California Health and Safety Code 1374.60 – For purpose of this article, the following definitions shall …
For purpose of this article, the following definitions shall apply:
(a) A “point-of-service plan contract” means any plan contract offered by a health care service plan whereby the health care service plan assumes financial risk for both “in-network coverage or services” and “out-of-network coverage or services.”
Terms Used In California Health and Safety Code 1374.60
- Contract: A legal written agreement that becomes binding when signed.
- Director: means "State Director of Health Services. See California Health and Safety Code 21
- 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
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement, contract, brochure, or letter of entitlement issued to a subscriber or enrollee setting forth the coverage to which the subscriber or enrollee is entitled. See California Health and Safety Code 1345
- 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
- Provider: means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish 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
The term “point-of-service plan contract” shall not apply to a plan contract where the out-of-network coverage or service is underwritten by an insurance company admitted in this state or is provided by a self-insured employer and is offered in conjunction with in-network coverage or services provided pursuant to a health care service plan contract.
(b) “Out-of-network coverage or services” means health care services received either from (1) providers who are not employed by, under contract with, or otherwise affiliated with the health care service plan, except for health care services received from these providers in an emergency or when referred or authorized by the plan under procedures specifically reviewed and approved by the director or (2) providers who are employed by, under contract with, or otherwise affiliated with a health care service plan in instances when the “in-network coverage or services” requirements for care set forth in the health care service plan’s approved evidence of coverage are not met.
(c) “In-network coverage or services” means all of the following:
(1) All the health care services provided or offered under the requirements of this chapter that are received from a provider employed by, under contract with, or otherwise affiliated with the health care service plan and in accordance with the procedures set forth in the plan’s approved evidence of coverage.
(2) Health care services received from a provider not affiliated with the health care service plan when the plan arranges for the enrollee to receive services from that provider.
(3) Out-of-area emergency care provided in accordance with the procedures set by the health care service plan to be followed in securing these services.
(Amended by Stats. 1999, Ch. 525, Sec. 115. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.)