SECTIONS 12699.50-12699.63 - California Statutes

INSURANCE CODE

SECTION 12699.50-12699.63

12699.50. This part shall be known and may be cited as the County
Health Initiative Matching Fund.

12699.51. For the purposes of this part, the following definitions
shall apply:
(a) "Administrative costs" means those expenses that are described
in Section 1397ee(a)(1)(D) of Title 42 of the United States Code.
(b) "Adult" means an uninsured parent of, or, as defined by the
board, a person 19 years of age or older responsible for, a child
enrolled to receive coverage under Part 6.2 (commencing with Section
12693) or who is enrolled to receive the full scope of Medi-Cal
services with no share of cost.
(c) "Applicant" means a county, county agency, a local initiative,
or a county organized health system.
(d) "Board" means the Managed Risk Medical Insurance Board.
(e) "Child" means a person under 19 years of age.
(f) "Comprehensive health insurance coverage" means the coverage
described in Section 12693.60.
(g) "County organized health system" means a health system
implemented pursuant to Article 2.8 (commencing with Section 14087.5)
of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code and Article 1 (commencing with Section 101675) of Chapter 3 of
Part 4 of Division 101 of the Health and Safety Code.
(h) "Fund" means the County Health Initiative Matching Fund.
(i) "Local initiative" has the same meaning as set forth in
Section 12693.08.

12699.52. (a) The County Health Initiative Matching Fund is hereby
created within the State Treasury. The fund shall accept
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 (g) of Section 12699.53.
(b) Amounts deposited in the fund shall be used only for the
purposes specified by this part.
(c) The board shall administer this fund and the provisions of
this part in collaboration with the State Department of Health
Services for the express purpose of allowing local 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 (g) of Section 12699.53. 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 board shall authorize the expenditure of money in the fund
to cover program expenses, including cost to the state to administer
the program.

12699.525. The sum of eighty-nine million dollars ($89,000,000) is
hereby appropriated in the 2002-03 fiscal year from the fund, and the
sum of one hundred sixty-four million dollars ($164,000,000) is
hereby appropriated for the 2002-03 fiscal year from the Federal
Trust Fund, to the board and shall be available for encumbrance
through June 30, 2004, for the purposes of this part.

12699.53. (a) An applicant that will provide an intergovernmental
transfer may submit a proposal to the board for funding for the
purpose of providing comprehensive health insurance coverage to any
child or adult 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 in
case of a child, whose family income is at or below 300 percent of
the federal poverty level, or in case of an adult, whose family
income does not exceed 200 percent of the federal poverty level, in
specific geographic areas, as published quarterly in the Federal
Register by the Department of Health and Human Services, and which
child or adult does not qualify for either the Healthy Families
Program (Part 6.2 (commencing with Section 12693) or Medi-Cal with no
share of cost pursuant to the Medi-Cal Act (Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9 of the Welfare and
Institutions Code).
(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 board'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
board may identify specific geographical areas that, in comparison 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 State Children's Health Insurance
Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7
of Title 42 of the United States Code), if these services are part
of an overall program with the measurable goal of enrolling served
children in the Healthy Families Program.
(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 part 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 part to a child who is eligible for
services under the California Children's Services Program.
(e) An applicant may submit a proposal for reimbursement of
medical, dental, or vision services delivered to adults as specified
in subdivision (a).
(f) (1) If a proposal from an applicant for coverage of an adult
includes state funds or funds derived from county sources, the
applicant shall, to the extent feasible, include participation by
health care service plans licensed by the Department of Managed
Health Care or health insurers regulated by the Department of
Insurance that contract with the board to provide services to Healthy
Families Program subscribers in the geographic area.
(2) This subdivision shall not apply if the population to be
served by the applicant's proposal is less than 1,000 persons.
(g) Notwithstanding any other provision of this section, an
applicant may submit a proposal to the board 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, 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 board, these proposals shall comply with both of the
following requirements:
(1) Meet all applicable requirements for funding under this part,
except for availability of funding through Title XXI of the Social
Security Act.
(2) Provide for the administration of children's coverage by the
board through the administrative infrastructure serving the Healthy
Families Program, and through health, dental, and vision plans
serving the Healthy Families Program.

12699.54. (a) The board, in consultation with the State Department
of Health Services, the Healthy Families Advisory Committee, and
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 Medi-Cal and the Healthy
Families Program.
(5) The extent to which the proposal provides for coordination and
conformity with existing Healthy Families Program 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
in regulations adopted pursuant to the Healthy Families Program.
(7) For children's coverage, 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 coverage proposals for adults, the extent to which the
proposal seeks to pursue assistance from employers in the payment of
premiums and whether the proposal requires, as a condition of
parental enrollment, the enrollment of children in the applicant's
plan or a competing plan.
(12) For coverage proposals for adults, the extent to which the
proposal offers subscribers a choice of health care service plans or
health insurers similar to the choices available to children eligible
for the Healthy Families Program in that county.
(13) For the purposes of defining an applicant's eligibility for
funding under this part, the following shall apply:
(A) The same income methodology shall be used for the proposed
program that is currently used for the Medi-Cal and the Healthy
Families programs.
(B) Only participating licensed Healthy Families dental, health,
and vision plans may be used. However, the board may permit
exceptions to this requirement consistent with the purpose, of this
part.
(b) The board may, in its sole discretion, approve or disapprove
projects for funding pursuant to this part on an annual basis.
(c) To the extent that an applicant's proposal pursuant to this
part provides for health plan or administrative services under a
contract entered into by the board or at rates negotiated for the
applicant by the board, a contract entered into by the board 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 Part 6.2 (commencing
with Section 12693). The board 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.

12699.55. The board, in collaboration with the State Department of
Health Services, shall review each funding proposal submitted by an
applicant in accordance with the criteria described in Section
12699.54 and based on that criteria, approve or reject the proposal.

12699.56. (a) Upon its approval of a proposal that shall include
any allowable amount of federal funds under the State Children's
Health Insurance Program (Subchapter 21 (commencing with Section
1397aa) of Chapter 7 of Title 42 of the United States Code), the
board, in collaboration with the State Department of Health Services,
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 board 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 12699.62, or unless the board determines
that an expenditure for administrative costs has no impact on
available federal funding. The board, in collaboration with the State
Department of Health Services, may audit the expenses incurred by
the applicant in implementing its program to ensure that the
expenditures comply with the provisions of this part. No
reimbursement may be made to an applicant that fails to meet its
financial participation obligation under this part. 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 (g) of Section
12699.53 that requires any funding not allowable for a federal match
under the State Children's Health Insurance Program (Subchapter 21
(commencing with Section 1397aa) of Chapter 7 of Title 42 of the
United States Code) shall provide the board 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 part shall
submit to the board 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.

12699.57. Each health care service plan, specialized health care
service plan, and health insurer that contracts to provide health
care benefits under this part shall be licensed by the Department of
Managed Health Care or the Department of Insurance.

12699.58. (a) The board, in collaboration with the State Department
of Health Services, shall administer the provisions of this part and
may do all of the following:
(1) Administer the expenditure of moneys from the fund.
(2) Issue rules and regulations as necessary.
(3) Enter into contracts.
(4) Sue and be sued.
(5) Employ necessary staff.
(6) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
part.
(b) The adoption and readoption of regulations pursuant to this
section shall be deemed to be an emergency and necessary for the
immediate preservation of 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. The regulation shall become effective immediately upon filing
with the Secretary of State.

12699.59. All expenses incurred by the board and the State
Department of Health Services in administering this part, including,
but not limited to, expenses for developing standards and processes
to implement any of the provisions of this part, evaluating
applications, or processing or granting appeals growing out of any of
the provisions of this part, shall be paid from the fund or directly
by applicants, except that the board 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
part.

12699.60. Nothing in this part creates a right or an entitlement to
the provision of health insurance coverage or health care benefits.
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
part.

12699.61. To the extent necessary to obtain federal financial
participation for projects approved pursuant to this part, the
Governor, in collaboration with the Managed Risk Medical Insurance
Board and the State Department of Health Services, 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) in coordination with the Managed Risk Medical
Insurance Board and the State Department of Health Services 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.

12699.62. (a) The provisions of this part 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 Managed Risk Medical Insurance Board determines that
federal State Children's Health Insurance Program (Subchapter 21
(commencing with Section 1397aa) of Chapter 7 of Title 42 of the
United States Code) funds remain available after providing funds for
all current enrollees and eligible children and parents that are
likely to enroll in the Healthy Families Program and, to the extent
funded through the federal State Children's Health Insurance Program,
the Access for Infants and Mothers Program and Medi-Cal program, as
determined by a Department of Finance estimate. In each fiscal year,
funds for adults shall only be provided to the extent that the funds
are not needed for the children's expansion portion of the County
Health Initiative Matching Fund.
(4) Funds are appropriated specifically for this purpose.
(b) The State Department of Health Services and the Managed Risk
Medical Insurance Board may accept funding necessary for the
preparation of the federal waiver applications or state plan
amendments described in Section 12699.61 from a not-for-profit group
or foundation.

12699.63. The state shall be held harmless for any federal
disallowance resulting from this part and any other expenses or
liabilities, including, but not limited to, the cost of processing or
granting appeals. An applicant receiving supplemental reimbursement
pursuant to this part 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 part with respect
to that applicant. The state may recoup any federal disallowance from
the applicant.