Section 1374.67 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.
1374.67
. A health care service plan offering a point-of-service
plan contract is subject to the following limitations:
(a) A health care service plan shall limit its offering of
point-of-service plan contracts so that no more than 50 percent of
the plan's total premium revenue in any fiscal quarter is earned from
point-of-service plan contracts.
(b) A health care service plan offering a point-of-service plan
contract shall not expend in any fiscal-year quarter more than 20
percent of its total health care expenditures for all its enrollees
for out-of-network services for point-of-service enrollees.
(c) If the amount specified in subdivision (a) or (b) is exceeded
by 2 percent in any quarter, the health care service plan shall come
into compliance with subdivisions (a) and (b) by the end of the next
following quarter. If compliance with the amount specified in
subdivisions (a) and (b) is not demonstrated in the health care
service plan's next quarterly report, the director may prohibit the
health care service plan from offering a point-of-service plan
contract to new groups, or may require the health care service plan
to amend one or more of its point-of-service contracts at the time of
renewal to delete some or all of the out-of-network coverage or
services as may be necessary for the plan to demonstrate compliance
to the director's satisfaction.
(d) The limitation imposed by this section shall not apply to a
plan which in substantial part indemnified subscribers and enrollees
pursuant to contracts issued under such plan's former registration
under the Knox-Mills Health Plan Act in 1975 and as of that date, and
on September 1, 1993, was offering point-of-service plan contracts
previously approved by the director.