California Health Benefit Exchange

Section § 100500

This law establishes the California Health Benefit Exchange, also known as Covered California, as an independent public entity. It is managed by a board of five California residents appointed by the Governor and legislative leaders, with the Secretary of California Health and Human Services as a voting member.

Board members serve for four years, with their initial terms varying. They must have expertise in two health-related areas. Members have a duty to meet legal requirements and ensure the Exchange operates effectively.

The board avoids conflicts of interest by restricting affiliations with health-related businesses. It upholds transparency with some closed sessions and is protected from personal liability when acting in good faith. The board applies for federal grants for planning and establishing the Exchange.

Covered California is the recognized name for the Exchange, which seeks cultural and geographical diversity in its board composition to reflect the communities it serves.

(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 the secretary’s 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 shall be subject to confirmation by the Senate. A member of the board may continue to serve until the appointment and qualification of the member’s successor. A vacancy shall be filled by appointment for the unexpired term. The board shall elect a chairperson on an annual basis.

(c)

(1) A 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) A 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 professional, 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 professionals 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 professional unless the member or staff does not receive compensation for rendering services as a health care professional and does not have an ownership interest in a professional health care practice.

(2) A board member shall not receive compensation for 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 professional” 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.

(4)

(A) It is the intent of the Legislature that clinical volunteer services be performed in settings that predominantly serve populations that are high need, underserved, or otherwise vulnerable, including the homeless and those who receive health care coverage through the Medi-Cal program. Notwithstanding paragraph (1), a member of the board or of the staff of the Exchange may perform volunteer services if all of the following conditions are met:

(i) The member of the board or staff is a health care professional who was actively participating in that profession prior to appointment to the Exchange.

(ii) The member of the board or staff does not receive compensation for performing volunteer services and does not have an ownership interest or other financial interest in the entity, facility, clinic, or provider group.

(iii) The volunteer services are performed at the University of California or a nonprofit educational institution; a facility, clinic, or provider group operated by, or affiliated with, an academic medical center of either the University of California or a nonprofit educational institution; or a facility, clinic, or provider group operated by a state agency or county health system that does not directly contract with the Exchange.

(B) For purposes of this paragraph, compensation and financial interest for a health care professional who performs volunteer services does not include either of the following:

(i) A contribution to a professional liability insurance program made by the entity, facility, clinic, or provider group for the member or staff.

(ii) The provision of physical space, equipment, support staff, or other supports made by the entity, facility, clinic, or provider group for the member or staff necessary for the performance of volunteer services described in subparagraph (A).

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

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

(h) The board or a member of the board, or an officer or employee of the board, is not liable in a private capacity 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 is 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 is 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) A reference to the California Health Benefit Exchange or the Exchange is deemed to refer to Covered California.

Covered California California Health Benefit Exchange executive board ...

Section § 100501

This section provides definitions for key terms used in the title concerning California's health care systems. It defines entities like the 'Board,' 'Exchange,' and 'Fund,' explaining their roles and affiliations with California's health benefit programs.

'Bridge plan product,' 'carrier,' 'health plan,' and 'qualified health plan' are also defined, indicating different types of health insurance plans and insurers involved in the state's marketplace.

It also clarifies federal and state health programs like 'Medi-Cal coverage' and 'Healthy Families coverage.' Finally, it outlines income-related definitions like 'modified adjusted gross income' and its household members under the federal act.

The section notes its own expiration date, contingent on federal approvals related to bridge plan options.

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.

California Health Benefit Exchange Bridge plan product Medi-Cal coverage ...

Section § 100501

This section defines key terms related to the California Health Benefit Exchange. It clarifies what the 'Board,' 'Carrier,' 'Exchange,' 'Federal act,' 'Fund,' 'Health plan,' 'SHOP Program,' and 'Supplemental coverage' mean for these purposes. These definitions help in understanding how the California Health Benefit Exchange operates, including the role of health insurers, health care service plans, and the federal health care laws it aligns with. The section is applicable only under specific legislative conditions.

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.

California Health Benefit Exchange health insurer health care service plan ...

Section § 100501.1

This law section defines terms related to insurance programs in California. It explains what an 'insurance affordability program' includes, such as Medi-Cal, the children's health insurance program, and programs that offer health plan coverage with tax credits or cost-sharing reductions through the Exchange. The term 'combined eligibility notice' refers to a notice that tells individuals or families about their eligibility for these programs and enrollment in health plans.

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.

insurance affordability program Medi-Cal children's health insurance program ...

Section § 100502

This California law requires the board to oversee several key tasks to implement a federal health act. First, they must certify health plans and require them to justify premium increases and disclose important information, like claim payment policies and financial data, to the public.

The board is also responsible for providing a hotline for assistance, running an informative website, assigning health plan ratings, and educating the public about plan eligibility. They calculate costs after tax credits and certify exemptions from certain penalties.

The board must share relevant data with the Treasury and employers and manage duties tied to premium tax credits. Additionally, it initiates educational programs to help people understand and enroll in health plans, including for small businesses.

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 websites. 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 website 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 website 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, any cost-sharing reduction under Section 1402 of the federal act, and any state financial assistance under Title 25.

(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, cost-sharing reductions under Section 1402 of the federal act, and state financial assistance under Title 25.

(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 the enrollee’s 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.

health plan certification premium increase justification claims payment policies ...

Section § 100503

This section outlines the responsibilities and operations of the California Health Benefit Exchange. It requires the board to set eligibility criteria, coordinate with state and local health coverage programs, and protect applicants' personal data. Additionally, the board is tasked with establishing standards for health plan offerings and ensuring access across different coverage levels. They must develop processes for smooth transitions between plans, market and publicize the Exchange, assess charges to support operations, and maintain fiscal solvency through careful financial management. Reports on activities are mandated annually, and the Exchange should facilitate plan choice for small businesses, while ensuring services are available to all, including language assistance. The section includes oversight measures and requires consultation with various stakeholders.

By January 1, 2014, the board must facilitate the purchase of health plans through the Exchange, and by 2018, report to the Legislature on the potential impacts of merging individual and small employer markets. The law remains operative until five years after federal approval of the bridge plan option unless extended by new legislation.

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.

California Health Benefit Exchange eligibility criteria health care coverage programs ...

Section § 100503

This section outlines the responsibilities of the board overseeing California's health insurance Exchange. It includes tasks such as setting criteria for eligibility and enrollment, ensuring privacy of personal information, and coordinating with other health agencies. The board must establish minimum requirements for insurers and make sure health plans offer a range of coverage levels. They are also tasked with marketing and enrolling individuals and small employers. Additionally, the board runs audits, submits reports, and maintains fiscal solvency. Special provisions ensure accessible services for diverse populations, including language interpretation, while also outlining roles for key staff members and making salary determinations for these positions. The board's authority extends to enhancing public awareness and easing enrollment, particularly for those facing barriers.

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.

health insurance exchange eligibility criteria privacy of personal information ...

Section § 100503.1

This law mandates that the board must make sure the website includes a direct link to the list of covered medications, known as formularies, for each health plan available through the Exchange. These formularies are posted by insurance carriers as required by other specific sections of the Health and Safety Code and Insurance Code.

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.

health plan formulary Exchange website insurance carriers ...

Section § 100503.2

This law states that a board must inform individuals if they qualify for cheaper health insurance through the Exchange or free coverage through Medi-Cal, based on certain information. The notice will help people understand how to get this coverage.

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.

health insurance eligibility reduced-cost coverage Exchange coverage ...

Section § 100503.3

This law requires California's health insurance Exchange to work with various stakeholders to create ways to provide financial help for low- and middle-income residents so they can afford health care coverage. They need to present these options to the state government by February 2019 for budget planning. The focus is on helping those who pay a large portion of their income on premiums even with federal help, and includes people earning up to 600% of the federal poverty level.

The Exchange should aim to use all available federal funds while ensuring that state programs like Medi-Cal are not affected. The solutions suggested should not rely on federal waivers. Additionally, the report on these options should be accessible to the public online.

(a) The Exchange, in consultation with stakeholders and the Legislature, shall develop options for providing financial assistance to help low- and middle-income Californians access health care coverage. On or before February 1, 2019, the Exchange shall report those developed options to the Legislature, Governor, and Council on Health Care Delivery Systems, established pursuant to Section 1001 of the Health and Safety Code, for consideration in the 2019–20 budget process.

(b) In developing the options, the Exchange shall do both of the following:

(1) Include options to assist low-income individuals who are paying a significant percentage of their income on premiums, even with federal financial assistance, and individuals with an annual income of up to 600 percent of the federal poverty level.

(2) Consider maximizing all available federal funding and, in consultation with the State Department of Health Care Services, determine whether federal financial participation for the Medi-Cal program would otherwise be jeopardized. The report shall include options that do not require a federal waiver authorized under Section 1332 of the federal act, as defined in subdivision (e) of Section 100501, from the United States Department of Health and Human Services.

(c) The Exchange shall make the report publicly available on its Internet Web site.

health insurance exchange financial assistance options low-income healthcare coverage ...

Section § 100503.4

This law requires the Exchange to enroll individuals in the lowest cost silver health plan available using electronic account information from an insurance affordability program, unless other information guides them to enroll the person in their previous managed care plan. Enrollment must happen before their current coverage ends. The first premium is due at the end of the first month. The Exchange must notify individuals about the plan they’re enrolled in, their rights to choose another plan, not to enroll, to get help choosing, and how to appeal previous coverage. Services in the first month are covered only if the premium is paid on time. This should be in effect by July 1, 2021.

(a) Upon receipt of an individual’s electronic account pursuant to subdivision (h) of Section 15926 of the Welfare and Institutions Code from the insurance affordability program coverage, as specified in subparagraphs (A) and (B) of paragraph (3) of subdivision (a) of Section 15926 of the Welfare and Institutions Code, the Exchange shall use the available information to enroll the individual or individuals in the lowest cost silver plan available, unless the Exchange has information from the county, State Department of Health Care Services, managed care plan, or another plan as determined by the Exchange that enables the Exchange to enroll the individual with the individual’s previous managed care plan within the timeframe required by subdivision (b).

(b) Plan enrollment shall occur before the termination date of coverage through the insurance affordability program.

(c) The plan’s premium due date shall be no sooner than the last day of the first month of enrollment.

(d) The Exchange shall provide an individual who is enrolled in a plan pursuant to this section with a notice that includes the following information:

(1) The plan in which the individual is enrolled.

(2) The individual’s right to select another available plan and any relevant deadlines for that selection.

(3) How to receive assistance to select a plan.

(4) The individual’s right not to enroll in the plan.

(5) Information for an individual appealing their previous coverage through an insurance affordability program.

(6) A statement that services received during the first month of enrollment will only be covered by the plan if the premium is paid by the due date.

(e) This section shall be implemented no later than July 1, 2021.

Exchange enrollment process lowest cost silver plan previous managed care plan ...

Section § 100503.5

This law mandates that the Exchange provides payments to cover certain services for people enrolled in individual health plans through the Exchange. These payments must be at least $1 per person per month. The Exchange pays these directly to health plan issuers on behalf of the enrollees. The payments are funded only when the Legislature allocates money and are not taken from the California Health Trust Fund. Payments began on January 1, 2022, but are only for health plans, not dental plans. Importantly, this law does not establish guaranteed benefits, allocate funds, or change taxes.

(a) The Exchange shall provide payments equaling the cost of providing coverage of services described in Section 18023(b)(1)(B)(i) of Title 42 of the United States Code to individuals enrolled in a qualified health plan through the Exchange in the individual market. The payments shall not be less than one dollar ($1) per enrollee per month.

(b) The Exchange shall make the payments required under subdivision (a) directly to the qualified health plan issuers on behalf of the enrollees.

(c) The payments required under subdivision (a) shall be made upon appropriation by the Legislature. The payments shall not be made from the California Health Trust Fund established by Section 100520.

(d) Subject to appropriation, the payments shall be made for months beginning on or after January 1, 2022.

(e) For purposes of this section, “qualified health plan” does not include a qualified dental plan offered through the Exchange.

(f) This section does not create an entitlement program of any kind, appropriate any funds, require the Legislature to appropriate any funds, or increase or decrease taxes owed by a taxpayer.

qualified health plan payments individual market health coverage Exchange payment procedures ...

Section § 100503.6

The law states that if a health plan in California is required to cover extra gender-affirming care benefits beyond the essential benefits defined by federal law, the state’s health insurance exchange will compensate the plan providers for these costs. However, these payments can only be made if the California Legislature decides to allocate the necessary funds, and they cannot come from the California Health Trust Fund. This funding decision is specifically slated to start from the plan years that begin on or after January 1, 2026. Importantly, this does not promise funds or require any tax changes. Additionally, the Director of the Department of Managed Health Care may provide guidance on these gender-affirming care benefits without the need to follow certain administrative processes.

(a) If a qualified health plan is required to cover state-mandated gender-affirming care benefits determined to be in addition to essential health benefits pursuant to Section 18031(d)(3)(B) of Title 42 of the United States Code, the Exchange shall provide payments to issuers of qualified health plans offered through the Exchange to defray the costs of offering those benefits to qualified health plan enrollees.

(b) In accordance with Section 155.170 of Title 45 of the Code of Federal Regulations, the payments required by subdivision (a) shall equal the cost of the additional required benefits reported to the Exchange.

(c) The payments required under subdivision (a) shall only be made upon appropriation by the Legislature. The payments shall not be made from the California Health Trust Fund established by Section 100520.

(d) Subject to an appropriation by the Legislature, the payments shall be made for plan years beginning on or after January 1, 2026.

(e) This section does not create an entitlement program of any kind, appropriate any funds, require the Legislature to appropriate any funds, or increase or decrease taxes owed by a taxpayer.

(f) The Director of the Department of Managed Health Care may issue guidance regarding gender-affirming care benefits subject to this section. This guidance 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).

qualified health plan gender-affirming care benefits essential health benefits ...

Section § 100503.7

This law mandates that if the Exchange board requires health plans to report on efforts related to cost reduction, quality improvement, or reducing disparities, it must publish specific data on its website. This data should show how well plans meet these goals, without exposing personal information.

Qualified health plans must supply the needed data to the Exchange, ensuring privacy compliance. While certain payment rate details are kept confidential, plans are required to share detailed enrollee and financial data for evaluating contractual compliance and improving health equity.

Plans must report on products in the individual and small group markets, providing quality and disparity data when requested, except for large group, Medi-Cal, or Medicare plans. Detailed reports on past and current performance are also necessary.

Moreover, the law clarifies terms like 'disparity reduction' which focuses on minimizing health outcome differences across various demographic groups, and 'financial data' related to healthcare cost specifics.

(a)

(1) If the board requires, or has previously required in its contracts with qualified health plans, a qualified health plan to report on cost reduction efforts, quality improvements, or disparity reductions, the board shall make public on the internet website of the Exchange plan-specific data on cost reduction efforts, quality improvements, and disparity reductions.

(2) Data and information posted on the internet website of the Exchange pursuant to paragraph (1) shall be posted in a way that demonstrates the compliance and performance of a qualified health plan with respect to cost reduction efforts, quality improvement, or disparity reduction reporting, but protects the personal information of an enrollee. Comparison among qualified health plans shall contribute to the understanding of the data and progress in achieving goals established by the Exchange through qualified health plan contracts.

(3) The board shall post information on the internet website of the Exchange pursuant to paragraphs (1) and (2) no less than annually.

(b)

(1) A qualified health plan shall provide data on enrollees to the Exchange in a form, manner, and frequency specified by the Exchange.

(2) Data and information made public by the Exchange shall be disclosed in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws, including the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).

(3) Records that reveal contracted rates paid by qualified health plans to providers and enrollee coinsurance that can be used to determine contracted rates paid by plans to providers shall not be subject to public disclosure.

(c)

(1) A qualified health plan shall provide to the Exchange information that the board identifies as necessary to conduct its duties or exercise its oversight powers.

(2) The information shall be furnished in the form, manner, and frequency specified by the Exchange.

(d)

(1) A qualified health plan shall provide enrollee data and other information on quality measures, including contract compliance with measures that affect individual and population health, as well as improvements in care coordination and patient safety, in a manner that allows for an analysis by demographic subpopulations.

(2) A qualified health plan shall provide enrollee data, encounter data, and other information on quality measures, performance improvement strategies, payment methods, and other information necessary to monitor adherence to contract provisions designed to improve health equity and reduce health disparities on an individual and population health basis.

(3) A qualified health plan shall also provide financial data and information, including cost detail, claims data, encounter data, and payment methods to evaluate cost and utilization experience for enrollees. Enrollment data and information shall include demographic, coverage, premium, product, network, and benefit design detail for each enrollee.

(e) A health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall disclose to the board the following information:

(1) Nongrandfathered individual market products, whether offered through the Exchange or otherwise.

(2) Nongrandfathered small group products, whether offered through the Exchange or otherwise.

(f) A health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall also disclose to the board, at the request of the board, quality and disparity data and information for all of the enrollees and insureds of the carrier in the individual and small group markets, but not including large group, Medi-Cal, or Medicare.

(g) In order to permit the Exchange to implement the provisions of subdivision (c) of Section 100503 and Section 2 of Chapter 655 of the Statutes of 2010, a health care service plan or health insurer contracted with the Exchange to offer a qualified health plan shall also disclose to the board data and information required by this section for each of the plan years in which the qualified health plan is or has been contracted with the Exchange, including prior years.

(h) For purposes of this section:

(1) “Disparity reduction” means a reduction in variation in disease occurrence, including communicable diseases and chronic conditions, as well as health outcomes between population groups by age, geographic area, primary language, race, ethnicity, sex, gender identity, sexual orientation, and disability status.

(2) “Financial data and information” means cost detail, including enrollee cost sharing, allowed amounts, fee schedules, and fee-for-service equivalent amounts.

(3) “Personal information” has the same meaning as set forth in Section 1798.3 of the Civil Code.

qualified health plans cost reduction efforts quality improvements ...

Section § 100503.8

This law section mandates that the board is responsible for overseeing health care operations within the Exchange. This includes performing tasks like audits, investigations, and data analysis related to health plans and insurers. The board can carry out these duties directly or appoint others to do so and will function as a health oversight agency as defined by federal regulations.

The board shall engage in health oversight activities relating to Exchange operations, including, but not limited to, audits, investigations, inspections, evaluations, analyses, data collection through routine reporting, and any other activities for oversight of the Exchange, including qualified health plan contracts with health care service plans and health insurers. In performing those duties, the board may exercise its authority directly or through its designees, and shall be acting as a health oversight agency, as defined in Section 164.501 of Title 45 of the Code of Federal Regulations.

health oversight Exchange operations audits ...

Section § 100503.9

This section mandates that beginning September 1, 2023, the Exchange must request detailed personal information about new applicants for unemployment, disability, and family leave benefits from the Employment Development Department every month. This includes names, social security numbers, contact information, job loss details, and benefit data. The Exchange will use this information to inform these individuals about health care coverage options and assist them in obtaining coverage.

The Exchange is responsible for protecting the confidentiality of this data and can only use or share the minimum amount for its intended purpose. Marketing and outreach must offer individuals the chance to opt out of future contacts. Privacy and security requirements apply to all information shared by the Exchange, which must be destroyed securely when no longer needed.

(a)

(1) Beginning no later than September 1, 2023, and at least monthly thereafter, subject to the restrictions in paragraph (5) of subdivision (b), the Exchange shall request from the Employment Development Department the following information of each new applicant for unemployment compensation, state disability, and paid family leave:

(A) Last name.

(B) First name.

(C) Middle initial.

(D) Social security number.

(E) Date of birth.

(F) Race or ethnicity, to the extent available.

(G) Preferred language.

(H) Gender.

(I) All mailing addresses, including city, state, and ZIP Code.

(J) All telephone numbers, including home, work, and cellular.

(K) Email address, to the extent available.

(L) Date of most recent job loss, to the extent available.

(M) Wages or prior wages.

(N) The Employment Development Department program for which the applicant filed.

(O) Date the claim was filed.

(P) Claimant eligibility status.

(Q) Date initial payment was approved by the Employment Development Department.

(R) The weekly benefit amount.

(S) The benefit period start date.

(T) The benefit period end date.

(2) The Employment Development Department shall provide the information pursuant to paragraph (1) in a manner prescribed by the Exchange.

(3) The Employment Development Department may provide the information pursuant to paragraph (1) more frequently than monthly during periods of high unemployment.

(b)

(1) Consistent with subdivision (k) of Section 100503, the Exchange shall market and publicize the availability of health care coverage through the Exchange, and shall engage in outreach activities, to the individuals whose information the Exchange receives pursuant to subdivision (a).

(2) The Exchange may use any contact method that is intended to reach the person at their residence or other personal contact channel to communicate with and inform an individual whose information the Exchange receives pursuant to subdivision (a) of available health care coverage options through the exchange and to assist those individuals in obtaining health care coverage.

(3)

(A) The Exchange may disclose information obtained from the Employment Development Department to outreach and marketing vendors under contract to the Exchange.

(B) The Exchange shall not disclose information obtained from the Employment Development Department to a certified insurance agent, a certified enrollment counselor, or any other entity without the consent of the applicant, except as provided in subparagraph (A).

(4) Any outreach and marketing conducted pursuant to this section shall include, in a conspicuous and easy to access manner, the ability for individuals to decline all future outreach and marketing.

(5) The Exchange shall take all necessary measures to safeguard the confidentiality of any information obtained from the Employment Development Department and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals whose information the Exchange receives pursuant to paragraph (1) of subdivision (a). The Exchange shall at all times only request from the Employment Development Department, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was obtained.

(6) A person or entity that receives information from the Exchange pursuant to this section shall take all necessary measures to safeguard the confidentiality of any information obtained from the Exchange and shall at no time use or disclose that information for any purpose other than to market and publicize the availability of health care coverage through the Exchange to individuals, as directed by the Exchange. A person or entity shall at all times only request from the Exchange, use, or disclose the minimum amount of information necessary to accomplish the purposes for which it was received.

(7) Information received by the Exchange from the Employment Development Department shall both:

(A) At all times be subject to applicable privacy and information security-related requirements arising under both federal and state law.

(B) Be destroyed in a manner that maintains confidentiality.

(8) The Exchange shall ensure that information disclosed to outreach and marketing vendors or any other entity pursuant to this section shall comply with paragraph (7).

unemployment applicants employment development department health care coverage outreach ...

Section § 100504

This law section outlines what the board of the Exchange can do to manage health coverage in California. It permits the board to collect premiums, make contracts, and engage in legal actions. The board can also receive donations and gifts while following conflict of interest rules. It has the authority to adopt emergency regulations until 2030, with particular provisions for amendments up to 2035. They are required to work with health services to help people retain their providers and carriers when eligibility changes occur. Furthermore, the board must ensure health providers' information in the Exchange is accurate and available to consumers. They can offer extra coverage without using the General Fund and should only gather necessary personal data. Lastly, the board can standardize the health products offered by the Exchange, bypassing regular rule-making processes.

(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 an agency of the United States, an agency of the state, and a 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)

(A) Adopt rules and regulations, as necessary. Until January 1, 2030, necessary rules and regulations, except those implementing Section 1043, 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, an 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 within five years of the initial adoption of the emergency regulation. A rule or regulation adopted pursuant to this section shall be discussed by the board during at least one properly noticed board meeting before the board meeting at which the board adopts the rule or regulation. Notwithstanding subdivision (h) of Section 11346.1, until January 1, 2035, the Office of Administrative Law may approve more than two readoptions of an emergency regulation adopted pursuant to this section.

(B) The amendments made to this paragraph by the act that added this subparagraph also shall apply to a regulation adopted pursuant to this section before January 1, 2025.

(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 the individual’s carrier and provider network if the individual experiences a loss of eligibility of premium tax credits and becomes eligible for the Medi-Cal program, or loses eligibility for the Medi-Cal 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 General Fund money is not used to pay the cost of that coverage. 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. A product standardized by the board pursuant to this subdivision shall be discussed by the board during at least one properly noticed board meeting before 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).

health coverage Exchange board powers premiums collection ...

Section § 100504.5

This law allows the California Health Benefit Exchange to offer special health insurance plans called 'bridge plan products' to certain individuals under specific conditions, with federal approval. To be a 'bridge plan product,' it must be a health plan that already provides Medi-Cal services, meets federal and state health plan qualifications, enrolls eligible individuals, complies with financial regulations, and has a provider network similar to Medi-Cal plans. The Exchange must inform eligible individuals about all available health plans, including bridge plans. The law will expire five years after federal approval is obtained, unless renewed by a later statute.

(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.

bridge plan products Medi-Cal managed care health insurance ...

Section § 100504.6

This law gives the Exchange the power to create rules for implementing a bridge plan option. Before making any regulations, the board and its staff must meet specific requirements. Regulations made under this law are temporarily free from certain state procedures until January 1, 2016. The section will stop being active five years after federal approval of the bridge plan option, and it will be officially removed two years after that unless extended by another law.

(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.

Exchange authority bridge plan option federal approval ...

Section § 100505

This law section explains that the board must use a competitive process to choose insurance carriers and other contractors. They don't have to follow the usual state contract rules or get approval from the Department of General Services. Instead, they will create their own manual for how to handle contracts, similar to the state's guidelines.

Also, any changes to the rules or manual don't have to go through the normal rulemaking process, which usually involves a lot of formal steps and public input.

(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).

competitive process participating carriers contractors ...

Section § 100506

This law requires the board to create a way for people signing up for or enrolled in health plans through the Exchange to appeal decisions. This appeals process must follow federal law rules about how state Exchanges handle appeals. If new federal rules come out, the board can add extra requirements, but only if they cost nothing extra to the state’s General Fund or fees. However, if the appeal deals with issues covered by the state's Department of Managed Health Care or Department of Insurance, then the board doesn’t handle it; those departments do.

(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. 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.

appeals process health insurance Exchange federal appeals compliance ...

Section § 100506.1

This law gives individuals the right to appeal if there's an issue with their insurance affordability program or if they feel there's a mistake about their eligibility, the amount of tax credits and subsidies they receive, or affordable plan options. It also covers appeals for exemption from the insurance mandate penalties and notices related to eligibility or enrollment.

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, or eligibility for state financial assistance, or the amount of the advanced premium assistance subsidy.

(b) An eligibility determination for an exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act or an eligibility determination for an exemption from the Minimum Essential Coverage Individual Mandate, as specified in Section 100715.

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

appeal rights insurance affordability program eligibility determination ...

Section § 100506.2

This law requires that when determining eligibility or enrollment for health care programs in California, applicants must be informed about the appeals process both when they first apply and when any decisions are made about their eligibility. An eligibility notice must be provided after the California Healthcare Eligibility, Enrollment, and Retention System is ready, which must happen by July 1, 2017. This notice should include reasons for the decision, legal references, and contact information for help. It also needs to inform applicants about their rights and choices, such as appealing decisions and choosing legal representation. The law ensures that eligibility can be maintained during an appeal.

This law must align with federal rules to be put into action.

(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, state financial assistance, 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 or state financial assistance 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 themselves 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.

eligibility determination enrollment notice appeals process ...

Section § 100506.3

This law mandates that the board must contract with the State Department of Social Services to handle appeals related to decisions about eligibility, enrollment, or exemptions in the individual health insurance market within the Exchange's authority. The appeals process will follow certain federal and state regulations unless those rules don't apply, in which case the Medi-Cal hearing process will be used. This is all conditional on not conflicting with federal law.

(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.

Exchange appeals eligibility appeals enrollment appeals ...

Section § 100506.4

This law section clarifies the process for appealing eligibility or enrollment decisions related to health services through the California Health Benefit Exchange. Generally, you have 90 days to appeal after receiving a notice about a decision. If urgent health needs exist, you can request an expedited appeal. Appeals can be submitted in various ways, like phone, mail, or online, and you can get help in making your appeal.

Your appeal will be acknowledged, and you'll receive information about your eligibility while the appeal is pending. There's an opportunity for informal resolution before a formal hearing. You won't have to repeat information you've already provided, and the informal process won't affect your right to a hearing.

Hearings can be held via phone, video conference, or in-person, and you'll have a chance to present evidence and question witnesses. Decisions on appeals must be made within 90 days, explaining their impact on your eligibility. Finally, if you disagree with the decision, you can escalate the appeal or seek judicial review.

(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 and advanced premium assistance subsidy 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 the appellant’s 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 the applicant’s or enrollee’s 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 to 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 the appellant 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 the appellant 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) or state financial assistance under Title 25, 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 the appellant’s 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, the appellant 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) Upon final exhaustion of administrative or judicial review, whichever is later, that affects the amount of advance payment of the premium tax credit or the amount of advanced premium assistance subsidy, or both, for a taxable year that has been reconciled previously, the appellant shall file an amended return for that taxable year to reconcile the advanced premium assistance subsidy pursuant to subdivision (a) of Section 100810.

(n) 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.

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

appeal process eligibility determination enrollment decisions ...

Section § 100506.5

If you're appealing a decision about your health insurance financial help, like advance premium tax credits or cost-sharing reductions, you will keep receiving the same benefits you had before the decision until your appeal is decided.

For appeals of redetermination of Exchange advance premium tax credits, cost-sharing reductions, or state financial assistance, 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, cost-sharing reductions, or state financial assistance while the appeal is pending in accordance with the level of eligibility immediately before the redetermination being appealed.

health insurance appeals advance premium tax credits cost-sharing reductions ...

Section § 100507

This law states that the Exchange, which is likely a state-run health insurance marketplace, does not need to get a license or be regulated by the Department of Insurance or the Department of Managed Health Care.

However, any insurance companies (called carriers) that work with the Exchange must be properly licensed and in good standing with their own regulatory bodies.

(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.

Insurance Exchange Department of Managed Health Care Department of Insurance ...

Section § 100508

This law specifies what records the California Health Benefit Exchange, known simply as the Exchange, must keep confidential and what can eventually be publicly inspected. First, there are two types of records that are always off-limits to the public: details about negotiations and contracts, and sensitive financial data like payment rates and claims data between health plans and providers.

Second, contracts with health plans become public one year after their start date, including any amendments to those contracts. However, the Joint Legislative Audit Committee can inspect all contracts and amendments but must keep them confidential until they become publicly available after a year.

(a) Notwithstanding subdivision (b), records of the Exchange that reveal either of the following shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1):

(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.

(2) Records that reveal claims data, encounter data, cost detail, information about payment methods, contracted rates paid by qualified health plans to providers, and enrollee coinsurance or other cost sharing that can be used to determine contracted rates paid by plans to providers.

(b) Subject to subdivision (a), the following records of the Exchange shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1) as follows:

(1) Contracts with participating carriers entered into pursuant to this title on or after October 1, 2013, shall be open to inspection one year after the effective dates of the contracts.

(2) 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) 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 subdivision (b).

California Health Benefit Exchange public disclosure confidential records ...

Section § 100510

This law states that no person or organization can claim they work for or provide services for the Exchange without having a valid agreement with the Exchange.

If someone helps another violate this rule, they are also breaking the law.

(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.

Exchange representation valid agreement service provision ...

Section § 100520

This law establishes the California Health Trust Fund within the State Treasury to support specific health programs. The fund's money is continuously available without a year-end expiration, but it can't be borrowed or lent to other funds. Federal funds can be added if allowed, and a prudent reserve must be maintained. Spending on inappropriate expenses like retreats or excess pay is prohibited. Interest earned stays in the fund for health-related use. If there’s a surplus, fees can be lowered the next year. The fund doesn’t cover basic health coverage mandates or financial aid, except for operation costs related to these areas. These health programs are crucial for the state's health goals.

(a) The California Health Trust Fund is hereby created in the State Treasury for the purpose of this title, Title 24 (commencing with Section 100700), and Title 25 (commencing with Section 100800). Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title, Title 24 (commencing with Section 100700), and Title 25 (commencing with Section 100800). 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) To the extent permitted by federal law, moneys deposited in the Federal Trust Fund established pursuant to Section 16360 may be transferred to the California Health Trust Fund if the money is made available by the United States federal government for expenditure by the state for purposes consistent with the implementation of this section.

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

(e) 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.

(f) 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.

(g) 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.

(h) Notwithstanding subdivision (a), moneys in the fund shall not be used to fund the minimum essential coverage individual mandate pursuant to Title 24 (commencing with Section 100700) or the financial assistance program authorized pursuant to Title 25 (commencing with Section 100800), except for the Exchange’s operational costs necessary to administer the individual mandate and financial assistance program.

(i) The Legislature finds and declares that the Exchange’s operations of the programs in Title 24 (commencing with Section 100700) and Title 25 (commencing with Section 100800) are necessary and directly related to furthering the Exchange’s purposes pursuant to this title and the federal act.

California Health Trust Fund fiscal year unexpended funds ...

Section § 100520.5

This law establishes the Health Care Affordability Reserve Fund in California's State Treasury to support health care affordability. Money from this fund can be temporarily loaned to the General Fund to manage cash flow issues. Funds are transferred from the state's General Fund and can be used for health care affordability and benefit programs run by California's Health Benefit Exchange, upon legislative approval.

The California Health Benefit Exchange must explore options to lower out-of-pocket costs, like copays and deductibles, for low to middle-income individuals enrolled in Covered California. These options, which include providing zero deductibles for certain income groups, should be reported to legislative bodies by January 1, 2022. The Exchange must also address any operational challenges and maximize federal funding opportunities.

A $600 million loan from this fund to the General Fund is authorized for the fiscal year 2023–24, to be repaid in $200 million installments over three subsequent fiscal years.

(a) The Health Care Affordability Reserve Fund is hereby created in the State Treasury.

(b) Notwithstanding any other law, the Controller may use the funds in the Health Care Affordability Reserve Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381.

(c) Upon the enactment of the Budget Act of 2021, and upon order of the Director of Finance, the Controller shall transfer three hundred thirty-three million four hundred thirty-nine thousand dollars ($333,439,000) from the General Fund to the Health Care Affordability Reserve Fund.

(d) Upon appropriation by the Legislature, the Health Care Affordability Reserve Fund shall be utilized, in addition to any other appropriations made by the Legislature for the same purpose, for the purpose of health care affordability programs, and benefit programs pursuant to Section 100503.6, operated by the California Health Benefit Exchange.

(e)

(1) The California Health Benefit Exchange shall, in consultation with stakeholders and the Legislature, develop options for providing cost sharing reduction subsidies to reduce cost sharing for low- and middle-income Californians. On or before January 1, 2022, the Exchange shall report those developed options to the Legislature, Governor, and the Healthy California for All Commission, established pursuant to Section 1001 of the Health and Safety Code, for consideration in the 2022–23 budget process.

(2) In developing the options, the Exchange shall do all of the following:

(A) Include options for all Covered California enrollees with income up to 400 percent of the federal poverty level to reduce cost sharing, including copays, deductibles, coinsurance, and maximum out-of-pocket costs.

(B) Include options to provide zero deductibles for all Covered California enrollees with income under 400 percent of the federal poverty level and upgrading those with income between 200 percent and 400 percent, inclusive, of the federal poverty level to gold-tier cost sharing.

(C) Address any operational issues that might impede implementation of enhanced cost-sharing reductions for the 2023 calendar year.

(D) Maximize federal funding and address interactions with federal law regarding federal cost-sharing reduction subsidies.

(3) The Exchange shall make the report publicly available on its internet website.

(4) The Exchange shall submit the report in compliance with Section 9795 of the Government Code.

(f) Upon order of the Department of Finance, a loan of six hundred million dollars ($600,000,000) is authorized from the Health Care Affordability Reserve Fund to the General Fund in the 2023–24 fiscal year. The loan shall be repaid in annual installments of two hundred million dollars ($200,000,000) over the 2026–27, 2027–28, and 2028–29 fiscal years.

Health Care Affordability Reserve Fund cashflow loans General Fund ...

Section § 100521

This section outlines the financial rules for the California Health Benefit Exchange. The Exchange must operate using only federal funds, private donations, and other non-state general funds. No state General Funds can be used without a specific allowance. Before implementing any provisions, the board must confirm that there are enough financial resources. If funds are insufficient, the board must report on necessary changes to the Department of Finance. Additionally, the board must annually assess the impact of the Exchange on other state health programs and vice versa.

(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.

California Health Benefit Exchange federal funds private donations ...

Section § 100522

This law allows California's health insurance marketplace, known as the Exchange, to seek federal permission to offer health coverage to immigrants who can't otherwise obtain it due to their immigration status. To do this, the Exchange must waive the requirement that it only offers qualified health plans, but only for the purpose of covering these individuals.

The Exchange must ensure that any health plan offered meets certain criteria and closely resembles qualified health plans in all respects except eligibility requirements. People who buy these plans must cover the full cost themselves, as they won't qualify for federal financial assistance. The Exchange is also tasked with protecting applicants' personal information and limiting its use to necessary procedures related to eligibility and enrollment.

If the federal waiver is granted, these provisions will take effect in 2019.

(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).

health insurance marketplace immigration status waiver application ...

Section § 100523

Starting July 1, 2023, California provides financial help for individuals who lose their employer health coverage due to strikes, lockouts, or labor disputes. Those affected can receive premium and cost-sharing subsidies similar to what others get with incomes above 138.1% of the federal poverty level.

The Exchange administers this program and can require proof from individuals or contact unions and employers to verify claims. Coverage begins when an application is submitted, and individuals must report income changes or reinstatement of employer insurance.

Employers and unions must inform the Exchange about labor disputes affecting health coverage. The Exchange aims to use federal funds first but will use state funds if needed, and any state subsidies aren't considered taxable income.

(a) Beginning July 1, 2023, the Exchange shall administer a program of financial assistance to help Californians obtain and maintain health benefits through the Exchange if they lose their employer-provided health care coverage as a result of a labor dispute.

(1) An individual who has lost minimum essential coverage from an employer or joint labor management trust fund as a result of a strike, lockout, or labor dispute is a qualified individual for purposes of financial assistance, including premium assistance and cost-sharing reduction subsidies, provided that the individual meets all eligibility requirements specified in Section 36B of the Internal Revenue Code and Section 18071 of Title 42 of the United States Code, except for the income requirements of those sections. Any household income of the qualified individual above 138.1 percent of the federal poverty level for a family of the qualified individual’s size shall not be taken into account for the qualified individual and the members of their tax household. Consistent with existing federal law and rules, an individual shall be screened for eligibility for the federal Medicaid program.

(2) An individual described in paragraph (1) shall receive subsidies for health insurance premiums and cost-sharing reductions that provide the same assistance that is provided to other individuals with household incomes of 138.1 percent of the federal poverty level who qualify for financial assistance through the Exchange. The cost-sharing reductions shall use a standard benefit design that has an actuarial value of 94 percent or greater, and, effective January 1, 2024, the program design shall have zero deductibles for any covered benefit if the standard benefit design for this income has zero deductibles.

(3) An individual shall be a qualified individual for purposes of financial assistance, including premium assistance and cost-sharing reduction subsidies, under this section if all of the following are met:

(A) The individual loses minimum essential coverage from an employer as a result of a strike, lockout, or labor dispute.

(B) The employer that provided the minimum essential coverage to the individual is involved in the strike, lockout, or labor dispute.

(C) The individual provides a self-attestation confirming that they lost minimum essential coverage from an employer as a result of a strike, lockout, or labor dispute, and that the employer that provided them the minimum essential coverage is involved in the strike, lockout, or labor dispute.

(4) If further documentation is required, the Exchange shall contact the affected collective bargaining agent and may contact the employer.

(b) Notwithstanding Sections 1399.848 and 1399.849 of the Health and Safety Code, and Sections 10965.3 and 10965.4 of the Insurance Code, the effective date of coverage shall be the first day of the month of application submission and plan selection or the first day of the following month, at the discretion of the qualified individual.

(c)

(1) The Exchange, on a monthly basis, shall notify an enrollee receiving financial assistance pursuant to this section that the enrollee is required to notify the Exchange if their household income changes or minimum essential coverage provided by the enrollee’s employer is reinstated. The notice shall include information on the potential state and federal income tax consequences of any amount received as a subsidy provided under this section.

(2) Upon resolution of a strike, lockout, or labor dispute, an individual shall no longer be eligible for financial assistance under this section when the Exchange verifies that employer-provided minimum essential coverage from the employer has been reinstated for that individual and dependents and only after prior notification to the qualified individual of loss of financial assistance under this section.

(d) An employer or labor organization shall notify the Exchange before employer-provided coverage is affected by a strike, lockout, or labor dispute pursuant to a process established by the Exchange. The Exchange may contact an employer, labor organization, or other appropriate representative to determine the status of a strike, lockout, or labor dispute, its impact to coverage, and any other information necessary to determine eligibility for financial assistance under this section.

(e)

(1) The Exchange shall maximize federal affordability assistance for an individual enrolled pursuant to this section and shall use state affordability assistance funds for financial assistance not otherwise available under federal law.

(2) Financial assistance provided pursuant to this section shall be funded upon appropriation by the Legislature.

(f) Gross income, as defined in Section 17071 of the Revenue and Taxation Code, does not include any amount received as a state subsidy provided under this section.

(g) The following definitions apply for purposes of this section:

(1) “Employer-provided coverage” means coverage provided by an employer, a “multiemployer health plan,” as defined in Section 1002(37)(A) of Title 29 of the United States Code, or a joint labor-management trust.

(2) “Labor dispute” has the same meaning as set forth in clauses (i), (ii), and (iii) of paragraph (4) of subdivision (b) of Section 527.3 of the Code of Civil Procedure.

(3) “Labor organization” has the same meaning as defined in Section 1117 of the Labor Code.

(4) “Lockout” has the same meaning as defined in Section 1132.8 of the Labor Code.

(5) “Strike” has the same meaning as defined in Section 1132.6 of the Labor Code.

financial assistance health benefits employer-provided coverage ...

California Health Benefit Exchange

Section § 100500

Section § 100501

Section § 100501

Section § 100501.1

Section § 100502

Section § 100503

Section § 100503

Section § 100503.1

Section § 100503.2

Section § 100503.3

Section § 100503.4

Section § 100503.5

Section § 100503.6

Section § 100503.7

Section § 100503.8

Section § 100503.9

Section § 100504

Section § 100504.5

Section § 100504.6

Section § 100505

Section § 100506

Section § 100506.1

Section § 100506.2

Section § 100506.3

Section § 100506.4

Section § 100506.5

Section § 100507

Section § 100508

Section § 100510

Section § 100520

Section § 100520.5

Section § 100521

Section § 100522

Section § 100523

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