California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 1 - GENERAL PROVISIONS › Section 53902 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions shall control the construction
						of this chapter, unless the context requires otherwise.
(a) Assignment. Assignment means the actions
					 taken by the GMC enrollment contractor to enroll an eligible beneficiary into a
					 GMC plan, in the absence of a selection made by the beneficiary. Assignment
					 also means action by a GMC plan to assign a member to a primary care provider,
					 in the absence of a selection made by the member.
(b) Capitated Service. Capitated service
					 means a medical or dental service for which a GMC plan is compensated in its
					 fixed monthly per member rate.
(c)
					 Dental Plan. Dental plan means a specialized health care service plan, which
					 provides only dental services and is licensed under the Knox-Keene Health Care
					 Services Plan Act of 1975.
(d)
					 Eligible Beneficiary. Eligible beneficiary means a person who resides in an
					 area covered by the GMC program, who has been determined eligible to receive
					 Medi-Cal services, whose scope of Medi-Cal benefits is not limited, and who has
					 been determined to have a share of cost equal to zero, as specified in Section
					 53906.
(e) Fair Hearing. Fair hearing means an
					 administrative hearing conducted by the state relating to Medi-Cal eligibility
					 or benefits, pursuant to Sections
					 50951 through
					 50955.
(f) Federally Qualified Health Maintenance
					 Organization (HMO). Federally qualified HMO means a PHP that has been
					 determined by the federal Health Care Financing Administration to be a
					 qualified HMO under Section
					 1310(d) of the
					 Public Health Service Act.
(g)
					 Geographic Managed Care (GMC) Program. GMC Program means the program authorized
					 by Section
					 14089 et seq. of the Welfare and
					 Institutions Code.
(h) GMC
					 Contract. GMC contract means the written agreement entered into between a
					 prepaid health plan, primary care case management plan, or dental plan and the
					 department to provide health care services to GMC plan members.
(i) GMC Enrollment Contractor. GMC enrollment
					 contractor means the entity contracting with the department to provide GMC
					 options presentations, enrollment and disenrollment activities, and problem
					 resolution functions.
(j) GMC Plan.
					 GMC plan means a PHP, PCCM plan, or dental plan that has entered into a GMC
					 contract with the department.
(k)
					 Indian. Indian means any Indian who is eligible under federal law to receive
					 health services provided directly by the United States Indian Health Services
					 (IHS) or by a tribal or urban contractor through contract with IHS.
(l) Indian Health Service Program Facility.
					 Indian Health Service program facility means a tribal or urban Indian Health
					 Service (IHS) organization operating health care programs or facilities with
					 funds from the IHS under the Indian Self-Determination Act and the Indian
					 Health Care Improvement Act, through which services are provided, directly or
					 by contract, to the eligible Indian population within a defined geographic
					 area.
(m) Initial Health
					 Assessment. Initial health assessment means an assessment conducted by the GMC
					 plan of a member's medical or dental health status.
(n) Member. Member means an eligible
					 beneficiary who is enrolled in a GMC plan.
(o) Prepaid Health Plan (PHP). PHP means a
					 health care service plan licensed pursuant to the Knox-Keene Health Care
					 Service Plan Act of 1975, which has entered into a contract with the department
					 on a capitated rate basis to furnish health services to eligible
					 beneficiaries.
(p) Primary Care
					 Case Management (PCCM) Plan. PCCM plan means a primary care provider that has
					 contracted with the department pursuant to Article 2.9, commencing with Section
					 14088,
					 Welfare and Institutions Code.
(q)
					 Primary Care Provider. Primary care provider means a physician or dentist who
					 has the responsibility for providing initial and primary care to members, for
					 maintaining the continuity of member care, and for initiating referrals for
					 specialist care.
(r) Service Site.
					 Service site means the location designated by a GMC plan at which a member
					 received primary care physician or dentist services.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  10950-
						  10965,
						  14088,
						  14088.05,
						  14089,
						  14251
						  and
						  14252,
						  Welfare and Institutions Code.