2016 California Code
Insurance Code - INS
DIVISION 2 - CLASSES OF INSURANCE
PART 6.6 - QUALIFIED HIGH RISK POOLS
Section 12739.52.

12739.52. The board shall have the authority to do all of the following, consistent with Section 1101 of the federal Patient Protection and Affordable Care Act (Public Law 111-148):

(a) Enter into an agreement with the federal Department of Health and Human Services to administer the federal temporary high risk pool as provided in Section 12739.53.

(b) Determine eligibility criteria and enrollment and disenrollment criteria and processes, including processes for waiting lists, enrollment limits, disenrollments, and any other limits on enrollment needed to maintain program expenditures within available federal funds.

(c) Determine the participation requirements of applicants, subscribers, and participating health plans, third-party administrators, and other contractors.

(d) Determine when subscribers coverage begins and ends.

(e) Provide for the processing of applications and the enrollment of subscribers.

(f) Determine the high risk medical coverage to be provided to subscribers, including the scope of benefits and subscriber cost sharing.

(g) Establish subscriber contributions and plan rates.

(h) (1) Provide high risk medical coverage for subscribers through contracts with participating health plans or third-party administrators to provide or administer the coverage. A contract between the board and a participating health plan may provide that the contracting health plan assumes full or partial risk for the cost of covered health services or that the contracting health plan undertakes to provide only administrative services for the state s self-insured high risk medical coverage. A contract between the board and a third-party administrator may provide that the third-party administrator undertakes to provide only administrative services for the state s self-insured high risk medical coverage. The board may provide or purchase stop-loss coverage under which the program and participating health plans or stop-loss insurers share the risk for health plan expenses that exceed plan rates.

(2) Nothing in paragraph (1) shall be construed to alter the rights of a participating health plan under existing law if the board is unable to continue payment to the plan in accordance with the terms of the plan s contract with the board.

(i) Authorize expenditures from the fund to pay program expenses that exceed subscriber contributions.

(j) Contract for administration of the program or any portion of the program with any public agency, including any agency of state government, or with any private entity.

(k) If, and to the extent, permitted by federal law and by the federal Department of Health and Human Services, align program administration with the administration of the Major Risk Medical Insurance Program established pursuant to Part 6.5 (commencing with Section 12700) to ensure coordination and administrative efficiency.

(l) Sue and be sued.

(m) Employ necessary staff.

(n) Refer potential violations of state and federal law by participating health plans and other entities and persons to the appropriate regulatory agencies.

(o) Subject to the approval of the Department of Finance, obtain loans from the General Fund for all necessary and reasonable expenses related to the administration of the fund and the program. The board shall repay principal and interest, using the pooled money investment account rate of interest, to the General Fund no later than July 1, 2014.

(p) (1) Issue rules and regulations to carry out the purposes of this part. The adoption and readoption of regulations to implement this part shall be deemed to be an emergency that calls for immediate action to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that the board describe facts showing the need for immediate action and from review by the Office of Administrative Law.

(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the board shall, without taking any regulatory action, initially implement this section pursuant to the agreement with the federal Department of Health and Human Services described in subdivision (a) of Section 12739.53. Thereafter, the board shall adopt any necessary regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code and with paragraph (1) of this subdivision.

(q) Exercise all powers reasonably necessary to carry out the powers and responsibilities expressly granted or imposed upon the board under this part, including the powers and responsibilities necessary to enter into an agreement with, and comply with the requirements of, the federal Department of Health and Human Services as described in subdivision (a) of Section 12739.53.

(Added by Stats. 2010, Ch. 31, Sec. 5. Effective June 29, 2010. Repealed as of January 1, 2020, pursuant to Section 12739.62.)