Section 1374.60 Of Article 5.6. Point-of-service Health Care Service Plan Contracts From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.6.
1374.60
. 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.
(c) "In-network coverage or services" means all of the following:
(1) All the health care services provided or offered under the
requirements of this chapter that are received from a provider
employed by, under contract with, or otherwise affiliated with the
health care service plan and in accordance with the procedures set
forth in the plan's approved evidence of coverage.
(2) Health care services received from a provider not affiliated
with the health care service plan when the plan arranges for the
enrollee to receive services from that provider.
(3) Out-of-area emergency care provided in accordance with the
procedures set by the health care service plan to be followed in
securing these services.