Sec. 2594 - Definitions

§ 2594. Definitions

"Actuarial value" has the same meaning as defined in section 156.20 of Title 45 of the Code of Federal Regulations.

"Base-benchmark plan" means the Kaiser Foundation Health Plan, Inc. Northern California Region Small Group HMO $30 Copayment Plan (federal health product identification number 40513CA035), as the plan was offered during the first quarter of 2014.

"Cost sharing" has the same meaning as defined in section 155.20 of Title 45 of the Code of Federal Regulations.

"Disability insurance" has the same meaning as defined in section 106 of the Insurance Code.

"Excepted benefits" has the same meaning as defined in subsection (c) of section 2791 of the federal Public Health Service Act (42 U.S.C. § 300gg-91(c)).

"Exchange" means the California Health Benefit Exchange created by section 100500 of the Government Code.

"Federal Employees Dental and Vision Insurance Program plan" means the BlueCross BlueShield Association 2014 FEP BlueVision High Option plan.

"Grandfathered health plan" has the same meaning as defined in section 1251 of PPACA (42 U.S.C. § 18011) and any rules, regulations, or guidance issued pursuant to that section.

"Habilitative services" has the same meaning as defined in section 10112.27 of the Insurance Code.

"Health benefits" has the same meaning as defined in section 10112.27 of the Insurance Code.

"Health insurance" has the same meaning as defined in section 106 of the Insurance Code.

"Health insurance policy form," or "policy form," for the purposes of this article, means a health insurance product, as defined in section 159.110 of Title 45 of the Code of Federal Regulations, which provides coverage for a uniform set of essential health benefits, limitations, and exclusions. A health insurance product may include multiple plans which differ only in their cost sharing provisions.

"Level of coverage" has the same meaning as defined in sections 10112.295 and 10112.297 of the Insurance Code. "Level of coverage" for a specialized health insurance policy that covers the pediatric oral essential health benefit has the same meaning as defined in section 156.150 of Title 45 of the Code of Federal Regulations.

"Medi-Cal Dental Program" means the same health benefits for pediatric oral care covered under the dental benefit received by children under Medi-Cal as of 2014, including the provision of medically necessary orthodontic care provided pursuant to the federal Children's Health Insurance Program Reauthorization Act of 2009.

"Pediatric services" means health benefits provided to an individual until the last day of the month in which the individual turns nineteen years of age.

"PPACA" means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.

"Small group health insurance policy" means a group health insurance policy issued to a small employer, as defined in section 10753 of the Insurance Code.

"Specialized health insurance" has the same meaning as defined in section 106 of the Insurance Code. Specialized health insurance includes a stand-alone pediatric dental plan certified by the Exchange pursuant to section 1311(d)(2)(B)(ii) of PPACA (42 U.S.C. § 18031(d)(2)(B)(ii)) and section 155.1065 of Title 45 of the Code of Federal Regulations that covers, at a minimum, the pediatric oral essential health benefit.

"Treatment limitations" means limitations on coverage of essential health benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting or benefit period, or other similar limitations on the amount, scope, or duration of covered benefits. Treatment limitations include both quantitative treatment limitations, which are expressed numerically, and non-quantitative treatment limitations, which otherwise limit the scope or duration of health benefits covered by a health insurance policy.

(1. New article 22 (sections 2594-2594.7) and section filed 6-13-2013 as an emergency; operative 6-13-2013 (Register 2013, No. 24). A Certificate of Compliance must be transmitted to OAL by 12-10-2013 or emergency language will be repealed by operation of law on the following day. 2. New article 22 (sections 2594-2594.7) and section refiled 12-9-2013 as an emergency; operative 12-9-2013 (Register 2013, No. 50). Pursuant to Insurance Code section 10112.27(o)(2) a Certificate of Compliance must be transmitted to OAL by 6-9-2014 or emergency language will be repealed by operation of law on the following day. 3. Certificate of Compliance as to 12-9-2013 order, including amendment of section and Note, transmitted to OAL 1-15-2014 and filed 2-24-2014; amendments effective 2-24-2014 pursuant to Government Code section 11343.4(b)(3)(Register 2014, No. 9). 4. Change without regulatory effect amending definitions of "Base-benchmark plan" and "Federal Employees Dental and Vision Insurance Program plan," repealing definition of "Healthy Families Program plan" and adopting definition of "Medi-Cal Dental Program" filed 1-3-2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 1).)

Note: Authority cited: Sections 10112.27, 10112.295, 10112.297, 10112.3, 12921 and 12926, Insurance Code. Reference: Sections 106, 10112.27, 10112.295, 10112.297, 10112.3 and 10753, Insurance Code.

The following state regulations pages link to this page.