§ 1374.60

318 words·~1 min read·/ca/health-and-safety-code/1374-60

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

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.”

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.