California Code of Regulations
Title 10 - Investment
Chapter 5.5 - Major Risk Medical Insurance Board
Article 2 - Eligibility, Application, and Enrollment
Section 2698.201 - Application

Universal Citation: 10 CA Code of Regs 2698.201

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The Board shall establish an application review process which assures timely action on applications. The program shall complete the application review process within 30 days of the receipt of the application and payment of the initial subscriber contribution.

(b) To apply for the program an individual shall submit:

(1) all information, documentation, and declarations necessary to determine program eligibility as set forth in subsection (d) of this section, and

(2) a check or money order for an amount equal to the initial subscriber contribution for the individual's first choice participating health plan.

(c) A complete application is one that meets the requirements of (b)(1) and (b)(2) of this section. All applications shall be reviewed for completeness upon receipt by the program.

(1) If the application is complete, it will be reviewed for an eligibility determination.

(2) An incomplete application shall be returned to the individual and shall not be processed.

(d)

(1) The applicant shall use the application form entitled California Major Risk Medical Insurance Program Enrollment Application.

(2) The applicant shall provide the following information:
(A) The applicant's full name.

(B) The applicant's current home address including house or unit number, street, city, county, state, and zip code.

(C) The applicant's date of birth.

(D) The applicant's sex.

(E) The applicant's marital or registered domestic partnership status.

(F) The applicant's home and/or business telephone number.

(G) If dependents are to be included in the coverage, the full names, dates of birth, sex, and relationship of the dependents to be covered.

(H) The name and address to which the bills for the subscriber contribution are to be sent, if different from the applicant's.

(I) Proof of rejection within 12 months of the date of application for health insurance coverage for reasons other than fraud or nonpayment of premium. The proof shall include a letter or other formal written communication from a health plan, documenting one or more of the following:
1. Having been denied health insurance coverage as an individual.

2. Having been involuntarily terminated from health insurance coverage.

3. Having been offered an individual, not a group, health insurance premium rate in excess of the subscriber rate for the individual's first choice participating health plan.

(J) An initialed declaration that the applicant is not eligible for Part A and Part B of Medicare, in accordance with subsection 2698.200(b)(1)(B).

(K) An initialed declaration that the applicant is a resident of the State of California.

(L) An initialed declaration that the applicant will abide by the rules of participation, utilization review process, and dispute resolution process of any participating health plan in which the applicant is enrolled.

(M) An initialed declaration that the applicant is not, to the applicant's knowledge, being excluded from a group for the purpose of being made eligible for the program.

(N) An initialed declaration that the applicant has reviewed the benefits offered by the participating health plans and the subscriber contribution rates.

(O) An initialed declaration that the applicant understands and will follow the rules and regulations of the program.

(P) Name and address of the applicant's primary employer, if employed.

(Q) The applicant's occupation, if employed.

(R) An initialed declaration that the applicant is not currently eligible to purchase any health insurance for continuation of benefits under the provisions of Health and Safety Code section 1366.20 et. seq., or under the provisions of Insurance Code section 10128.50 et. seq. or has exhausted any health insurance for continuation of benefits under the provisions of 29 US Code 1161 et. seq.

(S) An initialed declaration that the applicant has not been terminated from a standard benefit plan available under the provisions of Health and Safety Code section 1373.62 or Insurance code section 10127.15 within the last 12 months due to non-payment of premiums or as a result of the applicant's request to voluntarily disenroll or as a result of fraud.

(T) An indication of the applicant's selected participating health plan.

(U) If an applicant is not currently eligible for the program, but anticipates becoming eligible, the applicant shall explain and document the reason or reasons, and provide the date on which, eligibility will occur.

(V) The applicant or the applicant's parent, conservator, or guardian shall sign and date the application stating that the information given is true and correct.

(3) The following information is requested but not mandatory, and will be used for identification and administrative purposes:
(A) The applicant's ethnicity.

(B) The applicant's social security number.

(C) The dependent's social security number, if dependents are to be included in the coverage.

(e) In order for the program to determine that a pre-existing condition exclusion or a post-enrollment waiting period should be waived, or partially waived, each individual applying for coverage must provide one of the following:

(1) Documentation that the individual had prior creditable coverage, or

(2) Documentation that the individual has been covered by a similar plan sponsored by another state before becoming a resident of the State of California.

(f) Applications may be submitted at any time. An applicant shall not be enrolled nor shall the applicant be placed on a waiting list until the applicant has fulfilled all of the requirements for eligibility. Once the requirements for eligibility are fulfilled, applicants shall be enrolled or placed on a waiting list in order of the date of receipt of the completed application.

1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order including amendment of subsections (a) and (e) transmitted to OAL 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Amendment of subsection (e) filed 6-27-91 as an emergency; operative 6-27-91 (Register 91, No. 40). A Certificate of Compliance must be transmitted to OAL by 10-25-91 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 6-27-91 order transmitted to OAL 10-23-91 and filed 11-22-91 (Register 92, No. 11).
5. Amendment of subsection (e)(1)(Q) and NOTE filed 8-11-92; operative 9-11-92 pursuant to Government Code section 11346.2(d) (Register 92, No. 34).
6. Amendment of subsections (e)(1)(H)5., (e)(1)(I), and (f)-(f)(1), repealer of subsection (f)(2) and subsection renumbering filed 5-19-95; operative 6-19-95 (Register 95, No. 20).
7. Amendment of subsection (e)(1), repealer of subsection (e)(1)(H)4. and subsection renumbering, and amendment of newly designated subsection (e)(1)(H)4. filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
8. Repealer of subsection (e)(1)(H)4. filed 3-22-2002 as an emergency; operative 3-22-2002 (Register 2002, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-22-2002 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 3-22-2002 order transmitted to OAL 7-19-2002 and filed 8-29-2002 (Register 2002, No. 35).
10. Amendment filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-4-2003 order, including further amendment of subsection (d)(1), transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).
12. Amendment of subsections (d)(1) and (d)(2)(E) and amendment of NOTE filed 1-14-2009; operative 2-13-2009 (Register 2009, No. 3).

Note: Authority cited: Sections 12711 and 12712, Insurance Code. Reference: Sections 12711, 12725 and 12728, Insurance Code; and Sections 297, 299 and 299.2, Family Code.

Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.