California Health and Safety Code 1399.826 – (a) (1) During each open enrollment period, every health …
(a) (1) During each open enrollment period, every health care service plan offering plan contracts in the individual market, other than individual grandfathered plan coverage, shall offer to the responsible party for a child coverage for the child that does not exclude or limit coverage due to any preexisting condition of the child.
(b) A health care service plan offering coverage in the individual market shall not reject an application for a health care service plan contract from a child or filed on behalf of a child by the responsible party during an open enrollment period or from a late enrollee during a period no longer than 63 days from the qualifying event listed in subdivision (d) of Section 1399.825.
Terms Used In California Health and Safety Code 1399.826
- Child: means any individual under 19 years of age. See California Health and Safety Code 1399.825
- Contract: A legal written agreement that becomes binding when signed.
- department: means State Department of Health Services. See California Health and Safety Code 20
- Dependent: A person dependent for support upon another.
- Enrollee: means a person who is enrolled in a plan and who is a recipient of services from the plan. See California Health and Safety Code 1345
- Individual grandfathered plan coverage: means health care coverage in which an individual was enrolled on March 23, 2010, consistent with Section 1251 of PPACA and any rules or regulations adopted pursuant to that law. See California Health and Safety Code 1399.825
- Open enrollment period: means the annual open enrollment period, subsequent to the initial open enrollment period, applicable to each individual child that is the month of the child's birth date. See California Health and Safety Code 1399.825
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
- PPACA: means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent rules or regulations issued pursuant to that law. See California Health and Safety Code 1399.825
- Responsible party for a child: means an adult having custody of the child or with responsibility for the financial needs of the child, including the responsibility to provide health care coverage. See California Health and Safety Code 1399.825
- Service area: means a geographical area designated by the plan within which a plan shall provide health care services. See California Health and Safety Code 1345
- State: means the State of California, unless applied to the different parts of the United States. See California Health and Safety Code 23
(c) Except to the extent permitted by federal law, rules, regulations, or guidance issued by the relevant federal agency, a health care service plan shall not condition the issuance or offering of individual coverage on any of the following factors:
(1) Health status.
(2) Medical condition, including physical and mental illnesses.
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability, including conditions arising out of acts of domestic violence.
(8) Disability.
(9) Any other health status-related factor as determined by department.
This subdivision shall not apply to a contract providing individual grandfathered plan coverage.
(d) When a responsible party for a child submits a premium payment, based on the quoted premium charges, and that payment is delivered or postmarked, whichever occurs earlier, within the first 15 days of the month, coverage under the plan contract shall become effective no later than the first day of the following month. When that payment is neither delivered nor postmarked until after the 15th day of the month, coverage shall become effective no later than the first day of the second month following delivery or postmark of the payment.
(e) A health care service plan offering coverage in the individual market shall not reject the request of a responsible party for a child to include that child as a dependent on an existing health care service plan contract that includes dependent coverage during an open enrollment period.
(f) Nothing in this article shall be construed to prohibit a health care service plan offering coverage in the individual market from establishing rules for eligibility for coverage and offering coverage pursuant to those rules for children and individuals based on factors otherwise authorized under federal and state law for health plan contracts in addition to those offered on a guaranteed issue basis during an open enrollment period to children or late enrollees pursuant to this article. However, a health care service plan, other than a plan providing individual grandfathered plan coverage, shall not impose a preexisting condition provision on coverage, including dependent coverage, offered to a child.
(g) Nothing in this article shall be construed to require a plan to establish a new service area or to offer health coverage on a statewide basis, outside of the plan’s existing service area.
(h) Nothing in this article shall be construed to prevent a health care service plan from offering coverage to a family member of an enrollee in grandfathered health plan coverage consistent with Section 1251 of PPACA.
(Added by Stats. 2010, Ch. 656, Sec. 3. (AB 2244) Effective January 1, 2011. Inoperative, pursuant to Section 1399.836, on January 1, 2014, subject to condition for resuming operation.)