Code Section Group

Government Code - GOV


TITLE 22. CALIFORNIA HEALTH BENEFIT EXCHANGE [100500 - 100522]
  ( Title 22 added by Stats. 2010, Ch. 659, Sec. 2. )

100500.
  

(a) There is in state government the California Health Benefit Exchange, an independent public entity not affiliated with an agency or department, which shall also be known as Covered California. Covered California shall be governed by an executive board consisting of five members who are residents of California. Of the members of the board, two shall be appointed by the Governor, one shall be appointed by the Senate Committee on Rules, and one shall be appointed by the Speaker of the Assembly. The Secretary of California Health and Human Services or his or her designee shall serve as a voting, ex officio member of the board.

(b) Members of the board, other than an ex officio member, shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. Appointments by the Governor made after January 2, 2011, shall be subject to confirmation by the Senate. A member of the board may continue to serve until the appointment and qualification of his or her successor. Vacancies shall be filled by appointment for the unexpired term. The board shall elect a chairperson on an annual basis.

(c) (1) Each person appointed to the board shall have demonstrated and acknowledged expertise in at least two of the following areas:

(A) Individual health care coverage.

(B) Small employer health care coverage.

(C) Health benefits plan administration.

(D) Health care finance.

(E) Administering a public or private health care delivery system.

(F) Purchasing health plan coverage.

(G) Marketing of health insurance products.

(H) Information technology system management.

(I) Management information systems.

(J) Enrollment counseling assistance, with priority to cultural and linguistic competency.

(2) Appointing authorities shall consider the expertise of the other members of the board and attempt to make appointments so that the board’s composition reflects a diversity of expertise.

(d) Each member of the board shall have the responsibility and duty to meet the requirements of this title, the federal act, and all applicable state and federal laws and regulations, to serve the public interest of the individuals and small businesses seeking health care coverage through the Exchange, and to ensure the operational well-being and fiscal solvency of the Exchange.

(e) In making appointments to the board, the appointing authorities shall take into consideration the cultural, ethnic, and geographical diversity of the state so that the board’s composition reflects the communities of California.

(f) (1) A member of the board or of the staff of the Exchange shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a carrier or other insurer, an agent or broker, a health care provider, or a health care facility or health clinic while serving on the board or on the staff of the Exchange. A member of the board or of the staff of the Exchange shall not be a member, a board member, or an employee of a trade association of carriers, health facilities, health clinics, or health care providers while serving on the board or on the staff of the Exchange. A member of the board or of the staff of the Exchange shall not be a health care provider unless he or she receives no compensation for rendering services as a health care provider and does not have an ownership interest in a professional health care practice.

(2) A board member shall not receive compensation for his or her service on the board, but may receive a per diem and reimbursement for travel and other necessary expenses, as provided in Section 103 of the Business and Professions Code, while engaged in the performance of official duties of the board.

(3) For purposes of this subdivision, “health care provider” means a person licensed or certified pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or licensed pursuant to the Osteopathic Act or the Chiropractic Act.

(g) A member of the board shall not make, participate in making, or in any way attempt to use his or her official position to influence the making of a decision that he or she knows or has reason to know will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on him or her or a member of his or her immediate family, or on either of the following:

(1) Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status aggregating two hundred fifty dollars ($250) or more in value provided to, received by, or promised to the member within 12 months prior to the time when the decision is made.

(2) Any business entity in which the member is a director, officer, partner, trustee, employee, or holds any position of management.

(h) There shall not be liability in a private capacity on the part of the board or a member of the board, or an officer or employee of the board, for or on account of an act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this title or affairs related to this title.

(i) The board shall hire an executive director to organize, administer, and manage the operations of the Exchange. The executive director shall be exempt from civil service and shall serve at the pleasure of the board.

(j) The board shall be subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2), except that the board may hold closed sessions when considering matters related to litigation, personnel, contracting, and rates.

(k) (1) The board shall apply for planning and establishment grants made available to the Exchange pursuant to Section 1311 of the federal act. If an executive director has not been hired under subdivision (i) when the United States Secretary of Health and Human Services makes the planning and establishment grants available, the California Health and Human Services Agency shall, upon request of the board, submit the initial application for planning and establishment grants to the United States Secretary of Health and Human Services.

(2) If a majority of the board has not been appointed when the United States Secretary of Health and Human Services makes the planning and establishment grants available, the California Health and Human Services Agency shall submit the initial application for planning and establishment grants to the United States Secretary of Health and Human Services. Any subsequent applications shall be made as described in paragraph (1) once a majority of the members have been appointed to the board.

(3) The board shall be responsible for using the funds awarded by the United States Secretary of Health and Human Services for the planning and establishment of the Exchange, consistent with subdivision (b) of Section 1311 of the federal act.

(l) Any reference to the California Health Benefit Exchange or the Exchange is deemed to refer to Covered California.

(Amended by Stats. 2016, Ch. 733, Sec. 1. Effective January 1, 2017.)

100501.
  

For purposes of this title, the following definitions shall apply:

(a) “Board” means the board described in subdivision (a) of Section 100500.

(b) “Bridge plan product” means an individual health benefit plan as defined in subdivision (f) of Section 1399.845 of the Health and Safety Code that is offered by a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or as defined in subdivision (a) of Section 10198.6 of the Insurance Code that is offered by a health insurer licensed under the Insurance Code that contracts with the Exchange pursuant to this title.

(c) “Carrier” means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.

(d) “Exchange” means the California Health Benefit Exchange established by Section 100500.

(e) “Federal act” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments to, or regulations or guidance issued under, those acts.

(f) “Fund” means the California Health Trust Fund established by Section 100520.

(g) “Health plan” and “qualified health plan” have the same meanings as those terms are defined in Section 1301 of the federal act.

(h) “Healthy Families coverage” means coverage under the Healthy Families Program pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code.

(i) “Medi-Cal coverage” means coverage under the Medi-Cal program pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code.

(j) “Modified adjusted gross income” shall have the same meaning as the term is used in Section 1401(d)(2)(B) (26 U.S.C. Sec. 36B) of the federal act.

(k) “Members of the modified adjusted gross income household” shall mean any individual who would be included in the calculation for modified adjusted gross income pursuant to Section 1401(a) (26 U.S.C. Sec. 36B(d)) of the federal act and as otherwise determined by the Exchange as permitted by the federal act and this title.

(l) “SHOP Program” means the Small Business Health Options Program established by subdivision (m) of Section 100502.

(m) “Supplemental coverage” means coverage through a specialized health care service plan contract, as defined in subdivision (o) of Section 1345 of the Health and Safety Code, or a specialized health insurance policy, as defined in Section 106 of the Insurance Code.

(n) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

(Amended by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 2. Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date. See later operative version added by Sec. 3 of Ch. 5.)

100501.
  

For purposes of this title, the following definitions shall apply:

(a) “Board” means the board described in subdivision (a) of Section 100500.

(b) “Carrier” means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.

(c) “Exchange” means the California Health Benefit Exchange established by Section 100500.

(d) “Federal act” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments to, or regulations or guidance issued under, those acts.

(e) “Fund” means the California Health Trust Fund established by Section 100520.

(f) “Health plan” and “qualified health plan” have the same meanings as those terms are defined in Section 1301 of the federal act.

(g) “SHOP Program” means the Small Business Health Options Program established by subdivision (m) of Section 100502.

(h) “Supplemental coverage” means coverage through a specialized health care service plan contract, as defined in subdivision (o) of Section 1345 of the Health and Safety Code, or a specialized health insurance policy, as defined in Section 106 of the Insurance Code.

(i) This section shall become operative only if Section 2 of the act that added this section becomes inoperative pursuant to subdivision (n) of that Section 2.

(Repealed (in Sec. 2) and added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 3. Effective September 30, 2013. Section conditionally operative by its own provisions.)

100501.1.
  

For purposes of this title, the following definitions shall apply:

(a) “Insurance affordability program” means a program that is one of the following:

(1) The state’s Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).

(2) The state’s children’s health insurance program (CHIP) under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).

(3) A program that makes available to qualified individuals coverage in a qualified health plan through the Exchange with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code.

(4) A program that makes available coverage in a qualified health plan through the Exchange with cost-sharing reductions established under Section 1402 of the federal act.

(b) “Combined eligibility notice” means an eligibility notice that informs an individual, or multiple family members of a household, of eligibility for each of the insurance affordability programs and for enrollment in a qualified health plan through the Exchange, for which a determination of eligibility was made.

(Added by Stats. 2014, Ch. 869, Sec. 1. Effective January 1, 2015.)

100502.
  

The board shall, at a minimum, do all of the following to implement Section 1311 of the federal act:

(a) Implement procedures for the certification, recertification, and decertification, consistent with guidelines established by the United States Secretary of Health and Human Services, of health plans as qualified health plans. The board shall require health plans seeking certification as qualified health plans to do all of the following:

(1) Submit a justification for any premium increase prior to implementation of the increase. The plans shall prominently post that information on their Internet Web sites. The board shall take this information, and the information and the recommendations provided to the board by the Department of Insurance or the Department of Managed Health Care under paragraph (1) of subdivision (b) of Section 2794 of the federal Public Health Service Act, into consideration when determining whether to make the health plan available through the Exchange. The board shall take into account any excess of premium growth outside the Exchange as compared to the rate of that growth inside the Exchange, including information reported by the Department of Insurance and the Department of Managed Health Care.

(2) (A) Make available to the public and submit to the board, the United States Secretary of Health and Human Services, and the Insurance Commissioner or the Department of Managed Health Care, as applicable, accurate and timely disclosure of the following information:

(i) Claims payment policies and practices.

(ii) Periodic financial disclosures.

(iii) Data on enrollment.

(iv) Data on disenrollment.

(v) Data on the number of claims that are denied.

(vi) Data on rating practices.

(vii) Information on cost sharing and payments with respect to any out-of-network coverage.

(viii) Information on enrollee and participant rights under Title I of the federal act.

(ix) Other information as determined appropriate by the United States Secretary of Health and Human Services.

(B) The information required under subparagraph (A) shall be provided in plain language, as defined in subparagraph (B) of paragraph (3) of subdivision (e) of Section 1311 of the federal act.

(3) Permit individuals to learn, in a timely manner upon the request of the individual, the amount of cost sharing, including, but not limited to, deductibles, copayments, and coinsurance, under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider. At a minimum, this information shall be made available to the individual through an Internet Web site and through other means for individuals without access to the Internet.

(b) Provide for the operation of a toll-free telephone hotline to respond to requests for assistance.

(c) Maintain an Internet Web site through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on those plans.

(d) Assign a rating to each qualified health plan offered through the Exchange in accordance with the criteria developed by the United States Secretary of Health and Human Services.

(e) Utilize a standardized format for presenting health benefits plan options in the Exchange, including the use of the uniform outline of coverage established under Section 2715 of the federal Public Health Service Act.

(f) Inform individuals of eligibility requirements for the Medi-Cal program, the Healthy Families Program, or any applicable state or local public program and, if, through screening of the application by the Exchange, the Exchange determines that an individual is eligible for any such program, enroll that individual in the program.

(g) Establish and make available by electronic means a calculator to determine the actual cost of coverage after the application of any premium tax credit under Section 36B of the Internal Revenue Code of 1986 and any cost-sharing reduction under Section 1402 of the federal act.

(h) Grant a certification attesting that, for purposes of the individual responsibility penalty under Section 5000A of the Internal Revenue Code of 1986, an individual is exempt from the individual requirement or from the penalty imposed by that section because of either of the following:

(1) There is no affordable qualified health plan available through the Exchange or the individual’s employer covering the individual.

(2) The individual meets the requirements for any other exemption from the individual responsibility requirement or penalty.

(i) Transfer to the Secretary of the Treasury all of the following:

(1) A list of the individuals who are issued a certification under subdivision (h), including the name and taxpayer identification number of each individual.

(2) The name and taxpayer identification number of each individual who was an employee of an employer but who was determined to be eligible for the premium tax credit under Section 36B of the Internal Revenue Code of 1986 because of either of the following:

(A) The employer did not provide minimum essential coverage.

(B) The employer provided the minimum essential coverage but it was determined under subparagraph (C) of paragraph (2) of subsection (c) of Section 36B of the Internal Revenue Code of 1986 to either be unaffordable to the employee or not provide the required minimum actuarial value.

(3) The name and taxpayer identification number of each individual who notifies the Exchange under paragraph (4) of subsection (b) of Section 1411 of the federal act that they have changed employers and of each individual who ceases coverage under a qualified health plan during a plan year and the effective date of that cessation.

(j) Provide to each employer the name of each employee of the employer described in paragraph (2) of subdivision (i) who ceases coverage under a qualified health plan during a plan year and the effective date of that cessation.

(k) Perform duties required of, or delegated to, the Exchange by the United States Secretary of Health and Human Services or the Secretary of the Treasury related to determining eligibility for premium tax credits, reduced cost sharing, or individual responsibility exemptions.

(l) Establish the navigator program in accordance with subdivision (i) of Section 1311 of the federal act. Any entity chosen by the Exchange as a navigator shall do all of the following:

(1) Conduct public education activities to raise awareness of the availability of qualified health plans.

(2) Distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under Section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under Section 1402 of the federal act.

(3) Facilitate enrollment in qualified health plans.

(4) Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under Section 2793 of the federal Public Health Service Act, or any other appropriate state agency or agencies, for any enrollee with a grievance, complaint, or question regarding his or her health plan, coverage, or a determination under that plan or coverage.

(5) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange.

(m) Establish the Small Business Health Options Program, separate from the activities of the board related to the individual market, to assist qualified small employers in facilitating the enrollment of their employees in qualified health plans offered through the Exchange in the small employer market in a manner consistent with paragraph (2) of subdivision (a) of Section 1312 of the federal act.

(Added by Stats. 2010, Ch. 655, Sec. 6. Effective January 1, 2011.)

100503.
  

In addition to meeting the minimum requirements of Section 1311 of the federal act, the board shall do all of the following:

(a) (1) Determine the criteria and process for eligibility, enrollment, and disenrollment of enrollees and potential enrollees in the Exchange and coordinate that process with the state and local government entities administering other health care coverage programs, including the State Department of Health Care Services, the Managed Risk Medical Insurance Board, and California counties, in order to ensure consistent eligibility and enrollment processes and seamless transitions between coverage.

(2) (A) The Exchange shall not disclose personal information obtained from an application for health care coverage to a certified insurance agent or certified enrollment counselor without the consent of the applicant.

(B) Nothing in this section shall preclude the Exchange from sharing the information of current enrollees or applicants with the same certified enrollment counselor or certified insurance agent of record that provided the applicant assistance with an existing application, or their successor or authorized staff, as otherwise permitted by federal and state laws and regulations.

(C) For purposes of this section, the term “personal information” has the same meaning as set forth in Section 1798.3 of the Civil Code.

(b) Develop processes to coordinate with the county entities that administer eligibility for the Medi-Cal program and the entity that determines eligibility for the Healthy Families Program, including, but not limited to, processes for case transfer, referral, and enrollment in the Exchange of individuals applying for assistance to those entities, if allowed or required by federal law.

(c) Determine the minimum requirements a carrier must meet to be considered for participation in the Exchange, and the standards and criteria for selecting qualified health plans to be offered through the Exchange that are in the best interests of qualified individuals and qualified small employers. The board shall consistently and uniformly apply these requirements, standards, and criteria to all carriers. In the course of selectively contracting for health care coverage offered to qualified individuals and qualified small employers through the Exchange, the board shall seek to contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.

(d) Provide, in each region of the state, a choice of qualified health plans at each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act, subject to subdivision (e) of this section, paragraph (2) of subdivision (d) of Section 1366.6 of the Health and Safety Code, and paragraph (2) of subdivision (d) of Section 10112.3 of the Insurance Code.

(e) Require, as a condition of participation in the individual market of the Exchange, carriers to fairly and affirmatively offer, market, and sell in the individual market of the Exchange at least one product within each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act and require, as a condition of participation in the SHOP Program, carriers to fairly and affirmatively offer, market, and sell in the SHOP Program at least one product within each of the four levels of coverage contained in subsection (d) of Section 1302 of the federal act. The board may require carriers to offer additional products within each of those levels of coverage. This subdivision shall not apply to a carrier that solely offers supplemental coverage in the Exchange under paragraph (10) of subdivision (a) of Section 100504.

(f) (1) Except as otherwise provided in this section and Section 100504.5, require, as a condition of participation in the Exchange, carriers that sell any products outside the Exchange to do both of the following:

(A) Fairly and affirmatively offer, market, and sell all products made available to individuals in the Exchange to individuals purchasing coverage outside the Exchange.

(B) Fairly and affirmatively offer, market, and sell all products made available to small employers in the Exchange to small employers purchasing coverage outside the Exchange.

(2) For purposes of this subdivision, “product” does not include contracts entered into pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code between the Managed Risk Medical Insurance Board and carriers for enrolled Healthy Families beneficiaries or contracts entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code between the State Department of Health Care Services and carriers for enrolled Medi-Cal beneficiaries. “Product” also does not include a bridge plan product offered pursuant to Section 100504.5.

(3) Except as required by Section 1301(a)(1)(C)(ii) of the federal act, a carrier offering a bridge plan product in the Exchange may limit the products it offers in the Exchange solely to a bridge plan product contract.

(g) Determine when an enrollee’s coverage commences and the extent and scope of coverage.

(h) Provide for the processing of applications and the enrollment and disenrollment of enrollees.

(i) Determine and approve cost-sharing provisions for qualified health plans.

(j) Establish uniform billing and payment policies for qualified health plans offered in the Exchange to ensure consistent enrollment and disenrollment activities for individuals enrolled in the Exchange.

(k) Undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange. The board shall also undertake outreach and enrollment activities that seek to assist enrollees and potential enrollees with enrolling and reenrolling in the Exchange in the least burdensome manner, including populations that may experience barriers to enrollment, such as the disabled and those with limited English language proficiency.

(l) Select and set performance standards and compensation for navigators selected under subdivision (l) of Section 100502.

(m) Employ necessary staff.

(1) The board shall hire a chief fiscal officer, a chief operations officer, a director for the SHOP Exchange, a director of health plan contracting, a chief technology and information officer, a general counsel, and other key executive positions, as determined by the board, who shall be exempt from civil service.

(2) (A) The board shall set the salaries for the exempt positions described in paragraph (1) and subdivision (i) of Section 100500 in amounts that are reasonably necessary to attract and retain individuals of superior qualifications. The salaries shall be published by the board in the board’s annual budget. The board’s annual budget shall be posted on the Internet Web site of the Exchange. To determine the compensation for these positions, the board shall cause to be conducted, through the use of independent outside advisors, salary surveys of both of the following:

(i) Other state and federal health insurance exchanges that are most comparable to the Exchange.

(ii) Other relevant labor pools.

(B) The salaries established by the board under subparagraph (A) shall not exceed the highest comparable salary for a position of that type, as determined by the surveys conducted pursuant to subparagraph (A).

(C) The Department of Human Resources shall review the methodology used in the surveys conducted pursuant to subparagraph (A).

(3) The positions described in paragraph (1) and subdivision (i) of Section 100500 shall not be subject to otherwise applicable provisions of the Government Code or the Public Contract Code and, for those purposes, the Exchange shall not be considered a state agency or public entity.

(n) Assess a charge on the qualified health plans offered by carriers that is reasonable and necessary to support the development, operations, and prudent cash management of the Exchange. This charge shall not affect the requirement under Section 1301 of the federal act that carriers charge the same premium rate for each qualified health plan whether offered inside or outside the Exchange.

(o) Authorize expenditures, as necessary, from the California Health Trust Fund to pay program expenses to administer the Exchange.

(p) Keep an accurate accounting of all activities, receipts, and expenditures, and annually submit to the United States Secretary of Health and Human Services a report concerning that accounting. Commencing January 1, 2016, the board shall conduct an annual audit.

(q) (1) Annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, including, at a minimum, the manner in which funds were expended and the progress toward, and the achievement of, the requirements of this title. The report shall also include data provided by health care service plans and health insurers offering bridge plan products regarding the extent of health care provider and health facility overlap in their Medi-Cal networks as compared to the health care provider and health facility networks contracting with the plan or insurer in their bridge plan contracts. This report shall be transmitted to the Legislature and the Governor and shall be made available to the public on the Internet Web site of the Exchange. A report made to the Legislature pursuant to this subdivision shall be submitted pursuant to Section 9795.

(2) The Exchange shall prepare, or contract for the preparation of, an evaluation of the bridge plan program using the first three years of experience with the program. The evaluation shall be provided to the health policy and fiscal committees of the Legislature in the fourth year following federal approval of the bridge plan option. The evaluation shall include, but not be limited to, all of the following:

(A) The number of individuals eligible to participate in the bridge plan program each year by category of eligibility.

(B) The number of eligible individuals who elect a bridge plan option each year by category of eligibility.

(C) The average length of time, by region and statewide, that individuals remain in the bridge plan option each year by category of eligibility.

(D) The regions of the state with a bridge plan option, and the carriers in each region that offer a bridge plan, by year.

(E) The premium difference each year, by region, between the bridge plan and the first and second lowest cost plan for individuals in the Exchange who are not eligible for the bridge plan.

(F) The effect of the bridge plan on the premium subsidy amount for bridge plan eligible individuals each year by each region.

(G) Based on a survey of individuals enrolled in the bridge plan:

(i) Whether individuals enrolling in the bridge plan product are able to keep their existing health care providers.

(ii) Whether individuals would want to retain their bridge plan product, buy a different Exchange product, or decline to purchase health insurance if there was no bridge plan product available. The Exchange may include questions designed to elicit the information in this subparagraph as part of an existing survey of individuals receiving coverage in the Exchange.

(3) In addition to the evaluation required by paragraph (2), the Exchange shall post the items in subparagraphs (A) to (F), inclusive, on its Internet Web site each year.

(4) In addition to the report described in paragraph (1), the board shall be responsive to requests for additional information from the Legislature, including providing testimony and commenting on proposed state legislation or policy issues. The Legislature finds and declares that activities including, but not limited to, responding to legislative or executive inquiries, tracking and commenting on legislation and regulatory activities, and preparing reports on the implementation of this title and the performance of the Exchange, are necessary state requirements and are distinct from the promotion of legislative or regulatory modifications referred to in subdivision (d) of Section 100520.

(r) Maintain enrollment and expenditures to ensure that expenditures do not exceed the amount of revenue in the fund, and if sufficient revenue is not available to pay estimated expenditures, institute appropriate measures to ensure fiscal solvency.

(s) Exercise all powers reasonably necessary to carry out and comply with the duties, responsibilities, and requirements of this act and the federal act.

(t) Consult with stakeholders relevant to carrying out the activities under this title, including, but not limited to, all of the following:

(1) Health care consumers who are enrolled in health plans.

(2) Individuals and entities with experience in facilitating enrollment in health plans.

(3) Representatives of small businesses and self-employed individuals.

(4) The Chief Deputy Director of Health Care Programs.

(5) Advocates for enrolling hard-to-reach populations.

(u) Facilitate the purchase of qualified health plans in the Exchange by qualified individuals and qualified small employers no later than January 1, 2014.

(v) Report, or contract with an independent entity to report, to the Legislature by December 1, 2018, on whether to adopt the option in Section 1312(c)(3) of the federal act to merge the individual and small employer markets. In its report, the board shall provide information, based on at least two years of data from the Exchange, on the potential impact on rates paid by individuals and by small employers in a merged individual and small employer market, as compared to the rates paid by individuals and small employers if a separate individual and small employer market is maintained. A report made pursuant to this subdivision shall be submitted pursuant to Section 9795.

(w) With respect to the SHOP Program, collect premiums and administer all other necessary and related tasks, including, but not limited to, enrollment and plan payment, in order to make the offering of employee plan choice as simple as possible for qualified small employers.

(x) Require carriers participating in the Exchange to immediately notify the Exchange, under the terms and conditions established by the board when an individual is or will be enrolled in or disenrolled from any qualified health plan offered by the carrier.

(y) Ensure that the Exchange provides oral interpretation services in any language for individuals seeking coverage through the Exchange and makes available a toll-free telephone number for the hearing and speech impaired. The board shall ensure that written information made available by the Exchange is presented in a plainly worded, easily understandable format and made available in prevalent languages.

(z) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

(Amended (as amended by Stats. 2014, Ch. 572, Sec. 1) by Stats. 2016, Ch. 146, Sec. 1. Effective August 19, 2016. Operative October 1, 2016, by Stats. 2016, Ch. 146, Sec. 3. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date. See later operative version, as amended by Sec. 2 of Stats. 2016, Ch. 146.)

100503.
  

In addition to meeting the minimum requirements of Section 1311 of the federal act, the board shall do all of the following:

(a) (1) Determine the criteria and process for eligibility, enrollment, and disenrollment of enrollees and potential enrollees in the Exchange and coordinate that process with the state and local government entities administering other health care coverage programs, including the State Department of Health Care Services, the Managed Risk Medical Insurance Board, and California counties, in order to ensure consistent eligibility and enrollment processes and seamless transitions between coverage.

(2) (A) The Exchange shall not disclose personal information obtained from an application for health care coverage to a certified insurance agent or certified enrollment counselor without the consent of the applicant.

(B) Nothing in this section shall preclude the Exchange from sharing the information of current enrollees or applicants with the same certified enrollment counselor or certified insurance agent of record that provided the applicant assistance with an existing application, or their successor or authorized staff, as otherwise permitted by federal and state laws and regulations.

(C) For purposes of this section, the term “personal information” has the same meaning as set forth in Section 1798.3 of the Civil Code.

(b) Develop processes to coordinate with the county entities that administer eligibility for the Medi-Cal program and the entity that determines eligibility for the Healthy Families Program, including, but not limited to, processes for case transfer, referral, and enrollment in the Exchange of individuals applying for assistance to those entities, if allowed or required by federal law.

(c) Determine the minimum requirements a carrier must meet to be considered for participation in the Exchange, and the standards and criteria for selecting qualified health plans to be offered through the Exchange that are in the best interests of qualified individuals and qualified small employers. The board shall consistently and uniformly apply these requirements, standards, and criteria to all carriers. In the course of selectively contracting for health care coverage offered to qualified individuals and qualified small employers through the Exchange, the board shall seek to contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.

(d) Provide, in each region of the state, a choice of qualified health plans at each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act, subject to subdivision (e) of this section, paragraph (2) of subdivision (d) of Section 1366.6 of the Health and Safety Code, and paragraph (2) of subdivision (d) of Section 10112.3 of the Insurance Code.

(e) Require, as a condition of participation in the Exchange, carriers to fairly and affirmatively offer, market, and sell in the Exchange at least one product within each of the five levels of coverage contained in subsections (d) and (e) of Section 1302 of the federal act and require, as a condition of participation in the SHOP Program, carriers to fairly and affirmatively offer, market, and sell in the SHOP Program at least one product within each of the four levels of coverage contained in subsection (d) of Section 1302 of the federal act. The board may require carriers to offer additional products within each of those levels of coverage. This subdivision shall not apply to a carrier that solely offers supplemental coverage in the Exchange under paragraph (10) of subdivision (a) of Section 100504.

(f) (1) Require, as a condition of participation in the Exchange, carriers that sell any products outside the Exchange to do both of the following:

(A) Fairly and affirmatively offer, market, and sell all products made available to individuals in the Exchange to individuals purchasing coverage outside the Exchange.

(B) Fairly and affirmatively offer, market, and sell all products made available to small employers in the Exchange to small employers purchasing coverage outside the Exchange.

(2) For purposes of this subdivision, “product” does not include contracts entered into pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code between the Managed Risk Medical Insurance Board and carriers for enrolled Healthy Families beneficiaries or contracts entered into pursuant to Chapter 7 (commencing with Section 14000) of, or Chapter 8 (commencing with Section 14200) of, Part 3 of Division 9 of the Welfare and Institutions Code between the State Department of Health Care Services and carriers for enrolled Medi-Cal beneficiaries.

(g) Determine when an enrollee’s coverage commences and the extent and scope of coverage.

(h) Provide for the processing of applications and the enrollment and disenrollment of enrollees.

(i) Determine and approve cost-sharing provisions for qualified health plans.

(j) Establish uniform billing and payment policies for qualified health plans offered in the Exchange to ensure consistent enrollment and disenrollment activities for individuals enrolled in the Exchange.

(k) Undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange. The board shall also undertake outreach and enrollment activities that seek to assist enrollees and potential enrollees with enrolling and reenrolling in the Exchange in the least burdensome manner, including populations that may experience barriers to enrollment, such as the disabled and those with limited English language proficiency.

(l) Select and set performance standards and compensation for navigators selected under subdivision (l) of Section 100502.

(m) Employ necessary staff.

(1) The board shall hire a chief fiscal officer, a chief operations officer, a director for the SHOP Exchange, a director of health plan contracting, a chief technology and information officer, a general counsel, and other key executive positions, as determined by the board, who shall be exempt from civil service.

(2) (A) The board shall set the salaries for the exempt positions described in paragraph (1) and subdivision (i) of Section 100500 in amounts that are reasonably necessary to attract and retain individuals of superior qualifications. The salaries shall be published by the board in the board’s annual budget. The board’s annual budget shall be posted on the Internet Web site of the Exchange. To determine the compensation for these positions, the board shall cause to be conducted, through the use of independent outside advisors, salary surveys of both of the following:

(i) Other state and federal health insurance exchanges that are most comparable to the Exchange.

(ii) Other relevant labor pools.

(B) The salaries established by the board under subparagraph (A) shall not exceed the highest comparable salary for a position of that type, as determined by the surveys conducted pursuant to subparagraph (A).

(C) The Department of Human Resources shall review the methodology used in the surveys conducted pursuant to subparagraph (A).

(3) The positions described in paragraph (1) and subdivision (i) of Section 100500 shall not be subject to otherwise applicable provisions of the Government Code or the Public Contract Code and, for those purposes, the Exchange shall not be considered a state agency or public entity.

(n) Assess a charge on the qualified health plans offered by carriers that is reasonable and necessary to support the development, operations, and prudent cash management of the Exchange. This charge shall not affect the requirement under Section 1301 of the federal act that carriers charge the same premium rate for each qualified health plan whether offered inside or outside the Exchange.

(o) Authorize expenditures, as necessary, from the California Health Trust Fund to pay program expenses to administer the Exchange.

(p) Keep an accurate accounting of all activities, receipts, and expenditures, and annually submit to the United States Secretary of Health and Human Services a report concerning that accounting. Commencing January 1, 2016, the board shall conduct an annual audit.

(q) (1) Annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, including, at a minimum, the manner in which funds were expended and the progress toward, and the achievement of, the requirements of this title. This report shall be transmitted to the Legislature and the Governor and shall be made available to the public on the Internet Web site of the Exchange. A report made to the Legislature pursuant to this subdivision shall be submitted pursuant to Section 9795.

(2) In addition to the report described in paragraph (1), the board shall be responsive to requests for additional information from the Legislature, including providing testimony and commenting on proposed state legislation or policy issues. The Legislature finds and declares that activities including, but not limited to, responding to legislative or executive inquiries, tracking and commenting on legislation and regulatory activities, and preparing reports on the implementation of this title and the performance of the Exchange, are necessary state requirements and are distinct from the promotion of legislative or regulatory modifications referred to in subdivision (d) of Section 100520.

(r) Maintain enrollment and expenditures to ensure that expenditures do not exceed the amount of revenue in the fund, and if sufficient revenue is not available to pay estimated expenditures, institute appropriate measures to ensure fiscal solvency.

(s) Exercise all powers reasonably necessary to carry out and comply with the duties, responsibilities, and requirements of this act and the federal act.

(t) Consult with stakeholders relevant to carrying out the activities under this title, including, but not limited to, all of the following:

(1) Health care consumers who are enrolled in health plans.

(2) Individuals and entities with experience in facilitating enrollment in health plans.

(3) Representatives of small businesses and self-employed individuals.

(4) The Chief Deputy Director of Health Care Programs.

(5) Advocates for enrolling hard-to-reach populations.

(u) Facilitate the purchase of qualified health plans in the Exchange by qualified individuals and qualified small employers no later than January 1, 2014.

(v) Report, or contract with an independent entity to report, to the Legislature by December 1, 2018, on whether to adopt the option in Section 1312(c)(3) of the federal act to merge the individual and small employer markets. In its report, the board shall provide information, based on at least two years of data from the Exchange, on the potential impact on rates paid by individuals and by small employers in a merged individual and small employer market, as compared to the rates paid by individuals and small employers if a separate individual and small employer market is maintained. A report made pursuant to this subdivision shall be submitted pursuant to Section 9795.

(w) With respect to the SHOP Program, collect premiums and administer all other necessary and related tasks, including, but not limited to, enrollment and plan payment, in order to make the offering of employee plan choice as simple as possible for qualified small employers.

(x) Require carriers participating in the Exchange to immediately notify the Exchange, under the terms and conditions established by the board when an individual is or will be enrolled in or disenrolled from any qualified health plan offered by the carrier.

(y) Ensure that the Exchange provides oral interpretation services in any language for individuals seeking coverage through the Exchange and makes available a toll-free telephone number for the hearing and speech impaired. The board shall ensure that written information made available by the Exchange is presented in a plainly worded, easily understandable format and made available in prevalent languages.

(z) This section shall become operative only if Section 4 of the act that added this section becomes inoperative pursuant to subdivision (z) of that Section 4.

(Amended (as amended by Stats. 2014, Ch. 572, Sec. 2) by Stats. 2016, Ch. 146, Sec. 2. Effective August 19, 2016. Amending action operative October 1, 2016, by Stats. 2016, Ch. 146, Sec. 3. Amended section conditionally operative by its own provisions.)

100503.1.
  

 The board shall ensure that the Internet Web site maintained under subdivision (c) of Section 100502 provides a direct link to the formulary, or formularies, for each qualified health plan offered through the Exchange that is posted by the carrier pursuant to Section 1367.205 of the Health and Safety Code or Section 10123.192 of the Insurance Code.

(Added by Stats. 2014, Ch. 575, Sec. 1. Effective January 1, 2015.)

100503.2.
  

The board shall use the information received pursuant to Section 12712.5 of the Insurance Code to provide an individual a notice that he or she may be eligible for reduced-cost coverage through the Exchange or no-cost coverage through Medi-Cal. The notice shall include information on obtaining coverage pursuant to those programs.

(Added by Stats. 2013, Ch. 442, Sec. 1. Effective January 1, 2014.)

100504.
  

(a) The board may do the following:

(1) With respect to individual coverage made available in the Exchange, collect premiums and assist in the administration of subsidies.

(2) Enter into contracts.

(3) Sue and be sued.

(4) Receive and accept gifts, grants, or donations of moneys from any agency of the United States, any agency of the state, and any municipality, county, or other political subdivision of the state.

(5) Receive and accept gifts, grants, or donations from individuals, associations, private foundations, and corporations, in compliance with the conflict of interest provisions to be adopted by the board at a public meeting.

(6) Adopt rules and regulations, as necessary. Until January 1, 2017, any necessary rules and regulations may be adopted as emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2). Until January 1, 2019, any necessary rules and regulations to implement the eligibility, enrollment, and appeals processes for the individual and small business exchanges, changes to the small business exchange, or any act in effect that amends this title that is operative on or before December 31, 2016, may be adopted as emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2). The adoption of emergency regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2, including subdivisions (e) and (h) of Section 11346.1, any emergency regulation adopted pursuant to this section shall be repealed by operation of law unless the adoption, amendment, or repeal of the regulation is promulgated by the board pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code within five years of the initial adoption of the emergency regulation. Notwithstanding subdivision (h) of Section 11346.1, until January 1, 2020, the Office of Administrative Law may approve more than two readoptions of an emergency regulation adopted pursuant to this section. The amendments made to this paragraph by the act adding this sentence shall apply to any emergency regulation adopted pursuant to this section prior to the effective date of the Budget Act of 2015.

(7) Collaborate with the State Department of Health Care Services and the Managed Risk Medical Insurance Board, to the extent possible, to allow an individual the option to remain enrolled with his or her carrier and provider network in the event the individual experiences a loss of eligibility of premium tax credits and becomes eligible for the Medi-Cal program or the Healthy Families Program, or loses eligibility for the Medi-Cal program or the Healthy Families Program and becomes eligible for premium tax credits through the Exchange.

(8) Share information with relevant state departments, consistent with the confidentiality provisions in Section 1411 of the federal act, necessary for the administration of the Exchange.

(9) Require carriers participating in the Exchange to make available to the Exchange and regularly update an electronic directory of contracting health care providers so that individuals seeking coverage through the Exchange can search by health care provider name to determine which health plans in the Exchange include that health care provider in their network. The board may also require a carrier to provide regularly updated information to the Exchange as to whether a health care provider is accepting new patients for a particular health plan. The Exchange may provide an integrated and uniform consumer directory of health care providers indicating which carriers the providers contract with and whether the providers are currently accepting new patients. The Exchange may also establish methods by which health care providers may transmit relevant information directly to the Exchange, rather than through a carrier.

(10) Make available supplemental coverage for enrollees of the Exchange to the extent permitted by the federal act, provided that no General Fund money is used to pay the cost of that coverage. Any supplemental coverage offered in the Exchange shall be subject to the charge imposed under subdivision (n) of Section 100503.

(b) The Exchange shall only collect information from individuals or designees of individuals necessary to administer the Exchange and consistent with the federal act.

(c) (1) The board shall have the authority to standardize products to be offered through the Exchange. Any products standardized by the board pursuant to this subdivision shall be discussed by the board during at least one properly noticed board meeting prior to the board meeting at which the board adopts the standardized products to be offered through the Exchange.

(2) The adoption, amendment, or repeal of a regulation by the board to implement this subdivision is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

(Amended by Stats. 2016, Ch. 30, Sec. 1. Effective June 27, 2016.)

100504.5.
  

(a) To the extent approved by the appropriate federal agency, for the purpose of implementing the option in paragraph (7) of subdivision (a) of Section 100504, the Exchange shall make available bridge plan products to individuals specified in Section 14005.70 of the Welfare and Institutions Code. In implementing this requirement, the Exchange, using the selective contracting authority described in subdivision (c) of Section 100503, shall contract with, and certify as a qualified health plan, a bridge plan product that is, at a minimum, certified by the Exchange as a qualified bridge plan product. For purposes of this section, in order to be a qualified bridge plan product, the plan shall do all of the following:

(1) Be a health care service plan or health insurer that contracts with the State Department of Health Care Services to provide Medi-Cal managed care plan services pursuant to Section 14005.70 of the Welfare and Institutions Code.

(2) Meet minimum requirements to contract with the Exchange as a qualified health plan pursuant to Section 1301 of the federal Patient Protection and Affordable Care Act (Public Law 111-148) and Sections 100502, 100503, and 100507 of this code.

(3) Enroll in the bridge plan product only individuals who meet the requirements of Section 14005.70 of the Welfare and Institutions Code.

(4) Comply with the medical loss ratio requirements of Section 1399.864 of the Health and Safety Code or Section 10961 of the Insurance Code.

(5) Demonstrate the bridge plan product has, at minimum, a substantially similar provider network as the Medi-Cal managed care plan offered by the health care service plan or health insurer.

(b) The Exchange shall provide information on all of the available Exchange-qualified health plans in the area, including, but not limited to, bridge plan product options for selection by individuals eligible to enroll in a bridge plan product.

(c) Nothing in this section shall be implemented in a manner that conflicts with a requirement of the federal act.

(d) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

(Added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 6. Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date.)

100504.6.
  

(a) The Exchange shall have the authority to adopt regulations to implement the provisions of Section 100504.5. Prior to the adoption of regulations, the board and its staff shall meet the requirement of subdivision (t) of Section 100503 in implementing the bridge plan option. Until January 1, 2016, the adoption, amendment, or repeal of a regulation authorized by this section shall be exempted from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

(b) This section shall become inoperative on the October 1 that is five years after the date that federal approval of the bridge plan option occurs, and, as of the second January 1 thereafter, is repealed, unless a later enacted statute that is enacted before that date deletes or extends the dates on which it becomes inoperative and is repealed.

(Added by Stats. 2013, 1st Ex. Sess., Ch. 5, Sec. 7. Effective September 30, 2013. Conditionally inoperative, on date prescribed by its own provisions. Repealed, by its own provisions, on second January 1 after inoperative date.)

100505.
  

(a) The board shall establish and use a competitive process to select participating carriers and any other contractors under this title. Any contract entered into pursuant to this title shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. The board shall adopt a Health Benefit Exchange Contracting Manual incorporating procurement and contracting policies and procedures that shall be followed by the Exchange. The policies and procedures in the manual shall be substantially similar to the provisions contained in the State Contracting Manual.

(b) The adoption, amendment, or repeal of a regulation by the board to implement this section, including the adoption of a manual pursuant to subdivision (a) and any procurement process conducted by the Exchange in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).

(Amended by Stats. 2015, Ch. 323, Sec. 6. Effective September 22, 2015.)

100506.
  

(a) The board shall establish an appeals process for prospective and current enrollees of the Exchange that complies with all requirements of the federal act concerning the role of a state Exchange in facilitating federal appeals of Exchange-related determinations. In no event shall the scope of those appeals be construed to be broader than the requirements of the federal act. Once the federal regulations concerning appeals have been issued in final form by the United States Secretary of Health and Human Services, the board may establish additional requirements related to appeals, provided that the board determines, prior to adoption, that any additional requirement results in no cost to the General Fund and no increase in the charge imposed under subdivision (n) of Section 100503.

(b) The board shall not be required to provide an appeal if the subject of the appeal is within the jurisdiction of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and its implementing regulations, or within the jurisdiction of the Department of Insurance pursuant to the Insurance Code and its implementing regulations.

(Added by Stats. 2010, Ch. 655, Sec. 10. Effective January 1, 2011.)

100506.1.
  

An applicant or enrollee has the right to appeal any of the following:

(a) Any action or inaction related to the individual’s eligibility for or enrollment in an insurance affordability program, or for advance payment of premium tax credits and cost-sharing reductions, or the amount of the advance payment of the premium tax credit and level of cost sharing, or eligibility for affordable plan options.

(b) An eligibility determination for an exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act.

(c) A failure to provide timely or adequate notice of an eligibility determination or redetermination or an enrollment-related determination.

(Added by Stats. 2014, Ch. 869, Sec. 2. Effective January 1, 2015.)

100506.2.
  

(a) The entity making an eligibility or enrollment determination described in Section 100506.1 shall provide notice of the appeals process at the time of application and at the time of eligibility or enrollment determination or redetermination.

(b) The entity making an eligibility or enrollment determination described in Section 100506.1 shall also issue a combined eligibility notice after the Director of Health Care Services determines in writing that the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) has been programmed for the implementation of this section, but no later than July 1, 2017. The combined eligibility notice shall contain all of the following:

(1) Information about eligibility or ineligibility for Medi-Cal, premium tax credits and cost-sharing reductions, and, if applicable, for the Medi-Cal Access Program, for each individual, or multiple family members of a household, that has applied, including all of the following:

(A) An explanation of the action reflected in the notice, including the effective date of the action.

(B) Any factual bases upon which the decision is made.

(C) Citations to, or identification of, the legal authority supporting the action.

(D) Contact information for available customer service resources, including local legal aid and welfare rights offices.

(E) The effective date of eligibility and enrollment.

(2) Information regarding the bases of eligibility for non-modified adjusted gross income (MAGI) Medi-Cal and the benefits and services afforded to individuals eligible on those bases, sufficient to enable the individual to make an informed choice as to whether to appeal the eligibility determination or the date of enrollment, which may be included with the notice in a separate document.

(3) An explanation that the applicant or enrollee may appeal any action or inaction related to an individual’s eligibility for or enrollment in an insurance affordability program with which the applicant or enrollee is dissatisfied by requesting a state fair hearing consistent with this title and the provisions of Chapter 7 (commencing with Section 10950) of Part 2 of Division 9 of the Welfare and Institutions Code.

(4) Information on the applicant or enrollee’s right to represent himself or herself or to be represented by legal counsel or an authorized representative as provided in subdivision (f) of Section 100506.4.

(5) An explanation of the circumstances under which the applicant’s or enrollee’s eligibility shall be maintained or reinstated pending an appeal decision, pursuant to Section 100506.5.

(c) This section shall be implemented only to the extent it does not conflict with federal law.

(Added by Stats. 2014, Ch. 869, Sec. 3. Effective January 1, 2015.)

100506.3.
  

(a) The board shall enter into a contract with the State Department of Social Services to serve as the Exchange appeals entity designated to hear appeals of eligibility or enrollment determination or redetermination for persons in the individual market, or exemption determinations within the Exchange’s jurisdiction. To the extent applicable, the provisions of this title, Subpart F of Part 155 of Title 45 of the Code of Federal Regulations, and Article 7 of Chapter 12 of Title 10 of the California Code of Regulations shall govern the Exchange hearing process. If those provisions are not applicable, the Medi-Cal hearing process established in Chapter 7 (commencing with Section 10950) of Part 2 of Division 9 of the Welfare and Institutions Code shall govern the Exchange hearing process.

(b) This section shall be implemented only to the extent it does not conflict with federal law.

(Added by Stats. 2014, Ch. 869, Sec. 4. Effective January 1, 2015.)

100506.4.
  

(a) (1) Except as provided in paragraph (2), the State Department of Social Services, acting as the appeals entity, shall allow an applicant or enrollee to request an appeal within 90 days of the date of the notice of an eligibility or enrollment determination, or exemption determination within the Exchange’s jurisdiction, unless there is good cause as provided in Section 10951 of the Welfare and Institutions Code.

(2) The appeals entity shall establish and maintain a process for an applicant or enrollee to request an expedited appeals process where there is immediate need for health services because a standard appeal could seriously jeopardize the appellant’s life, health, or the ability to attain, maintain, or regain maximum function. If an expedited appeal is granted, the decision shall be issued as expeditiously as possible, but no later than five working days after the hearing, unless the appellant agrees to a delay to submit additional documents for the appeals record. If an expedited appeal is denied, the appeals entity shall notify the appellant within three days by telephone or through other commonly available secure electronic means, to be followed by a notice in writing, within five working days of the denial of an expedited appeal. If an expedited appeal is denied, the appeal shall be handled through the standard appeal process.

(b) Appeal requests may be submitted to the appeals entity by telephone, by mail, in person, through the Internet, through other commonly available electronic means, or by facsimile.

(c) The staff of the Exchange, the county, or the State Department of Health Care Services or its designee shall assist the applicant or enrollee in making the appeal request.

(d) (1) Upon receipt of an appeal, the appeals entity shall send timely acknowledgment to the appellant that the appeal has been received. The acknowledgment shall include information relating to the appellant’s eligibility for benefits while the appeal is pending, an explanation that advance payments of the premium tax credit while the appeal is pending may be subject to reconciliation if the appeal is unsuccessful, an explanation that the appellant may participate in informal resolution pursuant to subdivision (g), information regarding how to initiate informal resolution, and an explanation that the appellant shall have the opportunity to review his or her entire eligibility file, including information on how an income determination was made and all papers, requests, documents, and relevant information in the possession of the entity that made the decision that is the subject of the appeal at any time from the date on which an appeal request is filed to the date on which the appeal decision is issued.

(2) Upon receipt of an appeal request, the appeals entity shall send, via secure electronic means, timely notice of the appeal to the Exchange and the county, and the State Department of Health Care Services or its designee if applicable.

(3) Upon receipt of the notice of appeal from the appeals entity, the entity that made the determination of eligibility or enrollment being appealed shall transmit, either as a hardcopy or electronically, the appellant’s eligibility and enrollment records for use in the adjudication of the appeal to the appeals entity.

(e) A member of the board, employee of the Exchange, a county, the State Department of Health Care Services or its designee, or the appeals entity shall not limit or interfere with an applicant’s or enrollee’s right to make an appeal or attempt to direct the individual’s decisions regarding the appeal.

(f) An applicant or enrollee may be represented by counsel or designate an authorized representative to act on his or her behalf, including, but not limited to, when making an appeal request and participating in the informal resolution process provided in subdivision (g).

(g) An applicant or enrollee who files an appeal shall have the opportunity for informal resolution, prior to a hearing, that conforms with all of the following:

(1) A representative of the entity that made the eligibility or enrollment determination shall contact the appellant or the appellant’s appropriately authorized representative and offer to discuss the determination with the appellant if he or she agrees.

(2) The appellant’s right to a hearing shall be preserved if the appellant is dissatisfied with the outcome of the informal resolution process. The appellant or the authorized representative may withdraw the hearing request voluntarily or may agree to a conditional withdrawal that shall list the agreed-upon conditions that the appellant and the Exchange, county, or the State Department of Health Care Services or its designee shall meet.

(3) If the appeal advances to a hearing, the appellant shall not be required to provide duplicative information or documentation that he or she previously provided during the application, redetermination, enrollment, or informal resolution processes.

(4) The informal resolution process shall not delay the timeline for a provision of a hearing.

(5) The informal resolution process is voluntary and neither an appellant’s participation nor nonparticipation in the informal resolution process shall affect the right to a hearing under this section.

(6) For eligibility or enrollment determinations for insurance affordability programs based on modified adjusted gross income (MAGI), the appellant or the appellant’s appropriately authorized representative may initiate the informal resolution process with the entity that made the determination, except that all of the following shall apply:

(A) The Exchange shall conduct informal resolution involving issues related only to the Exchange, including, but not limited to, exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act, offers of affordable employer coverage, special enrollment periods, and eligibility for affordable plan options.

(B) Counties shall conduct informal resolution involving issues related to non-MAGI Medi-Cal eligibility or enrollment decisions.

(C) The State Department of Health Care Services or its designee shall conduct informal resolution involving issues related to eligibility or enrollment determinations for programs when the State Department of Health Care Services is the entity making the determination.

(7) The staff involved in the informal resolution process shall try to resolve the issue through a review of case documents, in person or through electronic means as desired by the appellant, and shall give the appellant the opportunity to review case documents, verify the accuracy of submitted documents, and submit updated information or provide further explanation of previously submitted documents.

(8) The informal resolution process set forth by the State Department of Social Services for Medi-Cal fair hearings shall be used for the informal resolutions pursuant to this subdivision and shall require the Exchange, county representative, or the State Department of Health Care Services or its designee to do the following:

(A) Review the file to determine the appropriateness of the action and whether a hearing is needed.

(B) Attempt to resolve the matter if the action was incorrect.

(C) Determine whether a dual agency appeal is required to resolve the matter at hearing and notice the other agency if not already included.

(D) Determine whether interpretation services are necessary and arrange for those services accordingly.

(E) Inform appellants of other agencies that may also be available to resolve the controversy.

(h) (1) A position statement, as required by Section 10952.5 of the Welfare and Institutions Code, shall be made available at least two working days before the hearing on the appeal. The position statement shall be made available electronically by the entity that determined eligibility if the entity has the capacity to send information electronically in a secure manner.

(2) The appeals entity shall send written notice, electronically or in hard copy, to the appellant of the date, time, and location of the hearing no later than 15 days prior to the date of the hearing. If the date, time, and location of the hearing are prohibitive of participation by the appellant, the appeals entity shall make reasonable efforts to set a reasonable, mutually convenient date, time, and location. The notice shall explain what format the hearing shall be held in, via telephone or video conference or in person, and include the right of the appellant to request that the hearing be held via telephone or video conference or in person. The notice shall include instructions for submitting the request on the notice, by telephone or through other commonly available electronic means.

(3) The hearing format may be held via telephone or video conference, unless the appellant requests the hearing be held in person pursuant to paragraph (2).

(4) The hearing shall be an evidentiary hearing where the appellant may present evidence, bring witnesses, establish all relevant facts and circumstances, and question or refute any testimony or evidence, including, but not limited to, the opportunity to confront and cross-examine adverse witnesses, if any.

(5) The hearing shall be conducted by one or more impartial officials who have not been directly involved in the eligibility or enrollment determination or any prior appeal decision in the same matter.

(6) The appellant shall have the opportunity to review his or her appeal record, case file, and all documents to be used by the appeals entity at the hearing, at a reasonable time before the date of the hearing as well as during the hearing.

(7) Cases and evidence shall be reviewed de novo by the appeals entity.

(i) Decisions shall be made within 90 days from the date the appeal is filed and shall be based exclusively on the application of the applicable laws and eligibility and enrollment rules to the information used to make the eligibility or enrollment decision, as well as any other information provided by the appellant during the course of the appeal. The content of the decision of appeal shall include a decision with a plain language description of the effect of the decision on the appellant’s eligibility or enrollment, a summary of the facts relevant to the appeal, an identification of the legal basis for the decision, and the effective date of the decision, which may be retroactive at the election of the appellant if the appellant is otherwise eligible.

(j) Upon adjudication of the appeal, the appeals entity shall transmit the decision of appeal to the entity that made the eligibility or enrollment determination via a secure electronic means.

(k) If an appellant disagrees with the decision of the appeals entity, he or she may make an appeal request regarding coverage in a qualified health plan through the Exchange to the federal Department of Health and Human Services within 30 days of the notice of decision through any of the methods in subdivision (b).

(l) An appellant may also seek judicial review to the extent provided by law. Appeal to the federal Department of Health and Human Services is not a prerequisite for seeking judicial review, nor shall seeking an appeal to the federal Department of Health and Human Services preclude a judicial review.

(m) Nothing in this section, or in Sections 100506.1 and 100506.2, shall limit or reduce an appellant’s rights to notice, hearing, and appeal under Medi-Cal, county indigent programs, or any other public programs.

(n) This section shall be implemented only to the extent it does not conflict with federal law.

(Added by Stats. 2014, Ch. 869, Sec. 5. Effective January 1, 2015.)

100506.5.
  

For appeals of redetermination of Exchange advance premium tax credits or cost-sharing reductions, upon receipt of notice from the appeals entity that it has received an appeal, the entity that made the redetermination shall continue to consider the applicant or enrollee eligible for the same level of advance premium tax credits or cost-sharing reductions while the appeal is pending in accordance with the level of eligibility immediately before the redetermination being appealed.

(Added by Stats. 2014, Ch. 869, Sec. 6. Effective January 1, 2015.)

100507.
  

(a) Notwithstanding any other provision of law, the Exchange shall not be subject to licensure or regulation by the Department of Insurance or the Department of Managed Health Care.

(b) Carriers that contract with the Exchange shall have a license or certificate of authority from, and shall be in good standing with, their respective regulatory agencies.

(Added by Stats. 2010, Ch. 655, Sec. 11. Effective January 1, 2011.)

100508.
  

(a) Records of the Exchange that reveal any of the following shall be exempt from disclosure under the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1):

The deliberative processes, discussions, communications, or any other portion of the negotiations with entities contracting or seeking to contract with the Exchange, entities with which the Exchange is considering a contract, or entities with which the Exchange is considering or enters into any other arrangement under which the Exchange provides, receives, or arranges services or reimbursement.

(b) The following records of the Exchange shall be exempt from disclosure under the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1) as follows:

(1) (A) Except for the portion of a contract that contains the rates of payments, contracts with participating carriers entered into pursuant to this title on or after the date the act that added this subparagraph becomes effective, shall be open to inspection one year after the effective dates of the contracts.

(B) If contracts with participating carriers entered into pursuant to this title are amended, the amendments shall be open to inspection one year after the effective date of the amendments.

(c) Three years after a contract or amendment is open to inspection pursuant to subdivision (b), the portion of the contract or amendment containing the rates of payment shall be open to inspection.

(d) Notwithstanding any other law, entire contracts with participating carriers or amendments to contracts with participating carriers shall be open to inspection by the Joint Legislative Audit Committee. The committee shall maintain the confidentiality of the contracts and amendments until the contracts or amendments to a contract are open to inspection pursuant to subdivisions (b) and (c).

(Amended by Stats. 2013, Ch. 446, Sec. 1. Effective October 1, 2013.)

100510.
  

(a) No individual or entity shall hold himself, herself, or itself out as representing, constituting, or otherwise providing services on behalf of the Exchange unless that individual or entity has a valid agreement with the Exchange to engage in those activities.

(b) Any individual or entity who aids or abets another individual or entity in violation of this section shall also be in violation of this section.

(Added by Stats. 2012, Ch. 876, Sec. 1. Effective January 1, 2013.)

100520.
  

(a)  The California Health Trust Fund is hereby created in the State Treasury for the purpose of this title. Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title. Any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year may be carried forward to the next succeeding fiscal year.

(b) Notwithstanding any other provision of law, moneys deposited in the fund shall not be loaned to, or borrowed by, any other special fund or the General Fund, or a county general fund or any other county fund.

(c) The board of the California Health Benefit Exchange shall establish and maintain a prudent reserve in the fund.

(d) The board or staff of the Exchange shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.

(e) Notwithstanding Section 16305.7, all interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.

(f) Effective January 1, 2016, if at the end of any fiscal year, the fund has unencumbered funds in an amount that equals or is more than the board approved operating budget of the Exchange for the next fiscal year, the board shall reduce the charges imposed under subdivision (n) of Section 100503 during the following fiscal year in an amount that will reduce any surplus funds of the Exchange to an amount that is equal to the agency’s operating budget for the next fiscal year.

(Added by Stats. 2010, Ch. 655, Sec. 13. Effective January 1, 2011.)

100521.
  

(a) The board shall ensure that the establishment, operation, and administrative functions of the Exchange do not exceed the combination of federal funds, private donations, and other non-General Fund moneys available for this purpose. No state General Fund moneys shall be used for any purpose under this title without a subsequent appropriation. No liability incurred by the Exchange or any of its officers or employees may be satisfied using moneys from the General Fund.

(b) The implementation of the provisions of this title, other than this section, Section 100500, and paragraphs (4) and (5) of subdivision (a) of Section 100504, shall be contingent on a determination by the board that sufficient financial resources exist or will exist in the fund. The determination shall be based on at least the following:

(1) Financial projections identifying that sufficient resources exist or will exist in the fund to implement the Exchange.

(2) A comparison of the projected resources available to support the Exchange and the projected costs of activities required by this title.

(3) The financial projections demonstrate the sufficiency of resources for at least the first two years of operation under this title.

(c) The board shall provide notice to the Joint Legislative Budget Committee and the Director of Finance that sufficient financial resources exist in the fund to implement this title.

(d) If the board determines that the level of resources in the fund cannot support the actions and responsibilities described in subdivision (a), it shall provide the Department of Finance and the Joint Legislative Budget Committee a detailed report on the changes to the functions, contracts, or staffing necessary to address the fiscal deficiency along with any contingency plan should it be impossible to operate the Exchange without the use of General Fund moneys.

(e) The board shall assess the impact of the Exchange’s operations and policies on other publicly funded health programs administered by the state and the impact of publicly funded health programs administered by the state on the Exchange’s operations and policies. This assessment shall include, at a minimum, an analysis of potential cost shifts or cost increases in other programs that may be due to Exchange policies or operations. The assessment shall be completed on at least an annual basis and submitted to the Secretary of California Health and Human Services and the Director of Finance.

(Amended by Stats. 2011, Ch. 296, Sec. 136. Effective January 1, 2012.)

100522.
  

(a) (1) The Exchange shall apply to the United States Department of Health and Human Services for a waiver authorized under Section 1332 of the federal act as defined in subdivision (e) of Section 100501 in order to allow persons otherwise not able to obtain coverage by reason of immigration status through the Exchange to obtain coverage from the Exchange by waiving the requirement that the Exchange offer only qualified health plans solely for the purpose of offering coverage to persons otherwise not able to obtain coverage by reason of immigration status.

(2) The waiver of the requirement that the Exchange offer only qualified health plans as described in paragraph (1) shall be limited to requiring the Exchange to offer California qualified health plans consistent with this section only and shall not be construed to authorize the Exchange to offer any other nonqualified health plan.

(b) The Exchange shall require an issuer that offers a qualified health plan in the individual market through the Exchange to concurrently offer a California qualified health plan that meets all of the following criteria:

(1) Is subject to the requirements of this title, including all of those requirements applicable to qualified health plans.

(2) Is subject to the requirements of subdivisions (a), (b), and (d) of Section 1366.6 of the Health and Safety Code and subdivisions (a), (b), and (d) of Section 10112.3 of the Insurance Code in the same manner as qualified health plans.

(3) Is identical to the corresponding qualified health plan, except for the eligibility requirements set forth in subdivision (c).

(c) Persons eligible to purchase California qualified health plans shall pay the cost of coverage and shall not:

(1) Be eligible to receive federal advanced premium tax credit, federal cost-sharing reduction, or any other federal assistance for the payment of premiums or cost sharing for a California qualified health plan.

(2) Otherwise be eligible for enrollment in a qualified health plan offered through the Exchange by reason of immigration status.

(d) An applicant for coverage under this section shall be required to provide only the information strictly necessary to authenticate identity and determine eligibility under this section. Any person who receives information provided by an applicant under this section, whether directly or by another person at the request of the applicant, or receives information from any agency, shall use the information only for the purposes of, and to the extent necessary for, ensuring the efficient operation of the Exchange, including verifying the eligibility of an individual to enroll through the Exchange. That information shall not be disclosed to any other person except as provided in this section.

(e) Subdivisions (b) to (d), inclusive, shall become operative on January 1, 2018, for coverage effective for California qualified health plans beginning January 1, 2019, contingent upon federal approval of the waiver pursuant to subdivision (a).

(Added by Stats. 2016, Ch. 22, Sec. 1. Effective June 10, 2016.)

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