Section 2240 - DefinitionsAs used in this Article:
(a) "Certificate" means an individual or family certificate of coverage issued pursuant to an insurance contract.(b) "Covered person" means either a primary covered person or a dependent covered person eligible to receive health care services under the insurance contract providing network provider services.(c) "Dependent covered person" means someone who is eligible for coverage under an insurance contract through such person's relationship with or dependency upon a primary covered person.(d) "Emergency health care services" means health care services rendered for any condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient's health in serious jeopardy,(2) Serious impairment to bodily functions,(3) Serious dysfunction of any bodily organ or part,(4) active labor. "Emergency health care services" also includes services rendered for a psychiatric emergency.(e) "Essential community provider" (ECP) means providers that serve predominantly low-income, medically underserved individuals, as defined in 45 CFR Section 156.235, published February 27, 2015 at 80 Federal Register 10873-10874, subdivision (c) of which is incorporated herein by this reference. "Essential community provider" also includes: (1) Disproportionate Share Hospitals as defined at Title 9, California Code of Regulations, section 1706;(2) Indian Health Care Service Facilities as defined in subdivision (v) of Title 10, California Code of Regulations, section 2699.6500;(3) Entities licensed as either a community clinic, or a free clinic, under Health and Safety Code section 1204 and entities that are either a community clinic as defined at subdivision (a)(1)(A) of Health and Safety Code section 1204, or a free clinic as defined at subdivision (a)(1)(B) of Health and Safety Code section 1204, that are exempt from licensure under Health and Safety Code section 1206;(4) Federally Qualified Health Centers as defined at Title 10, California Code of Regulations, section 6410, and(5) Physician providers whose application for the Medi-Cal Electronic Health Record Incentive Program has been accepted under Welfare and Institutions Code section 14046.2.(f) "Facility" means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings.(g) "Health care professional" means a licensee or certificate holder enumerated in Insurance Code section 10176 or as defined in Insurance Code Section 10133.4 as of the effective date of this Article or as either section may be amended thereafter.(h) "Insurer" means an insurer who provides "health insurance" as defined in Section 106(b), and includes those who authorize insureds to select providers who have contracted with the insurer for alternative rates of payment as described in Section 10133.(i) "Limited English proficiency" means a limited ability, or an inability, to speak, read, write, or understand the English language at a level that permits the covered person to interact effectively with the covered person's health care providers or health insurer.(j) "Network" means all institutions or health care professionals that are utilized to provide medical services to covered persons pursuant to a contract with an insurer to provide such services at alternative rates as described in Insurance Code Section 10133. A network as defined herein can be directly contracted with by an insurer or leased by an insurer.(k) "Network provider" means an institution or a health care professional which renders health care services to covered persons pursuant to a contract to provide such services at alternative rates.(l) "Network provider services" means health care services which are covered under an insurance contract when rendered by a network provider within the service area.(m) "Non-network provider services" means covered health care services delivered by a health care provider who is not contracted with the insurer either directly or indirectly.(n) "Primary care physician" means a physician who is responsible for providing initial and primary care to patients, for maintaining the continuity of patient care or for initiating referral for specialist care. A primary care physician may be either a physician whose practice of medicine is limited to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist or family practitioner.(o) "Primary covered person" means a person eligible for coverage under an insurance contract or certificate.(p) "Service area" means the State of California or any other geographic area within the state designated in the contract within which network provider services are rendered to covered persons for covered benefits.(q) "Tiered network" or "tiering" means a network of participating providers which has been divided into sub-groupings differentiated by the health insurer according to cost-sharing levels, provider payment, performance ratings, quality scores, or any combination of these or other factors established as a means of influencing the insured person's choice of provider.Cal. Code Regs. Tit. 10, § 2240
1. New Article 6 (Sections 2240, 2240.1-2240.4) filed 1-24-84; effective thirtieth day thereafter (Register 84, No. 4). For history of former Article 6, see Register 77, No. 19.
2. Amendment of article heading, section and NOTE filed 1-8-2008; operative 2-7-2008 (Register 2008, No. 2).
3. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) filed 1-30-2015 as an emergency; operative 1-30-2015 (Register 2015, No. 5). A Certificate of Compliance must be transmitted to OAL by 7-29-2015 or emergency language will be repealed by operation of law on the following day.
4. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) and new subsections (e) and (o) refiled 7-27-2015 as an emergency; operative 7-27-2015 (Register 2015, No. 31). A Certificate of Compliance must be transmitted to OAL by 10-26-2015 or emergency language will be repealed by operation of law on the following day.
5. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) and new subsections (e) and (o) refiled 10-26-2015 as an emergency; operative 10-26-2015 (Register 2015, No. 44). A Certificate of Compliance must be transmitted to OAL by 1-25-2016 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 10-26-2015 order, including amendment of article heading and further amendment of section, transmitted to OAL 1-25-2016 and filed 3-8-2016; amendments operative 3-8-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 11).
7. Change without regulatory effect amending subsections (c) and (i) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20. Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 106(b), 10133, 10133.5, 10144.5 and 10176, Insurance Code.
1. New Article 6 (Sections 2240, 2240.1-2240.4) filed 1-24-84; effective thirtieth day thereafter (Register 84, No. 4). For history of former Article 6, see Register 77, No. 19.
2. Amendment of article heading, section and Note filed 1-8-2008; operative 2-7-2008 (Register 2008, No. 2).
3. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) filed 1-30-2015 as an emergency; operative 1-30-2015 (Register 2015, No. 5). A Certificate of Compliance must be transmitted to OAL by 7-29-2015 or emergency language will be repealed by operation of law on the following day.
4. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) and new subsections (e) and (o) refiled 7-27-2015 as an emergency; operative 7-27-2015 (Register 2015, No. 31). A Certificate of Compliance must be transmitted to OAL by 10-26-2015 or emergency language will be repealed by operation of law on the following day.
5. Repealer of subsections (a)-(a)(8), subsection relettering, amendment of newly designated subsections (b) and (d) and new subsections (e) and (o) refiled 10-26-2015 as an emergency; operative 10-26-2015 (Register 2015, No. 44). A Certificate of Compliance must be transmitted to OAL by 1-25-2016 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 10-26-2015 order, including amendment of article heading and further amendment of section, transmitted to OAL 1-25-2016 and filed 3-8-2016; amendments operative 3/8/2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 11).
7. Change without regulatory effect amending subsections (c) and (i) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20.