California Code of Regulations › Title 22 - Social Security › Division 7 - Health Planning and Facility Construction › Chapter 11.5 - Promotion of Competitive Health Care Markets; Health Care Affordability › Article 2 - Health Care Spending Targets › Section 97445 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this Article, the following definitions
					 apply:
(a) "Affiliation" refers to a
				  situation in which an entity ("affiliate") controls, is controlled by, or is
				  under common control with another entity.
(b) "Control" (including the terms
				  "controlling," "controlled by," and "under common control with") means the
				  possession, direct or indirect, of the power to direct or cause the direction
				  of the management and policies of an entity, whether through the ownership of
				  voting shares, debt, by contract, or otherwise.
(c) "Department" shall mean the Department of
				  Health Care Access and Information.
(d) "Directly contracted plan" means a payer
				  or fully integrated delivery system that is directly contracted with a group
				  purchaser, individual subscriber, or a public agency, to arrange for the
				  provision of health care services to members.
(e) "Director" shall mean the director of the
				  Department of Health Care Access and Information.
(f) "Fully integrated delivery system" shall
				  have the meaning set forth in section
				  127500.2(h)
				  of the Health and Safety Code ("the Code").
(g) "Health insurer" means a health insurer
				  licensed to provide health insurance or specialized behavioral health-only
				  policies, as defined in Section
				  106 of the
				  Insurance Code.
(h) "Health plan"
				  means a health care service plan or a specialized mental health care service
				  plan as defined in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter
				  2.2 (commencing with Section
				  1340)
				  of Division 2 of the Health and Safety Code). "Health plan" does not include a
				  health care service plan that holds only a restricted or limited license under
				  28 CCR
				  §
											1300.49(a).
(i) "Office" shall mean the Office of Health
				  Care Affordability established by section
				  127501 of the Code.
(j) "Payer" shall have the meaning set forth
				  in section
				  127500.2(o) of
				  the Code.
(k) "Plan-to-plan
				  contract" means a contractual arrangement between a payer or fully integrated
				  delivery system and another payer or fully integrated delivery system, in which
				  the subcontracted plan makes network providers available to the directly
				  contracted plan's members, and the subcontracted plan may be responsible for
				  other directly contracted plan functions. Plan-to-plan contracts do not include
				  contractual arrangements between a payer or fully integrated delivery system
				  and a physician organization.
(l)
				  "Physician organization" shall have the meaning set forth in section
				  127500.2(p) of
				  the Code.
(m) "Registered
				  submitter" means a payer or fully integrated delivery system or approved
				  voluntary submitter that has registered to submit data to the System.
(n) "Reporting year" means the service year
				  for which data files are being reported.
(o) "Required submitter" means a payer or
				  fully integrated delivery system that meets any of the criteria in section
				  97449(a).
(p) "Subcontracted Plan" means a payer or
				  fully integrated delivery system that has a plan-to-plan contract allowing a
				  directly contracted plan's members access to the subcontracted plan's network
				  providers.
(q) "System" or "THCE
				  System" means the Total Health Care Expenditures Data System.
(r) "THCE Data Portal" or "Data Portal" means
				  the secure data submission mechanism through which health care entities
				  register to submit data and data files are submitted to the System. The Data
				  Portal is available via the Department's website, hcai.ca.gov.
(s) "THCE Data Submission Guide" or the
				  "Guide" means the Office of Health Care Affordability: Total Health Care
				  Expenditures Data Submission Guide (Version 1.0), dated February 2024, and
				  hereby incorporated by reference. The Guide is available on, and may be
				  downloaded from, the Department's website.
(t) "OHCA Attribution Addendum" means the
				  Office of Health Care Affordability: Attribution Addendum, dated February 2024,
				  and hereby incorporated by reference. The OHCA Attribution Addendum is
				  available on, and may be downloaded from, the Department's website.
(u) "Voluntary submitter" means a payer or
				  fully integrated delivery system that is not subject to the requirements of
				  this Article that chooses to voluntarily submit data to the Office and has been
				  approved by the Office to register to submit data to the System.
Note: Authority cited: Sections 127501, 127501.2 and
						127501.4, Health and Safety Code. Reference: Sections 127500.2 and 127501.4,
						Health and Safety Code.
The amended version of this section by
					 Register
					 2024, No. 28, effective 7/1/2024 is not yet
					 available.