California Insurance Code 12699.50-12699.63
12699.50. This part shall be known and may be cited as the County Health Initiative Matching Fund. 12699.51. For the purposes of this part, the following definitions shall apply: (a) "Administrative costs" means those expenses that are described in Section 1397ee(a)(1)(D) of Title 42 of the United States Code. (b) "Adult" means an uninsured parent of, or, as defined by the board, a person 19 years of age or older responsible for, a child enrolled to receive coverage under Part 6.2 (commencing with Section 12693) or who is enrolled to receive the full scope of Medi-Cal services with no share of cost. (c) "Applicant" means a county, county agency, a local initiative, or a county organized health system. (d) "Board" means the Managed Risk Medical Insurance Board. (e) "Child" means a person under 19 years of age. (f) "Comprehensive health insurance coverage" means the coverage described in Section 12693.60. (g) "County organized health system" means a health system implemented pursuant to Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code and Article 1 (commencing with Section 101675) of Chapter 3 of Part 4 of Division 101 of the Health and Safety Code. (h) "Fund" means the County Health Initiative Matching Fund. (i) "Local initiative" has the same meaning as set forth in Section 12693.08. 12699.52. (a) The County Health Initiative Matching Fund is hereby created within the State Treasury. The fund shall accept intergovernmental transfers as follows: (1) The nonfederal matching fund requirement for federal financial participation through the State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code). (2) Funding associated with a proposal approved pursuant to subdivision (g) of Section 12699.53. (b) Amounts deposited in the fund shall be used only for the purposes specified by this part. (c) The board shall administer this fund and the provisions of this part in collaboration with the State Department of Health Services for the express purpose of allowing local funds to be used to facilitate increasing the state's ability to utilize federal funds available to California and for costs associated with a proposal pursuant to subdivision (g) of Section 12699.53. Federal funds shall be used prior to the expiration of their authority for programs designed to improve and expand access for uninsured persons. (d) The board shall authorize the expenditure of money in the fund to cover program expenses, including cost to the state to administer the program. 12699.525. The sum of eighty-nine million dollars ($89,000,000) is hereby appropriated in the 2002-03 fiscal year from the fund, and the sum of one hundred sixty-four million dollars ($164,000,000) is hereby appropriated for the 2002-03 fiscal year from the Federal Trust Fund, to the board and shall be available for encumbrance through June 30, 2004, for the purposes of this part. 12699.53. (a) An applicant that will provide an intergovernmental transfer may submit a proposal to the board for funding for the purpose of providing comprehensive health insurance coverage to any child or adult who meets citizenship and immigration status requirements that are applicable to persons participating in the program established by Title XXI of the Social Security Act, and in case of a child, whose family income is at or below 300 percent of the federal poverty level, or in case of an adult, whose family income does not exceed 200 percent of the federal poverty level, in specific geographic areas, as published quarterly in the Federal Register by the Department of Health and Human Services, and which child or adult does not qualify for either the Healthy Families Program (Part 6.2 (commencing with Section 12693) or Medi-Cal with no share of cost pursuant to the Medi-Cal Act (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code). (b) The proposal shall guarantee at least one year of intergovernmental transfer funding by the applicant at a level that ensures compliance with the requirements of any applicable approved federal waiver or state plan amendment as well as the board's requirements for the sound operation of the proposed project, and shall, on an annual basis, either commit to fully funding the necessary intergovernmental amount or withdraw from the program. The board may identify specific geographical areas that, in comparison to the national level, have a higher cost of living or housing or a greater need for additional health services, using data obtained from the most recent federal census, the federal Consumer Expenditure Survey, or from other sources. The proposal may include an administrative mechanism for outreach and eligibility. (c) The applicant may include in its proposal reimbursement of medical, dental, vision, or mental health services delivered to children who are eligible under the State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code), if these services are part of an overall program with the measurable goal of enrolling served children in the Healthy Families Program. (d) If a child is determined to be eligible for benefits for the treatment of an eligible medical condition under the California Children's Services Program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, the health, dental, or vision plan providing services to the child pursuant to this part shall not be responsible for the provision of, or payment for, those authorized services for that child. The proposal from an applicant shall contain provisions to ensure that a child whom the health, dental, or vision plan reasonably believes would be eligible for services under the California Children's Services Program is referred to that program. The California Children's Services Program shall provide case management and authorization of services if the child is found to be eligible for the California Children's Services Program. Diagnosis and treatment services that are authorized by the California Children' s Services Program shall be performed by paneled providers for that program and approved special care centers of that program and approved by the California Children's Services Program. All other services provided under the proposal from the applicant shall be made available pursuant to this part to a child who is eligible for services under the California Children's Services Program. (e) An applicant may submit a proposal for reimbursement of medical, dental, or vision services delivered to adults as specified in subdivision (a). (f) (1) If a proposal from an applicant for coverage of an adult includes state funds or funds derived from county sources, the applicant shall, to the extent feasible, include participation by health care service plans licensed by the Department of Managed Health Care or health insurers regulated by the Department of Insurance that contract with the board to provide services to Healthy Families Program subscribers in the geographic area. (2) This subdivision shall not apply if the population to be served by the applicant's proposal is less than 1,000 persons. (g) Notwithstanding any other provision of this section, an applicant may submit a proposal to the board for the purposes of providing comprehensive health insurance coverage to children whose coverage is not eligible for funding under Title XXI of the Social Security Act, or to a combination of children whose coverage is eligible for funding under Title XXI of the Social Security Act and children whose coverage is not eligible for that funding. To be approved by the board, these proposals shall comply with both of the following requirements: (1) Meet all applicable requirements for funding under this part, except for availability of funding through Title XXI of the Social Security Act. (2) Provide for the administration of children's coverage by the board through the administrative infrastructure serving the Healthy Families Program, and through health, dental, and vision plans serving the Healthy Families Program. 12699.54. (a) The board, in consultation with the State Department of Health Services, the Healthy Families Advisory Committee, and other appropriate parties, shall establish the criteria for evaluating an applicant's proposal, which shall include, but not be limited to, the following: (1) The extent to which the program described in the proposal provides comprehensive coverage including health, dental, and vision benefits. (2) Whether the proposal includes a promotional component to notify the public of its provision of health insurance to eligible children. (3) The simplicity of the proposal's procedures for applying to participate and for determining eligibility for participation in its program. (4) The extent to which the proposal provides for coordination and conformity with benefits provided through Medi-Cal and the Healthy Families Program. (5) The extent to which the proposal provides for coordination and conformity with existing Healthy Families Program administrative entities in order to prevent administrative duplication and fragmentation. (6) The ability of the health care providers designated in the proposal to serve the eligible population and the extent to which the proposal includes traditional and safety net providers, as defined in regulations adopted pursuant to the Healthy Families Program. (7) For children's coverage, the extent to which the proposal intends to work with the school districts and county offices of education. (8) The total amount of funds available to the applicant to implement the program described in its proposal, and the percentage of this amount proposed for administrative costs as well as the cost to the state to administer the proposal. (9) The extent to which the proposal seeks to minimize the substitution of private employer health insurance coverage for health benefits provided through a governmental source. (10) The extent to which local resources may be available after the depletion of federal funds to continue any current program expansions for persons covered under local health care financing programs or for expanded benefits. (11) For coverage proposals for adults, the extent to which the proposal seeks to pursue assistance from employers in the payment of premiums and whether the proposal requires, as a condition of parental enrollment, the enrollment of children in the applicant's plan or a competing plan. (12) For coverage proposals for adults, the extent to which the proposal offers subscribers a choice of health care service plans or health insurers similar to the choices available to children eligible for the Healthy Families Program in that county. (13) For the purposes of defining an applicant's eligibility for funding under this part, the following shall apply: (A) The same income methodology shall be used for the proposed program that is currently used for the Medi-Cal and the Healthy Families programs. (B) Only participating licensed Healthy Families dental, health, and vision plans may be used. However, the board may permit exceptions to this requirement consistent with the purpose, of this part. (b) The board may, in its sole discretion, approve or disapprove projects for funding pursuant to this part on an annual basis. (c) To the extent that an applicant's proposal pursuant to this part provides for health plan or administrative services under a contract entered into by the board or at rates negotiated for the applicant by the board, a contract entered into by the board or by an applicant shall be exempt from any provision of law relating to competitive bidding, and shall be exempt from the review or approval of any division of the Department of General Services to the same extent as contracts entered into pursuant to Part 6.2 (commencing with Section 12693). The board and the applicant shall not be required to specify the amounts encumbered for each contract, but may allocate funds to each contract based on the projected or actual subscriber enrollments to a total amount not to exceed the amount appropriated for the project including family contributions. 12699.55. The board, in collaboration with the State Department of Health Services, shall review each funding proposal submitted by an applicant in accordance with the criteria described in Section 12699.54 and based on that criteria, approve or reject the proposal. 12699.56. (a) Upon its approval of a proposal that shall include any allowable amount of federal funds under the State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code), the board, in collaboration with the State Department of Health Services, may provide the applicant reimbursement in an amount equal to the amount that the applicant will contribute to implement the program described in its proposal, plus the appropriate and allowable amount of federal funds. Not more than 10 percent of the County Health Initiative Matching Fund and matching federal funds shall be expended in any one fiscal year for administrative costs, including the costs to the state to administer the proposal, unless the board permits the expenditure consistent with the availability of federal matching funds not needed for the purposes described in paragraph (3) of subdivision (a) of Section 12699.62, or unless the board determines that an expenditure for administrative costs has no impact on available federal funding. The board, in collaboration with the State Department of Health Services, may audit the expenses incurred by the applicant in implementing its program to ensure that the expenditures comply with the provisions of this part. No reimbursement may be made to an applicant that fails to meet its financial participation obligation under this part. The state's reasonable startup costs and ongoing costs for administering the program shall be reimbursed by those entities applying for funding. (b) Any program approved pursuant to subdivision (g) of Section 12699.53 that requires any funding not allowable for a federal match under the State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) shall provide the board with the total amount of funds needed to provide that portion of coverage not eligible for federal matching funds, including reasonable startup costs and ongoing costs for administering the program. (c) Each applicant that is provided funds under this part shall submit to the board a plan to limit initial and continuing enrollment in its program in the event the amount of moneys for its program is insufficient to maintain health insurance coverage for those participating in the program. 12699.57. Each health care service plan, specialized health care service plan, and health insurer that contracts to provide health care benefits under this part shall be licensed by the Department of Managed Health Care or the Department of Insurance. 12699.58. (a) The board, in collaboration with the State Department of Health Services, shall administer the provisions of this part and may do all of the following: (1) Administer the expenditure of moneys from the fund. (2) Issue rules and regulations as necessary. (3) Enter into contracts. (4) Sue and be sued. (5) Employ necessary staff. (6) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed by this part. (b) The adoption and readoption of regulations pursuant to this section shall be deemed to be an emergency and necessary for the immediate preservation of public peace, health, and safety, or general welfare and shall be exempt from review by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations and shall remain in effect for not more than 180 days. The regulation shall become effective immediately upon filing with the Secretary of State. 12699.59. All expenses incurred by the board and the State Department of Health Services in administering this part, including, but not limited to, expenses for developing standards and processes to implement any of the provisions of this part, evaluating applications, or processing or granting appeals growing out of any of the provisions of this part, shall be paid from the fund or directly by applicants, except that the board may accept funding from a not-for-profit group or foundation, or from a governmental entity providing grants for health-related activities, to administer this part. 12699.60. Nothing in this part creates a right or an entitlement to the provision of health insurance coverage or health care benefits. No costs shall accrue to the state for the provision of these services. The state shall not be liable beyond the assets of the fund for any obligation incurred or liabilities sustained by applicants in the operation of the fund or of the projects authorized by this part. 12699.61. To the extent necessary to obtain federal financial participation for projects approved pursuant to this part, the Governor, in collaboration with the Managed Risk Medical Insurance Board and the State Department of Health Services, shall apply for one or more waivers or shall file state plan amendments pursuant to the federal State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) in coordination with the Managed Risk Medical Insurance Board and the State Department of Health Services to allow a county agency, local initiative, or county organized health system to apply for matching funds through the federal State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) using local funds for the state matching funds. 12699.62. (a) The provisions of this part shall be implemented only if all of the following conditions are met: (1) Federal financial participation is available for this purpose. (2) Federal participation is approved. (3) The Managed Risk Medical Insurance Board determines that federal State Children's Health Insurance Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title 42 of the United States Code) funds remain available after providing funds for all current enrollees and eligible children and parents that are likely to enroll in the Healthy Families Program and, to the extent funded through the federal State Children's Health Insurance Program, the Access for Infants and Mothers Program and Medi-Cal program, as determined by a Department of Finance estimate. In each fiscal year, funds for adults shall only be provided to the extent that the funds are not needed for the children's expansion portion of the County Health Initiative Matching Fund. (4) Funds are appropriated specifically for this purpose. (b) The State Department of Health Services and the Managed Risk Medical Insurance Board may accept funding necessary for the preparation of the federal waiver applications or state plan amendments described in Section 12699.61 from a not-for-profit group or foundation. 12699.63. The state shall be held harmless for any federal disallowance resulting from this part and any other expenses or liabilities, including, but not limited to, the cost of processing or granting appeals. An applicant receiving supplemental reimbursement pursuant to this part shall be liable for any reduced federal financial participation, and any other expenses or liabilities, including, but not limited to, the costs of processing or granting appeals, resulting from the implementation of this part with respect to that applicant. The state may recoup any federal disallowance from the applicant.
