CA Welf & Inst Code Section 14148.67

(a)

When implementing the premium and cost-sharing payments required under Sections 14102 and 14148.65, the department shall make the premium and cost-sharing payments required under those sections to the beneficiary’s qualified health plan in conformity with the requirements of this section.

(b)

(1)The beneficiary shall not be charged, billed, asked, or required to make any premium or cost-sharing payments to his or her qualified health plan or service provider for any services that are subject to premium or cost-sharing payments by the department under Section 14102 or 14148.65.

(2)

If the beneficiary makes any premium or cost-sharing payments to his or her plan or provider for services that are subject to premium or cost-sharing payments by the department under Section 14102 or 14148.65, the department shall reimburse the beneficiary for those payments. The department shall make every reasonable effort to do both of the following:

(A)

Make the reimbursement process simple and easy for beneficiaries to use.

(B)

Promptly reimburse beneficiaries under this paragraph.

(3)

If, as a result of reconciliation in a tax year in which the beneficiary was eligible for covered premium payments under Section 14102 or 14148.65, the beneficiary owes and makes a tax payment to the federal government to return a portion of the advanced premium tax credit to which the beneficiary was not entitled and the beneficiary notifies the department, the department shall reimburse the beneficiary for the amount of the tax payment related to the tax credits for covered premium payments under Section 14102 or 14148.65.

(4)

If, as a result of reconciliation in a tax year in which the beneficiary was eligible for covered premium payments under Section 14102 or 14148.65, the federal government owes and makes a tax refund to the beneficiary based upon the beneficiary’s advanced premium tax credit, the beneficiary shall reimburse the department for the portion of the refund that is related to the tax credits that were applied to the premium payments made by the department.

(c)

(1)Except as provided in paragraph (2), beneficiaries who are eligible for benefits under Section 14102 or 14148.65 shall be eligible for the premium and cost-sharing payments required under those sections only up to the amount necessary to pay for the second lowest silver level plan in his or her qualified health plan pricing region, as modified by cost-sharing reductions.

(2)

If a beneficiary selects or remains in a metal level plan that is more expensive than the metal level plan amount limit required under paragraph (1), the beneficiary may select or remain in that plan only if he or she agrees to be responsible for paying all applicable premium and cost-sharing charges that are in excess of what is covered by the department. The department is not responsible for paying for any premium or cost sharing that is in excess of the metal level plan amount limit required under paragraph (1).

(d)

The department shall consult with the Exchange, Exchange contracting health care service plans and health insurers, and stakeholders, including consumer advocates, Medi-Cal providers, and the counties, in the development and implementation of the following:

(1)

Processes and procedures to inform affected applicants and beneficiaries in a clear, consumer-friendly manner of all of their enrollment options under the Medi-Cal program and the Exchange, of the manner in which they may receive the benefits and services covered through the Exchange coverage, and of the manner in which they may receive benefits and services under Section 14102.

(2)

Provider notices to ensure that Medi-Cal providers are aware of the Medi-Cal program under Section 14102 and that providers comply with state laws applicable to Medi-Cal coverage for individuals eligible under Section 14102.

(e)

All notices developed under subdivision (d) shall be accessible to persons with limited English language proficiency and persons with disabilities consistent with all federal and state requirements.

(f)

Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, 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. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.

(g)

This section shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.