Jurris.COM
Part 6.6. Qualified High Risk Pools of California Insurance Code >> Division 2. >> Part 6.6.
It is the intent of the Legislature to implement Section
1101 of the federal Patient Protection and Affordable Care Act
(Public Law 111-148) in California to establish a temporary high risk
pool so that access to health coverage for individuals with
preexisting medical conditions can be effectively and promptly
provided by the Managed Risk Medical Insurance Board.
For the purposes of this part, the following terms have
the following meanings:
(a) "Applicant" means an individual who applies for high risk medical coverage through the program.
(b) "Board" means the Managed Risk Medical Insurance Board.
(c) "Federal temporary high risk pool" is the temporary high risk health insurance pool program established pursuant to Section 1101 of the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(d) "Fund" means the Federal Temporary High Risk Health Insurance Fund, established in Section 12739.71, from which the board may authorize expenditures to pay for all of the following:
(1) Covered, medically necessary services that exceed subscribers' contributions.
(2) Administration of the program.
(3) Marketing and outreach.
(e) "High risk medical coverage" or "coverage" means payment for medically necessary services provided by institutional and professional providers through the program.
(f) "Participating health plan" means a private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, that contracts with the program to provide or administer high risk medical coverage to program subscribers.
(g) "Plan rates" means the total monthly amount charged by a participating health plan to provide or administer high risk medical coverage.
(h) "Program" means the Federal Temporary High Risk Pool through which the board operates the federal temporary high risk pool in California.
(i) "Subscriber" means an eligible individual, as defined in subsection (d) of Section 1101 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), who is enrolled in the program, and includes a member of a federally recognized California Indian tribe.
(j) "Subscriber contribution" means the premium for high risk medical coverage paid by the subscriber or, if authorized by the federal government, 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 coverage options, including participating health plans, available in the county where the member resides.
(a) "Applicant" means an individual who applies for high risk medical coverage through the program.
(b) "Board" means the Managed Risk Medical Insurance Board.
(c) "Federal temporary high risk pool" is the temporary high risk health insurance pool program established pursuant to Section 1101 of the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(d) "Fund" means the Federal Temporary High Risk Health Insurance Fund, established in Section 12739.71, from which the board may authorize expenditures to pay for all of the following:
(1) Covered, medically necessary services that exceed subscribers' contributions.
(2) Administration of the program.
(3) Marketing and outreach.
(e) "High risk medical coverage" or "coverage" means payment for medically necessary services provided by institutional and professional providers through the program.
(f) "Participating health plan" means a private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, that contracts with the program to provide or administer high risk medical coverage to program subscribers.
(g) "Plan rates" means the total monthly amount charged by a participating health plan to provide or administer high risk medical coverage.
(h) "Program" means the Federal Temporary High Risk Pool through which the board operates the federal temporary high risk pool in California.
(i) "Subscriber" means an eligible individual, as defined in subsection (d) of Section 1101 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), who is enrolled in the program, and includes a member of a federally recognized California Indian tribe.
(j) "Subscriber contribution" means the premium for high risk medical coverage paid by the subscriber or, if authorized by the federal government, 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 coverage options, including participating health plans, available in the county where the member resides.
The Federal Temporary High Risk Pool is hereby created in
the California Health and Human Services Agency. The program shall
be managed by the board.
The board shall have the authority to do all of the
following, consistent with Section 1101 of the federal Patient
Protection and Affordable Care Act (Public Law 111-148):
(a) Enter into an agreement with the federal Department of Health and Human Services to administer the federal temporary high risk pool as provided in Section 12739.53.
(b) Determine eligibility criteria and enrollment and disenrollment criteria and processes, including processes for waiting lists, enrollment limits, disenrollments, and any other limits on enrollment needed to maintain program expenditures within available federal funds.
(c) Determine the participation requirements of applicants, subscribers, and participating health plans, third-party administrators, and other contractors.
(d) Determine when subscribers' coverage begins and ends.
(e) Provide for the processing of applications and the enrollment of subscribers.
(f) Determine the high risk medical coverage to be provided to subscribers, including the scope of benefits and subscriber cost sharing.
(g) Establish subscriber contributions and plan rates.
(h) (1) Provide high risk medical coverage for subscribers through contracts with participating health plans or third-party administrators to provide or administer the coverage. A contract between the board and a participating health plan may provide that the contracting health plan assumes full or partial risk for the cost of covered health services or that the contracting health plan undertakes to provide only administrative services for the state's self-insured high risk medical coverage. A contract between the board and a third-party administrator may provide that the third-party administrator undertakes to provide only administrative services for the state's self-insured high risk medical coverage. The board may provide or purchase stop-loss coverage under which the program and participating health plans or stop-loss insurers share the risk for health plan expenses that exceed plan rates.
(2) Nothing in paragraph (1) shall be construed to alter the rights of a participating health plan under existing law if the board is unable to continue payment to the plan in accordance with the terms of the plan's contract with the board.
(i) Authorize expenditures from the fund to pay program expenses that exceed subscriber contributions.
(j) Contract for administration of the program or any portion of the program with any public agency, including any agency of state government, or with any private entity.
(k) If, and to the extent, permitted by federal law and by the federal Department of Health and Human Services, align program administration with the administration of the Major Risk Medical Insurance Program established pursuant to Part 6.5 (commencing with Section 12700) to ensure coordination and administrative efficiency.
(l) Sue and be sued.
(m) Employ necessary staff.
(n) Refer potential violations of state and federal law by participating health plans and other entities and persons to the appropriate regulatory agencies.
(o) Subject to the approval of the Department of Finance, obtain loans from the General Fund for all necessary and reasonable expenses related to the administration of the fund and the program. The board shall repay principal and interest, using the pooled money investment account rate of interest, to the General Fund no later than July 1, 2014.
(p) (1) Issue rules and regulations to carry out the purposes of this part. The adoption and readoption of regulations to implement this part shall be deemed to be an emergency that calls for immediate action to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that the board describe facts showing the need for immediate action and from review by the Office of Administrative Law.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the board shall, without taking any regulatory action, initially implement this section pursuant to the agreement with the federal Department of Health and Human Services described in subdivision (a) of Section 12739.53. Thereafter, the board shall adopt any necessary 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 and with paragraph (1) of this subdivision.
(q) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed upon the board under this part, including the powers and responsibilities necessary to enter into an agreement with, and comply with the requirements of, the federal Department of Health and Human Services as described in subdivision (a) of Section 12739.53.
(a) Enter into an agreement with the federal Department of Health and Human Services to administer the federal temporary high risk pool as provided in Section 12739.53.
(b) Determine eligibility criteria and enrollment and disenrollment criteria and processes, including processes for waiting lists, enrollment limits, disenrollments, and any other limits on enrollment needed to maintain program expenditures within available federal funds.
(c) Determine the participation requirements of applicants, subscribers, and participating health plans, third-party administrators, and other contractors.
(d) Determine when subscribers' coverage begins and ends.
(e) Provide for the processing of applications and the enrollment of subscribers.
(f) Determine the high risk medical coverage to be provided to subscribers, including the scope of benefits and subscriber cost sharing.
(g) Establish subscriber contributions and plan rates.
(h) (1) Provide high risk medical coverage for subscribers through contracts with participating health plans or third-party administrators to provide or administer the coverage. A contract between the board and a participating health plan may provide that the contracting health plan assumes full or partial risk for the cost of covered health services or that the contracting health plan undertakes to provide only administrative services for the state's self-insured high risk medical coverage. A contract between the board and a third-party administrator may provide that the third-party administrator undertakes to provide only administrative services for the state's self-insured high risk medical coverage. The board may provide or purchase stop-loss coverage under which the program and participating health plans or stop-loss insurers share the risk for health plan expenses that exceed plan rates.
(2) Nothing in paragraph (1) shall be construed to alter the rights of a participating health plan under existing law if the board is unable to continue payment to the plan in accordance with the terms of the plan's contract with the board.
(i) Authorize expenditures from the fund to pay program expenses that exceed subscriber contributions.
(j) Contract for administration of the program or any portion of the program with any public agency, including any agency of state government, or with any private entity.
(k) If, and to the extent, permitted by federal law and by the federal Department of Health and Human Services, align program administration with the administration of the Major Risk Medical Insurance Program established pursuant to Part 6.5 (commencing with Section 12700) to ensure coordination and administrative efficiency.
(l) Sue and be sued.
(m) Employ necessary staff.
(n) Refer potential violations of state and federal law by participating health plans and other entities and persons to the appropriate regulatory agencies.
(o) Subject to the approval of the Department of Finance, obtain loans from the General Fund for all necessary and reasonable expenses related to the administration of the fund and the program. The board shall repay principal and interest, using the pooled money investment account rate of interest, to the General Fund no later than July 1, 2014.
(p) (1) Issue rules and regulations to carry out the purposes of this part. The adoption and readoption of regulations to implement this part shall be deemed to be an emergency that calls for immediate action to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that the board describe facts showing the need for immediate action and from review by the Office of Administrative Law.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the board shall, without taking any regulatory action, initially implement this section pursuant to the agreement with the federal Department of Health and Human Services described in subdivision (a) of Section 12739.53. Thereafter, the board shall adopt any necessary 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 and with paragraph (1) of this subdivision.
(q) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed upon the board under this part, including the powers and responsibilities necessary to enter into an agreement with, and comply with the requirements of, the federal Department of Health and Human Services as described in subdivision (a) of Section 12739.53.
(a) The board shall, consistent with Section 1101 of the
federal Patient Protection and Affordable Care Act (P.L. 111-148) and
state and federal law and contingent on the agreement of the federal
Department of Health and Human Services and receipt of sufficient
federal funding, enter into an agreement with the federal Department
of Health and Human Services to administer the federal temporary high
risk pool in California.
(b) If the federal Department of Health and Human Services and the state enter into an agreement to administer the federal temporary high risk pool, the board shall do all of the following:
(1) Administer the program pursuant to that agreement.
(2) Begin providing coverage in the program on the date established pursuant to the agreement with the federal Department of Health and Human Services.
(3) Establish the scope and content of high risk medical coverage.
(4) Determine reasonable minimum standards for participating health plans, third-party administrators, and other contractors.
(5) Determine the time, manner, method, and procedures for withdrawing program approval from a plan, third-party administrator, or other contractor, or limiting enrollment of subscribers in a plan.
(6) Research and assess the needs of persons without adequate health coverage and promote means of ensuring the availability of adequate health care services.
(7) Administer the program to ensure the following:
(A) That the program subsidy amount does not exceed amounts transferred to the fund pursuant to this part.
(B) That the aggregate amount spent for high risk medical coverage and program administration does not exceed the federal funds available to the state for this purpose and that no state funds are spent for the purposes of this part.
(8) Maintain enrollment and expenditures to ensure that expenditures do not exceed amounts available in the fund and that no state funds are spent for purposes of this part. If sufficient funds are not available to cover the estimated cost of program expenditures, the board shall institute appropriate measures to limit enrollment.
(9) In adopting benefit and eligibility standards, be guided by the needs and welfare of persons unable to secure adequate health coverage for themselves and their dependents and by prevailing practices among private health plans.
(10) As required by the federal Department of Health and Human Services, implement procedures to provide for the transition of subscribers into qualified health plans offered through an exchange or exchanges to be established pursuant to the federal Patient Protection and Affordable Care Act (P.L. 111-148).
(11) Post on the board's Internet Web site the monthly progress reports submitted to the federal Department of Health and Human Services. In addition, the board shall provide notice of any anticipated waiting lists or disenrollments due to insufficient funding to the public, by making that notice available as part of its board meetings, and concurrently to the Legislature.
(12) Develop and implement a plan for marketing and outreach.
(c) There shall not be any liability in a private capacity on the part of the board or any member of the board, or any officer or employee of the board for or on account of any act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this part or affairs related to this part.
(b) If the federal Department of Health and Human Services and the state enter into an agreement to administer the federal temporary high risk pool, the board shall do all of the following:
(1) Administer the program pursuant to that agreement.
(2) Begin providing coverage in the program on the date established pursuant to the agreement with the federal Department of Health and Human Services.
(3) Establish the scope and content of high risk medical coverage.
(4) Determine reasonable minimum standards for participating health plans, third-party administrators, and other contractors.
(5) Determine the time, manner, method, and procedures for withdrawing program approval from a plan, third-party administrator, or other contractor, or limiting enrollment of subscribers in a plan.
(6) Research and assess the needs of persons without adequate health coverage and promote means of ensuring the availability of adequate health care services.
(7) Administer the program to ensure the following:
(A) That the program subsidy amount does not exceed amounts transferred to the fund pursuant to this part.
(B) That the aggregate amount spent for high risk medical coverage and program administration does not exceed the federal funds available to the state for this purpose and that no state funds are spent for the purposes of this part.
(8) Maintain enrollment and expenditures to ensure that expenditures do not exceed amounts available in the fund and that no state funds are spent for purposes of this part. If sufficient funds are not available to cover the estimated cost of program expenditures, the board shall institute appropriate measures to limit enrollment.
(9) In adopting benefit and eligibility standards, be guided by the needs and welfare of persons unable to secure adequate health coverage for themselves and their dependents and by prevailing practices among private health plans.
(10) As required by the federal Department of Health and Human Services, implement procedures to provide for the transition of subscribers into qualified health plans offered through an exchange or exchanges to be established pursuant to the federal Patient Protection and Affordable Care Act (P.L. 111-148).
(11) Post on the board's Internet Web site the monthly progress reports submitted to the federal Department of Health and Human Services. In addition, the board shall provide notice of any anticipated waiting lists or disenrollments due to insufficient funding to the public, by making that notice available as part of its board meetings, and concurrently to the Legislature.
(12) Develop and implement a plan for marketing and outreach.
(c) There shall not be any liability in a private capacity on the part of the board or any member of the board, or any officer or employee of the board for or on account of any act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this part or affairs related to this part.
(a) Plan rates for high 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.
(b) As a condition of reimbursement, participating health plans or third-party administrators shall submit claims to the board within 18 months following the date of service. The board may vary the time limit established in this subdivision if necessary to administer the reimbursement or reconciliation processes established by the board or to meet the requirements of the state's agreement with the federal Department of Health and Human Services described in subdivision (a) of Section 12739.53.
(b) As a condition of reimbursement, participating health plans or third-party administrators shall submit claims to the board within 18 months following the date of service. The board may vary the time limit established in this subdivision if necessary to administer the reimbursement or reconciliation processes established by the board or to meet the requirements of the state's agreement with the federal Department of Health and Human Services described in subdivision (a) of Section 12739.53.
The program 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 pursuant to this part.
Except as provided in Article 3.5 (commencing with
Section 14124.70) of Chapter 7 of Part 3 of Division 9 of the Welfare
and Institutions Code, benefits received under this part are in
excess of, and secondary to, any other form of health benefits
coverage.
The board shall provide coverage pursuant to this part
through participating health plans or through provider networks using
a third-party administrator and may contract for the processing of
applications, the enrollment of subscribers, and all activities
necessary to administer the program. Any contract entered into
pursuant to this part 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 board 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.
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 regulations of the program.
(a) Program decisions concerning an applicant's or
subscriber's eligibility or eligibility date may be appealed to the
board, according to procedures to be established by the board.
(b) Coverage determinations may be appealed to the board, according to procedures established by the board. If permitted by the federal Department of Health and Human Services, the board shall not be required to provide an appeal concerning a coverage determination if the subject of the appeal is within the jurisdiction of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and its implementing regulations or within the jurisdiction of the Department of Insurance pursuant to the Insurance Code and its implementing regulations.
(c) Hearings shall be conducted according to the requirements of the federal Department of Health and Human Services and, insofar as practicable and not inconsistent with those requirements, pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
(b) Coverage determinations may be appealed to the board, according to procedures established by the board. If permitted by the federal Department of Health and Human Services, the board shall not be required to provide an appeal concerning a coverage determination if the subject of the appeal is within the jurisdiction of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and its implementing regulations or within the jurisdiction of the Department of Insurance pursuant to the Insurance Code and its implementing regulations.
(c) Hearings shall be conducted according to the requirements of the federal Department of Health and Human Services and, insofar as practicable and not inconsistent with those requirements, pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
Upon enrollment as a subscriber in the program, the
subscriber shall be responsible for payment of the subscriber
contribution.
(a) Subject to subdivision (c), the board shall cease to
provide coverage through the program on July 1, 2013, except as
required by the contract between the board and the United States
Department of Health and Human Services, and at that time shall cease
to operate the program except as required to complete payments to,
or payment reconciliations with, participating health plans or other
contractors, process appeals, or conduct other necessary termination
activities.
(b) Any permanent or probationary civil service employee who is employed by the board and assigned to the program and whose function ceases due to this section shall immediately be transferred to the California Health Benefit Exchange and shall retain his or her status, position, and rights pursuant to Section 19050.9 of the Government Code and the State Civil Service Act (Part 2 (commencing with Section 18500) and Part 2.6 (commencing with Section 19815) of Division 5 of Title 2 of the Government Code).
(c) Commencing on July 1, 2014, the State Department of Health Care Services shall complete payments to, or payment reconciliations with, participating health plans or other contractors, process appeals, or conduct other necessary program termination activities.
(b) Any permanent or probationary civil service employee who is employed by the board and assigned to the program and whose function ceases due to this section shall immediately be transferred to the California Health Benefit Exchange and shall retain his or her status, position, and rights pursuant to Section 19050.9 of the Government Code and the State Civil Service Act (Part 2 (commencing with Section 18500) and Part 2.6 (commencing with Section 19815) of Division 5 of Title 2 of the Government Code).
(c) Commencing on July 1, 2014, the State Department of Health Care Services shall complete payments to, or payment reconciliations with, participating health plans or other contractors, process appeals, or conduct other necessary program termination activities.
This part shall remain in effect only until January 1,
2020, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2020, deletes or extends
that date.
