For the purposes of this chapter, the following terms have the following meanings:
(a) “Applicant” means an individual who applies for major risk medical coverage through the program.
(b) “Department” means the State Department of Health Care Services.
(c) “Exchange” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code.
(d) “Fund” means the Major Risk Medical Insurance Fund, from which the department may authorize expenditures to pay for medically necessary services which exceed subscribers’ contributions, and for administration of the program.
(e) “Major risk medical coverage” means the payment for medically necessary services provided by institutional and professional providers.
(f) “Participating health plan” means either of the following entities that contracts with the department to administer major risk medical coverage to program subscribers:
(1) A private insurer holding a valid outstanding certificate of authority from the Insurance Commissioner.
(2) A health care service plan as defined under subdivision (f) of Section 1345 of the Health and Safety Code.
(g) “Plan rates” means the total monthly amount charged by a participating health plan for a category of risk.
(h) “Program” means the California Major Risk Medical Insurance Program.
(i) “Subscriber” means an individual who is eligible for and receives major risk medical coverage through the program, and includes a member of a federally recognized California Indian tribe.
(j) “Subscriber contribution” means the portion of participating health plan rates paid by the subscriber, or paid on behalf of the subscriber by a federally recognized California Indian tribal government. If a federally recognized California Indian tribal government makes a contribution on behalf of a member of the tribe, the tribal government shall ensure that the subscriber is made aware of all the health plan options available in the county where the member resides.
(Added by Stats. 2014, Ch. 31, Sec. 90. (SB 857) Effective June 20, 2014. Section operative July 1, 2014, pursuant to Section 15872.5.)
Last modified: October 25, 2018