California Code of Regulations
Title 10 - Investment
Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program
Article 1 - Definitions
Section 2699.6500 - Definitions
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) "Access for Infants and Mothers (AIM) Program" means the State funded program operated pursuant to Part 6.3 (commencing with Section 12695) of Division 2 of the California Insurance Code, and that provides low-cost health care coverage for pregnant women and the newborns of subscribers who are enrolled in the AIM program prior to July 1, 2004.
(b) "Agriculture" means farming in all its branches and includes; the cultivation and tillage of the soil, the production of dairy products, the production, cultivation growing, and harvesting of any agricultural or horticultural commodities, the raising of livestock, bees, forbearing animals, or poultry, any practice performed by a farmer or on a farm as an incident to or in conjunction with such farming operations, including preparation for market, delivery to storage or to market or to carriers for transportation to market.
(c) "AIM infant" means a child born to an AIM subscriber who is enrolled in the AIM program on or after July 1, 2004.
(d) "Alaskan Native" means any person who is an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601.
(e) "American Indian" means any person who is eligible under federal law (25 U.S.C. Section 1603) to receive health services provided directly by the United States Department of Health and Human Services, Indian Health Service, or by a tribal or an urban Indian health program funded by the Indian Health Service to provide health services to eligible individuals either directly or by contract.
(f) "Anniversary date" means the day each year that corresponds to the day and month a person's coverage began in the program.
(g) "Applicant" means:
(h)
(i) "Board" means the Managed Risk Medical Insurance Board.
(j) "Caretaker relative" means a relative who provides care and supervision to a child if there is no parent living in the home. The caretaker relative may be any relation by blood, marriage, or adoption.
(k) "Child-linked adult" means:
(l) "Community provider plan" means that participating health plan in each county that has been so designated by the Board pursuant to Section 2699.6805.
(m) "Family contributions" means the monthly cost to an applicant for "family child contributions" and "family parent contributions." Family contributions do not include copayments for services.
(n) "Family child contributions" means the monthly cost to an applicant to enable a subscriber child or subscriber children to participate in the program. Family child contributions do not include copayments for services.
(o) "Family parent contributions" means the monthly cost to an applicant to enable a subscriber parent or subscriber parents to participate in the program. Family parent contributions do not include copayments for services.
(p) "Family contribution sponsor" means a person or entity that is registered with the Program and that pays the family child contributions and/or family parent contributions on behalf of an applicant for any twelve (12) consecutive months of the subscriber child or subscriber parent's participation in the program. A family contribution sponsor may sponsor a subscriber parent linked to a subscriber child enrolled in the program if the subscriber child is sponsored, or may sponsor only the subscriber parent if the subscriber parent is not linked to any subscriber children enrolled in the program and instead is linked to a child enrolled in no-cost Medi-Cal.
(q) "Family member" means the following persons living in the home, unless the individual receives public assistance benefits such as SSI/SSP:
(r) "Family value package" means the combination of participating health, dental, and vision plans available to subscribers in each county offering the lowest price and each of the combinations offering a price within seven and one half percent (7.5%) of the average price of the lowest priced combination and the second lowest price combination of health, dental, and vision plans. The second lowest price combination is calculated by summing the second lowest price health plan, the second lowest price dental plan, and the second lowest price vision plan. If only one health, dental, or vision plan is available to subscribers in a county, the price of the one available plan shall be used in the calculations of the second lowest price combination. A health, dental, or vision plan with a service area which does not include zip codes in which at least eighty-five percent (85%) of the residents of the county reside or that has enrollment limits unrelated to network capacity shall not be considered the lowest or second lowest price plan, unless it is the only health, dental or vision plan in the county. In addition, any combination of health, dental, and vision plans in which the health, dental, and vision plan are each available in at least one plan combination that is within seven and one half percent (7.5%) of the average price of the lowest and second lowest price combination of health, dental, and vision plans, is a family value package. In all family value package calculations, the health plan rate to be used is the rate for subscriber children from one year old up to the age of nineteen. The dental and vision plan rates to be used are the rates for subscriber children. When the Board calculates the family value package, it shall base the calculation on the plan prices expected to be available for the anticipated health, dental and vision plan contract terms. Calculations will not be redone if plans are later dropped from or added to a county. However, if the Board at any time determines that the seven and one half percent (7.5%) level is insufficient to assure that adequate network capacity exists in a specified county so that all subscribers may be enrolled in a family value package, the Board may increase the percentage for that county to a percentage at which sufficient capacity is assured. Such increased percentage shall be in effect only for the benefit year in which the increase is made. The Board may determine, if requested as a part of a rural demonstration project for a special population, that a combination of health, dental, and vision plans in a county with a price higher than the family value package may still be deemed a family value package for applicants and subscribers that are members of the special population; in addition the Board may determine, if requested as part of a rural demonstration project for rural area residents, that a combination of health, dental, and vision plans in a county with a price higher than the family value package may still be deemed a family value package for subscribers that are residents of the rural area. The Board may determine that a combination of health, dental, and vision plans in a county that includes health and vision plans available in at least one family value package plan combination is deemed a family value package even if the dental plan is not in any other family value package plan combination, but only for applicants with subscribers who are enrolled prior to the beginning of the benefit year in that dental plan, and only if the Board determines it necessary in order to avoid requiring fifty percent (50%) of subscribers or one-thousand (1,000) subscribers in a county to change their dental plan.
(s) "Federal Poverty Level" means the level determined by the "Poverty Guidelines for the 48 Contiguous States and the District of Columbia" as contained in the Annual Update of HHS Poverty Guidelines as published in the Federal Register by the U.S. Department of Health and Human Services.
(t) "Household income" means the total annual income of all family members in a household. Income includes before tax earnings from a job, including cash, wages, salary, commissions and tips, self-employment net profits, Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability workers' compensation, unemployment benefits, child support, alimony, spousal support, pensions and retirement benefits, loans to meet personal needs, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings and interest income. Income excludes public assistance program benefits such as SSI/SSP and CalWORKS payments, foster care payments, general relief, loans, grants or scholarships applied toward college expenses, or earned income of a child aged 13 or under, or a child attending school. Income does not include income exclusions applicable to all federal means tested programs such as, disaster relief payments, per capita payments to Native Americans from proceeds held in trust and/or arising from use of restricted lands, Agent Orange payments, Title IV student assistance, energy assistance payments to low income families, relocation assistance payments, victims of crime assistance program, Spina Bifida payments, earned income tax credit and Japanese reparation payments.
(u) "Income deduction" means any of the following:
(v) "Indian Health Service Facility" means a tribal or urban Indian organization operating health care programs or facilities with funds from the United States Department of Health and Human Service's Indian Health Service, pursuant to the Indian Health Care Improvement Act (25 U.S.C. Section 1601) or the Snyder Act (25 U.S.C. Section 13).
(w) "Living in the home" means all of the following:
(x) "Migratory worker" means an individual whose principal employment is in agriculture, fishing, and/or forestry, on a seasonal basis, as opposed to year-round employment; and who, for purposes of employment, does establish a temporary place of residence. Migrant workers live in a work area temporarily. Such employment must have been within the last twenty-four months.
(y) "Parent" means the natural or adoptive parent of a child.
(z) "Parental coverage start date" means the effective date for which the State of California enacts appropriation for the coverage of child linked adults pursuant to a budget act and/or any other applicable state statute.
(aa) "Participating dental plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal dental services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the Board to provide coverage to program subscribers:
(bb) "Participating health plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal health care services under insurance policies or contracts, medical and hospital service arrangements, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contracts with the Board to provide coverage to program subscribers:
(cc) "Participating plan" means a participating health, participating dental or participating vision care plan.
(dd) "Participating vision care plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal vision services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the board to provide coverage to program subscribers:
(ee) "Program" means the Healthy Families Program.
(ff)
(gg) "Qualifying event" means one of the following situations in which a child-linked adult may enroll in the program:
(hh) "Rural demonstration projects" means health, dental and vision plan projects approved by the Board to address the unique access needs of special population and/or residents of rural medical service study areas.
(ii) "Rural Medical Service Study Area" means an area with (1) a population density of less than 250 persons per square mile; and (2) no town with a population in excess of 50,000 within the area, as determined by the Office of Statewide Health Planning and Development.
(jj) "Seasonal worker" means an individual whose principal employment is in agriculture, fishing and/or forestry, on a seasonal basis, as opposed to year-round employment; and who, for purposes of employment, does not establish a temporary place of residence. Seasonal workers commute to work in the area of their permanent address. Such employment must have been within the last twenty-four months.
(kk) "Special population" means seasonal workers, migratory workers or American Indians.
(ll) "State Supported Services" means abortions that are not the result of incest or rape, and are not necessary to save the life of the mother.
(mm) "Stepparent" means a person who is married to the parent of a child and who is not the other parent of the child.
(nn) "Subscriber" means either a "subscriber child" or a "subscriber parent."
(oo) "Subscriber child" means a person age 18 or a child who is eligible for and participates in the program.
(pp) "Subscriber parent" means a child-linked adult age 19 or over who is eligible for and participates in the program.
(qq) Tenses, and Number. The present tense includes the past and future, and the future the present; the singular includes the plural and the plural the singular.
1. New chapter 5.8
(sections 2699.6500-2699.6815), article 1 (section 2699.6500) and section filed
2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of
Compliance must be transmitted to OAL by 6-22-98 or emergency language will be
repealed by operation of law on the following day.
2. Certificate of
Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register
98, No. 29).
3. Amendment of subsections (i), (k) and (o)(2)-(4) and
amendment of NOTE filed 12-14-98 as an emergency; operative 12-14-98 (Register 98,
No. 51). A Certificate of Compliance must be transmitted to OAL by 4-13-99 or
emergency language will be repealed by operation of law on the following
day.
4. Certificate of Compliance as to 12-14-98 order transmitted to OAL
3-25-99 and filed 5-6-99 (Register 99, No. 19).
5. Amendment of
subsection (s)(J)(3) filed 5-26-99 as an emergency; operative 5-26-99 (Register 99,
No. 22). A Certificate of Compliance must be transmitted to OAL by 9-23-99 or
emergency language will be repealed by operation of law on the following
day.
6. New subsections (a), (o) and (v)-(y), subsection relettering, and
amendment of NOTE filed 8-5-99 as an emergency; operative 8-5-99 (Register 99, No.
32). A Certificate of Compliance must be transmitted to OAL by 12-3-99 or emergency
language will be repealed by operation of law on the following day.
7.
Amendment of newly designated subsection (j) filed 8-5-99 as an emergency; operative
8-5-99 (Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL
by 12-3-99 or emergency language will be repealed by operation of law on the
following day.
8. Certificate of Compliance as to 5-26-99 order
transmitted to OAL 9-17-99 and filed 10-28-99 (Register 99, No. 44).
9.
Certificate of Compliance as to 8-5-99 order (amending subsection (j)) transmitted
to OAL 11-2-99 and filed 12-1-99 (Register 99, No. 49).
10. Certificate
of Compliance as to 8-5-99 order (adopting new subsections (a), (o) and (v)-(y),
relettering subsections, and amending NOTE) transmitted to OAL 10-29-99 and filed
12-3-99 (Register 99, No. 49).
11. Amendment of subsections (d), (l) and
(m) and amendment of NOTE filed 1-10-2000 as an emergency; operative 1-10-2000
(Register 2000, No. 2). A Certificate of Compliance must be transmitted to OAL by
5-9-2000 or emergency language will be repealed by operation of law on the following
day.
12. New subsection (b) and subsection relettering filed 3-21-2000 as
an emergency; operative 3-21-2000 (Register 2000, No. 12). A Certificate of
Compliance must be transmitted to OAL by 7-19-2000 or emergency language will be
repealed by operation of law on the following day.
13. Certificate of
Compliance as to 1-10-2000 order transmitted to OAL 5-5-2000 and filed 6-16-2000
(Register 2000, No. 24).
14. Amendment of subsection (k) filed 6-20-2000
as an emergency; operative 6-20-2000 (Register 2000, No. 25). A Certificate of
Compliance must be transmitted to OAL by 10-18-2000 or emergency language will be
repealed by operation of law on the following day.
15. Certificate of
Compliance as to 3-21-2000 order transmitted to OAL 6-23-2000 and filed 7-17-2000
(Register 2000, No. 29).
16. New subsection (j), subsection relettering
and amendment of NOTE filed 9-5-2000; operative 9-5-2000 pursuant to Government Code
11343.4(d) (Register 2000, No. 36).
17. Certificate of Compliance as to
6-20-2000 order transmitted to OAL 10-12-2000; disapproval and reinstatement of text
as it existed prior to emergency amendment pursuant to Government Code section
11349.6(d)
filed 11-27-2000 (Register 2000, No. 48).
18. Amendment of subsection (l)
filed 11-28-2000 as an emergency; operative 11-28-2000 (Register 2000, No. 48). A
Certificate of Compliance must be transmitted to OAL by 3-28-2001 or emergency
language will be repealed by operation of law on the following day.
19.
Certificate of Compliance as to 11-28-2000 order transmitted to OAL 1-31-2001 and
filed 2-20-2001 (Register 2001, No. 8).
20. Amendment of section and NOTE
filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18).
Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance
must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by
operation of law on the following day.
21. Certificate of Compliance as
to 4-29-2002 order, including further amendment of subsections (i)(1), (3) and (4),
(o)-(o)(1), (s)(4), (x) and (ee)(5)(E), transmitted to OAL 10-28-2002 and filed
12-12-2002 (Register 2002, No. 50).
22. Amendment of subsection (n), new
subsection (jj) and subsection relettering filed 7-31-2003 as an emergency;
operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be
transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation
of law on the following day.
23. Certificate of Compliance as to
7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004,
No. 1).
24. New subsections (a) and (c) and subsection relettering filed
7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to
Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be
transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation
of law on the following day.
25. Certificate of Compliance as to 7-1-2004
order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No.
1).
26. Amendment of subsection (r) filed 3-27-2008 as an emergency;
operative 3-27-2008 (Register 2008, No. 13). A Certificate of Compliance must be
transmitted to OAL by 9-23-2008 or emergency language will be repealed by operation
of law on the following day.
27. Certificate of Compliance as to
3-27-2008 order transmitted to OAL 8-15-2008 and filed 9-22-2008 (Register 2008, No.
39).
28. Redesignation of former subsection (h) as subsection (h)(1), new
subsections (h)(2)-(3) and amendment of NOTE filed 6-24-2010 as an emergency;
operative 7-1-2010 pursuant to Government Code section
11346.1(d)
(Register 2010, No. 26). A Certificate of Compliance must be transmitted to OAL by
12-28-2010 or the emergency action will be repealed by operation of law on the
following day.
29. Certificate of Compliance as to 6-24-2010 order
transmitted to OAL 12-21-2010 and filed 2-2-2011 (Register 2011, No.
5).
Note: Authority cited: Sections 12693.21, 12693.22 and 12693.755, Insurance Code. Reference: Sections 12693.02, 12693.03, 12693.045, 12693.06, 12693.065, 12693.08, 12693.09, 12693.10, 12693.70, 12693.105, 12693.11, 12693.12, 12693.13, 12693.14, 12693.16, 12693.17, 12693.22, 12693.755 and 12693.91, Insurance Code.