California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 2 - Definitions › Section 53810 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions shall be used throughout this
						chapter unless the context requires otherwise.
(a) Affiliate means an organization or person
					 that, directly or indirectly through one or more intermediaries, controls, or
					 is controlled by or is under common control with, a plan, and that provides
					 services to, or receives services from, a plan.
(b) Alternate Health Care Service Plan
					 (AHCSP) means a prepaid health plan that is a non-profit health care service
					 plan with at least 3.5 million enrollees statewide, owns or operates its own
					 pharmacies, and provides medical services to enrollees in specific geographic
					 regions through an exclusive contract with a single medical group in each
					 specific geographic region in which it operates. A wholly owned subsidiary of
					 the AHCSP qualifies as an AHCSP.
(c) AHCSP family member linkage means a
					 situation where a beneficiary's parent, guardian, minor child or minor sibling
					 is enrolled in or has been enrolled in the AHCSP at any time during the twelve
					 (12) months immediately prior to the beneficiary's MediCal
					 eligibility.
(d) American Indian
					 means any person who is eligible under federal law to receive health services
					 provided directly by the United States Department of Health and Human Services,
					 Indian Health Service (IHS) or by a tribal or urban Indian health program
					 funded by IHS to provide health services to eligible individuals either
					 directly or by contract. The definition includes members of an American
					 Indian's household.
(e) Assignment
					 means the actions taken by the Health Care Options Program to enroll an
					 eligible beneficiary into a plan, in the absence of a selection made by the
					 beneficiary. Assignment also means action by a plan to assign a member to a
					 primary care physician in the absence of a selection made by the
					 member.
(f) Capitated service means
					 a medical service for which a plan is compensated in its fixed monthly per
					 member rate.
(g) Caseload means the
					 number of Medi-Cal beneficiaries in mandatory aid categories in a given
					 month.
(h) Case Management means
					 services provided by a primary care provider/physician to ensure the
					 coordination of medically necessary health care services, assuring the
					 provision of preventive services in accordance with established standards and
					 periodicity schedules and ensuring continuity of care for Medi-Cal members. It
					 includes health risk assessment, treatment planning, coordination, referral,
					 follow-up, and monitoring of appropriate services and resources required to
					 meet an individual's health care needs.
(i) Commercial plan means the prepaid health
					 plan in a designated region awarded a contract by the department pursuant to
					 section 53800(b)(1).
(j) Commercial plan enrollment maximum means
					 the enrollment level established by the department pursuant to section
					 53820(b).
(k) Contract means the written agreement
					 entered into between a prepaid health plan and the department to provide health
					 care services to plan members in a designated region.
(l) Contracted capacity means the number of
					 Medi-Cal beneficiaries in the mandatory aid categories a prepaid health plan
					 has either contracted with the department to enroll and serve in a region, or
					 has committed to enter a prepaid health plan contract with the department to
					 enroll and serve in a region.
(m)
					 Department means the Department of Health Care Services.
(n) Designated region means that geographic
					 area designated by the director within which a plan is approved by the
					 department to provide services to Medi-Cal beneficiaries pursuant to a contract
					 authorized by Welfare and Institutions Code Section
					 14087.3.
					 The designated regions shall be within, between, or among the counties of
					 Alameda, Contra Costa, Fresno, Kern, Los Angeles, Riverside, San Bernardino,
					 San Francisco, San Joaquin, Santa Clara, Stanislaus, Tulare, and any other
					 county, with the approval of the Director, which may elect to participate in
					 accordance with the provisions of this regulation.
(o) Disproportionate share hospital (DSH)
					 means any hospital receiving payments as provided in Welfare and Institutions
					 Code Section
					 14105.98.
(p) Eligible beneficiary means a person who
					 resides in an area covered by the Two-Plan Model Managed Care Program, who has
					 been determined eligible to receive Medi-Cal services, whose scope of Medi-Cal
					 benefits is not limited, and meets the enrollment criteria as specified in
					 section 53845.
(q) Enrollment level means the number of
					 Medi-Cal beneficiaries enrolled in a plan.
(r) Fair hearing means an administrative
					 hearing conducted by the State relating to Medi-Cal eligibility or benefits,
					 pursuant to sections
					 50951 through
					 50955,
					 51014.1,
					 51014.2, and
					 53894.
(s) Federally qualified health centers means
					 an entity which:
(1) Is receiving a grant
					 under section
					 330 of the Public Health Service
					 Act; or
(2) Is receiving funding
					 from such a grant under a contract with the recipient of such a grant, and
					 meets the requirements to receive a grant under section
					 330 of such Act; or
(3) Based on the recommendation of the Health
					 Resources and Services Administration within the Public Health Service, is
					 determined by the Secretary of Health and Human Services to meet the
					 requirements for receiving such a grant; or
(4) Was treated by the Secretary, for
					 purposes of Part B of title XVIII, as a comprehensive federally funded health
					 center as of January 1, 1990; and
(5) May be an outpatient health program or
					 facility operated by a tribe or tribal organization under the Indian
					 Self-Determination Act (Public Law 93-638) or by an
					 urban Indian organization receiving funds under title V of the Indian Health
					 Care Improvement Act for the provision of primary health
					 services.