California Health and Safety Code 1399.829 – (a) A health care service plan may use the following …
(a) A health care service plan may use the following characteristics of an eligible child for purposes of establishing the rate of the plan contract for that child, where consistent with federal regulations under PPACA: age, geographic region, and family composition, plus the health care service plan contract selected by the child or the responsible party for the child.
(b) From the effective date of this article to December 31, 2013, inclusive, rates for a child applying for coverage shall be subject to the following limitations:
Terms Used In California Health and Safety Code 1399.829
- Child: means any individual under 19 years of age. See California Health and Safety Code 1399.825
- Contract: A legal written agreement that becomes binding when signed.
- department: means State Department of Health Services. See California Health and Safety Code 20
- Enrollee: means a person who is enrolled in a plan and who is a recipient of services from the plan. See California Health and Safety Code 1345
- Initial open enrollment period: means the open enrollment period beginning on January 1, 2011, and ending 60 days thereafter. See California Health and Safety Code 1399.825
- Late enrollee: means a child without coverage who did not enroll in a health care service plan contract during an open enrollment period because of any of the following:
California Health and Safety Code 1399.825
- Open enrollment period: means the annual open enrollment period, subsequent to the initial open enrollment period, applicable to each individual child that is the month of the child's birth date. See California Health and Safety Code 1399.825
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
- PPACA: means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent rules or regulations issued pursuant to that law. See California Health and Safety Code 1399.825
- Responsible party for a child: means an adult having custody of the child or with responsibility for the financial needs of the child, including the responsibility to provide health care coverage. See California Health and Safety Code 1399.825
- Standard risk rate: means the lowest rate that can be offered for a child with the same benefit plan, effective date, age, geographic region, and family status. See California Health and Safety Code 1399.825
(1) During any open enrollment period or for late enrollees, the rate for any child due to health status shall not be more than two times the standard risk rate for a child.
(2) The rate for a child shall be subject to a 20-percent surcharge above the highest allowable rate on a child applying for coverage who is not a late enrollee and who failed to maintain coverage with any health care service plan or health insurer for the 90-day period prior to the date of the child’s application. The surcharge shall apply for the 12-month period following the effective date of the child’s coverage.
(3) If expressly permitted under PPACA and any rules, regulations, or guidance issued pursuant to that act, a health care service plan may rate a child based on health status during any period other than an open enrollment period if the child is not a late enrollee.
(4) If expressly permitted under PPACA and any rules, regulations, or guidance issued pursuant to that act, a health care service plan may condition an offer or acceptance of coverage on any preexisting condition or other health status-related factor for a period other than an open enrollment period and for a child who is not a late enrollee.
(c) For any individual health care service plan contract issued, sold, or renewed prior to December 31, 2013, the health plan shall provide to a child or responsible party for a child a notice that states the following:
“Please consider your options carefully before failing to maintain or renewing coverage for a child for whom you are responsible. If you attempt to obtain new individual coverage for that child, the premium for the same coverage may be higher than the premium you pay now.”
(d) A child who applied for coverage between September 23, 2010, and the end of the initial open enrollment period shall be deemed to have maintained coverage during that period.
(e) Effective January 1, 2014, except for individual grandfathered health plan coverage, the rate for any child shall be identical to the standard risk rate.
(f) Health care service plans shall not require documentation from applicants relating to their coverage history.
(g) (1) On and after the operative date of the act adding this subdivision, and until January 1, 2014, a health care service plan shall provide the model notice, as provided in paragraph (3), to all applicants for coverage under this article and to all enrollees, or the responsible party for an enrollee, renewing coverage under this article that contains the following information:
(A) Information about the open enrollment period provided under Section 1399.849.
(B) An explanation that obtaining coverage during the open enrollment period described in Section 1399.849 will not affect the effective dates of coverage for coverage purchased pursuant to this article unless the applicant cancels that coverage.
(C) An explanation that coverage purchased pursuant to this article shall be effective as required under subdivision (d) of Section 1399.826 and that such coverage shall not prevent an applicant from obtaining new coverage during the open enrollment period described in Section 1399.849.
(D) Information about the Medi-Cal program, information about the Healthy Families Program if the Healthy Families Program is accepting enrollment, and information about subsidies available through the California Health Benefit Exchange.
(2) The notice described in paragraph (1) shall be in plain language and 14-point type.
(3) The department shall adopt a uniform model notice to be used by health care service plans in order to comply with this subdivision, and shall consult with the Department of Insurance in adopting that uniform model notice. Use of the model notice shall not require prior approval of the department. The model notice adopted by the department for purposes of this section shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(Amended by Stats. 2013, 1st Ex. Sess., Ch. 2, Sec. 16. (SB 2 1x) Effective September 30, 2013. Inoperative, pursuant to Section 1399.836, on January 1, 2014, subject to condition for resuming operation.)