Section 1374.66 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.
1374.66
. Any health care service plan that offers a
point-of-service plan contract may do all of the following:
(a) Limit or exclude coverage for specific types of services or
conditions when obtained out-of-plan.
(b) Include annual out-of-pocket limits, copayments, and annual
and lifetime maximum benefit limits for out-of-network coverage or
services that are different or separate from any amounts or limits
applied to in-network coverage or services, and may impose a
deductible on coverage for out-of-network coverage or services.
(c) To the extent permitted under this chapter, may limit the
groups to which a point-of-service plan contract is offered, and may
adopt nondiscriminatory renewal guidelines under which one or more
point-of-service plan contracts would be replaced with other than
point-of-service plan contracts. If a point-of-service plan contract
is sold to a group, then the group shall offer it to all members of
that group who are eligible for coverage by the health care service
plan.
(d) Treat as out-of-network services those services that an
enrollee obtains from a provider affiliated with the plan, but not in
accordance with the authorization procedures set forth in the health
care service plan's approved evidence of coverage.
(e) Contracts between health care service plans and medical
providers, for the purpose of providing medical services under
point-of-service contracts, may include risk-sharing arrangements for
out-of-network services, but only if the risk sharing arrangements
meet all of the following conditions:
(1) The contracting medical provider agrees to participate in
risk-sharing arrangements applicable to out-of-network services.
(2) If the medical provider is reimbursed on a capitated or
prepaid basis, the contract shall clearly disclose the capitation or
prepayment amount to be paid to the medical provider for in-network
services received by enrollees under point-of-service contracts.
(3) Any capitation or prepayment amounts paid to the medical
provider shall not place the medical provider directly at risk for or
directly transfer liability for out-of-network services received by
enrollees under point-of-service contracts.
(4) The risk-sharing arrangements for out-of-network services may
provide a bonus or incentive to the medical provider to attempt to
reduce the utilization of out-of-network services, but shall not
place the medical provider at risk for any amounts in excess of the
amounts used by the plan to budget for or fund the risk-sharing pool
for out-of-network services.
(5) The contract between the medical provider and the plan shall
clearly disclose the mathematical method by which funding for the
risk-sharing arrangement is established, the mathematical method by
which and the extent to which payments for out-of-network services
are debited against the risk-sharing funds, and the method by which
the risk-sharing arrangement is reconciled on no less than an annual
basis.
(6) The contract is approved by the director.