month's due date. An exception to this is specified in
				subsection (c).
(c) When the
				previous month's subscriber contribution is received on the due date for the
				current month, a final notice notice will be generated on the 15th day
				following the due date for the current month.
(d) Subscriber contributions more than 31
				days overdue shall result in the subscriber and any enrolled dependents or the
				dependent subscriber being disenrolled pursuant to section
				2698.204.
1. New section
				  filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
2. Amendment
				  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.
3. 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: Section
					 12735,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 4 - Risk Categories and Subscriber Contributions › Section 2698.407 - Reinstatement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A subscriber
				and enrolled dependents, if any, or a dependent subscriber who is disenrolled
				for nonpayment of the subscriber contribution may be reinstated once during a
				rolling twelve (12) month period if the subscriber or dependent subscriber
				requests reinstatement within sixty (60) days of the date of the disenrollment
				action and brings all delinquent payments up to date.
(b) A subscriber and enrolled dependents, if
				any, or a dependent subscriber who is disenrolled more than once during a
				rolling twelve (12) month period for nonpayment of the subscriber contribution
				may only be reinstated through an appeal to the board as set forth in Section
				2698.500 except as specified in
				subsection (c).
(c) A subscriber
				and enrolled dependents, if any, or a dependent subscriber who has been
				disenrolled due to the submission of two checks which were returned for
				insufficient funds during a rolling twelve (12) month period will not be
				reinstated.
1. New section
				  filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
2. Amendment
				  of subsection (a), new subsection (b), and subsection relettering filed
				  12-10-97; operative 1-9-98 (Register 97, No. 50).
3. Amendment 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.
4. 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: Section
					 12735,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.500 - Appeals to the Board

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				Any subscriber, enrolled dependent or dependent subscriber who is dissatisfied
				with any action or failure to act which has occurred in connection with a
				participating health plan's coverage may file an appeal with the
				Board.
(b) In addition, the
				following decisions may be appealed to the Executive Director only:
(1) A program determination as to eligibility
				of any applicant or the applicant's dependents.
(2) A program determination to disenroll a
				subscriber, enrolled dependent or dependent subscriber from the
				program.
(3) A program
				determination to deny a subscriber or dependent subscriber request or to grant
				a participating health plan request to transfer the subscriber to a different
				participating health plan.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.501 - Dispute Resolution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Notwithstanding other sections in this Article, when a
				  subscriber, enrolled dependent or dependent subscriber is dissatisfied with any
				  action, or inaction, of the program's participating health plan in which he/she
				  is enrolled, the subscriber, enrolled dependent or dependent subscriber shall
				  first attempt to resolve the dispute with the participating health plan
				  according to its established policies and procedures.
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 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.
4. 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: Sections
					 12711 and
					 12732,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.502 - Filing an Appeal

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
				appeal shall be filed in writing with the Executive Director within sixty (60)
				days of the action or failure to act or receipt of notice of the decision being
				appealed.
(b) An appeal shall
				include all of the following:
(1) A copy of
				any decision being appealed; or a written statement of the action or failure to
				act being appealed;
(2) A statement
				specifically describing the issues which are disputed by the
				appellant;
(3) A statement of the
				resolution requested by the appellant; and
(4) Any other relevant information the
				appellant wants to include.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.503 - Administrative Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any
				appeal filed pursuant to this Article will be given an administrative
				review.
(b) Administrative reviews
				of appeals shall be conducted by the Executive Director.
(c) In conducting an administrative review of
				an appeal, the Executive Director may contact the appellant and/or the
				participating health plan for further information.
(d) The Executive Director's decision shall
				be in writing.
(e) If an appeal was
				filed pursuant to section
				2698.500(a), the
				appellant retains the right to request an administrative hearing if the
				appellant is not satisfied with the decision of the Executive Director. Such a
				request shall be filed within thirty (30) days of receipt of the Executive
				Director's decision. It shall include a clear and concise statement of what
				action is being appealed, and the reason(s) the Executive Director's decision
				is not correct.
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 of subsections (a), (e) and NOTE filed 1-10-95 as an emergency;
				  operative 1-10-95 (Register 95, No. 2). A Certificate of Compliance must be
				  transmitted to OAL 5-10-95 or emergency language will be repealed by operation
				  of law on the following day.
4. Certificate of Compliance as to
				  1-10-95 order transmitted to OAL 4-25-95 and filed 6-7-95 (Register 95, No.
				  23).
5. Amendment of subsection (e) 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 and
					 12712,
					 Insurance Code. Reference: Sections
					 12711 and
					 12732,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.504 - Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Upon receipt of an appeal which requests an administrative
				  hearing, the Board shall determine the appropriate forum as follows:
(a) An appeal filed pursuant to subsection
				(a) of section
				2698.500 shall be reviewed by the
				Board to determine whether it is practicable to have the hearing conducted by
				an Administrative Law Judge employed by the Office of Administrative Hearings
				pursuant to the provisions of Chapter 5 (commencing with Section
				11500) of Part 1 of Division 3 of
				Title 2 of the Government Code. The Board will determine practicability by
				considering such issues as timing, location and costs to the parties. If it is
				determined to be practicable, such a hearing shall be scheduled. If it is
				determined not to be practicable, the appeal shall be heard in accordance with
				subsection (b) of this Section.
(b)
				An appeal filed pursuant to subsection (a) of section
				2698.500 but which it has been
				determined by the Board should be heard in accordance with this subsection,
				shall be heard according to the appeal procedures, including pre- and
				post-hearing procedures, set forth in Chapter 2.5 (commencing with section
				251) of Division 2 of Title 1 of
				the California Code of Regulations. Chapter 2.5, as adopted on June 4, 1984, is
				hereby incorporated by reference, subject to the following modifications:
(1) Reference to the Health and Welfare
				Agency or the component department shall be deemed reference to the Managed
				Risk Medical Insurance Board.
(2)
				Reference to the private non-profit human service organization shall be deemed
				reference to the petitioner.
(3)
				Reference to the grievance procedure established in accordance with Health and
				Safety Code section
				38036
				shall be deemed reference to the administrative review process set forth in
				section 2698.503.
(4) Reference to Health and Safety Code
				sections providing the bases, grounds, authorization or procedures for appeals
				shall be deemed reference to the bases and authorization for appeal found in
				section 2698.500, and the appeal
				procedures found in this section.
(5) The 30-day time period specified in
				section 251(b) shall be
				extended to 60 days, and the 10-day time period in section
				252(a) shall be
				extended to 30 days.
(6) If the
				proposed decision submitted to the Board is not adopted as the decision, the
				Board may itself decide the case on the record, or may refer the case to the
				same hearing officer to take additional evidence. If the case is referred back
				to the hearing officer, the hearing officer shall prepare a new proposed
				decision based on the additional evidence and the record of the prior
				hearing.
(7) The decision of the
				Board shall be issued within 90 days following the initial hearing or, if the
				case is referred back to the hearing officer, within 90 days of the second
				hearing.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.505 - Conduct of Hearing by Hearing Officer. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Certificate
				  of Compliance as to 12-20-90 order repealing former section
				  2698.505 and renumbering former
				  section 2698.506 to section
				  2698.505 transmitted to OAL
				  4-18-91 and filed 5-17-91 (Register 91, No. 27). For prior history, see
				  Register 91, No. 11.
2. Amendment of subsection (b) and NOTE filed
				  1-11-93; operative 2-10-93 (Register 93, No. 3).
3. Repealer filed
				  1-10-95 as an emergency; operative 1-10-95 (Register 95, No. 2). A Certificate
				  of Compliance must be transmitted to OAL 5-10-95 or emergency language will be
				  repealed by operation of law on the following day.
4. Certificate of
				  Compliance as to 1-10-95 order transmitted to OAL 4-25-95 and filed 6-7-95
				  (Register 95, No. 23).
Note: Authority cited: Sections
					 12711 and
					 12712,
					 Insurance Code. Reference: Sections
					 12711 and
					 12732,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.506 - Decision on Appeal Hearing by Hearing Officer. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Certificate
				  of Compliance as to 12-20-90 order renumbering former section
				  2698.506 to section
				  2698.505 and renumbering former
				  section 2698.507 to section
				  2698.506 transmitted to OAL on
				  4-18-91 and filed 5-17-91 (Register 91, No. 27). For prior history, see
				  Register 91, No. 11.
2. Editorial correction of subsection (b)
				  (Register 91, No. 27).
3. Repealer filed 1-10-95 as an emergency;
				  operative 1-10-95 (Register 95, No. 2). A Certificate of Compliance must be
				  transmitted to OAL 5-10-95 or emergency language will be repealed by operation
				  of law on the following day.
4. Editorial correction of HISTORY 1
				  (Register 95, No. 13).
5. Certificate of Compliance as to 1-10-95
				  order transmitted to OAL 4-25-95 and filed 6-7-95 (Register 95, No.
				  23).
Note: Authority cited: Sections
					 12711,
					 12712 and
					 12712.5,
					 Insurance Code. Reference: Sections
					 12711 and
					 12732,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 5 - Appeals › Section 2698.507 - Decision on Appeal Hearing by Hearing Officer. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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 renumbering
				  former section
				  2698.507 to section
				  2698.506 transmitted to OAL
				  5-17-90 and filed 5-17-91 (Register 91, No. 27).
Note: Authority cited: Sections
					 12711,
					 12712 and
					 12712.5,
					 Insurance Code. Reference: Sections
					 12711 and
					 12732,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 6 - Pilot Program Payments › Section 2698.602 - Annual Reconciliation Reporting and Payment Process for Pilot Program Health Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
				time period for annual reconciliation, reports and payment shall be as follows:
(1) The annual reconciliation reporting and
				payment process shall start one year after the end of each reporting period
				established in Health and Safety Code Section
				1373.62(g)(1)
				and Insurance Code 10127.15 (g)(1). These periods are as follows:
September 1, 2003, to December 31, 2003, inclusive,
January 1, 2004, to December 31, 2004, inclusive,
January 1, 2005, to December 31, 2005, inclusive,
January 1, 2006, to December 31, 2006, inclusive,
January 1, 2007, to August 30, 2007,
				  inclusive.
(2) However, for
				the purpose of reconciliation and payment, the January 1, 2007 to August 30,
				2007 reporting period shall be extended through December 31, 2007, and shall
				include Program Graduates and Program Graduate dependents that remain enrolled
				in a Pilot Program health plan's standard benefit plan on September 1, 2007
				(the day the Pilot Program becomes inoperative). Pilot Program health plans
				with such program graduates or program graduate dependents may continue to
				report, and be eligible for reconciliation and payment, one year after the
				close of each calendar year until the plan no longer has any remaining program
				graduates or program graduate dependents.
California Code of Regulations › Title 10 - Investment › Chapter 5.5 - Major Risk Medical Insurance Board › Article 6 - Pilot Program Payments › Section 2698.604 - Excess State Liability in the Pilot Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Board shall determine at least
				semiannually at a public meeting of the Board, the viability of the Major Risk
				Medical Insurance Fund, or other funding sources made available to the Board to
				make interim semiannual or final annual payments to Pilot Program health
				plans.
(b) If the Board determines
				that funds for the Pilot Program or for payments beyond the term of the Pilot
				Program are in a state of excess liability, the Board shall notify the
				Department of Managed Health Care, the Department of Insurance, and all Pilot
				Program health plans known to the Board, of the state of excess liability,
				within 30 days of the determination. The notification shall include a
				determination of the allowable premium rates change that may be charged to
				program graduates, to the amount the Board would charge without a state subsidy
				for the applicable standard benefit plan within the Major Risk Medical
				Insurance Program. Pilot Program health plans shall be allowed to charge these
				rates, consistent with the policies and procedures for rate increase
				notifications of the state department (either Department of Managed Health Care
				or Department of Insurance) which regulates the Pilot Program health
				plan.
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: Section
					 1373.62,
					 Health and Safety Code; and Sections
					 10127.15,
					 12711 and
					 12712,
					 Insurance Code. Reference: Sections
					 1373.62
					 and
					 1373.622,
					 Health and Safety Code; and Sections
					 10127.15,
					 10127.16,
					 12711 and
					 12712,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 1 - Definitions › Section 2699.100 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Appellant"
				means an applicant or subscriber who has filed an appeal with the
				program.
(b) "Applicant" means a
				pregnant woman 18 years of age or older who is applying on her own behalf, or a
				legal guardian or a natural parent, foster parent, or stepparent with whom the
				child resides, who applies for coverage under the program on behalf of a child.
				"Applicant" also means a pregnant woman who is applying for coverage on her own
				behalf who is under 18 years of age, or who is an emancipated minor, or who is
				a minor not living in the home of a natural or adoptive parent, a legal
				guardian, foster parent or stepparent.
(c) "Application Date" means the date an
				application is sent to the program as evidenced by the U.S. postmark date on
				the application envelope, or documentation from other delivery services
				including fax delivery.
(d) "Board"
				means the Managed Risk Medical Insurance Board.
(e) "Coverage" means the payment for benefits
				provided through the program.
(f)
				"Disenroll" means to terminate coverage by the program.
(g) "Eligible" means the applicant is
				qualified to be enrolled in a participating health plan.
(h) "Enroll" means to accept an applicant as
				a subscriber by notifying a participating health plan to accept the
				applicant.
(i) "Executive Director"
				means the executive director for the Board.
(j) "Family member" means the following
				persons living in the individual's home:
(1)
				Children under age 21, of married or unmarried parents living in the
				home.
(2) The married or unmarried
				parents of the child or sibling children.
(3) The stepparents of the sibling
				children.
(4) The separate children
				of either an unmarried parent or a married parent or stepparent.
(5) An unborn child of the pregnant woman who
				is applying for coverage on her own behalf or on whose behalf an application
				has been submitted.
(6) Children
				under the age of 21, of married or unmarried parents, away at school who are
				claimed as tax dependents.
(7) The
				spouse of the pregnant woman.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.200 - 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 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 individual shall meet the requirements of either (1) or (2):
(1) Meet all of the following requirements:
(A) Be pregnant and have a reasonable good
				faith belief that the pregnancy is not beyond the 30th week of gestation as of
				the application date; and
1. If the
				application is not complete a letter will be mailed to the applicant indicating
				the required information and documentation, if necessary, needed to complete
				the application. In addition, a telephone call will be placed to the applicant
				to request the missing information and documentation, if necessary. The
				applicant must provide all information and documentation, if necessary, needed
				for the application to be completed within 17 calendar days from the date the
				application was received by the program and prior to the 30th week of
				gestation, and the applicant will be so notified.
2. If the application submitted is not
				complete and it is not completed within seventeen (17) calendar days and prior
				to the 30th week of gestation, the application shall be denied. The applicant
				shall be sent a notice indicating that the application is denied on the basis
				that the program could not make an eligibility determination because of missing
				information or documentation.
3. If
				the application is complete it will be reviewed for an eligibility
				determination pursuant to Section
				2699.203; and
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.201 - Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) To apply for
				the program an individual shall submit:
(1)
				The application described in subsection (d) of this subsection, or
				alternatively, the Single Streamlined Application as promulgated by the
				Department of Health Care Services and the California Health Benefit Exchange
				pursuant to Section
				1413(b)(1)(B) of
				Public Law
				111-148(42 U.S.C. 18083), together with
				all information, documentation, and declarations necessary to determine program
				eligibility as set forth in subsection (d) of this section; and
(2) A cashier's check or money order for
				fifty dollars ($50.00), except that this pre-payment requirement shall not
				apply to applications received on or after January 1, 2014; and
(3) A statement signed by the applicant
				agreeing that if the pregnant woman is enrolled, the applicant will pay the
				full subscriber contribution and acknowledging that the program will take
				aggressive action to collect the full subscriber
				contribution.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.202 - Board Determinations of Program Funding and Initial Review of Applications. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
				  Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-12-91 order transmitted
				  to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Amendment
				  of subsection (b)(1), new subsection (b)(2) and subsection renumbering filed
				  5-20-2003; operative 5-20-2003 pursuant to Government Code section
				  11343.4
				  (Register 2003, No. 21).
4. Amendment of section heading, repealer
				  of first paragraph and repealer and new subsection (a), new subsections
				  (b)(1)-(c), subsection relettering and amendment of newly designated subsection
				  (d) filed 4-21-2010 as an emergency; operative 4-21-2010 (Register 2010, No.
				  17). A Certificate of Compliance must be transmitted to OAL by 10-18-2010 or
				  emergency language will be repealed by operation of law on the following
				  day.
5. Repealer filed 12-27-2013 as an emergency; operative
				  12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be
				  transmitted to OAL by 6-25-2014 or emergency language will be repealed by
				  operation of law on the following day. This filing is deemed an emergency and
				  is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes
				  of 2013, section
				  77.
6. Certificate of
				  Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed
				  6-10-2014 (Register 2014, No. 24).
Note: Authority cited: Section
					 12696.05,
					 Insurance Code. Reference: Sections
					 12696,
					 12696.05
					 and
					 12696.15,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.203 - Determination of Eligibility

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The program shall determine the
				applicant's eligibility based upon the criteria specified in Section
				2699.200. The program shall
				complete the application review process within 10 calendar days of receipt of
				the complete application.
(b)
				Applicants determined ineligible shall be notified in writing by the program.
				The notice shall include the reason for the determination of ineligibility and
				an explanation of the appeal process. The first portion of the applicant's
				subscriber contribution shall be refunded.
(c) Applicants determined eligible shall be
				enrolled.
1. New section
				  filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
				  Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-12-91 order transmitted
				  to OAL 4-8-92 and filed 5-20-92 (Register 92, No.
				  21).
Note: Authority cited: Section
					 12696.05,
					 Insurance Code. Reference: Sections
					 12696 and
					 12696.05,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.204 - Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Applicants
				determined eligible for the program shall be enrolled in their:
(1) First choice participating health plan,
				unless that plan is currently serving the number of subscribers which it has
				contracted with the program to serve.
(2) Second choice participating health plan
				when the first choice plan is currently serving the number of subscribers which
				it has contracted with the program to serve.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.205 - Registration of Infants

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				For infants born to subscribers who are enrolled on or after July 1, 2004, the
				subscriber shall register the infant in the Healthy Families Program as
				follows:
(1) Upon the birth of the infant,
				the subscriber shall provide to the Healthy Families Program the following
				information about the infant:
(A) Name;
				and
(B) Date of birth;
				and
(C) Sex; and
(D) For infants born on or after July 1,
				2007:
1. Information on whether or not the
				infant currently is enrolled in employer sponsored health coverage and the date
				coverage began; and
2. Information
				on whether or not the infant was previously enrolled in employer sponsored
				health coverage, the date coverage began, the date in which coverage
				terminated, and the reason for termination.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.206 - Change of Address and/or Phone Number

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An applicant shall notify the program in writing within
				  thirty (30) days of any change of the applicant's billing address or any change
				  of residence or phone number of a person participating in the
				  program.
1. New section
				  filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
				  Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-12-91 order transmitted
				  to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Amendment
				  of section heading and section filed 5-20-2003; operative 5-20-2003 pursuant to
				  Government Code section
				  11343.4
				  (Register 2003, No. 21).
Note: Authority cited: Section
					 12696.05,
					 Insurance Code. Reference: Section
					 12696,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.207 - Disenrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A subscriber
				shall be disenrolled from the program and from the program's participating
				health plan when any of the following occur:
(1) The subscriber so requests in
				writing.
(2) The subscriber becomes
				ineligible because:
(A) The subscriber fails
				to meet the residency requirement; or
(B) The subscriber has committed an act of
				fraud to circumvent the statutes or regulations of the program,
(C) The subscriber is no longer pregnant on
				her effective date of coverage, based on her self-attestation before the
				effective date. If notification to the program is received after the effective
				date, documentation by a licensed or certified healthcare professional must be
				submitted indicating the date of the miscarriage.
(D) More than 60 days have elapsed since the
				end of the pregnancy for which the subscriber enrolled in the program.
				Notwithstanding the previous sentence, beginning January 1, 2014, the program
				shall provide coverage through the last day of the month in which the
				60th day following the end of the pregnancy occurs.
				As a condition of receiving the premium reduction described in Section
				2699.400(a)(5),
				documentation by a licensed or certified healthcare professional must be
				submitted to the program indicating the date the pregnancy
				ended.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.208 - Continuation of Benefits. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
				  Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-12-91 order transmitted
				  to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Repealer
				  filed 12-27-2013 as an emergency; operative 12-27-2013 (Register 2013, No. 52).
				  A Certificate of Compliance must be transmitted to OAL by 6-25-2014 or
				  emergency language will be repealed by operation of law on the following day.
				  This filing is deemed an emergency and is exempt from review by OAL pursuant to
				  Assembly Bill 82, Chapter 23, Statutes of 2013, section
				  77.
4. Certificate of
				  Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed
				  6-10-2014 (Register 2014, No. 24).
Note: Authority cited: Section
					 12696.05,
					 Insurance Code. Reference: Section
					 12696.05,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.210 - Transfer of Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				A subscriber shall be transferred from one participating health plan to another
				if any of the following occurs:
(1) A
				subscriber so requests, in writing, because the subscriber has moved and no
				longer resides in an area served by the participating health plan in which the
				subscriber is enrolled, and there is at least one participating health plan
				serving the area in which the subscriber now resides that is accepting new
				enrollees.
(2) The 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 other participating health plan serving the area in
				which the subscriber resides that is accepting new enrollees.
(3) The program contract with the
				participating health plan in which the subscriber is enrolled is canceled or
				not renewed.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.211 - Payment for Application Assistance. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A
				  Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-12-91 order transmitted
				  to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Amendment
				  of subsections (a) and (a)(3) filed 8-29-94 as an emergency; operative 9-1-94
				  (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL
				  by 12-30-94 or emergency language will be repealed by operation of law on the
				  following day.
4. Certificate of Compliance as to 8-29-94 order
				  transmitted to OAL 12-9-94 and filed 1-23-95 (Register 95, No.
				  4).
5. Repealer filed 12-27-2013 as an emergency; operative
				  12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be
				  transmitted to OAL by 6-25-2014 or emergency language will be repealed by
				  operation of law on the following day. This filing is deemed an emergency and
				  is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes
				  of 2013, section
				  77.
6. Certificate of
				  Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed
				  6-10-2014 (Register 2014, No. 24).
Note: Authority cited: Section
					 12696.05,
					 Insurance Code. Reference: Section
					 12696,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.6 - Access for Infants and Mothers Program › Article 3 - Scope of Benefits › Section 2699.300 - Minimum Scope of Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				The basic scope of benefits offered by participating health plans to
				subscribers and infants 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, subject to the exclusions listed in this section and
				Section 2699.301. 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 scope of benefits shall be as follows:
(1) Health Facilities
(A) Inpatient Hospital Services: General
				hospital services, in a room of two or more, with customary furnishings and
				equipment, meals (including special diets as medically necessary), and general
				nursing care. All medically necessary ancillary services such as: use of
				operating room and related facilities; intensive care unit and services; drugs,
				medications, and biologicals; anesthesia and oxygen; diagnostic laboratory and
				x-ray services; special duty nursing as medically necessary; physical,
				occupational, and speech therapy, respiratory therapy; administration of blood
				and blood products; other diagnostic, therapeutic and rehabilitative services
				as appropriate; and coordinated discharge planning, including the planning of
				such continuing care as may be necessary.
Exclusions: Personal or comfort items or a private room in a
				  hospital are excluded unless medically necessary.
(B) Outpatient Services: Diagnostic,
				therapeutic and surgical services performed at a hospital or outpatient
				facility. Includes physical, occupational, and speech therapy as appropriate;
				and those hospital services, which can reasonably be provided on an ambulatory
				basis. Related services and supplies in connection with these services
				including operating room, treatment room, ancillary services, and medications
				which are supplied by the hospital or facility for use during the subscriber's
				stay at the facility.