SECTIONS 14250-14265 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14250-14265

14250. Unless the context otherwise requires, the definitions set
forth in this article govern the construction of this chapter.

14251. "Prepaid health plan" means any plan which meets all of the
following criteria:
(a) Licensed as a health care service plan by the Director of the
Department of Managed Health Care pursuant to the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340), Division 2, Health and Safety Code), other than a plan
organized and operating pursuant to Section 10810 of the Corporations
Code which substantially indemnifies subscribers or enrollees for
the cost of provided services, or has an application for licensure
pending and was registered under the Knox-Mills Health Plan Act prior
to its repeal (Chapter 941, Statutes of 1975) or licensed as a
nonprofit hospital service plan by the Insurance Commissioner
pursuant to Section 11493(e) and Sections 11501 to 11505 of the
Insurance Code.
(b) Meets the requirements for participation in the Medicaid
Program (Title XIX of the Social Security Act) on an at risk basis.
(c) Agrees with the State Department of Health Services to furnish
directly or indirectly health services to Medi-Cal beneficiaries on
a predetermined periodic rate basis.
"Prepaid health plan" includes any organization which is licensed
as a plan pursuant to the Knox-Keene Health Care Service Plan Act of
1975 and is subject to regulation by the Department of Managed Health
Care pursuant to that act, and which contracts with the State
Department of Health Services solely as a fiscal intermediary at
risk.
Except for the requirement of licensure pursuant to the Knox-Keene
Act, the State Director of Health Services may waive any provision
of this chapter which the director determines is inappropriate for a
fiscal intermediary at risk. Any such exemption or waiver shall be
set forth in the fiscal intermediary at risk contract with the State
Department of Health Services.
"Fiscal intermediary at risk" means any entity which entered into
a contract with the State Department of Health Services on a pilot
basis pursuant to subdivision (f) of Section 14000, as in effect June
1, 1973, in accordance with which the entity received capitated
payments from the state and reimbursed providers of health care
services on a fee-for-service or other basis for at least the basic
scope of health care services, as defined in Section 14256, provided
to all beneficiaries covered by the contract residing within a
specified geographic region of the state. The fiscal intermediary at
risk shall be at risk for the cost of administration and utilization
of services or the cost of services, or both, for at least the basic
scope of health care services, as defined in Section 14256, provided
to all beneficiaries covered by the contract residing within a
specified geographic region of the state. The fiscal intermediary at
risk may share the risk with providers or reinsuring agencies or
both. Eligibility of beneficiaries shall be determined by the State
Department of Health Services and capitation payments shall be based
on the number of beneficiaries so determined.

14252. "Medi-Cal beneficiary" means a person who is eligible to
receive benefits under Chapter 7 (commencing with Section 14000) of
this part.

14253. "Subcontract" means an agreement entered into by the prepaid
health plan with any of the following:
(a) A provider of health care services who agrees to furnish such
services to Medi-Cal beneficiaries enrolled in the prepaid health
plan.
(b) A marketing organization.
(c) Any other person or organization who agrees to perform any
administrative function or service for the operation of the prepaid
health plan specifically related to securing or fulfilling its
contractual obligations with the department.

14254. "Primary care physician" is a physician who has the
responsibility for providing initial and primary care to patients,
for maintaining the continuity of patient care, and for initiating
referral for specialist care. A primary care physician shall be
either a physician who has limited his practice of medicine to
general practice or who is a board-certified or board-eligible
internist, pediatrician, obstetrician-gynecol ogist, or family
practitioner.

14255. "Specialist" means a physician who is board certified or
board eligible in the specialty of medical care provided.

14256. The "basic scope of health care benefits" means:
(a) Physician's services;
(b) Hospital outpatient services;
(c) Laboratory and X-ray;
(d) Prescription drugs;
(e) Hospital inpatient care;
(f) Skilled nursing facility care.

14257. Nothing in this act shall preclude the director from
contracting with licensed specialized health care service plans which
provide only dental, pharmaceutical, optometric, or psychological
services in accordance with regulations issued by the department.

14258. "Service area" means a geographical area designated by the
department within which a prepaid health plan shall provide health
care services and within which the Medi-Cal beneficiaries eligible
for enrollment in the prepaid health plan reside.

14259. "Director" means the State Director of Health Services.

14260. "Department" means the State Department of Health Services.

14261. "Vendor" means any person who provides services or supplies
to a prepaid health plan or a subcontractor of a prepaid health plan
and who does not have a subcontract as defined by Section 14253 with
either the prepaid health plan or its subcontractors.

14263. "Marketing" means any activity conducted by or on behalf of
a prepaid health plan where information regarding the services
offered by a prepaid health plan is disseminated in order to persuade
Medi-Cal beneficiaries to enroll or accept any application for
enrollment in the prepaid health plan. Marketing shall also include
any similar activity to procure the endorsement of the prepaid health
plan from any individual or organization.

14264. "Marketing organization" means any subcontractor who agrees
to provide marketing services for a prepaid health plan.

14265. "Marketing representative" means any person who engages in
marketing activities on behalf of a marketing organization or the
prepaid health plan.