Section § 12693.01

Explanation

This section states that the specific definitions explained within this chapter will be used to interpret this part of the law, unless there's a specific context that needs a different understanding.

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

Section § 12693.02

Explanation

This law defines who can be considered an 'applicant' for a child’s health coverage program. Generally, it describes an applicant as someone over 18, like a parent or guardian, applying on a child's behalf. It also extends the definition to include certain minors, like those who are emancipated, living independently, or applying for their own or their child's health coverage.

(a)CA Insurance Code § 12693.02(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)CA Insurance Code § 12693.02(b) “Applicant” also means any of the following:
(1)CA Insurance Code § 12693.02(b)(1) A person 18 years of age who is applying on his or her own behalf for coverage under the program.
(2)CA Insurance Code § 12693.02(b)(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)CA Insurance Code § 12693.02(b)(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)CA Insurance Code § 12693.02(b)(4) A minor who applies for coverage under the program on behalf of his or her child.

Section § 12693.03

Explanation

This section defines the term "Board" as referring to the Managed Risk Medical Insurance Board.

“Board” means the Managed Risk Medical Insurance Board.

Section § 12693.04

Explanation

This section defines a 'child' as someone under 19 who qualifies for a specific program detailed in Chapter 9, starting with Section 12693.70.

“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).

Section § 12693.05

Explanation

This section defines a "county organized health system" as a health care organization that makes contracts with the State Department of Health Services. Its purpose is to provide full healthcare services to all eligible people who reside in the county and receive Medi-Cal benefits. Such an organization must be directly operated by a public entity set up by the county government following specific sections of the Welfare and Institutions Code or the Health and Safety Code.

“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.

Section § 12693.06

Explanation

The 'family contribution' is the amount a person pays for themselves or their eligible children to join and take part in a specific program. This does not cover copayments for services that are insured. Additionally, someone else, called a family contribution sponsor, can pay this amount under certain conditions.

“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.

Section § 12693.07

Explanation

This section defines the term "Fund" as referring specifically to the Healthy Families Fund.

“Fund” means the Healthy Families Fund.

Section § 12693.08

Explanation

This law defines a "local initiative" as a prepaid health plan set up or recognized by county governments, or formed by key players in a given area, to provide thorough medical care to those who qualify for Medi-Cal, California's Medicaid program. The law specifically mentions several sections of the Welfare and Institutions Code that establish these local initiatives.

“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.

Section § 12693.09

Explanation

A "participating dental plan" is a dental service plan that legally offers services and covers costs like insurance or membership plans in exchange for payments. These plans must work with a board to provide dental coverage to subscribers.

There are two main types of participating dental plans: (a) dental insurers that have a valid certificate from the commissioner, or (b) specialized health care service plans defined by a specific section of the Health and Safety Code.

“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)CA Insurance Code § 12693.09(a) A dental insurer holding a valid outstanding certificate of authority from the commissioner.
(b)CA Insurance Code § 12693.09(b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.

Section § 12693.10

Explanation

A 'participating health plan' is defined as any plan that provides or arranges for healthcare services and that has an agreement with the state to offer coverage to subscribers of a specific program. This can include private health insurers with state approval, health care service plans, county-organized health systems, or local initiatives.

“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)CA Insurance Code § 12693.10(a) A private health insurer holding a valid outstanding certificate of authority from the commissioner.
(b)CA Insurance Code § 12693.10(b) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.
(c)CA Insurance Code § 12693.10(c) A county organized health system.
(d)CA Insurance Code § 12693.10(d) A local initiative.

Section § 12693.11

Explanation

A "participating vision care plan" is basically a type of vision insurance that covers personal vision services. There are two main types that qualify: one is a vision insurer that has a valid certificate from the insurance commissioner, and the other is a specialized healthcare service plan as defined in another part of the Health and Safety Code. To participate, these plans must work with a governing board to offer coverage to people subscribed to the program.

“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)CA Insurance Code § 12693.11(a) A vision insurer holding a valid outstanding certificate of authority from the commissioner.
(b)CA Insurance Code § 12693.11(b) A specialized health care service plan as defined under subdivision (o) of Section 1345 of the Health and Safety Code.

Section § 12693.12

Explanation

This law section defines the 'Program' as the Healthy Families Program. It includes two main parts: a purchasing pool that helps give health coverage to children in families who don't have affordable employer-based dependent coverage, and a purchasing credit system that helps families with employer-based coverage by offering financial help for their children's coverage costs.

“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.

Section § 12693.13

Explanation

This law section defines a 'purchasing credit member' as either an adult applicant or a child who is eligible for and takes part in the purchasing credit aspect of the program.

“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.

Section § 12693.14

Explanation

The term “Subscriber” refers to either an adult who applies for or a child who can join and is part of the health care program's purchasing pool.

“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.

Section § 12693.15

Explanation

This law explains what "supplemental coverage" means within a specific insurance program. It refers to extra health insurance that can be bought either from a private insurer approved by the Insurance Commissioner or a health care service plan. The goal is to make sure that the supplemental coverage is at least 95% as good, from a value standpoint, as the main coverage offered to members in the program's purchasing pool. It also ensures that the costs members pay, such as deductibles or co-pays, should be adjusted to match those paid by members in the main purchasing pool, ensuring fairness.

“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.

Section § 12693.16

Explanation

This section defines a "Geographic managed care plan" as a company that works under a special contract set by specific California welfare laws aimed at managing healthcare services in a certain area.

“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.

Section § 12693.17

Explanation

In simple terms, a "family contribution sponsor" is a person or organization that covers the payment necessary for a family's health coverage application for a year. If this sponsor is covering the first year, the payment must be made when the application is first submitted.

“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.

Section § 12693.045

Explanation

A "community provider plan" is a health plan recognized by the board in each area for having the most traditional and safety net healthcare providers within its network.

“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.

Section § 12693.065

Explanation

A "family value package" refers to a set of health, dental, and vision insurance plans offered to subscribers that provide the lowest prices in a specific geographic area. The board can also consider packages that are slightly above the lowest price, either by a fixed percentage or dollar amount, as part of this value package option.

“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.

Section § 12693.105

Explanation

This law states that a health care service plan must be designed to function as a geographic managed care plan. Essentially, the plan should be organized to manage the delivery of health care services within a specific geographical area.

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.