Section 1373.10 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1373.10
. (a) On and after January 1, 1985, every health care
service plan, that is not a health maintenance organization or is not
a plan that enters exclusively into specialized health care service
plan contracts, as defined by subdivision (n) of Section 1345, which
provides coverage for hospital, medical, or surgical expenses, shall
offer coverage to group contract holders for expenses incurred as a
result of treatment by holders of certificates under Section 4938 of
the Business and Professions Code, under such terms and conditions as
may be agreed upon between the health care service plan and the
group contract holder.
A health care service plan is not required to offer the coverage
provided by this section as part of any contract covering employees
of a public entity.
(b) For the purposes of this section, "health maintenance
organization" or "HMO" means a public or private organization,
organized under the laws of this state, which does all of the
following:
(1) Provides or otherwise makes available to enrolled participants
health care services, including at least the following basic health
care services: usual physician services, hospitalization, laboratory,
X-ray, emergency and preventive services, and out-of-area coverage.
(2) Is compensated, except for copayments, for the provision of
basic health care services listed in paragraph (1) to enrolled
participants on a predetermined periodic rate basis.
(3) Provides physician services primarily directly through
physicians who are either employees or partners of the organization,
or through arrangements with individual physicians or one or more
groups of physicians, organized on a group practice or individual
practice basis.