reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6405 - Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
When an appeal which requests an administrative hearing is
				  received, the appeal shall be set for hearing as follows:
(a) Administrative hearings of appeals will
				be conducted 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 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 2699.6403.
(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 2699.6400, 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 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6407 - Conduct of Hearing by Hearing Officer. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Renumbering
				  of former section
				  2699.654 to section
				  2699.6407 filed 5-27-94; operative
				  5-27-94 (Register 94, No. 21).
2. 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.
3. 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: Section
					 10731,
					 Insurance Code. Reference: Sections
					 10731 and
					 10748,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6409 - Decision by Appeal Hearing by Hearing Officer. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Renumbering
				  of former section
				  2699.655 to section
				  2699.6409 filed 5-27-94; operative
				  5-27-94 (Register 94, No. 21).
2. 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.
3. 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: Section
					 10731,
					 Insurance Code. Reference: Sections
					 10731 and
					 10748,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6461 - Program Reinstatement Fee. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 5-5-93 as an emergency; operative 7-1-93 (Register 93, No. 19). A
				  Certificate of Compliance must be transmitted to OAL 10-29-93 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 5-5-93 order transmitted to
				  OAL 8-27-93 and filed 10-12-93 (Register 93, No. 42).
3. Amendment
				  filed 12-30-93 as an emergency; operative 12-30-93 (Register 93, No. 53). A
				  Certificate of Compliance must be transmitted to OAL by 4-28-94 or emergency
				  language will be repealed by operation of law on the following
				  day.
4. Certificate of Compliance as to 12-30-93 order including
				  renumbering former section
				  2699.6461 to section
				  2699.6317 transmitted to OAL
				  4-25-94 and filed 5-27-94 (Register 94, No. 21).
Note: Authority cited: Section
					 10731,
					 Insurance Code. Reference: Section
					 10731,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6462 - Reinstatement Following Disqualification for Non-Payment of Premium. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 5-5-93 as an emergency; operative 7-1-93 (Register 93, No. 19). A
				  Certificate of Compliance must be transmitted to OAL 10-29-93 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 5-5-93 order transmitted to
				  OAL 8-27-93 and filed 10-12-93 (Register 93, No. 42).
3. Amendment
				  filed 12-30-93 as an emergency; operative 12-30-93 (Register 93, No. 53). A
				  Certificate of Compliance must be transmitted to OAL by 4-28-94 or emergency
				  language will be repealed by operation of law on the following
				  day.
4. Certificate of Compliance as to 12-30-93 order including
				  renumbering and amending former section
				  2699.6462 to section
				  2699.6319 transmitted to OAL
				  4-25-94 and filed 5-27-94 (Register 94, No. 21).
Note: Authority cited: Section
					 10731,
					 Insurance Code. Reference: Section
					 10731,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6463 - Participating Employer Payment Requirement. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 5-5-93 as an emergency; operative 7-1-93 (Register 93, No. 19). A
				  Certificate of Compliance must be transmitted to OAL 10-29-93 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 5-5-93 order transmitted to
				  OAL 8-27-93 and filed 10-12-93 (Register 93, No. 42).
4. Certificate
				  of Compliance as to 12-30-93 order including renumbering and amending former
				  section 2699.650 to section
				  2699.6400 transmitted to OAL
				  4-25-94 and filed 5-27-94 (Register 94, No. 21).
3. Amendment of
				  section heading and subsection (b) filed 12-30-93 as an emergency; operative
				  12-30-93 (Register 93, No. 53). A Certificate of Compliance must be transmitted
				  to OAL by 4-28-94 or emergency language will be repealed by operation of law on
				  the following day.
4. Certificate of Compliance as to 12-30-93 order
				  including renumbering and amending former section
				  2699.6463 to section
				  2699.6321 transmitted to OAL
				  4-25-94 and filed 5-27-94 (Register 94, No. 21).
Note: Authority cited: Section
					 10731,
					 Insurance Code. Reference: Section
					 10731,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California) › Article 5 - Appeals › Section 2699.6463.5 - Individual Member Payment Requirement. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New section
				  filed 12-30-93 as an emergency; operative 12-30-93 (Register 93, No. 53). A
				  Certificate of Compliance must be transmitted to OAL by 4-28-94 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 12-30-93 order including
				  renumbering former section
				  2699.6463.5 to section
				  2699.6323 transmitted to OAL
				  4-25-94 and filed 5-27-94 (Register 94, No. 21).
Note: Authority cited: Section
					 10731,
					 Insurance Code. Reference: Section
					 10731,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 1 - Definitions › Section 2699.6500 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Access for
				Infants and Mothers (AIM) Program" means the State funded program operated
				pursuant to Part 6.3 (commencing with Section
				12695) of Division 2 of the
				California Insurance Code, and that provides low-cost health care coverage for
				pregnant women and the newborns of subscribers who are enrolled in the AIM
				program prior to July 1, 2004.
(b)
				"Agriculture" means farming in all its branches and includes; the cultivation
				and tillage of the soil, the production of dairy products, the production,
				cultivation growing, and harvesting of any agricultural or horticultural
				commodities, the raising of livestock, bees, forbearing animals, or poultry,
				any practice performed by a farmer or on a farm as an incident to or in
				conjunction with such farming operations, including preparation for market,
				delivery to storage or to market or to carriers for transportation to
				market.
(c) "AIM infant" means a
				child born to an AIM subscriber who is enrolled in the AIM program on or after
				July 1, 2004.
(d) "Alaskan Native"
				means any person who is an Eskimo or Aleut or other Alaska Native enrolled by
				the Secretary of the Interior pursuant to the Alaska Native Claims Settlement
				Act, 43 U.S.C.
				1601.
(e) "American Indian" means any person who is
				eligible under federal law (25 U.S.C. Section 1603) to receive
				health services provided directly by the United States Department of Health and
				Human Services, Indian Health Service, or by a tribal or an urban Indian health
				program funded by the Indian Health Service to provide health services to
				eligible individuals either directly or by contract.
(f) "Anniversary date" means the day each
				year that corresponds to the day and month a person's coverage began in the
				program.
(g) "Applicant" means:
(1) A person age 18 or over who is a parent;
				a legal guardian; or a caretaker relative, foster parent, or stepparent with
				whom the child resides, who applies for coverage under the program on behalf of
				a child.
(2) A person who is
				applying for coverage on his or her own behalf and who is 18 years of age; or
				an emancipated minor; or a minor not living in the home of a parent, a legal
				guardian, caretaker relative, foster parent, or stepparent.
(3) A minor who is applying for coverage on
				behalf of his or her child.
(4) A
				person who is age 19 or over and who is applying for coverage on his or her own
				behalf and/or that of another child-linked adult.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6600 - Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) To apply for
				the program:
(1) An applicant shall submit
				all information, documentation, and declarations required in subsection (c) of
				this section.
(2) Payment in full
				of the following arrears, incurred within the prior twelve (12) months, by the
				applicant is required prior to enrollment of a person under age 19:
(A) Family child contributions owed on behalf
				of any person under age 19 for whom the same applicant previously
				applied;
(B) Family child
				contributions owed on behalf of a person under age 19 for whom the applicant
				did not previously apply but for whom the applicant is currently requesting
				coverage if the applicant:
1. Is the parent
				of the person under age 19 for whom premiums are owed; and
2. Lived in the same home as the person under
				age 19 when the premiums were incurred.
(3) Payment in full of the following arrears,
				incurred within the prior twelve (12) months, by the applicant is required
				prior to enrollment of a person age 19 or over:
(A) Family contributions owed on behalf of
				any person for whom the same applicant previously applied;
(B) Family child contributions owed on behalf
				of a person under age 19 for whom the applicant did not previously apply but
				for whom the applicant is currently requesting coverage if the applicant:
1. Is the parent of the person under age 19
				for whom premiums are owed; and
2.
				Lived in the same home as the person under age 19 when the premiums were
				incurred.
(C) Family
				parent contributions owed on behalf of a person for whom the applicant is
				requesting coverage for coverage provided on or after the person's 19th
				birthday.
(4) The program
				application, entitled "Family Health Coverage Mail-In Application, for Medi-Cal
				and Healthy Families" (MC321 HFP, 4/06), is hereby incorporated by reference.
				Alternatively, the program shall utilize the on-line application submitted
				electronically via the internet and the school lunch application and any
				supplemental forms received pursuant to Section
				14005.41
				of the Welfare and Institutions Code to make an eligibility
				determination.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6602 - Early Applications

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An applicant may apply to the program in advance for persons
				  who are not eligible at the time of application, but who the applicant believes
				  will become eligible within three (3) months because of one of the
				  following:
(a) They are currently
				enrolled in the Medi-Cal 200% Program and will become one year old.
(b) They are currently enrolled in the
				Medi-Cal 133% Program and will become age 6.
(c) They are currently on Medi-Cal for at
				least one month of continued eligibility under no cost, full scope Medi-Cal and
				have been notified by the county welfare office that coverage is
				ending.
(d) It is anticipated that
				the child will be born. When the child is born, an applicant must submit
				documentation of the child's birth to the program, and must include the child's
				name, place and date of birth, and gender. The documentation and information
				must be received by the program within thirty (30) days from the birth for a
				child to be eligible pursuant to this section. Acceptable forms of
				documentation include a certificate of birth provided by a hospital or other
				health care facility, a signed statement by the health practitioner who
				presided over the delivery, or an equivalent document.
1. Renumbering
				  of former section
				  2699.6603 to new section
				  2699.6602 filed 11-30-2007 as an
				  emergency; operative 11-30-2007 (Register 2007, No. 48). A Certificate of
				  Compliance must be transmitted to OAL by 5-28-2008 or emergency language will
				  be repealed by operation of law on the following day.
2. Certificate
				  of Compliance as to 11-30-2007 order transmitted to OAL 5-28-2008 and filed
				  7-7-2008 (Register 2008, No. 28).
Note: Authority cited: Section
					 12693.21,
					 Insurance Code. Reference: Sections
					 12693.21 and
					 12693.70 Insurance
					 Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6603 - Board Determinations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the Board makes a finding that
				sufficient funds are not available to cover the estimated costs of program
				expenditures and that it is necessary to limit enrollment in the program to
				ensure that expenditures do not exceed amounts available for the program, the
				program shall establish a waiting list.
(b)
(1) If
				the Board makes a finding that sufficient funds are not available to cover the
				estimated cost of program expenditures and that, in addition to limiting new
				enrollment in the program, it is necessary to terminate subscribers in the
				program to ensure that expenditures do not exceed amounts available for the
				program, subscriber children shall be disenrolled from the program at the end
				of the month of their anniversary date following their Annual Eligibility
				Reviews. The program shall not effectuate disenrollments pursuant to this
				subsection unless it also has established a waiting list pursuant to subsection
				(a) of this section and is not currently enrolling additional children on the
				basis of new applications or Add-A-Person forms.
(2) Subscriber children who are determined by
				the California Children's Services Program (CCS) to be currently enrolled for
				benefits under CCS pursuant to Article 5 (commencing with Section
				123800) of Chapter 3 of Part 2 of
				Division 106 of the Health and Safety Code and financially eligible solely
				because they are deemed to be income-eligible for CCS pursuant to paragraph 2
				of subdivision (a) of Section
				123870
				of the Health and Safety Code shall not be subject to disenrollment pursuant to
				this section.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6604 - Waiting List for Children

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				If the program has established and is operating a waiting list pursuant to
				Section 2699.6603, children for whom the
				program has received applications or Add-A-Person forms shall be placed on the
				waiting list in the order their applications or Add-A-Person forms were
				received. A child's effective date on the waiting list shall be the date on
				which the program received the child's application. An eligibility
				determination shall not be made until the Executive Director has made a
				determination pursuant to Section
				2699.6603(d) and
				the applicant provides all supporting documentation pursuant to subsection
				(d)(2) of this section.
(b) If the
				Board makes a finding pursuant to Section
				2699.6603(b),
				each subscriber child disenrolled at Annual Eligibility Review pursuant to
				Section 2699.6603(b)
				shall be placed on the waiting list and the subscriber child's effective date
				on the waiting list shall be his or her disenrollment date.
(c) When the program places a child on the
				waiting list pursuant to subsections (a) or (b) of this section, the program
				shall provide the applicant with written notification of the child's placement
				on the waiting list.
(d) When the
				Executive Director determines, pursuant to Section
				2699.6603(d),
				that sufficient funds are available to cover some or all eligible children who
				are not currently enrolled, the program shall enroll the number of eligible
				wait-listed children for whom sufficient funds are available, as follows:
(1)
(A) The
				program shall first enroll those children who are on the waiting list because
				they were disenrolled at Annual Eligibility Review pursuant to Section
				2699.6603(b). The
				program shall enroll these children in the order of their effective dates on
				the waiting list, starting with those who have the earliest effective
				date.
(B) If and when there are no
				remaining children who are on the waiting list because they were disenrolled at
				Annual Eligibility Review pursuant to Section
				2699.6603(b), the
				program shall, to the extent that sufficient funds are available, enroll
				additional wait-listed children in the order of their effective dates on the
				waiting list, starting with those who have the earliest effective
				date.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6605 - Initial Review of Application for Child-Linked Adults

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Upon receipt of an application or an Add
				a Person Application form, the program shall determine if there is funding
				available for additional enrollment of child-linked adults in the
				program.
(b)
(1) If there is no funding available for
				coverage of child-linked adults and the Board estimates that the program will
				be closed to new enrollment of child-linked adults for less than six (6)
				consecutive weeks, applications will be reviewed for completeness as set forth
				in Section
				2699.6606 below and if complete,
				for eligibility. For persons age 19 and over who are determined to be eligible,
				the program will retain the applicant's family parent contributions payment to
				use to enroll the eligible child-linked adult(s) in the program once a vacancy
				opens in the program. The applicant may request a refund of the family parent
				contributions payment but the child-linked adult for whom enrollment was
				requested will be removed from the program waiting list. Persons age 19 and
				over for whom application is being made who are determined to be eligible will
				be placed on a waiting list in the following categories:
(A) Child-linked adults with an annual
				household income after income deductions of up to and including 100 percent of
				the federal poverty level.
(B)
				Child-linked adults with an annual household income after income deductions
				greater than 100 percent and up to and including 150 percent of the federal
				poverty level.
(C) Child-linked
				adults with an annual household income after income deductions greater than 150
				percent and up to and including 200 percent of the federal poverty
				level.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6606 - Review of Applications for Completeness

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All applications and Add a Person Forms
				shall be reviewed for completeness, except for applications, Add a Person
				Forms, and documentation solely applicable to child-linked adults if there is
				no funding available and the Board estimates that the program will be closed to
				new enrollment for six (6) consecutive weeks or more.
(b) An application that is complete except
				for documentation required by Section
				2699.6600(c)(1)(T)
				shall be considered complete.
(1) If the
				application is incomplete, a telephone call will be placed to the applicant to
				request the missing information and documentation. If the applicant is reached,
				the applicant will be asked to provide the necessary information and
				documentation. If the applicant is not reached by telephone, a notice
				indicating the required information and documentation will be mailed. The
				applicant must provide all information and documentation necessary for the
				application to be complete within seventeen (17) calendar days from the date
				the application was received by the program, 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, the application shall be denied. The applicant shall be sent a
				notice indicating that their 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 or is completed within seventeen (17) calendar
				days, it will be reviewed for an eligibility determination.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6608 - Enrollment of Aim Infants

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An AIM infant, who is born prior to July
				1, 2007, shall be enrolled without application when the program receives the
				required family child contribution beginning with the first full month of
				coverage pursuant to Section
				2699.6613(g), and
				the following information about the infant from the AIM infant's mother at any
				time through the end of the eleventh month following the month of birth:
(1) Name; and
(2) Date of birth; and
(3) Sex.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6609 - Change of Address

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 of a person participating in the program.
1. New section
				  filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A
				  Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 2-20-98 order transmitted to
				  OAL 6-5-98 and filed 7-15-98 (Register 98, No.
				  29).
Note: Authority cited: Section
					 12693.21,
					 Insurance Code. Reference: Section
					 12693.21,
					 Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6612 - Appeals

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following
				program decisions may be appealed to the board:
(1) A decision that an individual is not
				qualified to participate or continue to participate in the program.
(2) A decision that an individual is not
				eligible for enrollment or continuing enrollment in the program.
(3) A decision as to the effective date of
				coverage.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6613 - Starting Date of Coverage for Subscribers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Coverage shall begin for subscribers no
				later than ten (10) calendar days from the date the person is determined to be
				eligible unless any of the following applies:
(1) A person for whom application is being
				made is eligible for continued eligibility under no-cost, full scope Medi-Cal
				and that eligibility will continue for more than ten (10) calendar days from
				the date the person is determined to be eligible.
(2) Application is being made on behalf of a
				child less than 12 months of age for coverage to begin on the child's first
				birthday pursuant to Section
				2699.6603(a).
(3) Application is being made on behalf of a
				child who is currently enrolled in the Medi-Cal 133 percent program.
(4) Application is being made on behalf of a
				newborn prior to birth.
(5) Payment
				of in arrears family contributions is required prior to enrollment of the
				person pursuant to Section
				2699.6600(a)(2) or
				(3).
(6) The subscriber is an AIM
				infant.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6617 - Additional Enrollments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				To apply to the program for additional persons, the applicant shall submit an
				application pursuant to Section
				2699.6600 or the "Add a Person
				Form" (HF FM 067 EN, 11/17/2003), which requests information pursuant to
				Section 2699.6600(b),
				6600(c)(1)(A), (D),
				(F)1., (F)3., (F)11., (F)15., (I), (K), (L),
				(R), (S), and (T).
(b) Eligibility
				for the program will be determined pursuant to Section
				2699.6607.
(c) The "Add a Person Form" (HF FM 067 EN,
				11/17/2003), is hereby incorporated by reference.
1. New section
				  filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A
				  Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 2-20-98 order transmitted to
				  OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment
				  filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18).
				  Pursuant to Chapter 946, Statutes of 2000, section
				  2, a Certificate of Compliance
				  must be transmitted to OAL by 10-28-2002 or emergency language will be repealed
				  by operation of law on the following day.
4. Certificate of
				  Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed
				  12-12-2002 (Register 2002, No. 50).
5. Amendment of subsections (a)
				  and (c) filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No.
				  27). Pursuant to Section
				  80, A.B. 1762 (Chapter 230, Stats.
				  2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or
				  emergency language will be repealed by operation of law on the following
				  day.
6. Certificate of Compliance as to 7-1-2004 order transmitted
				  to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No.
				  1).
Note: Authority cited: Section
					 12693.21,
					 Insurance Code. Reference: Section
					 12693.21,
					 Insurance Code
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6619 - Transfer of Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				A subscriber shall be transferred from one participating health, dental, or
				vision plan to another if any of the following occurs:
(1) The applicant so requests in writing
				because the subscriber no longer resides in an area served by the participating
				plan in which the subscriber is enrolled, and there is at least one other
				participating plan serving the area in which the subscriber now resides.
(A) If the program learns that the subscriber
				no longer resides in an area served by the participating health plan in which
				the subscriber is enrolled, but the applicant does not choose a new health plan
				within thirty (30) days of a written notice from the program, the program will
				enroll the subscriber in the Community Provider Plan in the subscriber's county
				of residence.
(B) If the program
				learns that the subscriber no longer resides in an area served by the
				participating dental plan in which the subscriber is enrolled, but the
				applicant does not choose a new dental plan within thirty (30) days of a
				written notice from the program, the program will enroll the subscriber in a
				participating dental plan in the subscriber's county of residence. If there is
				more than one (1) participating dental plan in the subscriber's county of
				residence, the program will alternate assignments between the participating
				dental plans so that the transfers are evenly distributed among the
				participating dental plans.
(C) If
				the program learns that the subscriber no longer resides in an area served by
				the participating vision plan in which the subscriber is enrolled, but the
				applicant does not choose a new vision plan within thirty (30) days of a
				written notice from the program, the program will enroll the subscriber in a
				participating vision plan in the subscriber's county of residence. If there is
				more than one (1) participating vision plan in the subscriber's county of
				residence, the program will alternate assignments between the participating
				vision plans so that the transfers are evenly distributed among the
				participating vision plans.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6621 - Open Enrollment Period

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The program shall provide for an annual
				open enrollment period of at least forty-five (45) calendar days. During this
				period, applicants may for any reason request that subscribers be transferred
				from one participating health, dental, or vision plan to another. Open
				enrollment plan selection shall comply with Sections
				2699.6600(c)(1)(BB)1.
				and 2699.6623.
(b) For each
				subscriber for whom an applicant is requesting to change plans during an open
				enrollment period, the applicant shall provide the following:
(1) Full name
(2) Address
(3) Social Security Number
				(optional)
(4) Home telephone
				number
(5) Current participating
				plan(s)
(6) New participating
				plan(s)
(7) The applicant's choice
				of primary care provider/clinic (optional) and dentist (optional) for each
				child for whom application is being made.
(8) A declaration that the applicant
				understands that a change of participating plans may result in a change in the
				required family contribution.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6623 - Choosing Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If
				all persons for whom the applicant applies live in the same household, the
				applicant shall enroll all persons in the same participating health plan, the
				same participating dental plan, and the same participating vision
				plan.
(b) If the persons for whom
				the applicant applies live in more than one household, the applicant shall
				enroll all persons living in each household in the same participating health
				plan, the same participating dental plan and the same participating vision
				plan.
1. New section
				  filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A
				  Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency
				  language will be repealed by operation of law on the following
				  day.
2. Certificate of Compliance as to 2-20-98 order transmitted to
				  OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment
				  filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18).
				  Pursuant to Chapter 946, Statutes of 2000, section
				  2, a Certificate of Compliance
				  must be transmitted to OAL by 10-28-2002 or emergency language will be repealed
				  by operation of law on the following day.
4. Certificate of
				  Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed
				  12-12-2002 (Register 2002, No. 50).
Note: Authority cited: Section
					 12693.21,
					 Insurance Code. Reference: Section
					 12693.21 Insurance
					 Code.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 2 - Eligibility, Application, and Enrollment › Section 2699.6629 - Payment for Application Assistance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The program shall pay an application
				assistance fee to an eligible entity that assists an applicant in completing a
				program application or assists an applicant in completing annual eligibility
				review, if the following conditions are met:
(1) A child or a child-linked adult are
				enrolled or requalified as a result of the application;
(2) The request for payment is made in
				writing and specifies the entity to which the payment shall be made and
				includes:
(A) The certified application
				assistant identification number of the person who assisted the
				applicant.
(B) The entity
				identification number.
(3) The application includes a signed and
				dated declaration by the applicant stating that the certified application
				assistant helped the applicant complete the application.
(4) The certified application assistant has
				successfully completed a state-sponsored or approved training course, which may
				include continuing education courses.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 3 - Health, Dental and Vision Benefits › Section 2699.6700 - Scope of Health Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The basic scope of benefits offered by
				participating health plans 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 2699.6703. No other benefits shall
				be permitted to be offered by a participating health plan as part of the
				program. The basic scope of benefits shall include:
(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 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; 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 hospital services which can reasonably be provided on an
				ambulatory basis and 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. Includes physical, occupational, and speech
				therapy, if necessary.
(C)
				Inpatient and Outpatient Services include coverage for general anesthesia and
				associated facility charges, and outpatient services in connection with dental
				procedures when the use of a hospital or surgery center is necessary because of
				the subscriber's medical condition or clinical status or because of the
				severity of the dental procedure. This benefit is only available to subscribers
				under seven years of age; the developmentally disabled, regardless of age; and
				subscribers whose health is compromised and for whom general anesthesia is
				medically necessary, regardless of age.
Participating health plans shall coordinate such services
				  with the subscriber's participating dental plan. Services of the dentist or
				  oral surgeon for dental procedures are excluded.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 3 - Health, Dental and Vision Benefits › Section 2699.6703 - Excluded Health Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Health benefit plans offered under this
				program shall exclude all of the following:
(1) Any benefits specified as excluded within
				Section 2699.6700.
(2) Any benefits in excess of limits
				specified in Section
				2699.6700.
(3) Services, supplies, items, procedures or
				equipment, which are not medically necessary as determined by the plan, unless
				otherwise specified in Section
				2699.6700.
(4) Any benefits that are received prior to
				the subscriber's effective date of coverage. This exclusion does not apply to
				covered benefits to treat complications arising from services received prior to
				the subscriber's effective date of coverage.
(5) Any benefits that are received subsequent
				to the time the subscriber's coverage ends.
(6) Experimental or investigational services,
				including any treatment, therapy, procedure, drug or drug usage, facility or
				facility usage, equipment or equipment usage, device or device usage, or supply
				which is not recognized as being in accordance with generally accepted
				professional medical standards, or for which the safety and efficiency have not
				been determined for use in the treatment of a particular illness, injury or
				medical condition for which the item or service in question is recommended or
				prescribed. This section does not exclude clinical trials for cancer patients
				as provided pursuant to subsection
				2699.6700(a)(21).
(7) Medical services that are received in an
				emergency care setting for conditions that are not emergencies if the
				subscriber reasonably should have known that an emergency care situation did
				not exist.
(8) Eyeglasses, except
				for those eyeglasses or contact lenses necessary after cataract surgery which
				are covered under Subsection
				2699.6700(a)(3)(A).
(9) The diagnosis and treatment of
				infertility is not covered unless provided in conjunction with covered
				gynecological services. Treatments of medical conditions of the reproductive
				system are not excluded.
(10)
				Long-term care benefits including long-term skilled nursing care in a licensed
				facility and respite care are excluded except as a participating health plan
				shall determine they are less costly, satisfactory alternatives to the basic
				minimum benefits. This section does not exclude short-term skilled nursing care
				or hospice benefits as provided pursuant to Subsection
				2699.6700(a)(13) and
				(a)(18).
(11) Cosmetic surgery that is solely
				performed to alter or reshape normal structures of the body in order to improve
				appearance.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 3 - Health, Dental and Vision Benefits › Section 2699.6707 - Annual or Lifetime Benefit Maximums

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) There shall be no annual or lifetime
				financial benefit maximums in any of the coverage under the program.
(b)
(1) For
				the benefit year commencing July 1, 2009, the covered dental benefit for each
				subscriber shall be limited to eighteen hundred seventy-five dollars ($1,875)
				per benefit year.
(2) Effective
				October 1, 2010, through and including September 30, 2011, the covered dental
				benefit for each subscriber shall be limited to fifteen hundred dollars
				($1,500) per benefit year. Effective October 1, 2011, there shall be no annual
				limit on covered dental benefits for subscribers
(3) The limitations contained in this
				subsection shall not apply to dental benefits provided to a subscriber under
				the age of 21 who is determined by the California Children's Services Program
				(Health and Safety Code Section
				123800
				et seq.) to be eligible for dental benefits under that program and the
				particular services are authorized by the California Children's Services
				Program for the particular subscriber for the treatment of a California
				Children's Services Program eligible medical condition.
California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 3 - Health, Dental and Vision Benefits › Section 2699.6709 - Scope of Dental Benefits for Subscriber Children

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The basic scope of benefits for
				subscriber children offered by a participating dental plan 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 Section
				2699.6713.
The covered dental benefit is limited to the benefit level
				  for the least costly dentally appropriate alternative. If a more costly,
				  optional alternative is chosen by the applicant, the applicant will be
				  responsible for all charges in excess of the covered dental benefit.
No other dental benefits shall be permitted to be offered by
				  a participating dental plan as part of the program. The basic scope of dental
				  benefits shall be as follows:
(1)
				Diagnostic and Preventive Benefits
(A) Initial
				and periodic oral examinations.
(B)
				Consultations, including specialist consultations.
(C) Roentgenology, limited as follows:
1. Bitewing x-rays in conjunction with
				periodic examinations are limited to one series of four films in any 6
				consecutive month period. Isolated bitewing or periapical films are allowed on
				an emergency or episodic basis.
2.
				Full mouth x-rays in conjunction with periodic examinations are limited to once
				every 24 consecutive months.
3.
				Panoramic film x-rays are limited to once every 24 consecutive
				months.
(D) Prophylaxis
				services, limited as follows:
Not to exceed two in a twelve month period.
(E) Topical fluoride treatment.
(F) Dental sealant treatments, limited as
				follows:
Permanent first and second molars only.
(G) Space maintainers, including removable
				acrylic and fixed band type.
(H)
				Preventive dental education and oral hygiene instruction.