Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The following
program decisions may be appealed to the board:
(1) A decision that an individual is not qualified
to participate or continue to participate in the program.
(2) A decision that an individual is not eligible
for enrollment or continuing enrollment in the program.
(3) A decision as to the effective date of
coverage.
(b) An appeal shall
be filed in writing with the program within sixty (60) calendar days of the date of
the notice of the decision being appealed.
(c) Appeals shall be reviewed pursuant to the
following process:
(1) First level appeals shall
be filed with the program, and the program shall make a determination on the appeal
within thirty (30) calendar days from the receipt of the appeal. The program shall
notify the appellant in writing of the programs decision and that he or she may
request a second level review by the Executive Director.
(2) Second level appeals shall be filed with the
Executive Director within thirty (30) calendar days of the date of the notice of the
determination concerning the first level appeal. The program may contact the
appellant to get clarification and additional information to make a determination.
The program shall notify the appellant in writing of the Executive Director's
decision and that he or she may request an administrative hearing.
(3) As determined by the program, an
administrative hearing shall be conducted by an Administrative Law Judge employed by
the Office of Administrative Hearings pursuant to the provisions of Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government
Code, or pursuant to the pre- and post-hearing procedures set forth in Article 3
(commencing with Section 1140) of Chapter 2 of Division 2 of Title 1 of the
California Code of Regulations as modified by Section
12693.89 of the
Insurance Code. Requests for administrative hearings shall be filed with the program
within thirty (30) calendar days of receipt of the determination concerning the
second level appeal.
(d) An
appeal shall include all of the following:
(1) A
copy of any decision being appealed, or a written statement of the action or failure
to act being appealed.
(2) A statement
describing the issues that are being disputed.
(3) A statement describing the program statute,
regulation, or other written representation of program policy that the program or
board violated.
(4) A statement of the
resolution being requested.
(5) Any
other relevant information.
(e) An appellant may request continued enrollment
while the appeal is being determined. The enrollment shall continue until a
determination is made. Family contributions and copays are required during the
continued enrollment period. An appeal that requests continued enrollment shall:
(1) Be limited to appeals filed pursuant to
subsection (c)(1) of this section.
(2)
Be filed in writing with the program within fifteen (15) calendar days of the date
the notice of the decision being appealed.
(3) Meet all other requirements described in this
section.
1. New section
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.
2.
Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and
filed 12-30-2003 (Register 2004, No. 1).
Note: Authority cited: Sections
12693.21 and
12693.41,
Insurance Code. Reference: Sections
12693.85,
12693.86,
12693.87 and
12693.89,
Insurance Code; and 42 CFR
Section
457.1170.
