California Code of Regulations
Title 10 - Investment
Chapter 5.5 - Major Risk Medical Insurance Board
Article 1 - Definitions
Section 2698.100 - Definitions

Universal Citation: 10 CA Code of Regs 2698.100

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

For the purpose of this part:

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

(b) "Applicant" means an individual who has filed an application for major risk medical coverage with the program.

(c) "Authorized Representative" means any person or entity who has been designated, in writing, by the appellant to act on his/her behalf or individuals who have appropriate power of attorney or legal conservatorship.

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

(e) "Certificate of Program Completion" means a certificate issued by the Program to persons leaving the Program after 36 consecutive months of coverage.

(f) "Coverage" means the payment by the program or other health plan or insurer for medically necessary services provided by institutional and professional providers.

(g) "Creditable coverage" means:

(1) Any individual or group policy, contract or program, that is written or administered by a disability insurer, health care service plan, fraternal benefits society, self-insured employer plan, or any other entity, in this state or elsewhere, and that arranges or provides medical, hospital and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage but does not include accident only, credit, disability income, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement, Medicare supplement, long-term care, dental, vision, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(2) The federal Medicare program pursuant to Title XVIII of the Social Security Act.

(3) The Medicaid program pursuant to Title XIX of the Social Security Act.

(4) Any other publicly sponsored program, provided in this state or elsewhere of medical, hospital and surgical care.

(5) 10 U.S.C.A. Chapter 55 (commencing with Section 1071) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

(6) A medical care program of the Indian Health Service or of a tribal organization.

(7) A state health benefits risk pool.

(8) A health plan offered under 5 U.S.C.A. Chapter 89 (commencing with Section 8901)(FEHBP).

(9) A public health plan as defined in federal regulations authorized by Section 2701(c)(1) (l) of the Public Health Service Act, as amended by Public Law 104-191.

(10) A health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C.A. 2504(e)).

(h) "Day" means calendar day unless specified otherwise.

(i) "Dependent" means:

(1) The spouse or registered domestic partner of a subscriber or applicant at the time of application.

(2) A child under the age of 23 at the time of application, who is an adopted child or stepchild pursuant to subsection (C) below, or a natural child who:
(A) is neither married nor a registered domestic partner, and

(B)
(1) lives with the subscriber or applicant; or

(2) is economically dependent upon the subscriber or the applicant.

(C)
1. A child shall be considered to be adopted from the date on which the adoptive child's birth parents or other appropriate legal authority signs a written document, including, but not limited to, a health facility minor release report, a medical authorization form, or a relinquishment form, granting the subscriber or applicant, or the spouse or registered domestic partner of a subscriber or applicant, the right to control health care for the adoptive child or, absent this written document, on the date there exists evidence of the right of the subscriber or applicant, or the spouse or registered domestic partner of a subscriber or applicant, to control the health care of the child placed for adoption.

2. A child shall be considered a stepchild upon the subscriber's or applicant's marriage to the child's natural or adoptive parent or when the subscriber or applicant becomes the registered domestic partner of the child's natural or adoptive parent.

(3) A child over the age of 23 at the time of application, who is:
(A) an adopted child or stepchild pursuant to (2)(C) of this section, or a natural child,

(B) neither married nor a registered domestic partner, and

(C) at the time of attaining age 23 was incapable of self-support because of physical or mental disability which has existed continuously from a date prior to attainment of age 23.

(j) "Dependent Subscriber" means an enrolled dependent that has maintained eligibility pursuant to section 2698.205.

(k) "Disenroll" means termination from coverage by the program.

(l) "Eligible" means the applicant is qualified to be enrolled along with dependents in a participating health plan.

(m) "Enroll" means to accept an individual as a subscriber or as a dependent by notifying a participating health plan to accept the applicant and dependents, if any, for coverage.

(n) "Executive Director" means the Executive Director for the Board.

(o) "Fee-for-service plan" means either of the following:

(1) Service benefit plans under which retrospective payment is made by a carrier under contracts with physicians, hospitals, or other providers of health services rendered to subscribers.

(2) Indemnity benefit plans under which a carrier agrees to pay retrospectively certain sums of money, not in excess of actual expenses incurred, for health services.

(p) "Health maintenance organization" means either of the following:

(1) Comprehensive group-practice prepayment plans which offer benefits, in whole or substantial part, on a prepaid basis, with professional services thereunder provided by physicians or other providers of health services practicing as a group in a common center or centers. This group shall include physicians representing at least three major medical specialties who receive all or a substantial part of their professional income from the prepaid funds.

(2) Individual practice prepayment plans or network model prepayment plans which offer health services in whole or in part on a prepaid basis, with professional services thereunder provided by individual physicians or groups of physicians or other providers of health services who agree to accept the payments provided by the plans as full payment for covered services rendered by them.

(q) "Health plan" means a private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner, a nonprofit hospital service plan qualifying under chapter 11A (commencing with section 11491) of part 2 of division 2 of the Insurance Code, a nonprofit membership corporation lawfully operating under the Nonprofit Corporation Law (division 2 (commencing with section 5000) of the Corporations Code), or a health care service plan as defined under subdivision (f) of section 1345 of the Health and Safety Code, which is 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 agreements, or membership contracts, in consideration of premiums or other periodic charges payable to it.

(r) "Medicare" means the Health Insurance for The Aged 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.

(s) "Participating health plan" means a health plan which has a contract with the program to administer major risk medical coverage for program subscribers. Participating health plans are categorized as either fee-for-service plans or health maintenance organizations as defined in section 2698.100(p) or (q) respectively.

(t) "Pilot Program" means the program established by Health and Safety Code section 1373.62 and Insurance Code section 10127.15.

(u) "Pilot Program health plan" means any health care service plan or health insurer who has enrolled a program graduate into the Pilot Program and a Pilot Program standard benefit plan.

(v) "Pilot Program standard benefit plan" means a benefit package that meets the criteria of Health and Safety Code section 1373.62(c) or Insurance Code section 10127.15 (c).

(w) "Pre-existing condition" means any condition for which medical advice, diagnosis, care, or treatment was recommended or received during a six month period immediately preceding the effective date of coverage.

(x) "Pre-existing condition exclusion period" means that period of time for which there is no coverage for a pre-existing condition.

(y) "Post-enrollment waiting period" means that period of time between the date of enrollment and the date coverage begins.

(z) "Program" means the California Major Risk Medical Insurance Program.

(aa) "Program Graduate" means:

(1) A subscriber in the Program who has completed 36 consecutive months of coverage and has been issued a Certificate of Program Completion by the Program; or

(2) A dependent subscriber who has completed a total of 36 consecutive months of coverage in the program, and has been issued a Certificate of Program Completion by the Program.

(bb) "Program Graduate dependent" means an enrolled dependent who has completed 36 consecutive months of coverage and has been issued a Certificate of Program Completion by the Program at the same time as the subscriber.

(cc) "Registered domestic partner" means a person who either (1) has filed a Declaration of Domestic Partnership with the Secretary of State which meets the criteria specified by Family Code section 297 and the partnership has not been terminated pursuant to Family Code section 299, or (2) is a member of a domestic partnership validly formed in another jurisdiction which is cognizable as a valid domestic partnership in this state pursuant to Family Code section 299.2.

(dd) "Resident of the State of California" means a person who is present in California with intent to remain present except when absent for transitory or temporary purposes. However, a person who is absent from the state for a consecutive period greater than 210 days shall not be considered a resident.

(ee) "Standard average individual rate" means that rate a participating health plan estimates it would charge the general public for individual, non-group coverage for the benefits described in the program contract with the participating health plan.

(ff) "Standard monthly administrative fee" means the weighted monthly average per person administrative fee paid by the Pilot Program to participating Pilot Program health plans and calculated in accordance with section 2698.602(d).

(gg) "Subscriber" means an individual who is eligible for and receives major risk medical coverage through the program. "Subscriber" does not include an individual receiving major risk medical coverage through the program as an enrolled dependent of a subscriber. An individual who is enrolled but not yet receiving coverage due to a post-enrollment waiting period is considered a subscriber.

(hh) "Subscriber contribution" means the amount paid by a subscriber or a dependent subscriber on a periodic basis to the program for coverage for a subscriber and/or enrolled dependents, if any, or for a dependent subscriber.

(ii) "Unique Identification Number (UIN)" means a number assigned by the Program to each Program Graduate's Certificate of Program Completion to be used in the Pilot Program to track each Program Graduate for payment and reporting purposes.

1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order including amendment of subsections (f) and (g) and NOTE transmitted to OAL 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Editorial correction of printing errors (Register 91, No. 27).
4. New subsection (y) filed 6-27-91 as an emergency; operative 6-27-91 (Register 91, No. 40). A Certificate of Compliance must be transmitted to OAL by 10-25-91 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 6-27-91 order including amendment of subsection (y) transmitted to OAL 10-23-91 and filed 11-22-91 (Register 92, No. 11).
6. Amendment of subsection (f) and NOTE filed 12-19-91 as an emergency; operative 12-19-91 (Register 92, No. 19). A Certificate of Compliance must be transmitted to OAL 4-17-92 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 12-19-91 order transmitted to OAL 4-8-92 and filed 5-12-92 (Register 92, No. 23).
8. Amendment of subsections (d), (f) and (p), new subsections (s)-(s)(4), subsection relettering, and amendment of newly designated subsection (z) and NOTE filed 5-19-95; operative 6-19-95 (Register 95, No. 20).
9. Editorial correction of article 1 heading (Register 96, No. 17).
10. Amendment of subsections (t) and (w) and repealer of subsection (z) filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
11. Amendment of section and NOTE filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).
13. Amendment of subsections (i)(1)-(3), new subsections (i)(3)(A)-(C) and (cc), subsection relettering and amendment of NOTE filed 1-14-2009; operative 2-13-2009 (Register 2009, No. 3).

Note: Authority cited: Sections 12711 and 12712, Insurance Code; and ASSEM. Bill No. 1401 (Stats. 2002, ch. 794 Sec. 21). Reference: Sections 10900, 10127.15, 12705, 12711, 12712, 12725, 12726 and 12730, Insurance Code; and Section 1373.62, Health and Safety Code; and Sections 297, 299 and 299.2, Family Code.

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