SECTIONS 12693.70-12693.765 - California Statutes

INSURANCE CODE

SECTION 12693.70-12693.765

12693.70. To be eligible to participate in the program, an
applicant shall meet all of the following requirements:
(a) Be an applicant applying on behalf of an eligible child, which
means a child who is all of the following:
(1) Less than 19 years of age. An application may be made on
behalf of a child not yet born up to three months prior to the
expected date of delivery. Coverage shall begin as soon as
administratively feasible, as determined by the board, after the
board receives notification of the birth. However, no child less than
12 months of age shall be eligible for coverage until 90 days after
the enactment of the Budget Act of 1999.
(2) Not eligible for no-cost full-scope Medi-Cal or Medicare
coverage at the time of application.
(3) In compliance with Sections 12693.71 and 12693.72.
(4) A 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, except
as specified in Section 12693.76.
(5) A resident of the State of California pursuant to Section 244
of the Government Code; or, if not a resident pursuant to Section 244
of the Government Code, is physically present in California and
entered the state with a job commitment or to seek employment,
whether or not employed at the time of application to or after
acceptance in, the program.
(6) (A) In either of the following:
(i) In a family with an annual or monthly household income equal
to or less than 200 percent of the federal poverty level.
(ii) When implemented by the board, subject to subdivision (b) of
Section 12693.765 and pursuant to this section, a child under the age
of two years who was delivered by a mother enrolled in the Access
for Infants and Mothers Program as described in Part 6.3 (commencing
with Section 12695). Commencing July 1, 2007, eligibility under this
subparagraph shall not include infants during any time they are
enrolled in employer-sponsored health insurance or are subject to an
exclusion pursuant to Section 12693.71 or 12693.72, or are enrolled
in the full scope of benefits under the Medi-Cal program at no share
of cost. For purposes of this clause, any infant born to a woman
whose enrollment in the Access for Infants and Mothers Program begins
after June 30, 2004, shall be automatically enrolled in the Healthy
Families Program, except during any time on or after July 1, 2007,
that the infant is enrolled in employer-sponsored health insurance or
is subject to an exclusion pursuant to Section 12693.71 or 12693.72,
or is enrolled in the full scope of benefits under the Medi-Cal
program at no share of cost. Except as otherwise specified in this
section, this enrollment shall cover the first 12 months of the
infant's life. At the end of the 12 months, as a condition of
continued eligibility, the applicant shall provide income
information. The infant shall be disenrolled if the gross annual
household income exceeds the income eligibility standard that was in
effect in the Access for Infants and Mothers Program at the time the
infant's mother became eligible, or following the two-month period
established in Section 12693.981 if the infant is eligible for
Medi-Cal with no share of cost. At the end of the second year,
infants shall again be screened for program eligibility pursuant to
this section, with income eligibility evaluated pursuant to clause
(i), subparagraphs (B) and (C), and paragraph (2) of subdivision (a).
(B) All income over 200 percent of the federal poverty level but
less than or equal to 250 percent of the federal poverty level shall
be disregarded in calculating annual or monthly household income.
(C) In a family with an annual or monthly household income greater
than 250 percent of the federal poverty level, any income deduction
that is applicable to a child under Medi-Cal shall be applied in
determining the annual or monthly household income. If the income
deductions reduce the annual or monthly household income to 250
percent or less of the federal poverty level, subparagraph (B) shall
be applied.
(b) The applicant shall agree to remain in the program for six
months, unless other coverage is obtained and proof of the coverage
is provided to the program.
(c) An applicant shall enroll all of the applicant's eligible
children in the program.
(d) In filing documentation to meet program eligibility
requirements, if the applicant's income documentation cannot be
provided, as defined in regulations promulgated by the board, the
applicant's signed statement as to the value or amount of income
shall be deemed to constitute verification.
(e) An applicant shall pay in full any family contributions owed
in arrears for any health, dental, or vision coverage provided by the
program within the prior 12 months.
(f) By January 2008, the board, in consultation with stakeholders,
shall implement processes by which applicants for subscribers may
certify income at the time of annual eligibility review, including
rules concerning which applicants shall be permitted to certify
income and the circumstances in which supplemental information or
documentation may be required. The board may terminate using these
processes not sooner than 90 days after providing notification to the
Chair of the Joint Legislative Budget Committee. This notification
shall articulate the specific reasons for the termination and shall
include all relevant data elements that are applicable to document
the reasons for the termination. Upon the request of the Chair of the
Joint Legislative Budget Committee, the board shall promptly provide
any additional clarifying information regarding implementation of
the processes required by this subdivision.

12693.71. (a) The board shall monitor applications to determine
whether employers and employees have dropped employer-sponsored
dependent coverage in order to participate in the program.
(b) The board may disapprove an application if it is determined
that the children to be covered under the application were covered by
an employer-sponsored insurance within the last three months.
(c) If the board imposes the limitation identified in subdivision
(b) or (d), it shall also establish exceptions to this limitation in
cases where prior coverage ended due to reasons unrelated to the
availability of the program. This shall include, but not be limited
to:
(1) Loss of employment due to factors other than voluntary
termination.
(2) Change to a new employer that does not provide an option for
dependent coverage.
(3) Change of address so that no employer sponsored coverage is
available.
(4) Discontinuation of health benefits to all employees of the
applicant's employer.
(5) Expiration of COBRA coverage period.
(6) Coverage provided pursuant to an exemption authorized under
subdivision (i) of Section 1367 of the Health and Safety Code.
(d) If the board determines, based on evidence gathered during a
reasonable period of program operation, that a substantial share of
funds expended for the program are providing health coverage for
children that have discontinued employer-based coverage in order to
enter the program or if required by the federal government for state
plan approval, the board may take actions to increase the three-month
time limit specified in subdivision (b), to such a time limit that
cannot exceed six months.

12693.72. (a) The board may disapprove an application if it is
determined that the children to be covered under the application were
covered by an individual health care service plan contract or
individual disability insurance policy during a specified period of
time prior to the date of application only if required by the federal
government for state plan approval. This time limitation period
shall not exceed the time period required by the federal government.
(b) If the board imposes the time limitation identified in
subdivision (a), it shall also establish exceptions to this
limitation in cases where the prior coverage ended due to reasons
unrelated to the availability of the program. This shall include, but
not be limited to, the prior coverage being pursuant to a health
plan operating pursuant to an exemption authorized by subdivision (i)
of Section 1367 of the Health and Safety Code.

12693.73. Notwithstanding any other provision of law, children
excluded from coverage under Title XXI of the Social Security Act are
not eligible for coverage under the program, except as specified in
clause (ii) of subparagraph (A) of paragraph (6) of subdivision (a)
of Section 12693.70 and Section 12693.76.

12693.74. Subscribers shall continue to be eligible for the program
for a period of 12 months from the month eligibility is established.

12693.75. (a) The program shall make use of a simple and easy to
understand mail-in application process.
(b) For children referred pursuant to Section 14005.41 of the
Welfare and Institutions Code, the program shall utilize the school
lunch application and any supplemental forms received pursuant to
Section 14005.41 of the Welfare and Institutions Code to make an
eligibility determination and shall request additional information
only as needed to complete the eligibility process.
(c) The Managed Risk Medical Insurance Board may adopt emergency
regulations to implement subdivision (b) and coordinate with all
other state and local government entities in the implementation of
Section 49557.2 of the Education Code and Section 14005.41 of the
Welfare and Institutions Code. Any rules and regulations issued by
the board pertaining to the implementation of this section may be
adopted as emergency regulations in accordance with the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code).
The adoption and one readoption of these regulations shall be deemed
to be an emergency and necessary for the immediate preservation of
the public peace, health, and safety, or general welfare, and shall
be exempt from review by the Office of Administrative Law. Any
emergency regulations authorized by this section shall be submitted
to the Office of Administrative Law for filing with the Secretary of
State and publication in the California Code of Regulations, and
shall remain in effect for not more than 180 days unless the
department readopts those regulations. The regulations shall become
effective immediately upon filing with the Secretary of State.

12693.755. (a) Subject to subdivision (b), commencing four months
after the initial federal approval is obtained pursuant to the waiver
described in subdivision (b), the board shall expand eligibility
under this part to uninsured parents of, and as defined by the board,
adults responsible for, children enrolled to receive coverage under
this part or who are enrolled to receive the full scope of Medi-Cal
services with no share of cost and whose income does not exceed 250
percent of the federal poverty level, before applying the income
disregard provided for in subparagraph (B) of paragraph (6) of
subdivision (a) of Section 12693.70.
(b) (1) The board shall implement a program to provide coverage
under this part to any uninsured parent or responsible adult who is
eligible pursuant to subdivision (a), pursuant to the waiver
identified in paragraph (2).
(2) The program shall be implemented only in accordance with a
State Child Health Insurance Program waiver pursuant to Section
1397gg(e)(2)(A) of Title 42 of the United States Code, to provide
coverage to uninsured parents and responsible adults, and shall be
subject to the terms, conditions, and duration of the waiver. The
services shall be provided under the program only if the waiver is
approved by the federal Centers for Medicare and Medicaid Services,
and, except as provided under the terms and conditions of the waiver,
only to the extent that federal financial participation is available
and funds are appropriated specifically for this purpose.

12693.76. (a) Notwithstanding any other provision of law, a child
who is a qualified alien as defined in Section 1641 of Title 8 of the
United States Code Annotated shall not be determined ineligible
solely on the basis of his or her date of entry into the United
States.
(b) Notwithstanding any other provision of law, subdivision (a)
may only be implemented to the extent provided in the annual Budget
Act.
(c) Notwithstanding any other provision of law, any uninsured
parent or responsible adult who is a qualified alien, as defined in
Section 1641 of Title 8 of the United States Code, shall not be
determined to be ineligible solely on the basis of his or her date of
entry into the United States.
(d) Notwithstanding any other provision of law, subdivision (c)
may only be implemented to the extent of funding provided in the
annual Budget Act.

12693.765. (a) Notwithstanding any other provision of law and
subject to subdivision (b), a child described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70 shall be deemed eligible to participate in the program at
birth.
(b) Notwithstanding any other provision of law, subdivision (a)
and clause (ii) of subparagraph (A) of paragraph (6) of subdivision
(a) of Section 12693.70 may only be implemented to the extent that
funds are appropriated for that purpose in the annual Budget Act or
other statute.