SECTIONS 10810 - California Statutes

INSURANCE CODE

SECTION 10810

10810. As used in this chapter:
(a) "Ancillary benefit plan" means a policy or contract written or
administered by a participating carrier that covers dental or vision
benefits for the covered eligible employees of an employer or small
employer and their dependents.
(b) "Appropriate Regulatory Authority" means the Department of
Insurance except for health care service plans, in which case it
means the Department of Managed Health Care.
(c) "Benefit plan design" means a specific health coverage product
issued by a carrier to employers or small employers, to trustees of
associations, or to individuals if the coverage is offered through
employment or sponsored by an employer or small employer. It includes
the services covered and the levels of copayment and deductibles.
(d) "Board" means the governing body of the purchasing alliance.
This term shall include the board of directors of a nonprofit
corporation or trust, a for-profit corporation, the general partners
of a partnership, or a sole proprietor.
(e) "Carrier" means any licensed disability insurance company or
licensed health care service plan or any other entity that writes,
issues, or administers any health benefit plan or ancillary benefit
plan to employers or small employers in this state.
(f) "Commissioner" means the Insurance Commissioner, who shall
have regulatory jurisdiction over purchasing alliances.
(g) "Dependent" has the same meaning as in the subdivision (a) of
Section 1357 of the Health and Safety Code and in subdivision (e) of
Section 10700 of this code.
(h) "Eligible employee" means any permanent employee who is
actively engaged on a full-time basis in the conduct of business of
the employer or small employer and, who has satisfied any employer or
small employer waiting period requirements. The term includes sole
proprietors or partners of a partnership if they are actively engaged
on a full-time basis in the employer's or small employer's business,
but does not include employees who work on a part-time, temporary,
or substitute basis.
(i) "Employer" means any corporation, partnership, sole
proprietorship, or other business entity doing business in this state
that may be eligible to participate in a purchasing alliance. The
term "employer" shall not include "small employer" as defined in
subdivision (s).
(j) "Enrollee" means an eligible employee or a dependent of an
eligible employee who is enrolled in a health benefit plan or
ancillary benefit plan offered through the purchasing alliance by a
participating carrier.
(k) "Health benefit plan" means a policy or contract written or
administered by a participating carrier that arranges or provides
health care benefits for the covered eligible employees of an
employer or small employer and their dependents. The term does not
include accident only, credit, dental, vision, disability income, or
long-term care insurance, coverage issued as a supplement to
liability insurance, automobile medical payments insurance, or
insurance under which benefits are payable with or without regard to
fault and is statutorily required to be continued in any liability
insurance policy or equivalent self-insurance.
(l) "Management company" means the company under contract to the
purchasing alliance to provide managerial services for the operation
of the purchasing alliance.
(m) "Participating carrier" means a carrier that contracts with a
purchasing alliance to provide coverage to enrollees under a health
benefit plan or ancillary benefit plan.
(n) "Participating employer" means an employer or small employer
who contracts with a purchasing alliance to provide coverage to the
employer's or small employer's employees.
(o) "Purchasing alliance" means a non-risk-bearing entity issued a
certificate of registration pursuant to this chapter to provide
health benefits through multiple unaffiliated participating carriers
to multiple participating employers, small employers and their
employees within this state as authorized by the commissioner. That
entity shall include nonprofit corporations, for-profit corporations,
trusts, partnerships, and sole proprietorships.
(p) "Risk adjustment factor" for small employer benefit plan
designs and contracts has the same meaning as in subdivision (j) of
Section 1357 of the Health and Safety Code and in subdivision (u) of
Section 10700 of this code.
(q) "Service region" means that portion of the state, designated
by the commissioner pursuant to regulations as described in this
chapter in which each purchasing alliance must fairly and
affirmatively offer, market, and sell all of the health benefit plan
designs offered through the purchasing alliance that are sold or
offered to a small employer to all small employers.
(r) "Small employer" has the same meaning as in paragraph (1) of
subdivision (l) of Section 1357 of the Health and Safety Code and in
paragraph (1) of subdivision (w) of Section 10700 of this code.
(s) "Third-party administrator" means the company contracted by
the purchasing alliance to provide administrative services for the
purchasing alliance and that is licensed to provide those services by
the department pursuant to Section 1759.10.