Section 1373.622 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1373.622
. (a) (1) After the termination of the pilot program under
Section 1373.62, a health care service plan shall continue to provide
coverage under the same terms and conditions specified in Section
1376.62 as it existed on January 1, 2007, including the terms of the
standard benefit plan and the subscriber payment amount, to each
individual who was terminated from the program pursuant to
subdivision (f) of Section 12725 of the Insurance Code during the
term of the pilot program and who enrolled or applied to enroll in a
standard benefit plan within 63 days of termination. The State
Department of Health Care Services shall continue to pay the amount
described in Section 1376.62 for each of those individuals. A health
care service plan shall not be required to offer the coverage
described in Section 1373.62 after the termination of the pilot
program to individuals not already enrolled in the program.
(2) Notwithstanding paragraph (1) of this subdivision or Section
1373.62 as it existed on January 1, 2007, the following rules shall
apply:
(A) (i) A health care service plan shall not be obligated to
provide coverage to any individual pursuant to this section on or
after January 1, 2014.
(ii) The State Department of Health Care Services shall not be
obligated to provide any payment to any health care service plan
under this section for (I) health care expenses incurred on or after
January 1, 2014, or (II) the standard monthly administrative fee, as
defined in Section 1373.62 as it existed on January 1, 2007, for any
month after December 2013.
(B) Each health care service plan providing coverage pursuant to
this section shall, on or before October 1, 2013, send a notice to
each individual enrolled in a standard benefit plan that is in at
least 12-point type and with, at minimum, the following information:
(i) Notice as to whether or not the plan will terminate as of
January 1, 2014.
(ii) The availability of individual health coverage, including
through Covered California, including at least all of the following:
(I) That, beginning on January 1, 2014, individuals seeking
coverage may not be denied coverage based on health status.
(II) That the premium rates for coverage offered by a health care
service plan or a health insurer cannot be based on an individual's
health status.
(III) That individuals obtaining coverage through Covered
California may, depending upon income, be eligible for premium
subsidies and cost-sharing subsidies.
(IV) That individuals seeking coverage must obtain this coverage
during an open or special enrollment period, and a description of the
open and special enrollment periods that may apply.
(C) As a condition of receiving payment for a reporting period
pursuant to this section, a health care service plan shall provide
the State Department of Health Care Services with a complete, final
annual reconciliation report by the earlier of December 31, 2014, or
an earlier date as prescribed by Section 1373.62, as it existed on
January 1, 2007, for that reporting period. To the extent that it
receives a complete, final reconciliation report for a reporting
period by the date required pursuant to this subparagraph, the State
Department of Health Care Services shall complete reconciliation with
the health care service plan for that reporting period within 18
months after receiving the report.
(b) If the state fails to expend, pursuant to this section,
sufficient funds for the state's contribution amount to any health
care service plan, the health care service plan may increase the
monthly payments that its subscribers are required to pay for any
standard benefit plan to the amount that the State Department of
Health Care Services would charge without a state subsidy for the
same plan issued to the same individual within the program.
(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the State
Department of Health Care Services may implement, interpret, or make
specific this section by means of all-county letters, plan letters,
plan or provider bulletins, or similar instructions, without taking
regulatory action.