SECTIONS 12698-12698.35 - California Statutes

INSURANCE CODE

SECTION 12698-12698.35

12698. To be eligible to participate in the program, a person shall
meet all of the following requirements:
(a) Be a resident of the state for at least six continuous months
prior to application. A person who is a member of a federally
recognized California Indian tribe is a resident of the state for
these purposes.
(b) (1) Until the first day of the second month following the
effective date of the amendment made to this subdivision in 1994,
have a household income that does not exceed 250 percent of the
official federal poverty level unless the board determines that the
program funds are adequate to serve households above that level.
(2) Upon the first day of the second month following the effective
date of the amendment made to this subdivision in 1994, have a
household income that is above 200 percent of the official federal
poverty level but does not exceed 250 percent of the official federal
poverty level unless the board determines that the program funds are
adequate to serve households above the 250 percent of the official
federal poverty level.
(c) Pay an initial subscriber contribution of not more than fifty
dollars ($50), and agree to the payment of the complete subscriber
contribution. A federally recognized California Indian tribal
government may make the initial and complete subscriber contributions
on behalf of a member of the tribe only if a contribution on behalf
of members of federally recognized California Indian tribes does not
limit or preclude federal financial participation under Title XXI of
the Social Security Act. 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.

12698.05. A person shall not be eligible to participate in the
program if the person is eligible for Medi-Cal without a share of
cost or eligible for Medicare at the time of application.

12698.06. A person shall not be eligible to participate in the
program for covered services under this part for services that are
covered through private insurance arrangements at the time of
application.

12698.15. Subscribers shall not be disenrolled for failure to pay
subscriber contributions. The board may impose or contract for
collection actions to collect unpaid subscriber contributions.

12698.20. (a) 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 may appeal to the board and shall be
accorded an opportunity for a fair hearing. Hearings may be
conducted 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) 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 under a policy issued under this part.

12698.25. Services that would be covered under the program that are
provided to pregnant women who, after receiving those services, are
subsequently determined to be eligible for coverage under this part
may be reimbursed as determined by the board. In no case shall
services received prior to 40 days before a woman's date of
application be eligible for reimbursement.

12698.26. (a) A health care provider who is furnished documentation
of a subscriber's enrollment in the program shall not seek
reimbursement nor attempt to obtain payment for any covered services
provided to that subscriber other than from the participating health
plan covering the subscriber.
(b) The provisions of subdivision (a) do not apply to any
copayments required for the covered services provided to the
subscriber under his or her participating health plan.
(c) For purposes of this section, "health care provider" means any
professional person, organization, health facility, or other person
or institution licensed by the state to deliver or furnish health
care services.

12698.30. (a) At a minimum, coverage shall be provided to
subscribers during one pregnancy, and for 60 days thereafter, and to
children less than two years of age who were born of a pregnancy
covered under this program to a woman enrolled in the program before
July 1, 2004.
(b) Coverage provided pursuant to this part shall include, at a
minimum, those services required to be provided by health care
service plans approved by the Secretary of Health and Human Services
as a federally qualified health care service plan pursuant to Section
417.101 of Title 42 of the Code of Federal Regulations.
(c) Coverage shall include health education services related to
tobacco use.
(d) Medically necessary prescription drugs shall be a required
benefit in the coverage provided under this part.

12698.35. (a) Through its courts, statutes, and under its
Constitution, California protects a woman's right to reproductive
privacy. California reaffirms these protections and specifically its
Supreme Court decision in People v. Belous (1969) 71 Cal.2d 954,
966-68.
(b) The State Department of Health Services and the Managed Risk
Medical Insurance Board may accept or use moneys under Title XXI of
the federal Social Security Act (known as the State Children's Health
Insurance Program or S-CHIP), as interpreted in Section 457.10 of
Title 42 of the Code of Federal Regulations, to fund services for
women pursuant to Section 14007.7 of the Welfare and Institutions
Code (Medi-Cal) and Part 6.3 (commencing with Section 12695) (Access
for Infants and Mothers (AIM)) only when, during the period of
coverage, the woman is the beneficiary. The scope of services covered
under Medi-Cal and AIM, as defined in statutes, regulations, and
state plans, is not altered by this section or the state plan
amendment submitted pursuant to this section.
(c) California's S-CHIP plan and any amendments submitted and
implemented pursuant to this section shall be consistent with
subdivisions (a) and (b).
(d) This section is a declaration of existing law.