text:
(a) The County Health Initiative Matching Fund is hereby continued in existence within the State Treasury. The fund shall accept funding, including but not limited to, funding from intergovernmental transfers as follows:

(1) The nonfederal matching fund requirement for federal financial participation through the State Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code).

(2) Funding associated with a proposal approved pursuant to subdivision (e) Section 15853.

(3) State general fund amounts pursuant to subdivision (b) of Section 15850.5.

(b) Notwithstanding Section 13340 of the Government Code, amounts deposited in the fund shall be continuously appropriated to the department without regard to fiscal year, and shall be used only for the purposes specified by this section.

(c) The department shall administer this fund and the provisions of this chapter for the express purpose of allowing local or state funds to be used to facilitate increasing the state’s ability to utilize federal funds available to California and for costs associated with a proposal pursuant to subdivision (e) of Section 15853 or for costs incurred by the department pursuant to paragraph (1) of subdivision (b) of Section 15850.5. Federal funds shall be used prior to the expiration of their authority for programs designed to improve and expand access for uninsured persons.

(d) The department shall be reimbursed from the fund to cover the cost to administer the program.

history: (History: Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15864.)


kind: section

code: WIC

text:
(a) (1) An applicant that will provide an intergovernmental transfer may submit a proposal to the department for funding for the purpose of providing comprehensive health insurance coverage to any child who meets citizenship and immigration status requirements that are applicable to persons participating in the program established by Title XXI of the Social Security Act, and whose family income is at or below 317 percent of the federal poverty level or, at the option of the applicant, at or below 411 percent of the federal poverty level, in specific geographic areas, as published quarterly in the Federal Register by the United States Department of Health and Human Services, as determined, counted and valued in accordance with the requirements of Section 1396a(e)(14) of Title 42 of the United States Code, as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148) and as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments, and which child meets both of the following requirements:

(A) Does not qualify for the optional targeted low-income children group or the Access program.

(B) Does not qualify for Medi-Cal with no share of cost pursuant to Chapter 7 (commencing with Section 14000) of Part 3.

(2) In its application, the applicant shall specify the income level at or below 411 percent of the federal poverty level for which it will provide coverage.

(3) The intergovernmental transfer amount is limited to the expenditures which would be eligible for federal financial participation.

(b) The proposal shall guarantee at least one year of intergovernmental transfer funding by the applicant at a level that ensures compliance with the requirements of any applicable approved federal waiver or state plan amendment as well as the department’s requirements for the sound operation of the proposed project, and shall, on an annual basis, either commit to fully funding the necessary intergovernmental amount or withdraw from the program. The department may identify specific geographical areas that, compared to the national level, have a higher cost of living or housing or a greater need for additional health services, using data obtained from the most recent federal census, the federal Consumer Expenditure Survey, or from other sources. The proposal may include an administrative mechanism for outreach and eligibility.

(c) The applicant may include in its proposal reimbursement of medical, dental, vision, or mental health services delivered to children who are eligible under the Access program or under the Medi-Cal program as an optional targeted low-income children group beneficiary, if these services are part of an overall program with the measurable goal of enrolling served children in the Access program or the optional targeted low-income children group.

(d) If a child is determined to be eligible for benefits for the treatment of an eligible medical condition under the California Children’s Services Program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, the health, dental, or vision plan providing services to the child pursuant to this chapter shall not be responsible for the provision of, or payment for, those authorized services for that child. The proposal from an applicant shall contain provisions to ensure that a child whom the health, dental, or vision plan reasonably believes would be eligible for services under the California Children’s Services Program is referred to that program. The California Children’s Services Program shall provide case management and authorization of services if the child is found to be eligible for the California Children’s Services Program. Diagnosis and treatment services that are authorized by the California Children’s Services Program shall be performed by paneled providers for that program and approved special care centers of that program and approved by the California Children’s Services Program. All other services provided under the proposal from the applicant shall be made available pursuant to this chapter to a child who is eligible for services under the California Children’s Services Program.

(e) Notwithstanding any other provision of this section, an applicant may submit a proposal to the department for the purposes of providing comprehensive health insurance coverage to children whose coverage is not eligible for funding under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa, et seq.), or to a combination of children whose coverage is eligible for funding under Title XXI of the Social Security Act and children whose coverage is not eligible for that funding. To be approved by the department, these proposals shall comply with both of the following requirements:

(1) Meet all applicable requirements for funding under this chapter, except for availability of funding through Title XXI of the Social Security Act.

(2) Provide for the administration of children’s coverage by the department through the administrative infrastructure serving the Medi-Cal program, and through health care service plans serving the Medi-Cal program.

(f) Implementation of this section is conditioned on the department obtaining necessary federal approval of these provisions.

(g) Notwithstanding any other provision of this part, the status of any application previously submitted to, and approved by, the Managed Risk Medical Insurance Board pursuant to former Part 6.4 (commencing with Section 12699.50) of Division 2 of the Insurance Code shall not be altered as a result of the assumption by the department, pursuant to this chapter, of the responsibilities previously exercised by the Managed Risk Medical Insurance Board.

(h) (1) If the voters approve the addition of Chapter 7.5 (commencing with Section 14199.100) to Part 3 of this division at the November 5, 2024, statewide general election, and the conditions described in paragraph (1) of subdivision (k) of Section 15853, as added by Section 21 of the act that added this subdivision, have been met, this section shall become inoperative on January 1, 2025, or the date certified by the department pursuant to paragraph (2) of subdivision (k) of Section 15853, as added by Section 21 of the act that added this subdivision, whichever is later, and shall be repealed on January 1 directly following that date.

(2) If the voters do not approve the addition of Chapter 7.5 (commencing with Section 14199.100) to Part 3 of this division at the November 5, 2024, statewide general election, and the conditions described in paragraph (1) of subdivision (k) of Section 15853, as added by Section 21 of the act that added this subdivision, have been met, this section shall become inoperative on January 1, 2026, or the date certified by the department pursuant to paragraph (2) of subdivision (k) of Section 15853, as added by Section 21 of the act that added this subdivision, whichever is later, and shall be repealed on January 1 directly following that date.

history: (History: Amended (as amended by Stats. 2022, Ch. 738, Sec. 20) by Stats. 2024, Ch. 40, Sec. 79. (SB 159) Effective June 29, 2024. Conditionally inoperative on or after January 1, 2025, as prescribed by its own provisions. Conditionally repealed January 1 following the inoperative date. See later operative version as amended by Sec. 80 of Stats. 2024, Ch. 40.)

division: 9. PUBLIC SOCIAL SERVICES

path: 9. PUBLIC SOCIAL SERVICES > 3. County Children’s Health Initiative Program


text:
(a) (1) An applicant that will provide an intergovernmental transfer may submit a proposal to the department for funding for the purpose of providing comprehensive health insurance coverage to any child who meets citizenship and immigration status requirements that are applicable to persons participating in the program established by Title XXI of the Social Security Act, and whose family income is at or below 317 percent of the federal poverty level or, at the option of the applicant, at or below 411 percent of the federal poverty level, in specific geographic areas, as published quarterly in the Federal Register by the United States Department of Health and Human Services, as determined, counted, and valued in accordance with the requirements of Section 1396a(e)(14) of Title 42 of the United States Code, as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148) and as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments, and which child meets both of the following requirements:

(A) Does not qualify for the optional targeted low-income children group or the Access program.

(B) Does not qualify for Medi-Cal with no share of cost pursuant to Chapter 7 (commencing with Section 14000) of Part 3.

(2) In its application, the applicant shall specify the income level at or below 411 percent of the federal poverty level for which it will provide coverage.

(3) The intergovernmental transfer amount is limited to the expenditures which would be eligible for federal financial participation.

(b) The proposal shall guarantee at least one year of intergovernmental transfer funding by the applicant at a level that ensures compliance with the requirements of any applicable approved federal waiver or state plan amendment as well as the department’s requirements for the sound operation of the proposed project, and shall, on an annual basis, either commit to fully funding the necessary intergovernmental amount or withdraw from the program. The department may identify specific geographical areas that, compared to the national level, have a higher cost of living or housing or a greater need for additional health services, using data obtained from the most recent federal census, the federal Consumer Expenditure Survey, or from other sources. The proposal may include an administrative mechanism for outreach and eligibility.

(c) The applicant may include in its proposal reimbursement of medical, dental, vision, or mental health services delivered to children who are eligible under the Access program or under the Medi-Cal program as an optional targeted low-income children group beneficiary, if these services are part of an overall program with the measurable goal of enrolling served children in the Access program or the optional targeted low-income children group.

(d) If a child is determined to be eligible for benefits for the treatment of an eligible medical condition under the California Children’s Services Program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, the health, dental, or vision plan providing services to the child pursuant to this chapter shall not be responsible for the provision of, or payment for, those authorized services for that child. The proposal from an applicant shall contain provisions to ensure that a child whom the health, dental, or vision plan reasonably believes would be eligible for services under the California Children’s Services Program is referred to that program. The California Children’s Services Program shall provide case management and authorization of services if the child is found to be eligible for the California Children’s Services Program. Diagnosis and treatment services that are authorized by the California Children’s Services Program shall be performed by paneled providers for that program and approved special care centers of that program and approved by the California Children’s Services Program. All other services provided under the proposal from the applicant shall be made available pursuant to this chapter to a child who is eligible for services under the California Children’s Services Program.

(e) Notwithstanding any other provision of this section, an applicant may submit a proposal to the department for the purposes of providing comprehensive health insurance coverage to children whose coverage is not eligible for funding under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa, et seq.), or to a combination of children whose coverage is eligible for funding under Title XXI of the Social Security Act and children whose coverage is not eligible for that funding. To be approved by the department, these proposals shall comply with both of the following requirements:

(1) Meet all applicable requirements for funding under this chapter, except for availability of funding through Title XXI of the Social Security Act.

(2) Provide for the administration of children’s coverage by the department through the administrative infrastructure serving the Medi-Cal program, and through health care service plans serving the Medi-Cal program.

(f) This section shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.

(g) Notwithstanding any other provision of this part, the status of any application previously submitted to, and approved by, the Managed Risk Medical Insurance Board pursuant to former Part 6.4 (commencing with Section 12699.50) of Division 2 of the Insurance Code shall not be altered as a result of the assumption by the department, pursuant to this chapter, of the responsibilities previously exercised by the Managed Risk Medical Insurance Board.

(h) If at any time the director determines that the eligibility criteria established for the program described in this section may jeopardize the state’s ability to receive federal financial participation under the federal Patient Protection and Affordable Care Act (Public Law 111-148), any amendment or extension of that act, or any similar federal legislation affecting federal financial participation, the director may alter the eligibility criteria to the extent necessary for the state to receive that federal financial participation.

(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and Chapter 4 (commencing with Section 12693.25) and Chapter 9 (commencing with 12693.70) of Part 6.2 of Division 2 of the Insurance Code, the department may implement, interpret, or make specific this section, in whole or in part, through all-county letters or similar instructions, without taking any further regulatory action.

(j) For any child found eligible under this section, they shall remain continuously eligible until they are five years of age. A redetermination of eligibility shall not be conducted before the child reaches five years of age unless the department or county possesses facts indicating that the family has requested the child’s voluntary disenrollment, the child is deceased, the child is no longer a state resident, or the child’s original enrollment was based on a state or county error or on fraud, abuse, or perjury attributed to the child or the child’s representative.

(k) (1) Implementation of this section is contingent on all of the following conditions:

(A) All necessary federal approvals have been obtained by the department pursuant to subdivision (f).

(B) The Legislature has appropriated funding to implement this section after a determination that ongoing General Fund resources are available to support the ongoing implementation of this section in the 2024–25 fiscal year and subsequent fiscal years.

(C) The department has determined that systems have been programmed to implement this section.

(2) The department shall issue a declaration certifying the date that all conditions in paragraph (1) have been met. The department shall post the declaration on its internet website and provide a copy of the declaration to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel.

(l) (1) If the voters approve the addition of Chapter 7.5 (commencing with Section 14199.100) to Part 3 of this division at the November 5, 2024, statewide general election, this section shall become operative on January 1, 2025, or the date certified by the department pursuant to paragraph (2) of subdivision (k), whichever is later.

(2) If the voters do not approve the addition of Chapter 7.5 (commencing with Section 14199.100) to Part 3 of this division at the November 5, 2024, statewide general election, this section shall become operative on January 1, 2026, or the date certified by the department pursuant to paragraph (2) of subdivision (b) of Section 15832, as added by Section 137 of the act that added this subdivision, whichever is later, and shall be repealed on January 1 directly following that date.

history: (History: Amended (as added by Stats. 2022, Ch. 738, Sec. 21) by Stats. 2024, Ch. 40, Sec. 80. (SB 159) Effective June 29, 2024. Section conditionally operative on January 1, 2025, or later, as prescribed by its own provisions. Conditionally repealed as prescribed by its own provisions.)

chapter: 3. County Children’s Health Initiative Program


text:
(a) The department, in consultation with other appropriate parties, shall establish the criteria for evaluating an applicant’s proposal, which shall include, but not be limited to, the following:

(1) The extent to which the program described in the proposal provides comprehensive coverage, including health, dental, and vision benefits.

(2) Whether the proposal includes a promotional component to notify the public of its provision of health insurance to eligible children.

(3) The simplicity of the proposal’s procedures for applying to participate and for determining eligibility for participation in its program.

(4) The extent to which the proposal provides for coordination and conformity with benefits provided through the Medi-Cal program.

(5) The extent to which the proposal provides for coordination and conformity with existing Medi-Cal administrative entities in order to prevent administrative duplication and fragmentation.

(6) The ability of the health care providers designated in the proposal to serve the eligible population and the extent to which the proposal includes traditional and safety net providers, as defined by the department.

(7) The extent to which the proposal intends to work with the school districts and county offices of education.

(8) The total amount of funds available to the applicant to implement the program described in its proposal, and the percentage of this amount proposed for administrative costs as well as the cost to the state to administer the proposal.

(9) The extent to which the proposal seeks to minimize the substitution of private employer health insurance coverage for health benefits provided through a governmental source.

(10) The extent to which local resources may be available after the depletion of federal funds to continue any current program expansions for persons covered under local health care financing programs or for expanded benefits.

(11) For the purposes of defining an applicant’s eligibility for funding under this chapter, the following shall apply:

(A) The same income methodology shall be used for the proposed program that is currently used for the Medi-Cal program.

(B) Only participating Medi-Cal managed care plans may be used. However, the department may permit exceptions to this requirement consistent with the purpose, of this chapter.

(b) The department may, in its sole discretion, approve or disapprove projects for funding pursuant to this chapter on an annual basis.

(c) To the extent that an applicant’s proposal pursuant to this chapter provides for health plan or administrative services under a contract entered into by the department or at rates negotiated for the applicant by the department, a contract entered into by the department or by an applicant shall be exempt from any provision of law relating to competitive bidding, and shall be exempt from the review or approval of any division of the Department of General Services to the same extent as contracts entered into pursuant to subdivision (p) of Section 14005.26. The department and the applicant shall not be required to specify the amounts encumbered for each contract, but may allocate funds to each contract based on the projected or actual subscriber enrollments to a total amount not to exceed the amount appropriated for the project, including family contributions, when applicable.

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 141. (SB 184) Effective June 30, 2022.)


text:
(a) Effective July 1, 2022, to the extent allowable under federal law, and notwithstanding the provisions of this chapter to the contrary, the department may elect not to impose subscriber contributions for purposes of coverage as described in this chapter for an applicable coverage period.

(b) If the department elects to not impose subscriber contributions for an applicable coverage period pursuant to subdivision (a) or elects to reinstate such subscriber contributions for a subsequent coverage period, the department shall specify that election in the published Medi-Cal Local Assistance Estimate for the impacted state fiscal year or years, subject to appropriation by the annual Budget Act.

history: (History: Added by Stats. 2022, Ch. 47, Sec. 142. (SB 184) Effective June 30, 2022.)


text: The department shall review each funding proposal submitted by an applicant in accordance with the criteria described in Section 15854 and based on that criteria, approve or reject the proposal.


text:
(a) Upon its approval of a proposal that shall include any allowable amount of federal funds under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et seq.), the department may provide the applicant reimbursement in an amount equal to the amount that the applicant will contribute to implement the program described in its proposal, plus the appropriate and allowable amount of federal funds. Not more than 10 percent of the County Health Initiative Matching Fund and matching federal funds shall be expended in any one fiscal year for administrative costs, including the costs to the state to administer the proposal, unless the department permits the expenditure consistent with the availability of federal matching funds not needed for the purposes described in paragraph (3) of subdivision (a) of Section 15862, or unless the department determines that an expenditure for administrative costs has no impact on available federal funding. The department may audit the expenses incurred by the applicant in implementing its program to ensure that the expenditures comply with the provisions of this chapter. No reimbursement may be made to an applicant that fails to meet its financial participation obligation under this chapter. The state’s reasonable startup costs and ongoing costs for administering the program shall be reimbursed by those entities applying for funding.

(b) Any program approved pursuant to subdivision (e) of Section 15853 that requires any funding not allowable for a federal match under Title XXI of the Social Security Act shall provide the department with the total amount of funds needed to provide that portion of coverage not eligible for federal matching funds, including reasonable startup costs and ongoing costs for administering the program.

(c) Each applicant that is provided funds under this chapter shall submit to the department a plan to limit initial and continuing enrollment in its program in the event the amount of moneys for its program is insufficient to maintain health insurance coverage for those participating in the program.

(d) (1) Notwithstanding any other provision of this chapter, the state shall be held harmless, in accordance with paragraphs (2) and (3), from any federal audit disallowance and interest resulting from payments made to a participating applicant pursuant to this section, for the disallowed claim.

(2) To the extent that a federal audit disallowance and interest results from a claim or claims for which any participating applicant has received reimbursement for services rendered or other activities performed, the department shall recoup from the participating applicant that submitted the disallowed claim, through offsets or by a direct billing, amounts equal to the amount of the disallowance and interest for the disallowed claim. All subsequent claims submitted to the department applicable to any previously disallowed service, activity, or claim may be held in abeyance, with no payment made, until the federal disallowance issue is resolved.

(3) Notwithstanding paragraph (2), to the extent that a federal audit disallowance and interest results from a claim or claims for which the participating applicant has received reimbursement for services rendered or activities performed by an entity under contract with, and on behalf of, the participating applicant, the department shall be held harmless by that particular participating applicant for 100 percent of the amount of the federal audit disallowance and interest for the disallowed claim.


text: Each health care service plan, specialized health care service plan, and health insurer that contracts to provide health care benefits under this chapter shall be licensed by the Department of Managed Health Care or the Department of Insurance, or be a Medi-Cal managed care plan.


text:
(a) The department shall administer the provisions of this chapter and may do all of the following:

(1) Administer the expenditure of moneys from the fund.

(2) (A) Issue rules and regulations as necessary.

(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this chapter and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature pursuant to Section 9795 of the Government Code on a semiannual basis until regulations have been adopted.

(3) Enter into contracts.

(4) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed by this chapter.


text: All expenses incurred by the department in administering this chapter, including, but not limited to, expenses for developing standards and processes to implement any of the provisions of this chapter, evaluating applications, or processing or granting appeals growing out of any of the provisions of this chapter, shall be paid from the fund or directly by applicants, except that the department may accept funding from a not-for-profit group or foundation, or from a governmental entity providing grants for health-related activities, to administer this chapter.


text: Nothing in this chapter creates a right or an entitlement to the provision of health insurance coverage or health care benefits. Except as provided in Section 15850.5, no costs shall accrue to the state for the provision of these services. The state shall not be liable beyond the assets of the fund for any obligation incurred or liabilities sustained by applicants in the operation of the fund or of the projects authorized by this chapter.


text: To the extent necessary to obtain federal financial participation for projects approved pursuant to this chapter, the department shall apply for one or more waivers or shall file state plan amendments pursuant to the federal State Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) to allow a county agency, local initiative, or county organized health system to apply for matching funds through the federal State Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) using local funds for the state matching funds.


text:
(a) The provisions of this chapter shall be implemented only if all of the following conditions are met:

(1) Federal financial participation is available for this purpose.

(2) Federal participation is approved.

(3) The department determines that federal funds under Title XXI of the Social Security Act remain available after providing funds for all current enrollees and eligible children that are likely to enroll in the optional targeted low-income children group and, to the extent funded through the federal Children’s Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code), the Medi-Cal Access program and Medi-Cal program, as determined by a Department of Finance estimate.

(4) Funds are appropriated specifically for this purpose.

(b) The department may accept funding necessary for the preparation of the federal waiver applications or state plan amendments described in Section 15861 from a not-for-profit group or foundation, but only to the extent that the funding may be eligible for federal financial participation.

history: (History: Amended by Stats. 2015, Ch. 303, Sec. 625. (AB 731) Effective January 1, 2016.)


text: The state shall be held harmless for any federal disallowance resulting from this chapter and any other expenses or liabilities, including, but not limited to, the cost of processing or granting appeals, unless the department is acting pursuant to Section 15850.5. An applicant receiving supplemental reimbursement pursuant to this chapter shall be liable for any reduced federal financial participation, and any other expenses or liabilities, including, but not limited to, the costs of processing or granting appeals, resulting from the implementation of this chapter with respect to that applicant. The state may recoup any federal disallowance from the applicant for which it can be held harmless.


text: This chapter shall become operative on July 1, 2014.

history: (History: Added by Stats. 2014, Ch. 31, Sec. 89. (SB 857) Effective June 20, 2014. Note: This section prescribes a delayed operative date (July 1, 2014) for Chapter 3, commencing with Section 15850.)


text:
For the purposes of this chapter, the following terms have the following meanings:

(a) “Applicant” means an individual who applies for major risk medical coverage through the program.

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

(c) “Exchange” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code.

(d) “Fund” means the Major Risk Medical Insurance Fund, from which the department may authorize expenditures to pay for medically necessary services which exceed subscribers’ contributions, and for administration of the program.

(e) “Major risk medical coverage” means the payment for medically necessary services provided by institutional and professional providers.

(f) “Participating health plan” means either of the following entities that contracts with the department to administer major risk medical coverage to program subscribers:

(1) A private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner.

(2) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.

(g) “Plan rates” means the total monthly amount charged by a participating health plan for a category of risk.

(h) “Program” means the California Major Risk Medical Insurance Program.

(i) “Subscriber” means an individual who is eligible for and receives major risk medical coverage through the program, and includes a member of a federally recognized California Indian tribe.

(j) “Subscriber contribution” means the portion of participating health plan rates paid by the subscriber, or paid on behalf of the subscriber by a federally recognized California Indian tribal government. If a federally recognized California Indian tribal government makes a contribution on behalf of a member of the tribe, the tribal government shall ensure that the subscriber is made aware of all the health plan options available in the county where the member resides.

history: (History: Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)

article: 1. General

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 1. General


text: The California Major Risk Medical Insurance Program is hereby established within, and shall be administered by, the department.

chapter: 4. California Major Risk Medical Insurance Program

article: 1. General


history: (History: Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Note: This section prescribes a delayed operative date (July 1, 2014) for Chapter 4, comprising Sections 15870 to 15895.5.)

article: 1. General


text:
The department shall have the authority:

(a) To establish eligibility criteria, notwithstanding Section 15884, and determine the eligibility of applicants.

(b) To determine the major risk medical coverage to be provided to program subscribers.

(c) To research and assess the needs of persons not adequately covered by existing private and public health care delivery systems and promote means of assuring the availability of adequate health care services.

(d) To approve subscriber contributions, and plan rates, and establish program contribution amounts.

(e) To provide major risk medical coverage for subscribers or to contract with a participating health plan or plans or other vendor to provide or administer major risk medical coverage for subscribers.

(f) To authorize expenditures from the fund to pay program expenses which exceed subscriber contributions.

(g) To contract for administration of the program or any portion thereof with any public agency, including any agency of state government, or with any private entity.

(h) (1) To issue rules and regulations to carry out the purposes of this chapter.

(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature pursuant to Section 9795 of the Government Code on a semiannual basis until regulations have been adopted.

(i) To authorize expenditures from the fund or from other moneys appropriated in the annual Budget Act for purposes relating to Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.

(j) To exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed upon it under this chapter.

article: 2. Powers and Duties

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 2. Powers and Duties


text: Plan rates for major risk medical benefits approved for the program shall not be excessive, inadequate, or unfairly discriminatory, but shall be adequate to pay anticipated costs of claims or services and administration.

article: 2. Powers and Duties


text:
(a) The department shall direct the participating health plans to inform all program subscribers of the December 31, 2024, transition of coverage as follows:

(1) (A) On August 1, 2024, the participating health plans shall send an initial notification to all program subscribers. The initial notice will inform subscribers of all of the following:

(i) That a plan-based enroller shall assist the subscriber in applying to Medi-Cal or through the California Health Benefit Exchange for other health care coverage.

(ii) That assistance may be available through the California Health Benefit Exchange or clinic navigators and how to obtain that assistance.

(iii) Information regarding where and how subscribers can apply to the California Health Benefit Exchange for alternate health care coverage.

(B) If a participating health plan has plan-based enrollers through the California Health Benefit Exchange, the plan shall direct the plan-based enrollers to assist the subscribers in understanding their coverage options.

(C) Assistance to subscribers by plans shall provide information on continuity with an existing provider to the extent possible.

(2) On October 1, 2024, the participating health plans shall send a second notification informing all program subscribers that coverage shall transition on December 31, 2024, for those who are eligible for other coverage, and the notice shall include all of the information that was included in the initial notification sent on August 1, 2024.

(3) On December 1, 2024, the participating health plans shall send a third notification informing all program subscribers that coverage shall transition on December 31, 2024, for those who are eligible for other coverage, and the notice shall include all of the information that was included in the initial notification sent on August 1, 2024.

(b) (1) Upon request from the California Health Benefit Exchange, the department may disclose information to the Exchange to assist program subscribers to transition into new coverage pursuant to this section.

(2) The Exchange may disclose information obtained from the department to outreach and marketing vendors under contract to the Exchange.

(3) The Exchange shall not disclose information obtained from the department to a certified insurance agent, a certified enrollment counselor, or any other entity without the consent of the applicant, except as provided in paragraph (2).

(4) Any outreach and marketing conducted pursuant to this section shall include, in a conspicuous and easy-to-access manner, the ability for individuals to decline all future outreach and marketing.

(5) The Exchange shall take all necessary measures to safeguard the confidentiality of any information obtained from the department and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals whose information the Exchange receives pursuant to subdivision (c). The Exchange shall at all times only request, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was obtained.

(6) A person or entity that receives information from the Exchange pursuant to this section shall take all necessary measures to safeguard the confidentiality of any information obtained from the Exchange and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals, as directed by the Exchange. A person or entity shall at all times only request from the Exchange, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was received.

(7) Information received by the Exchange from the department shall both:

(A) At all times be subject to applicable privacy and information security-related requirements arising under both federal and state law.

(B) Be destroyed in a manner that maintains confidentiality.

(8) The Exchange shall ensure that information disclosed to outreach and marketing vendors or any other entity pursuant to this section complies with paragraph (7).

(c) Sections 1373.65, 1373.95, and 1373.96 of the Health Safety Code shall apply, whether or not the plan is licensed under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code.

(d) The department shall cease to provide coverage through the program on December 31, 2024, and on that date shall cease to operate the program except as necessary to comply with subdivision (e).

(e) The department shall complete payments to, or payment reconciliations with, participating health plans or other contractors, process appeals, and conduct other necessary termination activities.

(f) Commencing November 1, 2024, and ending when the transition of coverage is complete, the department shall provide monthly updates to the Assembly Committees on Health and Budget and the Senate Committees on Health and Budget and Fiscal Review on the status of the transition of subscribers to other coverage. These updates shall include the number of subscribers who have transitioned and, to the extent available, to where, the number remaining in the program, and any available demographic information of each subscriber.

history: (History: Added by Stats. 2024, Ch. 40, Sec. 81. (SB 159) Effective June 29, 2024.)

article: 2. Powers and Duties


text: The department may place a lien on compensation or benefits recovered or recoverable by a subscriber from any party or parties responsible for the compensation or benefits for which benefits have been provided under a policy issued under this article or Article 4 (commencing with Section 15881).

article: 3. Policies Issued by the Department

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 3. Policies Issued by the Department


text: Except as provided in Article 3.5 (commencing with Section 14124.70) of Chapter 7 of Part 3, benefits received under this article or Article 4 (commencing with Section 15881) are in excess of and secondary to, any other form of health benefits coverage.

article: 3. Policies Issued by the Department


text: Benefits under this article or Article 4 (commencing with Section 15881) shall be subject to required subscriber copayments and deductibles as the department may authorize. Any authorized copayments shall not exceed 25 percent and any authorized deductible shall not exceed an annual household deductible amount of five hundred dollars ($500). However, health plans not utilizing a deductible may be authorized to charge an office visit copayment of up to twenty-five dollars ($25). If the department contracts with participating health plans pursuant to Article 4 (commencing with Section 15881), copayments or deductibles shall be authorized in a manner consistent with the basic method of operation of the participating health plans. The aggregate amount of deductible and copayments payable annually under this section shall not exceed two thousand five hundred dollars ($2,500) for an individual and four thousand dollars ($4,000) for a family.

article: 3. Policies Issued by the Department


text: The department shall provide coverage through participating health plans and may contract for the processing of applications, the enrollment of subscribers, and activities necessary to administer the program. A contract entered into pursuant to this chapter shall be exempt from any provision of law relating to competitive bidding, and shall be exempt from the review or approval of any division of the Department of General Services. The department shall not be required to specify the amounts encumbered for each contract but may allocate funds to each contract based on projected and actual subscriber enrollments in a total amount not to exceed revenue available for the program.

article: 4. Participating Health Plans

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 4. Participating Health Plans


text: The department may provide or purchase stop-loss coverage under which the program and participating health plans share the risk for health plan expenses which exceed plan rates.

article: 4. Participating Health Plans


text: The department shall withdraw its approval of any participating health benefits plan for noncompliance with program standards, nonpayment of claims, or other good cause shown. Approval shall not be withdrawn except after reasonable notice to the health plan, program subscribers enrolled in the plan, physicians or organizations of physicians offering services through the plan, and all interested parties.

article: 4. Participating Health Plans


text:
(a) Each resident of the state meeting the eligibility criteria of this section and who is unable to secure adequate private health coverage is eligible to apply for major risk medical coverage through the program. For these purposes, “resident” includes a member of a federally recognized California Indian tribe.

(b) To be eligible for enrollment in the program, an applicant shall have been rejected for health care coverage by at least one private health plan. An applicant shall be deemed to have been rejected if the only private health coverage that the applicant could secure would do one of the following:

(1) Impose substantial waivers that the department determines would leave a subscriber without adequate coverage for medically necessary services.

(2) Afford limited coverage that the department determines would leave the subscriber without adequate coverage for medically necessary services.

(3) Afford coverage only at an excessive price, which the department determines is significantly above standard average individual coverage rates.

(c) Rejection for policies or certificates of specified disease or policies or certificates of hospital confinement indemnity, as described in Section 10198.61 of the Insurance Code, shall not be deemed to be rejection for the purposes of eligibility for enrollment.

(d) The department may permit dependents of eligible subscribers to enroll in major risk medical coverage through the program if the department determines the enrollment can be carried out in an actuarially and administratively sound manner.

(e) Notwithstanding the provisions of this section, the department shall prescribe a period of time during which a resident is ineligible to apply for major risk medical coverage through the program if the resident either voluntarily disenrolls from, or was terminated for nonpayment of the premium from, a private health plan after enrolling in that private health plan pursuant to either Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 5. Subscriber Eligibility and Enrollment


text:
(a) It shall constitute unfair competition for purposes of Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions Code for an insurer, an insurance agent or broker, or an administrator, as defined in Section 1759 of the Insurance Code, to refer an individual employee, or his or her dependents, to the program, or arrange for an individual employee, or his or her dependents, to apply to the program, for the purpose of separating that employee, or his or her dependents, from group health coverage provided in connection with the employees employment.

(b) It shall constitute an unfair labor practice contrary to public policy and enforceable under Section 95 of the Labor Code for any employer to refer an individual employee, or his or her dependents, to the program, or to arrange for an individual employee, or his or her dependents, to apply to the program, for the purpose of separating that employee, or his or her dependents, from group health coverage provided in connection with the employee’s employment.

(c) As used in this section, “group health coverage” includes any nonprofit hospital service plan, health care service plan, self-insured employee welfare benefit plan, or disability insurance providing medical or hospital benefits.

article: 5. Subscriber Eligibility and Enrollment


text:
The department may permit the exclusion of coverage or benefits for charges or expenses incurred by a subscriber during the first six months of enrollment in the program for any condition for which, during the six months immediately preceding enrollment in the program medical advice, diagnosis, care, or treatment was recommended or received as to the condition during that period.

However, the exclusion from coverage of this section shall be waived to the extent to which the subscriber was covered under any creditable coverage, as defined in Section 10900 of the Insurance Code, that was terminated, provided the subscriber has applied for enrollment in the program not later than 63 days following termination of the prior coverage, or within 180 days of termination of coverage if the subscriber lost his or her previous creditable coverage because the subscriber’s employment ended, the availability of health coverage offered through employment or sponsored by an employer terminated, or an employer’s contribution toward health coverage terminated. The exclusion from coverage of this section shall also be waived as to any condition of a subscriber previously receiving coverage under a plan of another state similar to the program established by this chapter if the subscriber was eligible for benefits under that other-state coverage for the condition. The department may establish alternative mechanisms applicable to enrollment in participating health plans. These mechanisms may include, but are not limited to, a postenrollment waiting period.


text: If more than one participating health plan is offered, the department shall make available to applicants eligible to enroll in the program sufficient information to make an informed choice among the various types of participating health plans. Each applicant shall be issued an appropriate document setting forth or summarizing the services to which an enrollee is entitled, procedures for obtaining major risk medical coverage, a list of contracting health plans and providers, and a summary of grievance procedures.

history: (History: Amended by Stats. 2015, Ch. 303, Sec. 626. (AB 731) Effective January 1, 2016.)


text: After the applicant notifies the department in writing of his or her choice of participating health plan, the department shall assist the applicant in enrolling as a subscriber and securing major risk medical coverage for the subscriber and any dependents.


text: A subscriber may request a change in coverage based upon a change in the family status of any dependent, by filing an application within 30 days after the occurrence of the change in family status, or at other times and under conditions as may be prescribed by the department.


text: Health coverage secured through the program shall permit a covered dependent of a subscriber to elect to continue the same coverage upon the death of the subscriber, or upon the subscriber becoming eligible for Medicare Part A and Part B.


text: A transfer of enrollment from one participating health plan to another may be made by a subscriber at times and under conditions as may be prescribed by the department.


text: If a subscriber is dissatisfied with any action or failure to act which has occurred in connection with a participating plan’s coverage, the subscriber shall have the right to appeal to the department and shall be accorded an opportunity for a fair hearing. Hearings may be conducted, insofar as practicable, pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.


text: Subscribers and their dependents who become eligible for Medicare Part A and Part B, excluding those on Medicare solely because of end-stage renal disease, shall not be enrolled, or continue to be enrolled, in major risk medical coverage afforded by this chapter.


text: Upon enrollment as a subscriber in the program, the subscriber shall be responsible for payment of the subscriber contribution. Termination of coverage by a participating health plan for nonpayment of the subscriber contribution shall be governed by the same laws and regulations by which the participating health plan is regulated as to all its subscribers and enrollees.

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 6. Plan Rates and Compensation from the Fund


text: Each health plan contracting with the department pursuant to Article 4 (commencing with Section 15881) shall submit annually to the department rates which it estimates are sufficient to cover the cost of providing major risk medical coverage to its subscribers. The rates shall be submitted on the basis of categories of risk which shall be established by the department.

article: 6. Plan Rates and Compensation from the Fund


text:
(a) The department shall establish program contribution amounts for each category of risk for each participating health plan. The program contribution amounts shall be based on the average amount of subsidy funds required for the program as a whole. To determine the average amount of subsidy funds required, the department shall calculate a loss ratio, including all medical costs, administration fees, and risk payments, for the program in the prior calendar year. The loss ratio shall be calculated using 125 percent of the standard average individual rates for comparable coverage as the denominator, and all medical costs, administration fees, and risk payments as the numerator. The average amount of subsidy funds required is calculated by subtracting 100 percent from the program loss ratio. For purposes of calculating the program loss ratio, no participating health plan’s loss ratio shall be less than 100 percent and participating health plans with fewer than 1,000 program members shall be excluded from the calculation.

Subscriber contributions shall be established to encourage members to select those health plans requiring subsidy funds at or below the program average subsidy. Subscriber contribution amounts shall be established so that no subscriber receives a subsidy greater than the program average subsidy, except that:

(1) In all areas of the state, at least one plan shall be available to program participants at an average subscriber contribution of 125 percent of the standard average individual rates for comparable coverage.

(2) No subscriber contribution shall be increased by more than 10 percent above 125 percent of the standard average individual rates for comparable coverage.

(3) Subscriber contributions for participating health plans joining the program after January 1, 1997, shall be established at 125 percent of the standard average individual rates for comparable coverage for the first two benefit years the plan participates in the program.

(b) The department shall pay program contribution amounts to participating health plans from the Major Risk Medical Insurance Fund.

(c) Commencing January 1, 2013, in addition to the amount of subsidy funds required pursuant to subdivision (a), the department may further subsidize subscriber contributions so that the amount paid by each subscriber is below 125 percent of the standard average individual risk rate for comparable coverage but no less than 100 percent of the standard average individual risk rate for comparable coverage. For purposes of calculating premiums for the following products, any reference to, or use of, subscriber contributions, premiums, average premiums, or amounts paid by subscribers in the program shall be construed to mean subscriber contributions as described in subdivision (a) without application of the additional subsidies permitted by this subdivision:

(1) Standard benefit plans pursuant to Section 10127.16 of the Insurance Code and Section 1373.622 of the Health and Safety Code.

(2) Health benefit plans and health care service plan contracts for federally eligible defined individuals pursuant to Sections 10901.3 and 10901.9 of the Insurance Code and Sections 1399.805 and 1399.811 of the Health and Safety Code.

(3) Conversion coverage pursuant to Section 12682.1 of the Insurance Code and Section 1373.6 of the Health and Safety Code.


text: A participating health plan may charge subscriber contributions under this article that do not exceed the difference between its plan rate for the category of risk and the program contribution amount for the category of risk.


text:
(a) There is hereby continued in existence in the State Treasury a special fund known as the Major Risk Medical Insurance Fund that is, notwithstanding Section 13340 of the Government Code, continuously appropriated to the department for the purposes specified in Section 15894, Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.

(b) Funds may be deposited in the Major Risk Medical Insurance Fund from one or more of the following accounts in the Cigarette and Tobacco Products Surtax Fund:

(1) The Hospital Services Account.

(2) The Physician Services Account.

(3) The Unallocated Account.

(c) Effective July 1, 2017, the Major Risk Medical Insurance Fund in the State Treasury is abolished and all moneys in the fund shall be transferred to the Health Care Services Plan Fines and Penalties Fund created pursuant to subdivision (d). Any remaining balance, assets, liabilities, and encumbrances of the Major Risk Medical Insurance Fund as of July 1, 2017, shall be transferred to, and become part of, the Health Care Services Plan Fines and Penalties Fund.

(d) There is hereby created in the State Treasury a special fund known as the Health Care Services Plan Fines and Penalties Fund that is, notwithstanding Section 13340 of the Government Code, continuously appropriated to the department for the purpose of funding the nonfederal share of health care services for children, adults, seniors, persons with disabilities, and dual-eligible beneficiaries in the Medi-Cal program.

(e) Any law that refers to the Major Risk Medical Insurance Fund, including, but not limited to, a reference in this chapter to the Major Risk Medical Insurance Fund or the “fund,” shall be construed to refer to the Health Care Services Plan Fines and Penalties Fund, effective July 1, 2017.

(f) Notwithstanding any other law, the Controller may use the funds in the Health Care Services Plan Fines and Penalties Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code.

history: (History: Amended by Stats. 2024, Ch. 40, Sec. 82. (SB 159) Effective June 29, 2024.)

article: 7. Major Risk Medical Insurance Fund

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 7. Major Risk Medical Insurance Fund


text:
(a) Except as provided in Section 15894.5, the department shall authorize the expenditure of money in the fund to cover program expenses, including program expenses that exceed subscriber contributions, and to cover expenses relating to Section 10127.16 of the Insurance Code, Section 1373.622 of the Health and Safety Code, and health care services for eligible individuals in the Medi-Cal program. The department shall determine the amount of funds expended for each of these purposes, taking into consideration the requirements of this chapter, Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code. Funds may be expended for health care services for eligible individuals in the Medi-Cal program only after all costs for the administration and delivery of health care services under Section 1373.622 of the Health and Safety Code and Section 10127.16 of the Insurance Code have been fully funded.

(b) Following consultation with a health care service plan or health insurer, if the department and the health care service plan or health insurer have not agreed to a final reconciliation of the amount to be expended from the fund or to be reimbursed to the fund, the department shall give written notice of its determination to the health care service plan or health insurer of the final reconciliation amount, as determined by the department. The health care service plan or health insurer shall remit payment to the department within 60 days of the date of notice from the department. If payment is not received, interest shall accrue in the amount of 7 percent per annum. The department may offset the amount to be reimbursed to the fund against any other payments owed to the health care service plan or health insurer by the department, or may negotiate a payment plan with the health care service plan or health insurer for full payment, and in that case may waive interest accrual as long as payment from the health care service plan or health insurer is made in accordance with the payment plan. This subdivision shall control over any conflict or ambiguity between this subdivision and the provisions of Section 1373.622 of the Health and Safety Code, Section 10127.16 of the Insurance Code, Part 6.5 (commencing with Section 12700) of Division 2 of the Insurance Code, or this chapter.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 81. (SB 97) Effective July 10, 2017.)

article: 7. Major Risk Medical Insurance Fund


text:
(a) From money appropriated by the Legislature to the fund, the department may expend sufficient funds to carry out the purposes of this chapter and of Section 10127.16 of the Insurance Code, and Section 1373.622 of the Health and Safety Code.

(b) However, the state is not liable beyond the assets of the fund for any obligations incurred, or liabilities sustained, in the operation of the California Major Risk Medical Insurance Program or for the expenditures described in Section 10127.16 of the Insurance Code and Section 1373.622 of the Health and Safety Code.

history: (History: Amended by Stats. 2015, Ch. 303, Sec. 627. (AB 731) Effective January 1, 2016.)

article: 7. Major Risk Medical Insurance Fund


text: Any moneys remaining in the fund at the end of any fiscal year may be carried forward to the next succeeding fiscal year.

article: 7. Major Risk Medical Insurance Fund


text:
The Legislature finds and declares the following:

(a) Approximately 21 percent of nonelderly Californians lack health insurance coverage. Many are low-income individuals who are not eligible for existing public health coverage programs.

(b) One hundred eighty million dollars ($180,000,000) in federal funds will be available for three years to reimburse for public expenditures made under a Health Care Coverage Initiative for uninsured individuals. These funds are to be provided pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.

(c) California’s health care safety net system plays an essential role in delivering critical health services to low-income individuals.

(d) Local governments have the unique ability to design health service delivery models that meet the needs of their diverse populations and build on local infrastructures.

history: (History: Added by Stats. 2006, Ch. 76, Sec. 2. Effective July 18, 2006. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)

part: 3.5. HEALTH CARE COVERAGE INITIATIVE

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 3.5. HEALTH CARE COVERAGE INITIATIVE


text:
(a) There is hereby established the Health Care Coverage Initiative to expand health care coverage to low-income uninsured individuals in California.

(b) The Health Care Coverage Initiative shall operate pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion that became effective September 1, 2005. The initiative shall be implemented only to the extent that federal financial participation is available.


text:
(a) Persons eligible to be served by the Health Care Coverage Initiative are low-income uninsured individuals who are not currently eligible for the Medi-Cal program, Healthy Families Program, or Access for Infants and Mothers program.

(b) Funding for the Health Care Coverage Initiative shall be used to expand health care coverage for eligible uninsured individuals.

(c) Any expansion of health care coverage for uninsured individuals shall not diminish access to health care available for other uninsured individuals, including access through disproportionate share hospitals, county clinics, or community clinics.

(d) Services provided under the Health Care Coverage Initiative shall be available to those eligible uninsured individuals enrolled in a Health Care Coverage program, and nothing in this part shall be construed to create an entitlement program of any kind.

(e) No state General Fund moneys shall be used to fund the Health Care Coverage Initiative, nor to fund any related administrative costs provided to counties.


text:
The Health Care Coverage Initiative shall be designed and implemented to achieve all of the following outcomes:

(a) Expand the number of Californians who have health care coverage.

(b) Strengthen and build upon the local health care safety net system, including disproportionate share hospitals, county clinics, and community clinics.

(c) Improve access to high quality health care and health outcomes for individuals.

(d) Create efficiencies in the delivery of health services that could lead to savings in health care costs.

(e) Provide grounds for long-term sustainability of the programs funded under the initiative.

(f) Implement programs in an expeditious manner in order to meet federal requirements regarding the timing of expenditures.


text:
(a) The State Department of Health Care Services shall issue a request for applications for funding the Health Care Coverage Initiative.

(b) The department shall allocate federal funds available to be claimed under the Health Care Coverage programs.

(c) The department shall select the Health Care Coverage programs that best meet the requirements and desired outcomes set forth in this part.

(d) The following elements shall be used in evaluating the proposals to make selections and to determine the allocation of the available funds:

(1) Enrollment processes, with an identification system to demonstrate enrollment of the uninsured into the program.

(2) Use of a medical record system, which may include electronic medical records.

(3) Designation of a medical home and assignment of eligible individuals to a primary care provider. For purposes of this paragraph, “medical home” means a single provider or facility that maintains all of an individual’s medical information. The primary care provider shall be a provider from which the enrollee can access primary and preventive care.

(4) Provision of a benefit package of services, including preventive and primary care services, and care management services designed to treat individuals with chronic health care conditions, mental illness, or who have high costs associated with their medical conditions, to improve their health and decrease future costs. Benefits may include case management services.

(5) Quality monitoring processes to assess the health care outcomes of individuals enrolled in the Health Care Coverage program.

(6) Promotion of the use of preventive services and early intervention.

(7) The provision of care to Medi-Cal beneficiaries by the applicant and the degree to which the applicant coordinates its care with services provided to Medi-Cal beneficiaries.

(8) Screening and enrollment processes for individuals who may qualify for enrollment into Medi-Cal, the Healthy Families Program, and the Access for Infants and Mothers Program prior to enrollment into the Health Care Coverage program.

(9) The ability to demonstrate how the Health Care Coverage program will promote the viability of the existing safety net health care system.

(10) Documentation to support the applicant’s ability to implement the Health Care Coverage program by September 1, 2007, and to use its allocation for each project year.

(11) Demonstration of how the program will provide consumer assistance to individuals applying to, participating in, or accessing services in the program.

(e) Entities eligible to apply for the initiative funds are a county, city and county, consortium of counties serving a region consisting of more than one county, or health authority. No entity shall submit more than one proposal.

(f) The department shall rank the program applications based on the criteria in this section. The amount of federal funding available to be claimed shall be allocated based upon the ranking of the applications. The department shall allocate the available federal funding to the highest ranking applications until all of the funding is allocated. The department shall select at least five programs, and no single program shall receive an allocation greater than 30 percent of the total federal allotment. The department is not required to fund the entire amount requested in a program application.

(g) The department shall seek to balance the allocations throughout geographic areas of the state.

(h) Each county, city and county, consortium of counties, or health authority that is selected to receive funding shall provide the necessary local funds for the nonfederal share of the certified public expenditures, or intergovernmental transfers to the extent allowable under the demonstration project, required to claim the federal funds made available from the federal allotment. The certified public expenditures, or intergovernmental transfers to the extent allowable under the demonstration project, shall meet the requirements of the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion that became effective September 1, 2005.

(i) The federal allocation shall be available to the selected programs for the three-year period covering the Health Care Coverage program pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion, unless the selected programs do not incur expenditures sufficient to claim the allocation of federal funds in the particular program year. Selected programs shall expend the funds according to an expenditure schedule determined by the department.

(j) The department may reallocate the available federal funds among selected programs or other program applicants that were previously not selected for funding, if necessary to meet federal requirements regarding the timing of expenditures, notwithstanding subdivision (f). If a selected program fails to substantially comply with the requirements of this article, the department may reallocate the available federal funds from that selected program to other selected programs or other program applications that previously were not selected for funding. If a selected program is unable to meet its spending targets, determined at the end of the second quarter of each program year, the department may reallocate funds to other selected programs or other program applications that previously were not selected for funding, to ensure that all available federal funds are claimed. Selected programs receiving reallocated funds must have the ability to make the certified public expenditures necessary to claim the reallocated federal funds.

(k) Federal funds provided for the initiative shall supplement, and not supplant, any county, city and county, health authority, state, or federal funds that would otherwise be spent on health care services in the county, city and county, consortium of counties, or a health authority region. Federal funds allocated under the initiative shall reimburse the selected county, city and county, consortium of counties, or health authority for the benefits and services provided under subdivision (d) of Section 15904. Administrative costs associated with the development and management of the initiative shall not be paid from the Health Care Coverage program allocation, and any allocations for administrative funds shall be in addition to the allocations made for the initiative.

history: (History: Amended by Stats. 2007, Ch. 483, Sec. 52. Effective January 1, 2008. Inoperative on date prescribed in Section 15908. Repealed six months after inoperative date, pursuant to Section 15908.)


text:
Applications submitted to the department shall include, but not be limited to, each of the following:

(a) A description of the proposed Health Care Coverage program, including, but not limited to, all of the following:

(1) Eligibility criteria.

(2) Screening and enrollment processes that include an identification system to demonstrate enrollment into the Health Care Coverage program.

(3) Screening processes to identify individuals who may qualify for enrollment into Medi-Cal, the Healthy Families Program, or the Access for Infants and Mothers Program.

(b) A description of the quality monitoring system to be implemented with the Health Care Coverage program.

(c) A description of the population to be served.

(d) A list of health care providers who have agreed to participate in the Health Care Coverage program.

(e) A description of the organized health care delivery systems to be used for the Health Care Coverage program, including, but not limited to, designation of a medical home and processes used to assign eligible individuals to a primary care provider.

(f) A list of the health benefits to be provided, including the preventive and primary care services and how they will be promoted.

(g) A description of the care management services to be provided, and the providers of those services.

(h) A calculation of the average cost per individual served.

(i) The number of individuals to be served.

(j) The mechanism under which the proposed Health Care Coverage Initiative will make expenditures to, or on behalf of, providers and other entities, including, but not limited to, documentation to support the ability to implement the Health Care Coverage program by September 1, 2007, and to claim the full amount of the allocation for each program year.

(k) A description of the source of the local nonfederal share of funds.

(l) A description of how the proposed Health Care Coverage program will strengthen the local health care safety net system.

(m) A consent form signed by the applicant to provide requested data elements as required per the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.

(n) Use of a reliable medical record system, that may include, but need not be limited to, existing electronic medical records.

(o) A complete description of health care services currently provided to Medi-Cal beneficiaries and a description as to how the proposed Health Care Coverage program will coordinate its Health Care Coverage program with services provided to Medi-Cal beneficiaries.


text:
(a) The department shall seek partnership with an independent, nonprofit group or foundation, an academic institution, or a governmental entity providing grants for health-related activities, to evaluate the programs funded under the initiative.

(b) The evaluation shall, at a minimum, include an assessment of the extent to which the programs have met the outcomes listed in Section 15903.

(c) The department and the selected programs shall provide the data for the evaluation.

(d) The evaluation shall be submitted concurrently to the appropriate policy and fiscal committees of the Legislature and to the Secretary of Health and Human Services.


text:
(a) The department shall monitor the programs funded under the initiative for compliance with applicable federal requirements and the requirements under this part, and pursuant to the Special Terms and Conditions of California’s Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.

(b) To the extent necessary to implement this part, the department shall submit, by September 1, 2006, to the federal Centers for Medicare and Medicaid Services, proposed waiver amendments on the structure of, and eligibility and benefits under, the Health Care Coverage Initiative.

(c) The department shall monitor the allocations to selected programs at least quarterly for spending levels.

(d) No funds made available from the Health Care Support Fund for the Health Care Coverage Initiative shall be used by the department for administration.

(e) The request for applications, including any part of the process described herein for selecting entities to operate the Health Care Coverage programs, and any agreements entered into with a county, city and county, consortium of counties, or health authority pursuant to this part shall not be subject to Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code.

(f) The department may adopt regulations to implement this part. These regulations may initially be adopted as emergency regulations in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). For purposes of this part, the adoption of regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare. Any emergency regulations adopted pursuant to this section shall not remain in effect subsequent to the date that this part is repealed pursuant to Section 15908.

(g) As an alternative to subdivision (f), and notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, or any other provision of law, the department may implement and administer this part by means of provider bulletins, county letters, manuals, or other similar instructions, without taking regulatory action. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue a provider bulletin, county letter, manual, or other similar instruction, at least five days prior to issuance. In addition, the department shall provide a copy of any provider bulletin, county letter, manual, or other similar instruction issued under this paragraph to the fiscal and appropriate policy committees of the Legislature.

(h) The department shall consult with interested parties and appropriate stakeholders regarding the implementation and ongoing administration of this part.


text:
(a) This part shall become inoperative on the date that the director executes a declaration, which shall be retained by the director and provided to the fiscal and appropriate policy committees of the Legislature, stating that the Low Income Health Program authorized under Part 3.6 (commencing with Section 15909) and under the Special Terms and Conditions of the demonstration project, as defined in Section 15909.1, has been implemented, and that each Health Care Coverage Initiative program approved under this part that has sought approval under Part 3.6 (commencing with Section 15909) has been transitioned to a Low Income Health Program, if authorized under the demonstration project and Part 3.6 (commencing with Section 15909), and shall, six months after the date the declaration is executed, be repealed.

(b) In addition to the requirements specified in subdivision (a), the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State and the Legislative Counsel.

(c) Until the effective date of the repeal of this part pursuant to subdivision (a), the director may continue and administer any extensions, modifications, or continuation of the projects under this part approved by the federal Centers for Medicare and Medicaid Services.

history: (History: Amended by Stats. 2011, Ch. 86, Sec. 23. (AB 1066) Effective July 15, 2011. Repealed on date prescribed by its own provisions. Note: Termination clause affects Part 3.5, commencing with Section 15900.)


text:
The Legislature finds and declares all of the following:

(a) Pursuant to Section 14180, the Legislature directed the department to apply for a successor federal waiver or demonstration project, in part, to coincide with the end of the waiver described in relevant part in subdivision (b) of Section 15900 to, among other requirements, optimize opportunities to increase federal financial participation and maximize financial resources to address uncompensated care.

(b) Passage of federal health care reform, pursuant to 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), presents new options of federal support for coverage of low-income individuals and significant expansion of state coverage programs in 2014. Through the success of the Health Care Coverage Initiatives established pursuant to Part 3.5 (commencing with Section 15900), and with implementation of a successor federal Medicaid waiver or demonstration project, California is well positioned to develop enrollment and coverage expansion models that will lead the way to full implementation of comprehensive health care reforms in 2014.

history: (History: Added by Stats. 2010, Ch. 723, Sec. 2. (AB 342) Effective October 19, 2010.)

part: 3.6. Low Income Health Program

path: 9. PUBLIC SOCIAL SERVICES > 4. California Major Risk Medical Insurance Program > 3.6. Low Income Health Program


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

(a) “Demonstration project” means a federal waiver or demonstration project described in Section 14180 approved by the federal Centers for Medicare and Medicaid Services that authorizes the implementation of a successor to the Health Care Coverage Initiative under Part 3.5 (commencing with Section 15900).

(b) (1) “Eligible entity” means any of the following:

(A) A county.

(B) A city and county.

(C) A consortium of counties serving a region consisting of more than one county.

(D) A health authority.

(E) A nondesignated public hospital, or the entity with which it is affiliated, if all of the following conditions are met:

(i) The hospital is located in a county that does not have a designated public hospital.

(ii) The county does not intend to operate a LIHP pursuant to Section 15910.5.

(iii) If the county previously filed an application to operate a LIHP, the county has formally withdrawn its application.

(2) For purposes of this section and to the extent allowed under the Special Terms and Conditions of the demonstration project, a County Medical Services Program shall be considered a consortium of counties serving a region consisting of more than one county.

(c) “LIHP” means a local Low Income Health Program authorized pursuant to this part that is comprised of the following populations:

(1) The Medicaid Coverage Expansion (MCE) population, which means low-income individuals 19 to 64 years of age, inclusive, who are not pregnant, have family incomes at or below 133 percent of the federal poverty level, are not eligible for the Medi-Cal program or the Children’s Health Insurance Program, are United States citizens, nationals, or have satisfactory immigration status, and meet the county of residence requirements.

(2) The Health Care Coverage Initiative (HCCI) population, which means low-income individuals 19 to 64 years of age, inclusive, who are not pregnant, have family incomes above 133 percent through 200 percent of the federal poverty level, are not eligible for the Medicare Program, the Medi-Cal program, the Children’s Health Insurance Program, or other third-party coverage, are United States citizens, nationals, or have satisfactory immigration status, and meet the county of residence requirements.

(d) “Participating entity” means an eligible entity that operates an approved LIHP.

(e) “Designated public hospital” has the same meaning as defined in subdivision (d) of Section 14166.1.

(f) “Nondesignated public hospital” has the same meaning as defined in subdivision (f) of Section 14166.1.

history: (History: Amended by Stats. 2012, Ch. 453, Sec. 1. (SB 1081) Effective September 22, 2012.)


text:
(a) Subject to federal approval of a demonstration project effective on or after November 1, 2010, the department shall, by no later than July 1, 2011, authorize local LIHPs to provide scheduled health care services, consistent with the Special Terms and Conditions of the demonstration project, to eligible low-income individuals 19 to 64 years of age, inclusive, who are not otherwise eligible for the Medi-Cal program or the Children’s Health Insurance Program, with family incomes at or below 133 percent of the federal poverty level. To the extent federal financial participation is made available under the Special Terms and Conditions of the demonstration project pursuant to Section 15910.1, LIHP health care services may be made available to eligible individuals with family incomes above 133 percent through 200 percent of the federal poverty level.

(b) Eligible entities, consistent with the Special Terms and Conditions of the demonstration project, may perform outreach and enrollment activities to target populations, including, but not limited to, people who are homeless, individuals who frequently use hospital inpatient or emergency department services for avoidable reasons, or people with mental health or substance abuse treatment needs.

(c) The LIHP shall be designed and implemented with the systems and program elements necessary to facilitate the transition of those eligible individuals to Medi-Cal coverage, or alternatively, to coverage through the California Health Benefit Exchange, by 2014, pursuant to state and federal law, and the Special Terms and Conditions of the demonstration project.

(d) The department shall authorize a LIHP that meets the requirements set forth in this part and the Special Terms and Conditions of the demonstration project.

(e) (1) By January 1, 2011, or alternatively, 60 days after federal approval of the demonstration project, whichever occurs later, the department shall notify all eligible entities of the opportunity to elect to implement a LIHP, the applicable requirements, and the process for submitting an application for department approval of a LIHP application.

(2) The director shall approve or deny an eligible entity’s LIHP application within 60 days of receipt of the application. If the director denies an application, the denial shall be in writing and shall specify the reasons therefor.

(3) Within 10 days of a denial by the director under this subdivision, a participating entity may submit a written request for reconsideration. The director shall respond in writing to a request for reconsideration within 20 days, confirming or reversing the denial, and specifying the reasons for the reconsidered decision.

(f) If the eligible entity had in operation a Health Care Coverage Initiative program under Part 3.5 (commencing with Section 15900) as of November 1, 2010, and the eligible entity elects to continue funding the program, then the existing Health Care Coverage Initiative program shall, to the extent permitted by the Special Terms and Conditions of the demonstration project, remain in effect and receive federal reimbursement in accordance with the Special Terms and Conditions of the demonstration project until the LIHP is effective, but no later than July 1, 2011.

(g) Health care services provided pursuant to this part shall be available to those eligible, low-income individuals enrolled in the applicable LIHP, subject to the limitations of this part and the Special Terms and Conditions of the demonstration project. However, nothing in this part is intended to create an entitlement program of any kind.

(h) Each LIHP may establish an upper income limit for eligible MCE individuals to enroll in the LIHP, which shall be expressed as a percentage between 0 percent and up to, and including, 133 percent of the federal poverty level. If the LIHP elects to enroll HCCI-eligible individuals with family incomes above 133 percent through 200 percent of the federal poverty level, it may also establish an upper income limit between this range. Notwithstanding any established upper income limit, the LIHP may impose a limit on enrollment in the LIHP, which shall be subject to all of the following provisions:

(1) The Special Terms and Conditions required by the federal Centers for Medicare and Medicaid Services for the approval of the demonstration project described in Section 14180 permit a limitation on enrollment in a LIHP.

(2) Any enrollment limitation by a LIHP shall be administered in accordance with the Special Terms and Conditions required by the federal Centers for Medicare and Medicaid Services.

(3) Any enrollment limitation by a LIHP is subject to approval by the director, and notification to the federal Centers for Medicare and Medicaid Services. A LIHP shall establish an income limit at a level that minimizes the need for imposing a limit on enrollment for the MCE population.

(4) Prior to applying for approval from the director, the LIHP shall submit to the director a resolution from its governing board approving the proposed limitation on enrollment by the LIHP.

(i) LIHPs shall be established and implemented only to the extent that federal financial participation is available and only to the extent that available federal financial participation is not jeopardized.

(j) For the purposes of operating a LIHP approved under this part, and notwithstanding Section 14181, participating entities shall be exempt from the provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, shall not be considered Medi-Cal managed care health plans subject to the requirements applicable to the two-plan model and geographic managed care plans, as contained in Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), and Article 2.91 (commencing with Section 14089) of Chapter 7 of Part 3 and the corresponding regulations, and shall not be considered prepaid health plans as defined in Section 14251.

history: (History: Amended by Stats. 2012, Ch. 162, Sec. 228. (SB 1171) Effective January 1, 2013.)


text:
(a) For LIHPs serving HCCI-eligible individuals , subject to federal funding limits or requirements that differ from the requirements for individuals described in subdivision (a) of Section 15910, the department shall, in consultation with participating entities, develop a process for allocating the available federal funding to those approved LIHPs that elect to serve the additional group of individuals identified in this subdivision, if the participating entity voluntarily agrees to provide the nonfederal share of the LIHP expenditures for the additional group.

(b) To the extent permitted by the Special Terms and Conditions of the demonstration project, the allocation of funding under this section shall ensure that a Health Care Coverage Initiative program under Part 3.5 (commencing with Section 15900) as of November 1, 2010, that elects to continue as a participating entity under this part receives, at a minimum, an allocation in an amount adequate to ensure that their existing eligible enrollees can continue to receive services under their LIHP.

(c) If a LIHP elects to serve eligible persons with incomes above 133 percent through 200 percent of the federal poverty level, the LIHP shall also serve eligible persons with incomes up to 133 percent of the federal poverty level.

(d) Section 15910 and Section 15910.2 shall apply with respect to LIHPs funded under this section, as appropriate.

(e) Reimbursements to LIHPs approved under this section shall be made in accordance with Section 15910.3 or through another mechanism authorized under the Special Terms and Conditions for the demonstration project.

(f) The nonfederal share of funding for LIHP expenditures authorized under this section shall be provided in accordance with Section 15911 or through another mechanism authorized by the Special Terms and Conditions of the demonstration project.

(g) Any unused federal funds shall be distributed in accordance with the Special Terms and Conditions of the demonstration project.

history: (History: Amended by Stats. 2011, Ch. 86, Sec. 27. (AB 1066) Effective July 15, 2011.)