SECTIONS 12725-12733 - California Statutes

INSURANCE CODE

SECTION 12725-12733

12725. (a) Each resident of the state meeting the eligibility
criteria of this section and who is unable to secure adequate private
health coverage is eligible to apply for major risk medical coverage
through the program. For these purposes, "resident" includes a
member of a federally recognized California Indian tribe.
(b) To be eligible for enrollment in the program, an applicant
shall have been rejected for health care coverage by at least one
private health plan. An applicant shall be deemed to have been
rejected if the only private health coverage that the applicant could
secure would do one of the following:
(1) Impose substantial waivers that the program determines would
leave a subscriber without adequate coverage for medically necessary
services.
(2) Afford limited coverage that the program determines would
leave the subscriber without adequate coverage for medically
necessary services.
(3) Afford coverage only at an excessive price, which the board
determines is significantly above standard average individual
coverage rates.
(c) Rejection for policies or certificates of specified disease or
policies or certificates of hospital confinement indemnity, as
described in Section 10198.61, shall not be deemed to be rejection
for the purposes of eligibility for enrollment.
(d) The board may permit dependents of eligible subscribers to
enroll in major risk medical coverage through the program if the
board determines the enrollment can be carried out in an actuarially
and administratively sound manner.
(e) Notwithstanding the provisions of this section, the board
shall by regulation prescribe a period of time during which a
resident is ineligible to apply for major risk medical coverage
through the program if the resident either voluntarily disenrolls
from, or was terminated for nonpayment of the premium from, a private
health plan after enrolling in that private health plan pursuant to
either Section 10127.15 or Section 1373.62 of the Health and Safety
Code.
(f) For the period commencing September 1, 2003, to December 31,
2007, inclusive, subscribers and their dependents receiving major
risk coverage through the program may receive that coverage for no
more than 36 consecutive months. Ninety days before a subscriber or
dependent's eligibility ceases pursuant to this subdivision, the
board shall provide the subscriber and any dependents with written
notice of the termination date and written information concerning the
right to purchase a standard benefit plan from any health care
service plan or health insurer participating in the individual
insurance market pursuant to Section 10127.15 or Section 1373.62 of
the Health and Safety Code. This subdivision shall become inoperative
on December 31, 2007.

12725.5. (a) It shall constitute unfair competition for purposes of
Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of
the Business and Professions Code for an insurer, an insurance agent
or broker, or an administrator, as defined in Section 1759, to refer
an individual employee, or his or her dependents, to the program, or
arrange for an individual employee, or his or her dependents, to
apply to the program, for the purpose of separating that employee, or
his or her dependents, from group health coverage provided in
connection with the employee's employment.
(b) It shall constitute an unfair labor practice contrary to
public policy and enforceable under Section 95 of the Labor Code for
any employer to refer an individual employee, or his or her
dependents, to the program, or to arrange for an individual employee,
or his or her dependents, to apply to the program, for the purpose
of separating that employee, or his or her dependents, from group
health coverage provided in connection with the employee's
employment.
(c) As used in this section, "group health coverage" includes any
nonprofit hospital service plan, health care service plan,
self-insured employee welfare benefit plan, or disability insurance
providing medical or hospital benefits.

12726. The board may permit the exclusion of coverage or benefits
for charges or expenses incurred by a subscriber during the first six
months of enrollment in the program for any condition for which,
during the six months immediately preceding enrollment in the program
medical advice, diagnosis, care, or treatment was recommended or
received as to the condition during that period.
However, the exclusion from coverage of this section shall be
waived to the extent to which the subscriber was covered under any
creditable coverage, as defined in Section 10900, that was
terminated, provided the subscriber has applied for enrollment in the
program not later than 63 days following termination of the prior
coverage, or within 180 days of termination of coverage if the
subscriber lost his or her previous creditable coverage because the
subscriber's employment ended, the availability of health coverage
offered through employment or sponsored by an employer terminated, or
an employer's contribution toward health coverage terminated. The
exclusion from coverage of this section shall also be waived as to
any condition of a subscriber previously receiving coverage under a
plan of another state similar to the program established by this part
if the subscriber was eligible for benefits under that other-state
coverage for the condition. The board may establish alternative
mechanisms applicable to enrollment in health plans described in
subdivision (c) or (d) of Section 12723. These mechanisms may
include, but are not limited to, a postenrollment waiting period.

12727. Where more than one participating health plan is offered,
the program shall make available to applicants eligible to enroll in
the program sufficient information to make an informed choice among
the various types of participating health plans. Each applicant shall
be issued an appropriate document setting forth or summarizing the
services to which an enrollee is entitled, procedures for obtaining
major risk medical coverage, a list of contracting health plans and
providers, and a summary of grievance procedures.

12728. After the applicant notifies the program in writing of his
or her choice of participating health plan, the program shall assist
the applicant in enrolling as a subscriber and securing major risk
medical coverage for the subscriber and any dependents.

12729. A subscriber may request a change in coverage based upon a
change in the family status of any dependent, by filing an
application within 30 days after the occurrence of the change in
family status, or at other times and under conditions as may be
prescribed by program regulations.

12730. Health coverage secured through the program shall permit a
covered dependent of a subscriber to elect to continue the same
coverage upon the death of the subscriber, or upon the subscriber
becoming eligible for Medicare Part A and Part B.

12731. 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.

12732. 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 shall have the right to appeal to the board
and shall be accorded an opportunity for a fair hearing. Hearings
shall be conducted, insofar as practicable, pursuant to the
provisions of Chapter 5 (commencing with Section 11500) of Part 1 of
Division 3 of Title 2 of the Government Code.

12733. Subscribers and their dependents who become eligible for
Part A and Part B of Medicare, excluding those on Medicare solely
because of end-stage renal disease, shall not be enrolled, or
continue to be enrolled, in major risk medical coverage afforded by
this part.