§ 1374.67
277 words·~1 min read·
/ca/health-and-safety-code/1374-67A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
A health care service plan offering a point-of-service plan contract is subject to the following limitations:
(a)A health care service plan shall limit its offering of point-of-service plan contracts so that no more than 50 percent of the plan’s total premium revenue in any fiscal quarter is earned from point-of-service plan contracts.
(b)A health care service plan offering a point-of-service plan contract shall not expend in any fiscal-year quarter more than 20 percent of its total health care expenditures for all its enrollees for out-of-network services for point-of-service enrollees.
(c)If the amount specified in subdivision
(a)or
(b)is exceeded by 2 percent in any quarter, the health care service plan shall come into compliance with subdivisions
(a)and
(b)by the end of the next following quarter. If compliance with the amount specified in subdivisions
(a)and
(b)is not demonstrated in the health care service plan’s next quarterly report, the director may prohibit the health care service plan from offering a point-of-service plan contract to new groups, or may require the health care service plan to amend one or more of its point-of-service contracts at the time of renewal to delete some or all of the out-of-network coverage or services as may be necessary for the plan to demonstrate compliance to the director’s satisfaction.
(d)The limitation imposed by this section shall not apply to a plan which in substantial part indemnified subscribers and enrollees pursuant to contracts issued under such plan’s former registration under the Knox-Mills Health Plan Act in 1975 and as of that date, and on September 1, 1993, was offering point-of-service plan contracts previously approved by the director.