text:
For purposes of this article, the following definitions shall apply:

(a) “Child” means a child described in Section 22775 of the Government Code and subdivisions (n) to (p), inclusive, of Section 599.500 of Title 2 of the California Code of Regulations.

(b) “Dependent” means the spouse or registered domestic partner, child, or parent or stepparent pursuant to Section 1374.1, of an individual, subject to applicable terms of the health benefit plan.

(c) “Exchange” means the California Health Benefit Exchange created by Section 100500 of the Government Code.

(d) “Family” means the subscriber and their dependent or dependents.

(e) “Grandfathered health plan” has the same meaning as defined in Section 1251 of PPACA.

(f) “Health benefit plan” means an individual or group health care service plan contract that provides medical, hospital, and surgical benefits. The term does not include a specialized health care service plan contract, a health care service plan contract provided in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), the Healthy Families Program (Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code), the Access for Infants and Mothers Program (Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code), or the program under Part 6.4 (commencing with Section 12699.50) of Division 2 of the Insurance Code, or Medicare supplement coverage, to the extent consistent with PPACA.

(g) “Policy year” means the period from January 1 to December 31, inclusive.

(h) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.

(i) “Preexisting condition provision” means a contract provision that excludes coverage for charges or expenses incurred during a specified period following the enrollee’s effective date of coverage, as to a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

(j) “Rating period” means the calendar year for which premium rates are in effect pursuant to subdivision (d) of Section 1399.855.

(k) “Registered domestic partner” means a person who has established a domestic partnership as described in Section 297 of the Family Code.

history: (History: Amended by Stats. 2021, Ch. 468, Sec. 2. (AB 570) Effective January 1, 2022.)

path: 2. LICENSING PROVISIONS > 2.2. Health Care Service Plans > 11.8. Individual Access to Health Care Coverage


kind: section

code: HSC

text: For the purposes of determining eligibility for small employer coverage, a sole proprietor and the sole proprietor’s spouse are not employees with respect to a sole proprietorship that consists only of the sole proprietor and the sole proprietor’s spouse. A partner and a partner’s spouse are not employees of a partnership that consists solely of partners and their spouses. Employer group health care service plans shall not be issued, marketed, or sold to a sole proprietorship or partnership without employees directly or indirectly through any arrangement. Only individual health care service plans shall be sold to any entity without employees.

history: (History: Added by Stats. 2018, Ch. 700, Sec. 6. (SB 1375) Effective January 1, 2019.)

division: 2. LICENSING PROVISIONS

chapter: 2.2. Health Care Service Plans

article: 11.8. Individual Access to Health Care Coverage


text: Except as provided in Sections 1399.858 and 1399.861, the provisions of this article shall only apply with respect to nongrandfathered individual health benefit plans offered by a health care service plan, and shall apply in addition to the other provisions of this chapter and the rules adopted thereunder.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 2, Sec. 18. (SB 2 1x) Effective September 30, 2013.)


text:
(a) Notwithstanding paragraph (1) of subdivision (c) of Section 1399.849, with respect to individual health benefit plans offered outside of the Exchange, a plan shall provide an annual enrollment period for policy years beginning on or after January 1, 2020, from November 1 of the preceding calendar year, to January 31 of the benefit year, inclusive.

(b) Notwithstanding paragraphs (2) and (3) of subdivision (c) of Section 1399.849, with respect to individual health benefit plans offered through the Exchange, for policy years beginning on or after January 1, 2023, a plan shall provide an annual enrollment period from November 1 of the preceding calendar year to January 31 of the benefit year, inclusive.

(c) Notwithstanding paragraph (3) of subdivision (c) of Section 1399.849, with respect to individual health benefit plans offered outside and through the Exchange, the effective date of coverage shall be as follows:

(1) No later than January 1 of the benefit year for plan selection made from November 1 to December 31 of the preceding calendar year, inclusive.

(2) No later than February 1 of the benefit year for plan selection made from January 1 to January 31 of the benefit year, inclusive.

history: (History: Amended by Stats. 2022, Ch. 545, Sec. 3. (SB 1473) Effective September 25, 2022.)


text:
(a) (1) On and after October 1, 2013, a plan shall fairly and affirmatively offer, market, and sell all of the plan’s health benefit plans that are sold in the individual market for policy years on or after January 1, 2014, to all individuals and dependents in each service area in which the plan provides or arranges for the provision of health care services. A plan shall limit enrollment in individual health benefit plans to open enrollment periods, annual enrollment periods, and special enrollment periods as provided in subdivisions (c) and (d).

(2) A plan shall allow the subscriber of an individual health benefit plan to add a dependent to the subscriber’s plan at the option of the subscriber, consistent with the open enrollment, annual enrollment, and special enrollment period requirements in this section.

(b) An individual health benefit plan issued, amended, or renewed on or after January 1, 2014, shall not impose any preexisting condition provision upon any individual.

(c) (1) With respect to individual health benefit plans offered outside of the Exchange, a plan shall provide an initial open enrollment period from October 1, 2013, to March 31, 2014, inclusive, an annual enrollment period for the policy year beginning on January 1, 2015, from November 15, 2014, to February 15, 2015, inclusive, annual enrollment periods for policy years beginning on or after January 1, 2016, to December 31, 2018, inclusive, from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment periods for policy years beginning on or after January 1, 2019, from October 15, of the preceding calendar year, to January 15 of the benefit year, inclusive.

(2) With respect to individual health benefit plans offered through the Exchange, a plan shall provide an annual enrollment period for the policy years beginning on January 1, 2016, to December 31, 2018, inclusive, from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive, and annual enrollment periods for policy years beginning on or after January 1, 2019, from November 1 to December 15 of the preceding calendar year, inclusive.

(3) With respect to individual health benefit plans offered through the Exchange, for policy years beginning on or after January 1, 2019, a plan shall provide a special enrollment period for all individuals selecting an individual health benefit plan through the Exchange from October 15 to October 31 of the preceding calendar year, inclusive, and from December 16, of the preceding calendar year, to January 15 of the benefit year, inclusive. An application for a health benefit plan submitted during these two special enrollment periods shall be treated the same as an application submitted during the annual open enrollment period. The effective date of coverage for plan selections made between October 15 and October 31, inclusive, shall be January 1 of the benefit year, and for plan selections made from December 16 to January 15, inclusive, shall be no later than February 1 of the benefit year.

(4) Pursuant to Section 147.104(b)(2) of Title 45 of the Code of Federal Regulations, for individuals enrolled in noncalendar year individual health plan contracts, a plan shall also provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.

(d) (1) Subject to paragraph (2), commencing January 1, 2014, a plan shall allow an individual to enroll in or change individual health benefit plans as a result of the following triggering events:

(A) The individual or the individual’s dependent loses minimum essential coverage. For purposes of this paragraph, the following definitions shall apply:

(i) “Minimum essential coverage” has the same meaning as that term is defined in Section 1345.5 or subsection (f) of Section 5000A of the Internal Revenue Code (26 U.S.C. Sec. 5000A).

(ii) “Loss of minimum essential coverage” includes, but is not limited to, loss of that coverage due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code. “Loss of minimum essential coverage” also includes loss of that coverage for a reason that is not due to the fault of the individual.

(iii) “Loss of minimum essential coverage” does not include loss of that coverage due to the individual’s failure to pay premiums on a timely basis or situations allowing for a rescission, subject to clause (ii) and Sections 1389.7 and 1389.21.

(B) The individual gains a dependent or becomes a dependent.

(C) The individual is mandated to be covered as a dependent pursuant to a valid state or federal court order.

(D) The individual has been released from incarceration.

(E) The individual’s health coverage issuer substantially violated a material provision of the health coverage contract.

(F) The individual gains access to new health benefit plans as a result of a permanent move.

(G) The individual was receiving services from a contracting provider under another health benefit plan, as defined in Section 1399.845 of this code or Section 10965 of the Insurance Code, for one of the conditions described in subdivision (c) of Section 1373.96 of this code and that provider is no longer participating in the health benefit plan.

(H) The individual demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the department, with respect to health benefit plans offered outside the Exchange, that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because the individual was misinformed that the individual was covered under minimum essential coverage.

(I) The individual is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.

(J) With respect to individual health benefit plans offered through the Exchange, in addition to the triggering events listed in this paragraph, any other events listed in Section 155.420(d) of Title 45 of the Code of Federal Regulations.

(2) With respect to individual health benefit plans offered outside the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to apply for coverage from a health care service plan subject to this section. With respect to individual health benefit plans offered through the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to select a plan offered through the Exchange, unless a longer period is provided in Part 155 (commencing with Section 155.10) of Subchapter B of Subtitle A of Title 45 of the Code of Federal Regulations.

(e) With respect to individual health benefit plans offered through the Exchange, the effective date of coverage required pursuant to this section shall be consistent with the dates specified in Section 155.410 or 155.420 of Title 45 of the Code of Federal Regulations, as applicable. A dependent who is a registered domestic partner pursuant to Section 297 of the Family Code shall have the same effective date of coverage as a spouse.

(f) With respect to individual health benefit plans offered outside the Exchange, the following provisions shall apply:

(1) After an individual submits a completed application form for a plan contract, the health care service plan shall, within 30 days, notify the individual of the individual’s actual premium charges for that plan established in accordance with Section 1399.855. The individual shall have 30 days in which to exercise the right to buy coverage at the quoted premium charges.

(2) With respect to an individual health benefit plan for which an individual applies during the initial open enrollment period described in paragraph (1) of subdivision (c), when the subscriber submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, by December 15, 2013, coverage under the individual health benefit plan shall become effective no later than January 1, 2014. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16, 2013, to December 31, 2013, inclusive, or after the 15th day of any subsequent month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.

(3) With respect to an individual health benefit plan for which an individual applies during the annual open enrollment period described in paragraph (1) of subdivision (c), when the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs later, by December 15 of the preceding calendar year, coverage shall become effective on January 1 of the benefit year. When that payment is delivered or postmarked within the first 15 days of any subsequent month, coverage shall become effective no later than the first day of the following month. When that payment is delivered or postmarked between December 16 to December 31, inclusive, or after the 15th day of any subsequent month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.

(4) With respect to an individual health benefit plan for which an individual applies during a special enrollment period described in subdivision (d), the following provisions shall apply:

(A) When the individual submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, within the first 15 days of the month, coverage under the plan shall become effective no later than the first day of the following month. When the premium payment is neither delivered nor postmarked until after the 15th day of the month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.

(B) Notwithstanding subparagraph (A), in the case of a birth, adoption, or placement for adoption, the coverage shall be effective on the date of birth, adoption, or placement for adoption.

(C) Notwithstanding subparagraph (A), in the case of marriage or becoming a registered domestic partner or in the case where a qualified individual loses minimum essential coverage, the coverage effective date shall be the first day of the month following the date the plan receives the request for special enrollment.

(g) (1) A health care service plan shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of an individual health benefit plan based on any of the following factors:

(A) Health status.

(B) Medical condition, including physical and mental illnesses.

(C) Claims experience.

(D) Receipt of health care.

(E) Medical history.

(F) Genetic information.

(G) Evidence of insurability, including conditions arising out of acts of domestic violence.

(H) Disability.

(I) Any other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the federal Public Health Service Act (Public Law 78-410).

(2) Notwithstanding Section 1389.1, a health care service plan shall not require an individual applicant or the applicant’s dependent to fill out a health assessment or medical questionnaire prior to enrollment under an individual health benefit plan. A health care service plan shall not acquire or request information that relates to a health status-related factor from the applicant or the applicant’s dependent or any other source prior to enrollment of the individual.

(h) (1) A health care service plan shall consider as a single risk pool for rating purposes in the individual market the claims experience of all insureds and all enrollees in all nongrandfathered individual health benefit plans offered by that health care service plan in this state, whether offered as health care service plan contracts or individual health insurance policies, including those insureds and enrollees who enroll in individual coverage through the Exchange and insureds and enrollees who enroll in individual coverage outside of the Exchange. Student health insurance coverage, as that coverage is defined in Section 147.145(a) of Title 45 of the Code of Federal Regulations, shall not be included in a health care service plan’s single risk pool for individual coverage.

(2) Each calendar year, a health care service plan shall establish an index rate for the individual market in the state based on the total combined claims costs for providing essential health benefits, as defined pursuant to Section 1302 of PPACA, within the single risk pool required under paragraph (1). The index rate shall be adjusted on a marketwide basis based on the total expected marketwide payments and charges under the risk adjustment program established for the state pursuant to Section 1343 of PPACA and Exchange user fees, as described in subdivision (d) of Section 156.80 of Title 45 of the Code of Federal Regulations. The premium rate for all of the health benefit plans in the individual market within the single risk pool required under paragraph (1) shall use the applicable marketwide adjusted index rate, subject only to the adjustments permitted under paragraph (3).

(3) A health care service plan may vary premium rates for a particular health benefit plan from its index rate based only on the following actuarially justified plan-specific factors:

(A) The actuarial value and cost-sharing design of the health benefit plan.

(B) The health benefit plan’s provider network, delivery system characteristics, and utilization management practices.

(C) The benefits provided under the health benefit plan that are in addition to the essential health benefits, as defined pursuant to Section 1302 of PPACA and Section 1367.005. These additional benefits shall be pooled with similar benefits within the single risk pool required under paragraph (1) and the claims experience from those benefits shall be utilized to determine rate variations for plans that offer those benefits in addition to essential health benefits.

(D) With respect to catastrophic plans, as described in subsection (e) of Section 1302 of PPACA, the expected impact of the specific eligibility categories for those plans.

(E) Administrative costs, excluding user fees required by the Exchange.

(i) This section shall only apply with respect to individual health benefit plans for policy years on or after January 1, 2014.

(j) This section shall not apply to a grandfathered health plan.

history: (History: Amended by Stats. 2021, Ch. 764, Sec. 5. (SB 326) Effective January 1, 2022.)


text:
(a) Commencing October 1, 2013, a health care service plan or solicitor shall not, directly or indirectly, engage in the following activities:

(1) Encourage or direct an individual to refrain from filing an application for individual coverage with a plan because of the health status, claims experience, industry, occupation, or geographic location, provided that the location is within the plan’s approved service area, of the individual.

(2) Encourage or direct an individual to seek individual coverage from another plan or health insurer or the California Health Benefit Exchange because of the health status, claims experience, industry, occupation, or geographic location, provided that the location is within the plan’s approved service area, of the individual.

(3) Employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs or discriminate based on an individual’s race, color, national origin, present or predicted disability, age, sex, gender identity, sexual orientation, expected length of life, degree of medical dependency, quality of life, or other health conditions.

(b) Commencing October 1, 2013, a health care service plan shall not, directly or indirectly, enter into any contract, agreement, or arrangement with a solicitor that provides for or results in the compensation paid to a solicitor for the sale of an individual health benefit plan to be varied because of the health status, claims experience, industry, occupation, or geographic location of the individual. This subdivision does not apply to a compensation arrangement that provides compensation to a solicitor on the basis of percentage of premium, provided that the percentage shall not vary because of the health status, claims experience, industry, occupation, or geographic area of the individual.

(c) This section shall only apply with respect to individual health benefit plans for policy years on or after January 1, 2014.


text:
(a) An individual health benefit plan shall be renewable at the option of the enrollee except as permitted to be canceled, rescinded, or not renewed pursuant to Section 1365 and Section 155.430(b) of Title 45 of the Code of Federal Regulations.

(b) Any plan that ceases to offer for sale new individual health benefit plans pursuant to Section 1365 shall continue to be governed by this article with respect to business conducted under this article.


text:
(a) With respect to individual health benefit plans for policy years on or after January 1, 2014, a health care service plan may use only the following characteristics of an individual, and any dependent thereof, for purposes of establishing the rate of the individual health benefit plan covering the individual and the eligible dependents thereof, along with the health benefit plan selected by the individual:

(1) Age, pursuant to the age bands established by the United States Secretary of Health and Human Services and the age rating curve established by the federal Centers for Medicare and Medicaid Services pursuant to Section 2701(a)(3) of the federal Public Health Service Act (42 U.S.C. Sec. 300gg(a)(3)). Rates based on age shall be determined using the individual’s age as of the date of the health benefit plan contract issuance or renewal, as applicable, and shall not vary by more than three to one for like individuals of different age who are 21 years of age or older as described in federal regulations adopted pursuant to Section 2701(a)(3) of the federal Public Health Service Act (42 U.S.C. Sec. 300gg(a)(3)).

(2) (A) Geographic region. The geographic regions for purposes of rating shall be the following:

(i) Region 1 shall consist of the Counties of Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba.

(ii) Region 2 shall consist of the Counties of Marin, Napa, Solano, and Sonoma.

(iii) Region 3 shall consist of the Counties of El Dorado, Placer, Sacramento, and Yolo.

(iv) Region 4 shall consist of the City and County of San Francisco.

(v) Region 5 shall consist of the County of Contra Costa.

(vi) Region 6 shall consist of the County of Alameda.

(vii) Region 7 shall consist of the County of Santa Clara.

(viii) Region 8 shall consist of the County of San Mateo.

(ix) Region 9 shall consist of the Counties of Monterey, San Benito, and Santa Cruz.

(x) Region 10 shall consist of the Counties of Mariposa, Merced, San Joaquin, Stanislaus, and Tulare.

(xi) Region 11 shall consist of the Counties of Fresno, Kings, and Madera.

(xii) Region 12 shall consist of the Counties of San Luis Obispo, Santa Barbara, and Ventura.

(xiii) Region 13 shall consist of the Counties of Imperial, Inyo, and Mono.

(xiv) Region 14 shall consist of the County of Kern.

(xv) Region 15 shall consist of the ZIP Codes in the County of Los Angeles starting with 906 to 912, inclusive, 915, 917, 918, and 935.

(xvi) Region 16 shall consist of the ZIP Codes in the County of Los Angeles other than those identified in clause (xv).

(xvii) Region 17 shall consist of the Counties of Riverside and San Bernardino.

(xviii) Region 18 shall consist of the County of Orange.

(xix) Region 19 shall consist of the County of San Diego.

(B) No later than June 1, 2017, the department, in collaboration with the Exchange and the Department of Insurance, shall review the geographic rating regions specified in this paragraph and the impacts of those regions on the health care coverage market in California, and make a report to the appropriate policy committees of the Legislature.

(3) Whether the plan covers an individual or family, as described in PPACA.

(b) The rate for a health benefit plan subject to this section shall not vary by any factor not described in this section.

(c) With respect to family coverage under an individual health benefit plan, the rating variation permitted under paragraph (1) of subdivision (a) shall be applied based on the portion of the premium attributable to each family member covered under the plan. The total premium for family coverage shall be determined by summing the premiums for each individual family member. In determining the total premium for family members, premiums for no more than the three oldest family members who are under 21 years of age shall be taken into account.

(d) The rating period for rates subject to this section shall be from January 1 to December 31, inclusive.

(e) This section does not apply to an individual health benefit plan that is a grandfathered health plan.

(f) The requirement for submitting a report imposed under subparagraph (B) of paragraph (2) of subdivision (a) is inoperative on June 1, 2021, pursuant to Section 10231.5 of the Government Code.

history: (History: Amended by Stats. 2021, Ch. 764, Sec. 6. (SB 326) Effective January 1, 2022.)


text:
(a) A health care service plan shall not be required to offer an individual health benefit plan or accept applications for the plan pursuant to Section 1399.849 in the case of any of the following:

(1) To an individual who does not live or reside within the plan’s approved service areas.

(2) (A) Within a specific service area or portion of a service area, if the plan reasonably anticipates and demonstrates to the satisfaction of the director both of the following:

(i) It will not have sufficient health care delivery resources to ensure that health care services will be available and accessible to the individual because of its obligations to existing enrollees.

(ii) It is applying this subparagraph uniformly to all individuals without regard to the claims experience of those individuals or any health status-related factor relating to those individuals.

(B) A health care service plan that cannot offer an individual health benefit plan to individuals because it is lacking in sufficient health care delivery resources within a service area or a portion of a service area pursuant to subparagraph (A) shall not offer a health benefit plan in that area to individuals until the later of the following dates:

(i) The 181st day after the date coverage is denied pursuant to this paragraph.

(ii) The date the plan notifies the director that it has the ability to deliver services to individuals, and certifies to the director that from the date of the notice it will enroll all individuals requesting coverage in that area from the plan.

(C) Subparagraph (B) shall not limit the plan’s ability to renew coverage already in force or relieve the plan of the responsibility to renew that coverage as described in Section 1365.

(D) Coverage offered within a service area after the period specified in subparagraph (B) shall be subject to this section.

(b) (1) A health care service plan may decline to offer an individual health benefit plan to an individual if the plan demonstrates to the satisfaction of the director both of the following:

(A) It does not have the financial reserves necessary to underwrite additional coverage. In determining whether this subparagraph has been satisfied, the director shall consider, but not be limited to, the plan’s compliance with the requirements of Section 1367, Article 6 (commencing with Section 1375), and the rules adopted thereunder.

(B) It is applying this subdivision uniformly to all individuals without regard to the claims experience of those individuals or any health status-related factor relating to those individuals.

(2) A plan that denies coverage to an individual under paragraph (1) shall not offer coverage before the later of the following dates:

(A) The 181st day after the date that coverage is denied pursuant to this subdivision.

(B) The date the plan demonstrates to the satisfaction of the director that the plan has sufficient financial reserves necessary to underwrite additional coverage.

(3) Paragraph (2) shall not limit the plan’s ability to renew coverage already in force or relieve the plan of the responsibility to renew that coverage as described in Section 1365.

(4) Coverage offered within a service area after the period specified in paragraph (2) shall be subject to this section.

(c) Nothing in this article shall be construed to limit the director’s authority to develop and implement a plan of rehabilitation for a health care service plan whose financial viability or organizational and administrative capacity has become impaired, to the extent permitted by PPACA.

(d) This section shall not apply to an individual health benefit plan that is a grandfathered health plan.


text: The director may require a plan to discontinue the offering of contracts or acceptance of applications from any individual, or responsible party for an individual, upon a determination by the director that the plan does not have sufficient financial viability, or organizational and administrative capacity to ensure the delivery of health care services to its enrollees. In determining whether the conditions of this section have been met, the director shall consider, but not be limited to, the plan’s compliance with the requirements of Section 1367, Article 6 (commencing with Section 1375), and the rules adopted thereunder.


text:
(a) A health care service plan that receives an application for an individual health benefit plan outside the Exchange during the initial open enrollment period, an annual enrollment period, or a special enrollment period described in Section 1399.849 shall inform the applicant that he or she may be eligible for lower cost coverage through the Exchange and shall inform the applicant of the applicable enrollment period provided through the Exchange described in Section 1399.849.

(b) On or before October 1, 2013, and annually every October 1 thereafter, a health care service plan shall issue a notice to a subscriber enrolled in an individual health benefit plan offered outside the Exchange. The notice shall inform the subscriber that he or she may be eligible for lower cost coverage through the Exchange and shall inform the subscriber of the applicable open enrollment period and special enrollment periods provided through the Exchange described in Section 1399.849.

(c) This section shall not apply where the individual health benefit plan described in subdivision (a) or (b) is a grandfathered health plan.

history: (History: Amended by Stats. 2017, Ch. 468, Sec. 4. (AB 156) Effective January 1, 2018.)


text:
(a) On or before October 1, 2013, and annually every October 1 thereafter, a health care service plan shall issue the following notice to all subscribers enrolled in an individual health benefit plan that is a grandfathered health plan: New improved health insurance options are available in California. You currently have health insurance that is not required to follow many of the new laws. For example, your plan may not provide preventive health services without you having to pay any cost sharing (copayments or coinsurance). Also, your current plan may be allowed to increase your rates based on your health status while new plans and policies cannot. You have the option to remain in your current plan or switch to a new plan. Under the new rules, a health plan cannot deny your application based on any health conditions you may have. For more information about your options, please contact Covered California at ____, your plan representative or insurance agent, or an entity paid by Covered California to assist with health coverage enrollment such as a navigator or an assister. (b) Commencing October 1, 2013, a health care service plan shall include the notice described in subdivision (a) in any renewal material of the individual grandfathered health plan and in any application for dependent coverage under the individual grandfathered health plan.

(c) A health care service plan shall not advertise or market an individual health benefit plan that is a grandfathered health plan for purposes of enrolling a dependent of a subscriber into the plan for policy years on or after January 1, 2014. Nothing in this subdivision shall be construed to prohibit an individual enrolled in an individual grandfathered health plan from adding a dependent to that plan to the extent permitted by PPACA.

history: (History: Amended by Stats. 2014, Ch. 31, Sec. 9. (SB 857) Effective June 20, 2014.)


text: Except as otherwise provided in this article, this article shall only be implemented to the extent that it meets or exceeds the requirements set forth in PPACA.


text:
(a) The department may adopt emergency regulations implementing this article no later than December 31, 2014. The department may readopt any emergency regulation authorized by this section that is the same as or substantially equivalent to an emergency regulation previously adopted under this section.

(b) The initial adoption of emergency regulations implementing this article and the one readoption of emergency regulations authorized by this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. Initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than one year, by which time final regulations may be adopted. The department shall consult with the Insurance Commissioner prior to adopting any regulations pursuant to this section for the specific purpose of ensuring, to the extent practical, that there is consistency of regulations applicable to entities regulated by the department and those regulated by the Insurance Commissioner.


text:
(a) For purposes of this article, a bridge plan product shall mean an individual health benefit plan, as defined in subdivision (f) of Section 1399.845, that is offered by a health care service plan licensed under this chapter that contracts with the Exchange pursuant to Title 22 (commencing with Section 100500) of the Government Code.

(b) Until December 31, 2014, a health care service plan that contracts with the California Health Benefit Exchange to offer a qualified bridge plan product pursuant to Section 100504 of the Government Code shall do all of the following:

(1) As of the effective date of this section, if the health care service plan has not been approved by the director to offer individual health benefit plans pursuant to this chapter, the plan shall file a material modification pursuant to Section 1352 to expand its license to include individual health benefit plans.

(2) As of the effective date of this section, if the health care service plan has been approved by the director to offer individual health benefit plans pursuant to this chapter, the plan shall, pursuant to Section 1352, file an amendment to expand its license to include a bridge plan product as an individual health benefit plan.

(c) During the time the health care service plan’s material modification or amendment is pending approval by the director, the health care service plan shall be deemed to comply with subdivision (b) of Section 100507 of the Government Code.

(d) A health care service plan shall maintain a medical loss ratio of 85 percent for the bridge plan product. A health care service plan shall utilize, to the extent possible, the same methodology for calculating the medical loss ratio for the bridge plan product that is used for calculating the health care service plan medical loss ratio pursuant to Section 1367.003 and shall report its medical loss ratio for the bridge plan product to the department as provided in Section 1367.003.

(e) Notwithstanding subdivision (a) of Section 1399.849, a health care service plan selling a bridge plan product shall not be required to fairly and affirmatively offer, market, and sell the health care service plan’s bridge plan product except to individuals eligible for the bridge plan product pursuant to the State Department of Health Care Services and the Medi-Cal managed care plan’s contract entered into pursuant to Section 14005.70 of the Welfare and Institutions Code, provided the health care service plan meets the requirements of subdivision (b) of Section 14005.70 of the Welfare and Institutions Code.

(f) Notwithstanding subdivision (c) of Section 1399.849, a health care service plan selling a bridge plan product shall provide an initial open enrollment period of six months, and an annual enrollment period and a special enrollment period consistent with the annual enrollment and special enrollment periods of the Exchange.

(g) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 10. (SB 3 1x) Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date.)


text:
(a) (1) On or before March 1, 2022, the department shall convene a Health Equity and Quality Committee to make recommendations to the department for standard health equity and quality measures, including annual benchmark standards for assessing equity and quality in health care delivery. The department may contract with consultants to assist the committee with the implementation and administration of its duties.

(2) The committee shall provide initial recommendations, as well as recommendations on updating and revising standard health equity and quality measures and annual benchmark standards, consistent with this article. These recommendations shall consider the interaction of multiple characteristics in determining where disparate outcomes exist, including, but not limited to, race, ethnicity, gender, sexual orientation, language, age, income, and disability.

(3) Meetings of the committee shall be subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of the Government Code).

(4) The department may contract with consultants to assist the committee with the implementation and administration of its duties.

(b) In appointing members to the committee, the director shall consider all of the following:

(1) The expertise of each committee member so that the committee’s composition reflects a diversity of relevant expertise.

(2) The racial, cultural, ethnic, sexual orientation, gender, economic, linguistic, age, disability, and geographical diversity of the state so that the committee’s composition reflects the communities of California.

(3) The expertise of representatives from other state agencies that are engaged in the work of setting quality and equity goals or standards for health care entities.

(4) The representation of consumer stakeholders that serve diverse populations.

(5) Inclusion of experts, researchers, and community members who are engaged in the development of alternative approaches to measuring health equity, consumer experience, and health outcomes.

(c) On or before September 30, 2022, the committee shall provide the recommendations described in subdivision (a), which may consider and may include all of the following:

(1) Quality measures, including, but not limited to, Healthcare Effectiveness Data and Information Set (HEDIS) measures and the federal Centers for Medicare and Medicaid Services Child and Adult Core Set measures.

(2) Surveys or other measures to assess consumer experience and satisfaction, including alternative approaches that take into account cultural competence, health literacy, exposure to discrimination, and social and cultural connectedness, such as connection to community, identity, traditions, and spirituality.

(3) Other child and adult quality or outcome measures that the committee determines are appropriate, including establishing new measures for patient-reported outcomes.

(4) Effective ways to measure health outcomes in the absence of quality measures, including both of the following:

(A) Demographic data or other data related to race, ethnicity, or socioeconomic variables that are currently collected by health care service plans.

(B) Other data sources, including the Health Care Payments Data Program established pursuant to Section 127671.1, the health evidence initiative of Covered California for the individual and small group markets, and other statistically valid and reliable sources of data.

(5) Approaches to stratifying reporting of results by factors, including, but not limited to, age, sex, geographic region, race, ethnicity, language, sexual orientation, gender identity, and income to the extent health plans or public programs have data on these factors and that the results are statistically valid and reliable.

(6) Alternative methods to measure health outcomes that permit sufficient stratification to determine impacts on health equity and quality that are not subject to the methodological limitations of current measurement approaches.

(7) Alternative methods to measure physical and behavioral health outcomes, including, but not limited to, measures to assess social and cultural connectedness, such as connection to community, identity, traditions, and spirituality. The department shall consult with the Office of Health Equity in identifying these alternative methods.

(8) Measures of social determinants of health, such as housing security, food insecurity, caregiving, and other nonmedical determinants of health.

(d) The committee’s recommendations shall include setting annual health equity and quality benchmarks.

(e) The department shall consider the committee’s recommendations in establishing the standard measures and annual benchmarks pursuant to Section 1399.871. The department shall enforce the established set of standard health equity and quality measures and applicable annual benchmarks consistent with Section 1399.872.

(f) The department shall reconvene the committee following the establishment of the standard measures and annual benchmarks pursuant to Section 1399.871 for the purpose of reviewing or revisiting the standard measures and annual benchmarks after the department has received data from health care service plans pursuant to Section 1399.872.

(g) Contracts entered into pursuant to this article are exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, and are exempt from the review or approval of any division of the Department of General Services, until January 1, 2024.

history: (History: Added by Stats. 2021, Ch. 143, Sec. 14. (AB 133) Effective July 27, 2021.)

article: 11.9. Health Equity and Quality

path: 2. LICENSING PROVISIONS > 2.2. Health Care Service Plans > 11.9. Health Equity and Quality


text:
(a) (1) The department shall establish standard measures and annual benchmarks for equity and quality in health care delivery.

(2) A standard measure or annual benchmark shall not be adopted, updated, or revised in any manner without being discussed during at least one public meeting of the Health Equity and Quality Committee before the meeting in which the committee makes recommendations to the director.

(3) Standard measures and annual benchmarks shall sunset at most every five years from the date the department establishes standard measures and annual benchmarks pursuant to paragraph (1). To continue the standard measures and annual benchmarks, the department shall conduct a public assessment, at least one year before the sunset, of whether the measures and benchmarks are improving quality and equity, consistent with this article.

(b) In establishing the standard measures and annual benchmarks pursuant to subdivision (a), the department shall consider the recommendations made by the Health Equity and Quality Committee pursuant to Section 1399.870, as well as stakeholder comments on draft standards and benchmarks.

(c) After the department establishes the standard measures and benchmarks pursuant to subdivision (a), a health care service plan shall comply with the annual benchmarks and shall demonstrate compliance in reports submitted to the department pursuant to Section 1399.872.

(d) (1) On or before January 1, 2026, a health care service plan and its subcontracted health care service plans shall have and maintain National Committee for Quality Assurance (NCQA) accreditation.

(2) This subdivision does not apply to a health care service plan that contracts with the State Department of Health Care Services to provide health care services to Medi-Cal beneficiaries. NCQA accreditation for these plans shall be in accordance with Section 14184.203 of the Welfare and Institutions Code.

(e) Throughout the development, implementation, and updating of the standard measures and annual benchmarks pursuant to this section, the department shall coordinate with the State Department of Health Care Services, the Office of Statewide Health Planning and Development, the California Health Benefit Exchange, CalPERS, and the State Department of Public Health.

article: 11.9. Health Equity and Quality


text:
(a) Upon the department’s establishment or updating of standard measures and annual benchmarks pursuant to Section 1399.871, a health care service plan shall annually submit to the department, at the time and in a manner specified by the department, a report containing health equity and quality data and information. A health care service plan shall implement the policies, procedures, and systems necessary for compliance with this article and shall, in a manner specified by the department, disclose substantiating documentation to the department demonstrating how the health care service plan shall achieve that compliance.

(b) The department shall review a health care service plan’s equity and quality report submitted pursuant to this section for compliance with the health equity and quality standard measures and annual benchmarks established pursuant to Section 1399.871. The department may also review and use other credible sources of information and data, including, but not limited to, relevant data provided by other state agencies, to determine a health care service plan’s compliance with the equity and quality standard measures and annual benchmarks.

(c) The department shall determine a health care service plan’s compliance with the health equity and quality standard measures and annual benchmarks and issue a report of its findings to the health care service plan, which shall also be made publicly available on the department’s internet website.

(d) If a health care service plan does not demonstrate compliance with this article, the department may take the following actions, which may be progressive, as appropriate:

(1) Require the health care service plan to implement corrective action to achieve and demonstrate compliance with the health equity and quality standard measures and annual benchmarks.

(2) Monitor a health care service plan’s corrective action plan and improvement efforts.

(3) Investigate and require supplemental reporting by the health care service plan.

(4) Assess an administrative penalty in an amount that is initially commensurate with the failure to meet the requirements of this article, and assess additional penalties, in escalating amounts for repeated or continuing failure to meet the requirements. The director may assess administrative penalties under this paragraph if a health care service plan engages in any of the following conduct:

(A) Fails to report complete and accurate data required by this article.

(B) Neglects to file a required corrective action plan with the department.

(C) Fails to file an acceptable required corrective action plan with the department.

(D) Fails to implement or monitor a required corrective action plan.

(E) Fails to provide information required by this article to the department.

(F) Falsifies information required by this section.

(G) Fails to meet the health equity and quality standard measures and annual benchmarks established pursuant to Section 1399.871.

(5) Take other disciplinary or other enforcement action, as determined necessary and appropriate by the director.

(6) If the department assesses an administrative penalty or takes other disciplinary action, the department shall inform the California Health Benefit Exchange, the Office of Statewide Health Planning and Development, CalPERS, and the State Department of Health Care Services, each of which shall consider appropriate action.

(e) (1) For the measurement years 2023 and 2024, the department’s enforcement activities pursuant to subdivision (d) shall address deficiencies in procedural data collection, reporting, corrective action plan implementation, or monitoring requirements pursuant to this article.

(2) Commencing with measurement year 2025, and for each following measurement year, the department’s enforcement activities shall address deficiencies in meeting the requirements under paragraph (1), compliance with the standard measures and annual benchmarks, and all other requirements pursuant to this article.

(3) For the purpose of this subdivision, “measurement year” means the time period within which a health care service plan shall collect the required information for the report required by this section.

(f) Commencing in 2025, and annually thereafter, the department shall publish on its internet website a Health Equity and Quality Compliance Report.

(g) The department shall coordinate with the State Department of Health Care Services to support the review of, and any compliance action taken with respect to, Medi-Cal managed care plans consistent with this article, to maintain consistency with the applicable federal and state Medicaid requirements governing those plans.

article: 11.9. Health Equity and Quality


text:
(a) Except as provided by any other law, the requirements of this article apply to health care service plans that cover hospital, medical, or surgical expenses, including a health care service plan that contracts with the State Department of Health Care Services to provide health care services to Medi-Cal beneficiaries, and specialized health care service plans that provide behavioral health care.

(b) The obligation of a health care service plan to comply with this article is not waived if the health care service plan delegates any services or functions to its medical groups, independent practice associations, or other contracting entities.

article: 11.9. Health Equity and Quality


text:
(a) This article does not restrict the director’s enforcement authority under this chapter.

(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article by means of all-plan letters, methodologies, rules, policies, forms, or similar instructions, without taking regulatory action, until January 1, 2027.

article: 11.9. Health Equity and Quality


text:
(a) For the purposes of this chapter, “disease management organization” means an entity that provides disease management programs and services and that contracts with any of the following:

(1) A health care service plan.

(2) A contractor of a health care service plan.

(3) An employer.

(4) A publicly financed health care program.

(5) A government agency.

(b) A disease management organization shall not include an entity whose primary purpose is to market specific products or services to enrollees of a health care service plan.

(c) No medical group, individual licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or health facility as defined in Section 1250, that provides disease management programs and services incidental to their primary professional practices, shall be considered a disease management organization.

history: (History: Added by Stats. 2000, Ch. 1065, Sec. 2. Effective January 1, 2001.)

chapter: 2.25. Disease Management

path: 2. LICENSING PROVISIONS > 2.25. Disease Management


text:
For the purposes of this chapter, “disease management programs and services” means services administered to patients in order to improve their overall health and to prevent clinical exacerbations and complications utilizing cost-effective, evidence-based, or consensus-based practice guidelines and patient self-management strategies. Disease management programs and services shall contain all of the following:

(a) A population identification process.

(b) Evidence-based or consensus-based clinical practice guidelines, risk identification, and matching of interventions with clinical need.

(c) Patient self-management and disease education.

(d) Process and outcomes measurement, evaluation, management, and reporting.


text:
(a) Every disease management organization shall obtain physician authorization prior to the time that the disease management organization, its employees, or independent contractors do either of the following:

(1) Provide home health care services utilized in the treatment of a patient.

(2) Dispense, administer, or prescribe a prescription medication.

(b) For purposes of this section, a valid prescription written by a treating physician shall constitute authorization to dispense a prescription medication.

(c) Home health care followup visits made solely for patient assessment, monitoring, or education are not subject to the physician authorization requirement in subdivision (a).

(d) Nothing in this section, in the absence of authorization granted by any other law, shall be construed to authorize the activities described in paragraphs (1) and (2) of subdivision (a).


text: A disease management organization may receive medical information as provided in paragraph (17) of subdivision (c) of Section 56.10 of the Civil Code. However, a disease management organization shall be subject to the other provisions of the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code), including, but not limited to, subdivisions (d) and (e) of Section 56.10 of, and Section 56.36 of, the Civil Code.


text: A disease management organization shall not use medical information obtained pursuant to Section 1399.903 to solicit or to offer for sale to a health care service plan enrollee any products or services in the provision of disease management services to the enrollee. However, an enrollee may elect to use a disease management organization to obtain information about health care products and services and, pursuant to that election by the enrollee, the disease management organization may offer to the enrollee health care products or services that are directly related to the enrollee’s condition.


citation: HSC § 1400

text:
(a) It is unlawful for any person, association, or corporation to establish, conduct or maintain a referral agency or to refer any person for remuneration to any extended care, skilled nursing home or intermediate care facility or a distinct part of a facility providing extended care, skilled nursing home care, or intermediate care, without first having obtained a written license therefor as provided in this chapter from the director or from an inspection service approved by the director pursuant to Section 1257.

(b) It is unlawful for any person, association, or corporation to establish, conduct, or maintain a referral agency or to refer any person for remuneration to any person or agency outside a long-term health care facility, as defined in Section 1418, for professional services for which the long-term health care facility does not employ a qualified professional person to furnish a specific service, including, but not limited to, laboratory, diagnostic, or therapy services, unless the long-term health care facility complies with current federal and state laws regarding the provision of these services and all of the following conditions are met:

(1) The services will be provided in accordance with professional standards applicable to the provision of these services in a long-term health care facility.

(2) The long-term health care facility assumes responsibility for timeliness of the services.

(3) Services are provided or obtained only when ordered by the attending physician and a notation is made in the resident’s medical chart reflecting that the service has been provided to the resident.

history: (History: Amended by Stats. 2004, Ch. 661, Sec. 1. Effective January 1, 2005.)

chapter: 2.3. Referral Agencies

article: 1. General Provisions

path: 2. LICENSING PROVISIONS > 2.3. Referral Agencies > 1. General Provisions


citation: HSC § 1401

text: As used in this chapter “referral agency” means a private, profit or nonprofit agency which is engaged in the business of referring persons for remuneration to any extended care, skilled nursing home or intermediate care facility or a distinct part of a facility providing extended care, skilled nursing home care, or intermediate care.

history: (History: Added by Stats. 1973, Ch. 924.)

article: 1. General Provisions


citation: HSC § 1403

text: Each application for a license or renewal of license under this chapter shall be accompanied by an annual Licensing and Certification Program fee set in accordance with Section 1266. Each license shall expire 12 months from its date of issuance and application for renewal accompanied by the fee shall be filed with the director not later than 30 days prior to the date of expiration.

history: (History: Amended by Stats. 2006, Ch. 74, Sec. 15. Effective July 12, 2006.)

article: 1. General Provisions


citation: HSC § 1404

text: No licensee under this chapter shall have a direct or indirect financial interest in any medical facility doing business with the licensee.

article: 1. General Provisions


text:
A license application shall be submitted to the department whenever any of the following circumstances occur:

(a) Change of ownership of the referral agency.

(b) Change of name of the referral agency.

(c) Change of location of the referral agency.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 10.)

article: 1. General Provisions


citation: HSC § 1405

text:
Any person, partnership, firm, corporation or association desiring to obtain a license shall file with the department an application on forms furnished by the department. The application shall contain all of the following:

(a) Name of applicant, and if an individual, whether the applicant has attained the age of 18 years.

(b) Name of referral agency.

(c) The location of the referral agency.

(d) The business or occupation engaged in by each applicant, and by each partner, officer and director, for at least two years immediately preceding the filing of the application. In addition, each such person shall submit a statement setting forth whether he or she has previously engaged in the operation of a referral agency, whether he or she has been involved in, or the subject of, a refusal or revocation of a referral agency license, and whether he or she has been convicted of a crime other than a minor traffic offense.

(e) If the applicant is a corporation, the name and principal business address of each officer and director of the corporation; and for nonpublic corporations, the name and business address of each stockholder owning 10 percent or more of the stock and the name and business address of any corporation member who has responsibility in the operation of the facility.

(f) If the applicant is a partnership, the name and principal business address of each partner.

(g) Evidence of the right to occupy the premises where the referral agency is to be located.

(h) A copy of the partnership agreement of the Articles of Incorporation, if applicable.

(i) A copy of the current organization chart.

(j) A schedule of fees to be charged and collected by the referral agency, and a statement of the method by which each fee is to be computed or determined.

(k) A declaration that the licensee will not have any financial interest in any health facility doing business with the referral agency.

( l) Evidence satisfactory to the department that the applicant demonstrates reputable and responsible character and the capability to comply with this chapter.

history: (History: Repealed and added by Stats. 1985, Ch. 700, Sec. 12.)

article: 1. General Provisions


citation: HSC § 1406

text: This chapter shall not apply to any local public agency performing referral services without cost to recipients of public social services when otherwise authorized by law.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 13.)

article: 1. General Provisions


citation: HSC § 1407

text:
(a) Any licensee desiring to voluntarily surrender his or her license for cancellation or temporary suspension shall notify the department in writing as soon as possible and, in all cases, at least 30 days prior to the effective date of cancellation or temporary suspension of the license.

(b) Any license placed in temporary suspension pursuant to this section may be reinstated by the department within 12 months of the date of the voluntary suspension on receipt of an application and evidence showing compliance with licensing requirements.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 14.)

article: 1. General Provisions


citation: HSC § 1408

text:
(a) Upon verification of compliance with this chapter and with the approval of the department, the department shall issue the license to the applicant.

(b) If the applicant is not in compliance with this chapter, the department shall deny the applicant a license. Immediately upon the denial of any license, the department shall notify the applicant in writing. Within 20 days of receipt of the department’s notice, the applicant may present his or her written petition for a hearing to the department. The proceedings shall be conducted in accordance with Section 100171.

history: (History: Amended by Stats. 1997, Ch. 220, Sec. 14. Effective August 4, 1997.)

article: 1. General Provisions


citation: HSC § 1409

text: Separate licenses shall be required for referral agencies which are maintained on separate, noncontiguous premises.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 16.)

article: 1. General Provisions


text: The license or true copy thereof shall be conspicuously posted in a prominent location accessible to public view.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 17.)

article: 1. General Provisions


text: Licenses issued pursuant to this article are not transferable.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 18.)

article: 1. General Provisions


text:
(a) The licensee shall notify the department within 10 days in writing when a change of stockholder owning 10 percent or more of the nonpublic corporate stock occurs. The writing shall include the name and principal mailing addresses of the new stockholder.

(b) When a change of agency manager occurs, the department shall be notified in writing within 10 days by the licensee. The notification shall include the name of the new agency manager.

(c) Each licensee shall notify the department within 10 days in writing of any change of the mailing address of the licensee. The writing shall include the new mailing address of the licensee.

(d) When a change in the principal officer of a corporate licensee, chairperson, president, or general manager, occurs the department shall be notified within 10 days in writing by the licensee. The writing shall include the name and principal business address of the officer.

history: (History: Added by Stats. 1985, Ch. 700, Sec. 19.)

article: 1. General Provisions


citation: HSC § 1410

text: The department may suspend or revoke licenses issued under this chapter for violation of any provisions of this chapter or rules and regulations promulgated hereunder. In addition, the department shall assess a civil penalty in the amount of fees received by a licensee as a result of a violation of any provisions of this chapter or rules and regulations promulgated hereunder. Proceedings to suspend or revoke a license shall be conducted pursuant to Section 100171.

history: (History: Amended by Stats. 1997, Ch. 220, Sec. 15. Effective August 4, 1997.)

article: 2. Penalties

path: 2. LICENSING PROVISIONS > 2.3. Referral Agencies > 2. Penalties


citation: HSC § 1411

text: A violation of the provisions of this chapter or rules and regulations promulgated hereunder by a person licensed pursuant to Division 2 (commencing with Section 500) or a person certificated or licensed pursuant to Chapter 17 (commencing with Section 9000) of Division 3 of, the Business and Professions Code may be grounds for suspension or revocation of the person’s license under such division.

article: 2. Penalties


citation: HSC § 1412

text: Any person, association or corporation referring persons without a license in violation of Section 1400 shall be liable for a civil penalty in the amount of the remuneration illegally recieved, which shall be assessed and recovered in a civil action brought in the name of the people of the State of California by the Attorney General in any court of competent jurisdiction.

article: 2. Penalties


citation: HSC § 1413

text: Civil penalties collected pursuant to this article shall be used to administer the provisions of this chapter.

article: 2. Penalties


citation: HSC § 1416

text: This chapter shall be known and may be cited as the Nursing Home Administrators’ Act.

history: (History: Added by Stats. 2001, Ch. 687, Sec. 5. Effective January 1, 2002.)

article: 1. General Provisions

path: 2. LICENSING PROVISIONS > 2.35. Nursing Home Administrator Program > 1. General Provisions


text: There is hereby established in the State Department of Health Services a Nursing Home Administrator Program (NHAP), which shall license and regulate nursing home administrators.

chapter: 2.35. Nursing Home Administrator Program

article: 1. General Provisions


text:
(a) The following definitions shall apply to this chapter:

(1) “Department” means the State Department of Health Services.

(2) “NHAP” or “program” means the Nursing Home Administrator Program.

(3) “State” means California, unless applied to the different parts of the United States. In this latter case, “state” includes the District of Columbia and the territories.

(4) “Nursing home” means any institution, facility, place, building, or agency, or portion thereof, licensed as a skilled nursing facility, intermediate care facility, or intermediate care facility/developmentally disabled, as defined in Chapter 2 (commencing with Section 1250). “Nursing home” also means an intermediate care facility/developmentally disabled habilitative, intermediate care facility/developmentally disabled-nursing, or congregate living health facility, as defined in Chapter 2 (commencing with Section 1250), if a licensed nursing home administrator is charged with the general administration of the facility.

(5) “Nursing home administrator” means an individual educated and trained within the field of nursing home administration who carries out the policies of the licensee of a nursing home and is licensed in accordance with this chapter. The nursing home administrator is charged with the general administration of a nursing home, regardless of whether he or she has an ownership interest and whether the administrator’s function or duties are shared with one or more other individuals.

(6) “Administrator-in-Training Program” or “AIT Program” means a program that is approved by the NHAP in which qualified persons participate under the coordination, supervision, and teaching of a preceptor, as described in Section 1416.57, who has obtained approval from the NHAP.

(b) Nothing in this section shall be construed to allow the program to have jurisdiction over an administrator of an intermediate care facility/developmentally disabled-nursing or an intermediate care facility/developmentally disabled habilitative, if the administrator of the facility is not using licensure under this chapter to qualify as an administrator in accordance with subdivision (d) of Section 1276.5.

(c) Nothing in this section shall be construed to define an intermediate care facility/developmentally disabled-nursing or an intermediate care facility/developmentally disabled habilitative as a nursing home for purposes other than the licensure of nursing home administrators under this chapter.

article: 1. General Provisions


text: The program shall adopt rules and regulations that are reasonably necessary to carry out this chapter. The rules and regulations shall be adopted, amended, and repealed in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. To the extent that the regulations governing the nursing home administrator program that are in effect prior to January 1, 2002, are not in conflict with this chapter, they shall remain in effect until new regulations are implemented for purposes of this chapter.

article: 1. General Provisions


text:
(a) It shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the holder of an active nursing home administrator’s license issued in accordance with this chapter. Persons carrying out functions and duties delegated by a licensed nursing home administrator shall not be acting in violation of this chapter.

(b) (1) This chapter shall not apply to any person who serves as an acting administrator as provided in this subdivision when a licensed administrator is not available because of death, illness, or any other reason.

(2) A person who is acting as an administrator shall notify the program in writing within five days of acting in this capacity and provide factual information and specific circumstances necessitating the use of an acting administrator.

(3) No person shall act as an administrator for more than 10 days unless arrangements have been made for part-time supervision of his or her activities by a nursing home administrator who holds a license or provisional license under this chapter. Supervision shall include at least 8 hours per week of direct onsite supervision by the licensed administrator. The program shall be notified in writing of the nature of this arrangement. No person shall act as an administrator for more than two months without the written approval of the program. The program shall not approve a person to act as an administrator for more than six months.

(4) If the acting administrator is an administrator in training, then the supervision required by paragraph (3) may be counted towards the total hours of supervised training required by subdivision (f) of Section 1416.57.

(c) Notwithstanding subdivision (b), an individual acting as an administrator for more than 10 days must have management experience in a health facility.

article: 1. General Provisions


text:
In conformity with the requirements of Section 1908(c) of the Social Security Act (42 U.S.C. Sec. 1396g(c)), the program shall have all of the following powers and duties:

(a) To develop, impose, and enforce standards that shall be met by individuals in order to receive a license as a nursing home administrator. At a minimum, the standards shall be designed to ensure that nursing home administrators shall be individuals who have not committed acts or crimes constituting grounds for denial of licensure and who are qualified by training or experience in the field of institutional administration to serve as nursing home administrators.

(b) To develop and apply procedures, including examinations and investigations, for determining whether an individual meets the standards.

(c) To issue licenses to individuals who have been determined to meet the standards, and to revoke or suspend licenses where grounds exist for those actions.

(d) To establish and carry out procedures designed to ensure that individuals licensed as nursing home administrators will, during any period that they serve as an administrator, comply with the required standards.

(e) To receive, investigate, and take appropriate action with respect to any charge or complaint filed with the program alleging that an individual licensed as a nursing home administrator has failed to comply with the required standards.

(f) To conduct studies of the administration of nursing homes within the state, with a view to the improvement of the standards imposed for the licensing of nursing home administrators, and of procedures and methods for the enforcement of standards with respect to administrators of nursing homes who have been licensed under this chapter.

(g) To receive and administer all funds and grants as are made available to the program in order to carry out the purposes of this chapter.

(h) To encourage qualified educational institutions and other qualified organizations to establish, provide, and conduct training and instruction programs and courses that will enable all otherwise qualified individuals to attain the qualifications necessary to meet the standards set by the program for licensed nursing home administrators, and to enable licensed nursing home administrators to meet the continuing education requirements for the renewal of their licenses.

(i) To consult with and seek the recommendations of the appropriate statewide professional societies, associations, institutional organizations, and educational institutions in the development of educational programs.

(j) To give due consideration to the recommendations of the National Advisory Council on Nursing Home Administration, in accordance with the provisions of subdivision (f) of Section 1908 of Title XIX of the Social Security Act (42 U.S.C. Sec. 1396g(f)).

article: 2. Administration

path: 2. LICENSING PROVISIONS > 2.35. Nursing Home Administrator Program > 2. Administration


text:
The following enforcement actions taken by the department against a facility and the name of the licensed administrator of the facility shall be reported to the program.

(a) Temporary suspension orders.

(b) Final decertification from the Medi-Cal or Medicare programs based on failure to meet certification requirements.

(c) Service of an accusation to revoke a facility’s license.

(d) All class “AA” citations and three class “A” citations issued to a facility with the same administrator within a one-calendar year period. The department shall notify the program in the event that citations are overturned or modified in citation review conference, through binding arbitration, or on appeal.

article: 2. Administration


text:
(a) The nursing home administrator licensing examination shall cover the broad aspects of nursing home administration.

(b) Unless otherwise provided in this article, every applicant for an initial license as a nursing home administrator shall pass a nursing home administrator licensing examination, which shall consist of a state and national examination. The state examination shall be held at least four times a year, at a time and place determined by the program. The national examination is computer-based and shall be scheduled by the applicant after the applicant is notified by the program of his or her eligibility to take the examination.

(c) If an applicant for licensure under this article, submits an endorsement certificate from another state indicating that he or she scored at least 75 percent on the national examination, the applicant shall be required to take only the California state part of the licensing examination. If the applicant scored less than 75 percent on the national examination, he or she shall take both the state and national examination.

article: 3. Licensing

path: 2. LICENSING PROVISIONS > 2.35. Nursing Home Administrator Program > 3. Licensing


text:
(a) To qualify for the licensing examination, an applicant must be at least 18 years of age, be a citizen of the United States or a legal resident, be of reputable and responsible character, demonstrate an ability to comply with this chapter, and comply with at least one of the following requirements:

(1) Have a master’s degree in nursing home administration or a related health administration field. The master’s program in which the degree was obtained must have included an internship or residency of at least 480 hours in a skilled nursing facility or intermediate care facility.

(2) (A) With regard to applicants who have a current valid license as a nursing home administrator in another state and apply for licensure in this state, meet the minimum education requirements that existed in this state at the time the applicant was originally licensed in the other state.

(B) The minimum education requirements that have existed in California are as follows:Prior to 7/1/73NoneFrom 7/1/73 to 6/30/7430 semester unitsFrom 7/1/74 to 6/30/7545 semester unitsFrom 7/1/75 to 6/30/8060 semester unitsFrom 7/1/80 to presentBaccalaureate degree(3) A doctorate degree in medicine, a current valid license as a physician and surgeon, and the completion of a program-approved AIT Program of at least 1,000 hours.

(4) A baccalaureate degree, and the completion of a program-approved AIT Program of at least 1,000 hours.

(5) Ten years of recent full-time work experience, and a current license, as a licensed registered nurse, and the completion of a program-approved AIT Program of at least 1,000 hours. At least the most recent five years of the 10 years of work experience shall be in a supervisory or director of nursing position.

(6) Ten years of full-time work experience in any department of a skilled nursing facility, an intermediate care facility, or an intermediate care facility developmentally/disabled with at least 60 semester units (or 90 quarter units) of college or university courses, and the completion of a program-approved AIT Program of at least 1,000 hours. At least the most recent five years of the 10 years of work experience shall be in a position as a department manager.

(7) Ten years of full-time hospital administration experience in an acute care hospital with at least 60 semester units (or 90 quarter units) of college or university courses, and the completion of a program-approved AIT Program of at least 1,000 hours. At least the most recent five years of the 10 years of work experience shall be in a supervisory position.

(b) An applicant for the licensing examination may obtain from the department a waiver of the education requirements in subdivision (a) if they meet the requirements of Section 1416.23.

(c) If the applicant and the preceptor provide compelling evidence that previous work experience of the applicant directly relates to nursing home administrator duties, the program may accept a waiver exception to a portion of the AIT Program that requires 1,000 hours. An applicant seeking a waiver of the educational requirements pursuant to Section 1416.23 shall not be eligible for a waiver under this subdivision.

(d) The applicant shall submit an official transcript that evidences the completion of required college and university courses, degrees, or both. An applicant who applies for the licensing examination on the basis of work experience shall submit a declaration signed under penalty of perjury, verifying his or her work experience. This declaration shall be signed by a licensed nursing home administrator, physician and surgeon, chief of staff, director of nurses, or registered nurse who can attest to the applicant’s work experience.

history: (History: Amended by Stats. 2008, Ch. 397, Sec. 1. Effective January 1, 2009.)

article: 3. Licensing


text:
(a) Upon request of an applicant who is a member of a church or religious denomination, recognized by the Internal Revenue Service under Section 501(c)(3) of the Internal Revenue Code, that owns and operates a faith-based skilled nursing facility in California, and whose teachings historically prohibit the acquisition of the formal education that would otherwise be required to qualify for the AIT Program and the licensing examination, that applicant may seek an educational waiver. That applicant shall be required to possess at least an accredited high school diploma or proof of successfully passing a General Educational Development (GED) test of the American Council on Education or the California High School Proficiency Examination, as well as 10 years of full-time work experience in business, health, or rehabilitation fields, with at least five of the 10 years of work experience in business, health, or rehabilitation management or administration.

(b) The department may review the applicant’s church’s or religious denomination’s Internal Revenue Code 501(c)(3) application, including attachments, the Internal Revenue Service’s Letter of Determination of tax-exempt status to the church or religious denomination, and the church’s or religious denomination’s bylaws, constitution, or member orientation information to confirm an applicant’s eligibility for the educational waiver. The applicant’s church or religious denomination shall provide the foregoing information to the department for its review and processing of the educational waiver application. The department shall accept notarized copies of these documents.

(c) If the educational requirements are waived, the applicant successfully completes the program-approved 1,000 hour AIT Program, and is successful in passing the national and state licensing examinations, the applicant may only serve as a nursing home administrator in a facility that is owned and operated by the applicant’s church or religious denomination.

history: (History: Added by Stats. 2008, Ch. 397, Sec. 2. Effective January 1, 2009.)

article: 3. Licensing


text:
(a) An application for a nursing home administrator license shall be submitted to the program on a form provided by the program, with the appropriate nonrefundable fee for any required examination, the application, and licensure. The application shall contain information the program deems necessary to determine the applicant’s qualifications and a statement whether the individual has been convicted of any crime other than a minor traffic violation. Each applicant shall meet the current requirements for any required examination and licensure. Applicants for licensure shall submit evidence of electronic transmission of fingerprints or fingerprint cards to the program.

(b) A completed application package, together with the examination application, and licensure fees must be received by the program at least 30 days prior to the examination date.

(c) (1) The withdrawal of an application for a license after it has been filed with the department shall not, unless the department consents in writing to the withdrawal, deprive the department of its authority to institute or continue a proceeding against the applicant for the denial of the license upon any ground provided by law or to enter an order denying the license upon that ground.

(2) The suspension, expiration, or forfeiture by operation of law of a license issued by the department, the suspension, forfeiture, or cancellation by order of the department or a court of law of a license, or the surrender without the written consent of the department of a license, shall not deprive the department of its authority to institute or continue a disciplinary proceeding against the licensee upon any ground provided by law or to enter an order suspending or revoking the license or otherwise taking disciplinary action against the licensee on any grounds.

(d) An application that is submitted to the program is valid for only one year after the date of receipt. An applicant who fails to meet all requirements for licensure, including successfully passing the national and state examinations during that one-year period, shall be required to submit another application and appropriate application and examination fees to the program before attempting further examinations.

(e) The program may extend the one-year period described in subdivision (d) upon a showing of good cause. For purposes of this subdivision, good causes shall include, but shall not be limited to, delays in the processing of the application, or delays in applying for and taking the examination caused by illness, accident, or other extenuating circumstances.

(f) An applicant shall submit documentation and evidence to the program of his or her eligibility for licensure.

(g) At the time of the examination, the applicant shall read and sign the Examination Security Agreement and comply with its terms.

article: 3. Licensing


text:
(a) As part of the application process for a nursing home administrator license, an applicant shall electronically submit fingerprint images and related information, for a criminal offender record information search, to the Department of Justice and the Federal Bureau of Investigation, through the Department of Justice. The applicant shall provide proof of electronic transmission of his or her fingerprint images and related information to the Department of Justice and the Federal Bureau of Investigation. Upon receipt of the fingerprint images and related information, the Department of Justice shall notify the department with a state or federal level criminal offender record information search response. If no state or federal level criminal record information has been recorded, the Department of Justice shall provide the department with a statement of that fact.

(b) This criminal record clearance shall be completed prior to issuing a license. Applicants shall be responsible for any costs associated with the criminal record clearance. The fee to cover the processing costs of the Department of Justice, not including the costs associated with capturing or transmitting the fingerprint images and related information, shall not exceed thirty-two dollars ($32) for a state level criminal offender record information search, and shall not exceed twenty-four dollars ($24) for a federal level criminal offender record information search.

history: (History: Amended by Stats. 2006, Ch. 902, Sec. 3. Effective January 1, 2007.)

article: 3. Licensing


text:
(a) Notwithstanding any other law, the program shall at the time of application, issuance, or renewal of a nursing home administrator license require that the applicant or licensee provide the federal employer identification number or social security number of the applicant or licensee.

(b) Any applicant or licensee failing to provide a federal identification number or social security number shall be reported by the program to the Franchise Tax Board and, if failing to provide after notification pursuant to paragraph (1) of subdivision (b) of Section 19528 of the Revenue and Taxation Code, shall be subject to the penalty provided in paragraph (2) of subdivision (b) of Section 19528 of the Revenue and Taxation Code.

(c) In addition to the penalty specified in subdivision (b), the program may not process any application, original license, or renewal of a license unless the applicant or licensee provides a federal employer identification number or social security number where requested on the application.

(d) The program shall, upon request of the Franchise Tax Board, furnish to the Franchise Tax Board the following information with respect to every licensee:

(1) Name.

(2) Address or addresses of record.

(3) Federal employer identification number or social security number.

(4) Type of license.

(5) Effective date of license or renewal.

(6) Expiration date of license.

(7) Whether license is active or inactive, if known.

(8) Whether license is new or a renewal.

(e) The reports required under this section shall be filed on magnetic media or in other machine-readable form, according to standards furnished by the Franchise Tax Board.

(f) The program shall provide to the Franchise Tax Board the information required by this section at a time that the Franchise Tax Board may require.

(g) Notwithstanding Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code, the social security number and federal employer identification number furnished pursuant to this section shall not be deemed to be a public record and shall not be open to the public for inspection.

(h) Any deputy, agent, clerk, officer, or employee of the program described in this chapter, any former officer or employee, or other individual who in the course of employment or duty has or has had access to the information required to be furnished under this chapter, may not disclose or make known in any manner that information, except as provided in this section to the Franchise Tax Board or as provided in subdivision (j).

(i) It is the intent of the Legislature in enacting this section to utilize the social security account number or federal employer identification number for the purpose of establishing the identification of persons affected by state tax laws and for purposes of compliance with Section 17520 of the Family Code and, to that end, the information furnished pursuant to this section shall be used exclusively for those purposes.

(j) If the program utilizes a national examination to issue a license, and if a reciprocity agreement or comity exists between California and the state requesting release of the social security number, any deputy, agent, clerk, officer, or employee of the program described in this chapter may release a social security number to an examination or licensing entity, only for the purpose of verification of licensure or examination status.

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 232. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

article: 3. Licensing


text:
(a) The program shall require compliance with any judgment or order for support prior to issuance or renewal of a license.

(b) Each applicant for the issuance or renewal of a nursing home administrator license, who is not in compliance with a judgment or order for support shall be subject to Section 11350.6 of the Welfare and Institutions Code.

(c) “Compliance with a judgment or order of support” has the same meaning as specified in paragraph (4) of subdivision (a) of Section 11350.6 of the Welfare and Institutions Code.

article: 3. Licensing


text:
(a) Prior to admission to the licensing examination, the applicant shall read and sign an examination security agreement and comply with its terms.

(b) The program may deny, suspend, revoke, or otherwise restrict the license of an applicant or a licensee for any of the following acts:

(1) Having or attempting to have an impersonator take the examination on one’s behalf.

(2) Impersonating or attempting to impersonate another to take the examination on that person’s behalf.

(3) Communicating or attempting to communicate about the examination content with another examinee or with any person other than the examination staff. This includes divulging the content of specific written examination items to examination preparation providers.

(4) Copying questions or making notes of examination materials or revealing the content of the examination to others who are preparing to take the NHAP examination or who are preparing others to take such examination.

(5) Obstructing or attempting to obstruct the administration of the examination in any way.

(c) It is a misdemeanor for any person to engage in any conduct that subverts or attempts to subvert any licensing examination or the administration of an examination, including, but not limited to, the following conduct:

(1) Conduct that violates the security of the examination materials, removing from the examination room any examination materials without authorization, the unauthorized reproduction by any means of any portion of the actual licensing examination, aiding by any means the unauthorized reproduction of any portion of the actual licensing examination, paying or using professional or paid examination-takers for the purpose of reconstructing any portion of the licensing examination, obtaining examination questions or other examination material, except by specific authorization either before, during, or after an examination, using or purporting to use any examination questions or materials that were improperly removed or taken from any examination for the purpose of instructing or preparing any applicant for examination, or selling, distributing, buying, receiving, or having unauthorized possession of any portion of a future, current, or previously administered licensing examination.

(2) Communicating with any other candidate during the administration of a licensing examination, copying answers from another examinee or permitting one’s answers to be copied by another examinee, having in one’s possession during the administration of the licensing examination any books, equipment, notes, written or printed materials, or data of any kind, other than the examination materials distributed, or otherwise authorized to be in one’s possession during the examination, or impersonating any examinee or having an impersonator take the licensing examination on one’s behalf.

(d) Nothing in this section shall preclude prosecution under the authority provided for in any other provision of law.

(e) In addition to any other penalties, a person found guilty of violating this section, shall be liable for the actual damages sustained by the agency administering the examination not to exceed ten thousand dollars ($10,000) and the costs of litigation.

(f) The proceedings under this section shall be governed by Chapter 3 (commencing with Section 525) of Title 7 of Part 2 of the Code of Civil Procedure.

(g) The remedy provided for by this section shall be in addition to, and not a limitation on, the authority provided for in any other provision of law.

article: 3. Licensing


text:
(a) (1) In order to have a passing score on either the national or state examination, an examinee shall earn a score of at least 75 percent.

(2) An applicant who fails to pass either the national or state examination shall retake the entire national or state examination.

(3) An applicant who fails to pass either the state or national examination after three attempts shall receive additional training as outlined by the program from a program-approved preceptor, prior to participating in another examination.

(b) The examination shall be administered and evaluated by either of the following:

(1) The department.

(2) A contractor or vendor pursuant to a written agreement with the program or department.

(c) The results of the examination shall be provided to each applicant in a timely manner, not to exceed 90 days from the date of the examination.

(d) The program shall issue a license to an applicant who successfully passes the required examination and has satisfied all other requirements for licensure.

(e) A license shall be effective for a period of two years from the date of issuance.

(f) The program shall issue a provisional license to candidates who meet the provisional licensure requirements established by this chapter.

(g) The program shall replace a lost, damaged, or destroyed license certificate upon receipt of a written request from a licensee and payment of the duplicate license fee. A licensee shall complete a request for a duplicate license on the required program form, and then submit it to the program.

(h) A licensee shall inform the program of the licensee’s current home address, mailing address, and if employed by a nursing facility, the name and address of that employer. A licensee shall report a change in any of this information to the program within 30 calendar days. Failure of the licensee to provide timely notice to the program may result in a citation penalty. A licensee shall provide to the program an address to be included in the public files.

(i) A licensee shall display his or her license and show to anyone upon request in order to inform patients or the public as to the identity of the regulatory agency that they may contact if they have questions or complaints regarding the licensee.

article: 3. Licensing