California Insurance Code 12698-12698.35
12698. To be eligible to participate in the program, a person shall meet all of the following requirements: (a) Be a resident of the state for at least six continuous months prior to application. A person who is a member of a federally recognized California Indian tribe is a resident of the state for these purposes. (b) (1) Until the first day of the second month following the effective date of the amendment made to this subdivision in 1994, have a household income that does not exceed 250 percent of the official federal poverty level unless the board determines that the program funds are adequate to serve households above that level. (2) Upon the first day of the second month following the effective date of the amendment made to this subdivision in 1994, have a household income that is above 200 percent of the official federal poverty level but does not exceed 250 percent of the official federal poverty level unless the board determines that the program funds are adequate to serve households above the 250 percent of the official federal poverty level. (c) Pay an initial subscriber contribution of not more than fifty dollars ($50), and agree to the payment of the complete subscriber contribution. A federally recognized California Indian tribal government may make the initial and complete subscriber contributions on behalf of a member of the tribe only if a contribution on behalf of members of federally recognized California Indian tribes does not limit or preclude federal financial participation under Title XXI of the Social Security Act. If a federally recognized California Indian tribal government makes a contribution on behalf of a member of the tribe, the tribal government shall ensure that the subscriber is made aware of all the health plan options available in the county where the member resides. 12698.05. A person shall not be eligible to participate in the program if the person is eligible for Medi-Cal without a share of cost or eligible for Medicare at the time of application. 12698.06. A person shall not be eligible to participate in the program for covered services under this part for services that are covered through private insurance arrangements at the time of application. 12698.15. Subscribers shall not be disenrolled for failure to pay subscriber contributions. The board may impose or contract for collection actions to collect unpaid subscriber contributions. 12698.20. (a) If a subscriber is dissatisfied with any action, or failure to act, which has occurred in connection with a participating plan's coverage, the subscriber may appeal to the board and shall be accorded an opportunity for a fair hearing. Hearings may be conducted pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code. (b) The program may place a lien on compensation or benefits, recovered or recoverable by a subscriber from any party or parties responsible for the compensation or benefits, for which benefits have been provided under a policy issued under this part. 12698.25. Services that would be covered under the program that are provided to pregnant women who, after receiving those services, are subsequently determined to be eligible for coverage under this part may be reimbursed as determined by the board. In no case shall services received prior to 40 days before a woman's date of application be eligible for reimbursement. 12698.26. (a) A health care provider who is furnished documentation of a subscriber's enrollment in the program shall not seek reimbursement nor attempt to obtain payment for any covered services provided to that subscriber other than from the participating health plan covering the subscriber. (b) The provisions of subdivision (a) do not apply to any copayments required for the covered services provided to the subscriber under his or her participating health plan. (c) For purposes of this section, "health care provider" means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services. 12698.30. (a) At a minimum, coverage shall be provided to subscribers during one pregnancy, and for 60 days thereafter, and to children less than two years of age who were born of a pregnancy covered under this program to a woman enrolled in the program before July 1, 2004. (b) Coverage provided pursuant to this part shall include, at a minimum, those services required to be provided by health care service plans approved by the Secretary of Health and Human Services as a federally qualified health care service plan pursuant to Section 417.101 of Title 42 of the Code of Federal Regulations. (c) Coverage shall include health education services related to tobacco use. (d) Medically necessary prescription drugs shall be a required benefit in the coverage provided under this part. 12698.35. (a) Through its courts, statutes, and under its Constitution, California protects a woman's right to reproductive privacy. California reaffirms these protections and specifically its Supreme Court decision in People v. Belous (1969) 71 Cal.2d 954, 966-68. (b) The State Department of Health Services and the Managed Risk Medical Insurance Board may accept or use moneys under Title XXI of the federal Social Security Act (known as the State Children's Health Insurance Program or S-CHIP), as interpreted in Section 457.10 of Title 42 of the Code of Federal Regulations, to fund services for women pursuant to Section 14007.7 of the Welfare and Institutions Code (Medi-Cal) and Part 6.3 (commencing with Section 12695) (Access for Infants and Mothers (AIM)) only when, during the period of coverage, the woman is the beneficiary. The scope of services covered under Medi-Cal and AIM, as defined in statutes, regulations, and state plans, is not altered by this section or the state plan amendment submitted pursuant to this section. (c) California's S-CHIP plan and any amendments submitted and implemented pursuant to this section shall be consistent with subdivisions (a) and (b). (d) This section is a declaration of existing law.
