Section 1399.801 Of Article 11.5. Individual Access To Contracts For Health Care Services From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 11.5.
1399.801
. As used in this article:
(a) "Creditable coverage" means:
(1) Any individual or group policy, contract, or program that is
written or administered by a disability insurer, health care service
plan, fraternal benefits society, self-insured employer plan, or any
other entity, in this state or elsewhere, and that arranges or
provides medical, hospital, and surgical coverage not designed to
supplement other plans. The term includes continuation or conversion
coverage but does not include accident only, credit, disability
income, Medicare supplement, long-term care, dental, vision, coverage
issued as a supplement to liability insurance, insurance arising out
of a workers' compensation or similar law, automobile medical
payment insurance, or insurance under which benefits are payable with
or without regard to fault and that is statutorily required to be
contained in any liability insurance policy or equivalent
self-insurance.
(2) The federal Medicare program pursuant to Title XVIII of the
Social Security Act.
(3) The medicaid program pursuant to Title XIX of the Social
Security Act.
(4) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(5) 10 U.S.C.A. Chapter 55 (commencing with Section 1071)
(CHAMPUS).
(6) A medical care program of the Indian Health Service or of a
tribal organization.
(7) A state health benefits risk pool.
(8) A health plan offered under 5 U.S.C.A. Chapter 89 (commencing
with Section 8901) (FEHBP).
(9) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)( l) of the Public Health Service
Act, as amended by Public Law 104-191, the Health Insurance
Portability and Accountability Act of 1996.
(10) A health benefit plan under 22 U.S.C.A. 2504(e) of the Peace
Corps Act.
(b) "Dependent" means the spouse or child of an eligible
individual or other individual applying for coverage, subject to
applicable terms of the health care plan contract covering the
eligible person.
(c) "Federally eligible defined individual" means an individual
who as of the date on which the individual seeks coverage under this
part, (1) has 18 or more months of creditable coverage, and whose
most recent prior creditable coverage was under a group health plan,
a federal governmental plan maintained for federal employees, or a
governmental plan or church plan as defined in the federal Employee
Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1002), (2) is
not eligible for coverage under a group health plan, Medicare, or
Medi-Cal, and has no other health insurance coverage, (3) was not
terminated from his or her most recent creditable coverage due to
nonpayment of premiums or fraud, and (4) if offered continuation
coverage under COBRA or Cal-COBRA, had elected and exhausted this
coverage.
(d) "In force business" means an existing health benefit plan
contract issued by the plan to a federally eligible defined
individual.
(e) "New business" means a health care service plan contract
issued to an eligible individual that is not the plan's in force
business.
(f) "Preexisting condition provision" means a contract provision
that excludes coverage for charges and expenses incurred during a
specified period following the eligible individual's effective date,
as to a condition for which medical advice, diagnosis, and care of
treatment was recommended or received during a specified period
immediately preceding the effective date of coverage.