California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 22 - Essential Health Benefits › Section 2594 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
"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.