PART 6.2. HEALTHY FAMILIES [12693. - 12694.2.]

Part 6.2 added by Stats. 1997, Ch. 623, Sec. 2.

§§ 12693–12694.2 · 105 sections

1. CHAPTER 1. Purpose § 12693 · 1 section

   • § 12693 The Legislature declares all of the following: (a) Approximately 1.6 million California children, 17 percent of children ages 17 and under, have no health…
2. CHAPTER 2. Definitions §§ 12693.01–12693.17 · 20 sections

   • § 12693.01 For purposes of this part, the definitions contained in this chapter shall govern the construction of this part, unless the context requires otherwise.
   • § 12693.02 (a) “Applicant” means a person over the age of 18 years who is a natural or adoptive parent; a legal guardian; or a caretaker relative, foster parent, or…
   • § 12693.03 “Board” means the Managed Risk Medical Insurance Board.
   • § 12693.04 “Child” means a person who is under 19 years of age who is eligible for the program pursuant to Chapter 9 (commencing with Section 12693.70).
   • § 12693.045 “Community provider plan” means that participating health plan in each geographic area that has been designated by the board as having the highest percentage…
   • § 12693.05 “County organized health system” means a health care organization that contracts with the State Department of Health Services to provide comprehensive health…
   • § 12693.06 “Family contribution” means the cost to an applicant to enable herself or himself or an eligible child or children to enroll in and participate in the program.…
   • § 12693.065 “Family value package” means the combination of participating health, dental, and vision plans available to subscribers in each geographic area offering the…
   • § 12693.07 “Fund” means the Healthy Families Fund.
   • § 12693.08 “Local initiative” means a prepaid health plan that is organized by, or designated by, a county government or county governments, or organized by stakeholders,…
   • § 12693.09 “Participating dental plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal…
   • § 12693.10 “Participating health plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal…
   • § 12693.105 A health care service plan, as defined in subdivision (b) of Section 12693.10, shall include a plan operating as a geographic managed care plan.
   • § 12693.11 “Participating vision care plan” means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of…
   • § 12693.12 “Program” means the Healthy Families Program, which includes a purchasing pool providing health coverage for children in families without access to affordable…
   • § 12693.13 “Purchasing credit member” means an applicant 18 years of age or a child who is eligible for and participates in the purchasing credit component of the program.
   • § 12693.14 “Subscriber” means an applicant 18 years of age or a child who is eligible for and participates in the purchasing pool component of the program.
   • § 12693.15 “Supplemental coverage” means coverage purchased by the program from (a) a private health insurer holding a valid outstanding certificate of authority from the…
   • § 12693.16 “Geographic managed care plan” means an entity that is operating pursuant to a contract entered into under Article 2.91 (commencing with Section 14089) of…
   • § 12693.17 “Family contribution sponsor” means a person or entity that pays the family contribution on behalf of an applicant for any period of 12 consecutive months and,…
3. CHAPTER 3. Creation of Program and Powers of the Board §§ 12693.20–12693.23 · 4 sections

   • § 12693.20 The Healthy Families Program is hereby created and shall be administered by the Managed Risk Medical Insurance Board.
   • § 12693.21 The board may do all of the following consistent with the standards in this part: (a) Determine eligibility criteria for the program. (b) Determine the…
   • § 12693.22 During the 2009–10 and 2010–11 fiscal years, the adoption and readoption of regulations to modify health, dental, and vision benefits or otherwise modify…
   • § 12693.23 Until July 1, 2012, the adoption and readoption of regulations to implement subdivision (q) of Section 12693.21, subdivision (b) of Section 12693.26, or…
4. CHAPTER 4. Administration §§ 12693.25–12693.55 · 35 sections

   • § 12693.25 The board may use a purchasing pool model, issuance of purchasing credits, supplemental coverage, or other means as appropriate to meet the purposes of this…
   • § 12693.26 (a) The board shall establish a purchasing pool for coverage of program subscribers to enable applicants without access to affordable and comprehensive…
   • § 12693.27 (a) The board shall develop a purchasing credit mechanism to enable applicants with access to affordable and comprehensive employer-sponsored dependent…
   • § 12693.271 (a) The Legislature finds and declares that the state faces a fiscal crisis that requires unprecedented measures to reduce General Fund expenditures. (b)…
   • § 12693.28 The program shall be administered without regard to gender, gender identity, gender expression, race, creed, color, sexual orientation, health status,…
   • § 12693.29 (a) The board shall use appropriate and efficient means to notify families of the availability of health coverage from the program. (b) The State Department of…
   • § 12693.30 (a) The board shall assure that written enrollment information issued or provided by the program is available to program subscribers and applicants in each of…
   • § 12693.31 No participating health, dental, or vision plan shall, in an area served by the program, directly, or through an employee, agent, or contractor, provide an…
   • § 12693.32 (a) The board may pay designated individuals or organizations an application assistance fee, if the individual or organization assists an applicant to complete…
   • § 12693.325 (a) (1) Notwithstanding any provision of this chapter, a participating health, dental, or vision plan that is licensed and in good standing as required by…
   • § 12693.326 Notwithstanding any other provision of this part, a new subscriber in the program shall be allowed to switch his or her choice of plans once within the first…
   • § 12693.33 To the extent feasible and permissible under federal law and with receipt of necessary federal approvals, the State Department of Health Services and the board…
   • § 12693.34 (a) The board may establish geographic areas within which participating health, dental, and vision plans may offer coverage to subscribers. (b) Nothing in this…
   • § 12693.35 Participating health, dental, and vision plans shall have, but need not be limited to, all of the following operating characteristics satisfactory to the board…
   • § 12693.36 (a) Notwithstanding any other provision of law, the board shall not be subject to licensure or regulation by the Department of Insurance or the Department of…
   • § 12693.37 (a) The board shall contract with a broad range of health plans in an area, if available, to ensure that subscribers have a choice from among a reasonable…
   • § 12693.38 (a) The board shall contract with a sufficient number of dental and vision plans to assure that dental and vision benefits are available to all subscribers.…
   • § 12693.39 The board shall establish a process for determining which employer-sponsored health plans are eligible to receive a purchasing credit issued by the program.…
   • § 12693.40 The board shall contract with health plans to provide coverage supplemental to that provided by an applicant’s or applicant’s spouse’s employer-sponsored…
   • § 12693.41 (a) The board shall consult and coordinate with the State Department of Health Services in implementing a preenrollment program into the Healthy Families…
   • § 12693.42 Any purchasing credit issued by the board, or a contractor acting on behalf of the board, pursuant to this part shall have an overall cost to the program no…
   • § 12693.43 (a) Applicants applying to the purchasing pool shall agree to pay family contributions, unless the applicant has a family contribution sponsor. Family…
   • § 12693.44 (a) The board shall establish family contribution amounts for purchasing credit members that are equivalent to the amounts charged to subscribers participating…
   • § 12693.45 (a) After two consecutive months of nonpayment of family contributions by an applicant, and a reasonable written notice period of no less than 30 days is…
   • § 12693.46 The board may prohibit applicants who drop coverage after enrolling in the pool from reenrollment in the program for up to six months.
   • § 12693.47 The program may place a lien on compensation or benefits, recovered or recoverable by a subscriber or applicant from any party or parties responsible for the…
   • § 12693.48 The board may adjust payments made to a participating health plan if the board finds that the plan has a significantly disproportionate share of high- or…
   • § 12693.49 (a) When an applicant is dissatisfied with any action or inaction of a participating plan in which a subscriber is enrolled through the purchasing pool, the…
   • § 12693.50 (a) The board shall consult and coordinate with the State Department of Health Services to implement the Medi-Cal to Healthy Families Accelerated Enrollment…
   • § 12693.51 (a) A transfer of enrollment from one participating health plan to another may be made by a subscriber at times and under conditions as may be prescribed by…
   • § 12693.515 (a) Effective July 1, 2004, any subscriber who affirmatively selects, or is assigned by default to, a federally qualified health center, as defined by Section…
   • § 12693.52 The board may negotiate or arrange for stop-loss insurance coverage that limits the program’s fiscal responsibility for the total costs of health services…
   • § 12693.53 The board shall develop and utilize appropriate cost containment measures to maximize the coverage offered under the program. Those measures may include…
   • § 12693.54 A contract entered pursuant to this part shall be exempt from any provision of law relating to competitive bidding, and shall be exempt from the review or…
   • § 12693.55 (a) A health care provider who is furnished documentation of a person’s enrollment in the program shall not seek reimbursement nor attempt to obtain payment…
5. CHAPTER 5. Health Benefits and Copayments §§ 12693.60–12693.62 · 4 sections

   • § 12693.60 (a) Coverage provided to subscribers shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act. Except as otherwise…
   • § 12693.61 The following provisions apply for subscribers who have been identified by the participating health plans as potentially seriously emotionally disturbed. (a)…
   • § 12693.615 (a) The board shall establish the required subscriber copayment levels for specific benefits consistent with the limitations of Section 2103 of Title XXI of…
   • § 12693.62 Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under…
6. CHAPTER 6. Dental Benefits and Copayments §§ 12693.63–12693.64 · 2 sections

   • § 12693.63 (a) The board shall determine the dental benefits to be provided to subscribers by the program. These benefits shall be consistent with those provided to state…
   • § 12693.64 Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under…
7. CHAPTER 7. Vision Benefits and Copayments §§ 12693.65–12693.66 · 2 sections

   • § 12693.65 (a) Vision benefits shall be provided to subscribers and shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act.…
   • § 12693.66 Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under…
8. CHAPTER 8. Linkages with Public Programs §§ 12693.68–12693.69 · 2 sections

   • § 12693.68 The board shall encourage all plans, including those receiving purchasing credits, that provide services under the program to have viable protocols for…
   • § 12693.69 A child enrolled in the Healthy Families Program who has a medical condition that is eligible for services pursuant to the California Children’s Services…
9. CHAPTER 9. Eligibility §§ 12693.70–12693.765 · 9 sections

   • § 12693.70 To be eligible to participate in the program, an applicant shall meet all of the following requirements: (a) Be an applicant applying on behalf of an eligible…
   • § 12693.71 (a) The board shall monitor applications to determine whether employers and employees have dropped employer-sponsored dependent coverage in order to…
   • § 12693.72 (a) The board may disapprove an application if it is determined that the children to be covered under the application were covered by an individual health care…
   • § 12693.73 Notwithstanding any other provision of law, children excluded from coverage under Title XXI of the Social Security Act are not eligible for coverage under the…
   • § 12693.74 (a) To the extent federal financial participation is available, and subject to subdivision (e), the child shall remain continuously eligible for the program up…
   • § 12693.75 (a) The program shall make use of a simple and easy to understand mail-in application process. (b) For children referred pursuant to Section 14005.41 of the…
   • § 12693.755 (a) Subject to subdivision (b), commencing four months after the initial federal approval is obtained pursuant to the waiver described in subdivision (b), the…
   • § 12693.76 (a) Notwithstanding any other provision of law, a child who meets the definition of the term defined in subsection (b) or (c) of Section 1641 of Title 8 of the…
   • § 12693.765 (a) Notwithstanding any other provision of law and subject to subdivision (b), a child described in clause (ii) of subparagraph (A) of paragraph (6) of…
10. CHAPTER 10. Fiscal Integrity § 12693.77 · 1 section

    • § 12693.77 (a) The board shall develop safeguards to assure the fiscal integrity of the program. (b) The program shall ensure that subscribers are not eligible for…
11. CHAPTER 11. Protection Against Substitution of Benefits §§ 12693.80–12693.84 · 5 sections

    • § 12693.80 The board shall use due diligence in the creation of participation standards for the program that minimize the incentive for employers or applicants to drop or…
    • § 12693.81 (a) It shall constitute unfair competition for purposes of Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions…
    • § 12693.82 It shall constitute an unfair labor practice contrary to public policy, and enforceable under Section 95 of the Labor Code, for any employer to refer an…
    • § 12693.83 (a) It shall constitute an unfair labor practice contrary to public policy and enforceable under Section 95 of the Labor Code for any employer to change the…
    • § 12693.84 For purposes of Sections 12693.82 and 12693.83, group health coverage includes any group disability insurance policy covering hospital, medical, or surgical…
12. CHAPTER 12. Appeals §§ 12693.85–12693.89 · 5 sections

    • § 12693.85 Program decisions described in this section may be appealed to the board. If an applicant believes that a written decision on one of the following specified…
    • § 12693.86 (a) An appeal shall be filed in writing with the executive director within 60 calendar days of the date of the notice of the decision being appealed. (b) An…
    • § 12693.87 (a) Any appellant who files an appeal pursuant to Section 12693.85 shall receive an initial administrative review of the appeal. (b) Administrative reviews of…
    • § 12693.88 In addition to the appeal process established above, the board shall establish a program review process. If a subscriber or purchasing credit member is not…
    • § 12693.89 (a) Administrative hearings of appeals shall be conducted according to the appeal procedures, including pre- and post-hearing procedures, set forth in Article…
13. CHAPTER 14. Rural Demonstration Project §§ 12693.91–12693.915 · 2 sections

    • § 12693.91 (a) The State Department of Health Services, in conjunction with the Managed Risk Medical Insurance Board, the County Medical Services Program board, and the…
    • § 12693.915 (a) It is the intent of the Legislature to utilize fiscal resources in the most prudent and cost-efficient manner and to maximize the use of federal funds for…
14. CHAPTER 15. Reports §§ 12693.92–12693.95 · 4 sections

    • § 12693.92 (a) The program shall prepare an annual report in conformance with the requirements of Section 2108 of Title XXI of the Social Security Act (P.L. 105-33). A…
    • § 12693.925 (a) The Managed Risk Medical Insurance Board shall report to the Legislature on or before January 30, 2004, the following information with respect to the State…
    • § 12693.93 The board shall prepare an evaluation of the program and other state efforts to expand coverage to children in conformance with Section 2108 of Title XXI of…
    • § 12693.95 (a) The board in consultation with the Department of Alcohol and Drug Programs shall provide the Legislature by April 15, 1998, a proposal assessing the…
15. CHAPTER 16. Funds §§ 12693.96–12693.97 · 2 sections

    • § 12693.96 (a) There is hereby created in the State Treasury the Healthy Families Fund which is, notwithstanding Section 13340 of the Government Code, continuously…
    • § 12693.97 The State Department of Health Services and the board may explore and utilize any options available under federal law to allow the use of charitable funding as…
16. CHAPTER 16.1. Healthy Families Bridge Benefits Program §§ 12693.98–12694 · 5 sections

    • § 12693.98 (a) (1) The Medi-Cal-to-Healthy Families Bridge Benefits Program is hereby established to provide any child who meets the criteria set forth in subdivision (b)…
    • § 12693.98a (a) (1) The Healthy Families Presumptive Eligibility Program is hereby established to provide any child who meets the criteria set forth in subdivision (b)…
    • § 12693.981 (a) (1) The Healthy Families-to-Medi-Cal Bridge Benefits Program is hereby established to provide any person enrolled for coverage under this part who meets…
    • § 12693.982 For purposes of this chapter, “Medi-Cal” means the state health care program established pursuant to Chapter 14 (commencing with Section 14000) of Part 3 of…
    • § 12694 (a) The board and the department, in collaboration with program offices for the California Special Supplemental Food Program for Women, Infants, and Children…
17. CHAPTER 16.2. Transition of Healthy Families Program Enrollees to Medi-Cal §§ 12694.1–12694.2 · 2 sections

    • § 12694.1 (a) Pursuant to Sections 14005.26 and 14005.27 of the Welfare and Institutions Code, subscribers enrolled in the Healthy Families Program pursuant to this part…
    • § 12694.2 All civil service employees who are currently employed by the Managed Risk Medical Insurance Board, whose functions are transferred to the State Department of…