Law:Division 113. The Adult Health Coverage Expansion Program (California)

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Contents

Chapter 1. General Provisions

Ca Codes (hsc:131500-131502) Health And Safety Code Section 131500-131502



131500. This division shall be known and may be cited as the Adult Health Coverage Expansion Program.


131501. It is the intent of the Legislature that the Adult Health Coverage Expansion Program provide health care coverage on a pilot program basis to eligible adults domiciled and employed in Santa Clara County who are without health care coverage.


131502. The following definitions apply for purposes of this division: (a) "Local initiative" has the same meaning as set forth in Section 12693.08 of the Insurance Code. (b) "Program" means the Adult Health Coverage Expansion Program. (c) "Small business" means an entity located in Santa Clara County that employs 50 or fewer persons, with at least 35 percent of the employees earning less than 350 percent of the federal poverty level for a family size of one, and that has not offered health care coverage to its employees for, at minimum, 12 consecutive months, provided that the provisions of any such prior coverage required the employer to contribute at least 50 percent of the total amount of the premium for that coverage. For purposes of the program authorized by this division, a small business shall be a "small employer" pursuant to Article 3.1 (commencing with Section 1357) of Chapter 2.2 of Division 2, subject to the provisions and exceptions of this division. Notwithstanding the company affiliation and tax filing provision of paragraph (1) of subdivision (l) of Section 1357, an individual franchise outlet shall be considered a small business.


Chapter 2. Administration

Ca Codes (hsc:131510-131511) Health And Safety Code Section 131510-131511



131510. The program may be implemented in Santa Clara County at the option of the local initiative, but if so implemented shall be as a pilot program. A maximum of 5,000 employees may be covered in the county, provided, however, that the number of enrollees may be increased pursuant to the prior approval of the Department of Managed Health Care. The local initiative shall administer the program.


131511. (a) In implementing the pilot program established pursuant to this division, the local initiative in Santa Clara County shall not be subject to the requirements of subdivision (a) of Section 1357.03. The program shall be otherwise subject to the requirements of Chapter 2.2 (commencing with Section 1340) of Division 2, including Article 3.1 (commencing with Section 1357) thereof, except as otherwise provided in this division, and shall be subject to approval as to regulatory filings with the Department of Managed Health Care as prescribed in Chapter 2.2 (commencing with Section 1340) of Division 2 and in implementing regulations promulgated by the department. (b) Except in the case of a late enrollee or for satisfaction of a preexisting condition clause in the case of initial coverage for an eligible employee, the local initiative may not exclude any eligible employee who would otherwise be eligible for health care coverage under this division on the basis of an actual or expected health care condition. The local initiative may not limit or exclude coverage for any eligible employee by type of illness, treatment, medical condition, or accident, except for preexisting conditions as permitted under Section 1357.06. (c) Coverage provided through the program to an eligible small business shall be renewable with respect to all eligible employees at the option of the participating small business.


Chapter 3. Eligibility

Ca Codes (hsc:131520-131522) Health And Safety Code Section 131520-131522



131520. Notwithstanding subdivision (b) of Section 1357, only an adult age 19 to 64 years, inclusive, employed by a small business for a minimum of 20 hours per week is eligible to participate in the program if he or she has a gross annual income that is less than 350 percent of the federal poverty level for a family size of one, and his or her employer participates in the program. Dependents, spouses, and domestic partners of employees are not eligible for the program.


131521. (a) A small business may apply to the local initiative that administers the program to obtain coverage for its employees who meet the requirements of Section 131520. (b) At least 50 percent of the employees of an otherwise eligible small business must meet the eligibility requirements of Section 131520, and at least 50 percent of those eligible employees must choose to receive coverage through the program in order for the small business to qualify to participate in the program.


131522. The program shall screen potential enrollees to determine if they meet the eligibility requirements for the Medi-Cal program.


Chapter 4. Benefits

Ca Codes (hsc:131530-131531) Health And Safety Code Section 131530-131531



131530. The local initiative that establishes a program shall offer health care coverage through the program, and all health care services shall be provided to participants by a provider operated by the county or by a provider with whom or with which the county or the local initiative has contracted to provide health care services, except for emergency or out-of-area care or instances in which a required specialized service is not contracted for by the county or the local initiative.


131531. The health care services provided through the program to eligible employees shall, to the extent practicable, be substantially similar to the benefits offered to adults under the Healthy Families Program pursuant to Chapter 5 (commencing with Section 12693.60) of Part 6.2 of the Insurance Code, but shall include at least all of the basic health care services included in subdivision (b) of Section 1345 and in Section 1300.67 of Title 28 of the California Code of Regulations.


Chapter 5. Funding

Ca Codes (hsc:131540-131541) Health And Safety Code Section 131540-131541



131540. (a) (1) The cost of the health care coverage provided through the program shall be paid through a combination of contributions paid by the small business, premiums paid by participating employees, and county, federal, state, or private sector funding made available for this purpose. (2) The local initiative may determine the amount of the employer contribution for each participating eligible employee, which shall not exceed one hundred fifty dollars ($150) per month, and the amount of the employee premium, which shall not exceed seventy-five dollars ($75) per month. The local initiative may adjust employer contribution and employee premium levels after the first year if necessary for changes in health care costs. (3) The local initiative may structure the required employee premium amounts according to a schedule that takes into account the individual employee's age or income level, or both, in a manner similar, but not necessarily identical, to that described in Section 12693.43 of the Insurance Code, pertaining to the Healthy Families Program. (4) The local initiative shall establish copayment levels and amounts in a manner substantially similar to that described in Section 12693.615 of the Insurance Code, pertaining to the Healthy Families Program. (5) For purposes of the program, "applicable rate charged for a covered employee" in Section 1366.26 means the total premium amount paid to the health plan on behalf of an employee, including amounts paid by the small business on behalf of the employee, the premium paid by the employee, and any county, federal, state, or private sector funding, which funding shall include the value of the discounted rates negotiated pursuant to subdivision (b), as apportioned to the employee. The program shall submit to the Department of Managed Health Care the procedures the local initiative will use for purposes of establishing the rates to be paid by a person eligible for continuation coverage under Section 1366.26, and the department shall only approve those procedures if it determines that they are consistent with the requirements of the Cal-COBRA program. (b) In order to enhance the affordability of coverage offered through the program to eligible small businesses and employees, the county and the local initiative shall negotiate discounted rates for services provided to participants in the program by providers operated by the county or by providers with whom, or with which, the county has contracted to provide health care services.


131541. The local initiative shall be authorized to establish, participate in, or apply to funding sources in the public and private sectors for purposes of providing or securing premium subsidies for eligible employees, pursuant to fair and equitable procedures to be established by the local initiative.


Chapter 6. Evaluation

Ca Codes (hsc:131550) Health And Safety Code Section 131550



131550. The county and the local initiative shall together evaluate the pilot program after three years, including all of the following: the number of individuals served, the demographics of the individuals served, the number of employees turned away due to the limitation on enrollment in Section 131510, the number of small businesses participating, the number of small businesses turned away due to the limitation on enrollment of individuals, funding sources (including employees, employers, county, state, federal, and other sources), and the health status of enrollees.


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