California Health and Safety Code

§ 1374.60

HSC § 1374.60 Effective Jan 1, 2000Div. 2 · Ch. 2.2 · Art. 5.6

Statute text

For purpose of this article, the following definitions shall apply:

(a)A “point-of-service plan contract” means any plan contract offered by a health care service plan whereby the health care service plan assumes financial risk for both “in-network coverage or services” and “out-of-network coverage or services.” The term “point-of-service plan contract” shall not apply to a plan contract where the out-of-network coverage or service is underwritten by an insurance company admitted in this state or is provided by a self-insured employer and is offered in conjunction with in-network coverage or services provided pursuant to a health care service plan contract.

(b)“Out-of-network coverage or services” means health care services received either from (1) providers who are not employed by, under contract with, or otherwise affiliated with the health care service plan, except for health care services received from these providers in an emergency or when referred or authorized by the plan under procedures specifically reviewed and approved by the director or (2) providers who are employed by, under contract with, or otherwise affiliated with a health care service plan in instances when the “in-network coverage or services” requirements for care set forth in the health care service plan’s approved evidence of coverage are not met.

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Legislative history

Amended by Stats. 1999, Ch. 525, Sec. 115. Effective January 1, 2000. Operative July 1, 2000, or sooner, by Sec. 214 of Ch. 525.