California Code of Regulations
Title 22 - Social Security
Division 7 - Health Planning and Facility Construction
Chapter 11.5 - Promotion of Competitive Health Care Markets; Health Care Affordability
Article 2 - Health Care Spending Targets
Section 97445 - Definitions

(a) "Affiliation" refers to a situation in which an entity ("affiliate") controls, is controlled by, or is under common control with another entity.

(b) "Control" (including the terms "controlling," "controlled by," and "under common control with") means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of an entity, whether through the ownership of voting shares, debt, by contract, or otherwise.

(c) "Department" shall mean the Department of Health Care Access and Information.

(d) "Directly contracted plan" means a payer or fully integrated delivery system that is directly contracted with a group purchaser, individual subscriber, or a public agency, to arrange for the provision of health care services to members.

(e) "Director" shall mean the director of the Department of Health Care Access and Information.

(f) "Fully integrated delivery system" shall have the meaning set forth in section 127500.2(h) of the Health and Safety Code ("the Code").

(g) "Health insurer" means a health insurer licensed to provide health insurance or specialized behavioral health-only policies, as defined in Section 106 of the Insurance Code.

(h) "Health plan" means a health care service plan or a specialized mental health care service plan as defined in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code). "Health plan" does not include a health care service plan that holds only a restricted or limited license under 28 CCR § 1300.49(a).

(i) "Office" shall mean the Office of Health Care Affordability established by section 127501 of the Code.

(j) "Payer" shall have the meaning set forth in section 127500.2(o) of the Code.

(k) "Plan-to-plan contract" means a contractual arrangement between a payer or fully integrated delivery system and another payer or fully integrated delivery system, in which the subcontracted plan makes network providers available to the directly contracted plan's members, and the subcontracted plan may be responsible for other directly contracted plan functions. Plan-to-plan contracts do not include contractual arrangements between a payer or fully integrated delivery system and a physician organization.

(l) "Physician organization" shall have the meaning set forth in section 127500.2(p) of the Code.

(m) "Registered submitter" means a payer or fully integrated delivery system or approved voluntary submitter that has registered to submit data to the System.

(n) "Reporting year" means the service year for which data files are being reported.

(o) "Required submitter" means a payer or fully integrated delivery system that meets any of the criteria in section 97449(a).

(p) "Subcontracted Plan" means a payer or fully integrated delivery system that has a plan-to-plan contract allowing a directly contracted plan's members access to the subcontracted plan's network providers.

(q) "System" or "THCE System" means the Total Health Care Expenditures Data System.

(r) "THCE Data Portal" or "Data Portal" means the secure data submission mechanism through which health care entities register to submit data and data files are submitted to the System. The Data Portal is available via the Department's website, hcai.ca.gov.

(s) "THCE Data Submission Guide" or the "Guide" means the Office of Health Care Affordability: Total Health Care Expenditures Data Submission Guide (Version 1.1), dated June 2024, and hereby incorporated by reference. The Guide is available on, and may be downloaded from, the Department's website.

(t) "OHCA Attribution Addendum" means the Office of Health Care Affordability: Attribution Addendum, dated June 2024, and hereby incorporated by reference. The OHCA Attribution Addendum is available on, and may be downloaded from, the Department's website.

(u) "Voluntary submitter" means a payer or fully integrated delivery system that is not subject to the requirements of this Article that chooses to voluntarily submit data to the Office and has been approved by the Office to register to submit data to the System.