Cal. Code Regs. tit. 10 § 2699.100

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2699.100 - Definitions

(a) "Appellant" means an applicant or subscriber who has filed an appeal with the program.

(b) "Applicant" means a pregnant woman 18 years of age or older who is applying on her own behalf, or a legal guardian or a natural parent, foster parent, or stepparent with whom the child resides, who applies for coverage under the program on behalf of a child. "Applicant" also means a pregnant woman who is applying for coverage on her own behalf who is under 18 years of age, or who is an emancipated minor, or who is a minor not living in the home of a natural or adoptive parent, a legal guardian, foster parent or stepparent.

(c) "Application Date" means the date an application is sent to the program as evidenced by the U.S. postmark date on the application envelope, or documentation from other delivery services including fax delivery.

(d) "Board" means the Managed Risk Medical Insurance Board.

(e) "Coverage" means the payment for benefits provided through the program.

(f) "Disenroll" means to terminate coverage by the program.

(g) "Eligible" means the applicant is qualified to be enrolled in a participating health plan.

(h) "Enroll" means to accept an applicant as a subscriber by notifying a participating health plan to accept the applicant.

(i) "Executive Director" means the executive director for the Board.

(j) "Family member" means the following persons living in the individual's home:

(1) Children under age 21, of married or unmarried parents living in the home.

(2) The married or unmarried parents of the child or sibling children.

(3) The stepparents of the sibling children.

(4) The separate children of either an unmarried parent or a married parent or stepparent.

(5) An unborn child of the pregnant woman who is applying for coverage on her own behalf or on whose behalf an application has been submitted.

(6) Children under the age of 21, of married or unmarried parents, away at school who are claimed as tax dependents.

(7) The spouse of the pregnant woman.

(k) "Federal poverty level" means the level determined by the "Poverty Guidelines for the 48 Contiguous States and the District of Columbia" as contained in the Annual Update of HHS Poverty Guidelines as published in the Federal Register by the U.S. Department of Health and Human Services.

(l) "First trimester" means the first 13 weeks of a 40-week, full-term pregnancy.

(m) "Gross household income" means the total annual gross income of all family members except dependent children. Income includes before tax earnings from a job, including cash, wages, salary, commissions and tips, self-employment net profits, Social Security, State Disability Insurance (SDI), Retirement Survivor Disability Insurance (RSDI), veterans benefits, Railroad Retirement, disability worker's compensation, unemployment benefits, alimony, spousal support, pensions and retirement benefits, grants that cover living expenses, settlement benefits, rental income, gifts, lottery/bingo winnings and interest income. Income excludes child support, public assistance program benefits such as SSI/SSP and CalWORKS payments, foster care payments, general relief, loans, grants or scholarships applied toward college expenses, or earned income of a child aged 13 or under, or a child attending school. Income does not include income exclusions applicable to all federal means tested programs such as, disaster relief payments, per capita payments to Native Americans from proceeds held in trust and/or arising from use of restricted lands, Agent Orange payments, Title IV student assistance, energy assistance payments to low income families, relocation assistance payments, victims of crime assistance program, Spina Bifida payments, earned income tax credit and Japanese reparation payments.

(n) "Healthy Families Program" (HFP) means the Federal/State funded program that is operated pursuant to Title XXI of the Social Security Act and Part 6.2 (commencing with Section 12693) of Division 2 of the California Insurance Code, and that provides low cost health, dental and vision insurance coverage to eligible children.

(o) "Income deduction" means any of the following:

(1) Work expenses of $90 per month for each family member except dependent children working or receiving disability workers' compensation or State Disability Insurance. If a family member earns less than $90, the deduction can only be for the amount earned.

(2) Child care expenses while a family member works or trains for a job of up to $200 per month for each family member under age 2, up to $175 per month for each family member over age 2 and disabled dependent care expenses of up to $175 for a disabled dependent living in the home.

(3) The amount paid by a family member per month for any court ordered alimony or child support.

(4) $50 for alimony payments received by the pregnant woman. If a woman receives less than $50, the deduction can only be for the amount received.

(p) "Infant" means a subscriber's child born to a subscriber while the subscriber is enrolled in the program.

(q) "Living in the home" means using the home as the primary place of residence.

(1) "MAGI" or "Modified Adjusted Gross Income" means, as specified in Section 1397 bb(b)(1)(B)(v) of Title 42 of the United States Code, modified adjusted gross income, for an individual, or household income, for a household of more than one person, as those terms are defined in Section 36 B(d)(2) of the Internal Revenue Code of 1986, applied in a manner consistent with Section 1902(e)(14) of the Social Security Act (42 U.S.C. 1396a(e)(14)), including but not limited to the five percent (5%) reduction specified at paragraph (14)(I).

(r) "Medi-Cal" means the California health care services program under Title XIX of the Social Security Act.

(s) "Medicare" means the Health Insurance for the aged and permanently disabled provided under Title XVIII of the Social Security Act; "Part A" means Hospital Insurance as defined in Title XVIII of the Social Security Act; and "Part B" means Medical Insurance as defined in Title XVIII of the Social Security Act.

(t) "Participating health plan" means any of the following plans which are lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal health care services under insurance policies or contracts, medical and hospital service arrangements, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contracts with the program to provide coverage to program subscribers:

(1) A private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner.

(2) A nonprofit hospital service plan qualifying under Chapter 11a (commencing with Section 11491) of Part 2 of Division 2 of the Insurance Code.

(3) A nonprofit membership corporation lawfully operating under the Nonprofit Corporation Law (Division 2 (commencing with Section 5000) of the Corporations Code).

(4) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.

(5) A county or a city and county, in which case no license or approval from the Department of Insurance or the Department of Corporations shall be required to meet the requirements of this part.

(6) A comprehensive primary care licensed community clinic that is an organized outpatient freestanding health facility and is not part of a hospital that delivers comprehensive primary care services, in which case, no license or approval from the Department of Insurance or the Department of Corporations shall be required to meet the requirements of this part.

(u) "Program" means the Access for Infants and Mothers Program.

(v) "Resident" means a person who is present in California with intent to remain present except when absent for transitory or temporary purposes.

(w) "State supported services" mean abortion services provided to the subscribers through the program.

(x) "Subscriber" means an individual who is eligible for and enrolled in the program.

(y) "Subscriber contribution" means the cost to the subscriber to participate in the program.

(z) "Tenses and Number". The present tense includes the past and future, and the future the present; the singular includes the plural and the plural the singular.

(aa) "Time." Whenever in this chapter a time is stated in which an act is to be done, the time is computed by excluding the first day and including the last day. If the last day is a holiday it is also excluded.

Cal. Code Regs. Tit. 10, § 2699.100

1. New section filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-12-91 order including amendment of subsections (j), (k)(1), (k)(4) and (p) transmitted to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. Change without regulatory effect amending subsection (j) filed 4-5-93 pursuant to title 1, section 100, California Code of Regulations (Register 93, No. 15).
4. Amendment of subsections (c) and (j) filed 8-29-94 as an emergency; operative 9-1-94 (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-30-94 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-29-94 order transmitted to OAL 12-9-94 and filed 1-23-95 (Register 95, No. 4).
6. Change without regulatory effect amending subsection (j) filed 4-25-95 pursuant to section 100, title 1, California Code of Regulations (Register 95, No. 17).
7. Change without regulatory effect amending subsection (j) filed 5-14-96 pursuant to section 100, title 1, California Code of Regulations (Register 96, No. 20).
8. Change without regulatory effect amending subsection (j) filed 4-28-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 18).
9. Change without regulatory effect amending subsection (j) filed 5-10-99 pursuant to section 100, title 1, California Code of Regulations (Register 99, No. 20).
10. Repealer and new subsection (j), new subsections (l) and (n)-(n)(4), subsection relettering, and amendment of newly designated subsection (m) filed 3-17-2000 as an emergency; operative 3-17-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-17-2000 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 3-17-2000 order transmitted to OAL 6-12-2000 and filed 7-10-2000 (Register 2000, No. 28).
12. Change without regulatory effect amending subsections (l) and (x) filed 5-23-2001 pursuant to section 100, title 1, California Code of Regulations (Register 2001, No. 21).
13. Amendment filed 5-20-2003; operative 5-20-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 21).
14. New subsections (j)(7) and (m) and subsection relettering filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).
16. New subsection (v) and subsection relettering filed 3-12-2008; operative 4-11-2008 (Register 2008, No. 11).
17. New subsection (l) and subsection relettering filed 8-14-2008; operative 8-14-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 33).
18. Amendment of subsection (l) and new subsection (q)(1) filed 12-27-2013 as an emergency; operative 12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be transmitted to OAL by 6-25-2014 or emergency language will be repealed by operation of law on the following day. This filing is deemed an emergency and is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes of 2013, section 77.
19. Certificate of Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed 6-10-2014 (Register 2014, No. 24).

Note: Authority cited: Section 12696.05, Insurance Code. Reference: Sections 12695, 12695.06, 12695.08, 12695.18, 12695.20, 12695.22, 12695.24, 12696 and 12698, Insurance Code.