Chapter 2. Definitions of California Insurance Code >> Division 2. >> Part 6.2. >> Chapter 2.

For purposes of this part, the definitions contained in this chapter shall govern the construction of this part, unless the context requires otherwise.

(a) "Applicant" means a person over the age of 18 years who is a natural or adoptive parent; a legal guardian; or a caretaker relative, foster parent, or stepparent with whom the child resides, who applies for coverage under the program on behalf of a child.
  (b) "Applicant" also means any of the following:
  (1) A person 18 years of age who is applying on his or her own behalf for coverage under the program.
  (2) A person who is under 18 years of age and is an emancipated minor who is applying on his or her own behalf for coverage under the program.
  (3) A minor who is not living in the home of a natural or adoptive parent, a legal guardian, or a caretaker relative, foster parent or stepparent, who is applying on his or her own behalf for coverage under the program.
  (4) A minor who applies for coverage under the program on behalf of his or her child.

"Board" means the Managed Risk Medical Insurance Board.

"Child" means a person who is under 19 years of age who is eligible for the program pursuant to Chapter 9 (commencing with Section 12693.70).

"Community provider plan" means that participating health plan in each geographic area that has been designated by the board as having the highest percentage of traditional and safety net providers in its provider network.

"County organized health system" means a health care organization that contracts with the State Department of Health Services to provide comprehensive health care to all eligible Medi-Cal beneficiaries residing in the county, and that is operated directly by a public entity established by a county government pursuant to Section 14087.51 or 14087.54 of the Welfare and Institutions Code, or Chapter 3 (commencing with Section 101675) of Part 4 of Division 101 of the Health and Safety Code.

"Family contribution" means the cost to an applicant to enable herself or himself or an eligible child or children to enroll in and participate in the program. Family contribution does not include copayments for insured services. The family contribution may be paid by a family contribution sponsor pursuant to Section 12693.17.

"Family value package" means the combination of participating health, dental, and vision plans available to subscribers in each geographic area offering the lowest prices to the program. The board may define the family value package to include not only the combination of participating health, dental, and vision plans offering the absolute lowest price to the program but also the combination of health, dental, and vision plans within a fixed percentage or dollar amount of the absolute lowest price.

"Fund" means the Healthy Families Fund.

"Local initiative" means a prepaid health plan that is organized by, or designated by, a county government or county governments, or organized by stakeholders, of a region designated by the department to provide comprehensive health care to eligible Medi-Cal beneficiaries. The entities established pursuant to the following sections of the Welfare and Institutions Code are local initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96.

"Participating dental plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal dental services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the board to provide coverage to program subscribers:
  (a) A dental insurer holding a valid outstanding certificate of authority from the commissioner.
  (b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.

"Participating health plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal health care services under insurance policies or contracts, medical and hospital service arrangements, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contracts with the board to provide coverage to program subscribers:
  (a) A private health insurer holding a valid outstanding certificate of authority from the commissioner.
  (b) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.
  (c) A county organized health system.
  (d) A local initiative.

A health care service plan, as defined in subdivision (b) of Section 12693.10, shall include a plan operating as a geographic managed care plan.

"Participating vision care plan" means any of the following plans that is lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal vision services under insurance policies or contracts, or membership contracts, in consideration of premiums or other periodic charges payable to it, and that contract with the board to provide coverage to program subscribers:
  (a) A vision insurer holding a valid outstanding certificate of authority from the commissioner.
  (b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.

"Program" means the Healthy Families Program, which includes a purchasing pool providing health coverage for children in families without access to affordable employer based dependent coverage and a purchasing credit mechanism through which families with access to employer based dependent coverage can receive financial assistance with the cost of dependent coverage for children.

"Purchasing credit member" means an applicant 18 years of age or a child who is eligible for and participates in the purchasing credit component of the program.

"Subscriber" means an applicant 18 years of age or a child who is eligible for and participates in the purchasing pool component of the program.

"Supplemental coverage" means coverage purchased by the program from (a) a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner, or (b) a health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code to bring the coverage available to purchasing credit members into at least 95 percent actuarial equivalence with the coverage provided to subscribers through the purchasing pool component of the program. The coverage shall provide for any necessary adjustment of the cost-sharing levels charged to purchasing credit members to be equivalent to those charged to subscribers through the purchasing pool component of the program. Subscriber costs and benefits for the purchasing credit members shall be at least 95 percent actuarially equivalent to subscriber costs and benefits in the purchasing pool component.

"Geographic managed care plan" means an entity that is operating pursuant to a contract entered into under Article 2.91 (commencing with Section 14089) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.

"Family contribution sponsor" means a person or entity that pays the family contribution on behalf of an applicant for any period of 12 consecutive months and, notwithstanding Section 12693.70, if the sponsor is paying for the initial 12 months of eligibility, the payment for 12 months is made with the application.