Section 2699.6000 - Definitions(a) "Benefit year" means the twelve (12) month period commencing July 1 of each year at 12:01 a.m.(b) "Board" means the Managed Risk Medical Insurance Board.(c) "Comprehensive individual dental premium" means the individual dental plan rate for an enrolled employee or individual member and enrolled dependents, agent and program participation fees.(d) "Comprehensive individual medical premium" means the individual medical plan rate for an enrolled employee or individual member and enrolled dependents, agent and program participation fees.(e) "Dental coverage" means the state of being eligible to receive specified dental benefits under the terms of a dental benefits plan.(f) "Dental benefit plan" means a policy or a contract written or administered by a participating dental carrier that arranges or provides health care benefits for enrollees.(g) "Dental benefits premium" means that portion of the employer premium or individual member premium that is owed each month by the participating employer or individual member to the program for coverage of dental benefits. It includes any portion of the participation fee that is for participation in the dental benefits option.(h) "Dental carrier" means any disability insurance company, health care service plan, specialized health care service plan, or any other entity that writes, issues, or administers group health benefit plans that cover sole employees or guaranteed association members.(i) "Carrier" means any disability insurance company, health care service plan, nonprofit hospital service plan, or any other entity that writes, issues, or administers group health benefit plans that cover the employees of sole employers or guaranteed association members.(j) "Coverage" means the state of being eligible to receive specified health benefits under the terms of a health benefit plan.(k) "Dependent" means a sole employee's or guaranteed association member's spouse and any unmarried dependent child who is an adopted child, a stepchild, or a recognized natural child. A child attains the status of "dependent" at birth or upon legal adoption. A child shall be considered to be adopted upon the sole employee or guaranteed association member receiving physical custody of the child to be adopted. A stepchild attains the status of "dependent" upon the sole employee's or guaranteed association member's marriage to the natural or adopted stepchild's parent. A child ceases to be a "dependent" upon marriage, or attainment of age 23, whichever first occurs; except that an unmarried child who at the time of attaining age 23 is incapable of self-support because of physical or mental disability which existed continuously from a date prior to attainment of age 23 continues in dependent status until termination of such incapacity.(l) "Disenroll" means termination of coverage in the program for an enrolled sole employee and dependents, if any, or guaranteed association member and dependents, if any.(m) "Eligible employee" means a sole employee or a member employee. An employee is not an eligible employee until the employee has completed any employer imposed waiting period.(n) "Employer imposed waiting period" means the period of time an employer requires a new employee to wait before being sponsored for coverage.(o) "Employer premium" means either:(1) For participating sole employers who have an effective date of coverage prior to September 1, 1998, who have not made an election pursuant to Section 2699.6116, and participating member employers whose guaranteed association has an effective date of coverage prior to September 1, 1998, and did not make an election pursuant to Section 2699.6116, the dollar amount owed each month by the participating employer to the program. It includes program participation fees, any required late fees, any required reinstatement fees, any required agent, or broker fees, and the sum of individual premiums. It includes the sum of individual premiums for dental benefits if the employer has elected to participate for dental benefits.(2) For participating sole employers who have an effective date of coverage on or after September 1, 1998, or who have made an election pursuant to Section 2699.6116, and participating member employers whose guaranteed association has an effective date of coverage on or after September 1, 1998, or made an election pursuant to Section 2699.6116, the dollar amount owed each month by the participating employer to the program. It includes the sum of comprehensive individual medical premiums and the sum of comprehensive individual dental premiums if the employer has elected to participate for dental benefits. It includes any required late fees and any required reinstatement fees.(p) "Enroll" means either: (1) To accept into the program the eligible employees of a qualified small employer who have applied for coverage and their dependents, or(2) To accept into the program the qualified individual members of a qualified guaranteed association who have applied for coverage and their dependents.(q) "Enrollee" means either: (1) An eligible employee or dependent who receives coverage through the program from a participating carrier, or(2) A qualified individual member or dependent who receives coverage through the program from a participating carrier.(r) "Exclusive provider organization" means any disability insurance company or non-profit hospital service plan that limits payments under a policy to services secured by insureds from institutional and professional providers charging alternative rates pursuant to the contract with the insurer.(s) "Executive Director" means the Executive Director of the Board.(t) "Fee-for-service dental organization" means dental benefit plans under which retrospective payment is made by a dental carrier on a fee-for-service basis for dental care benefits and services.(u) "Guaranteed association" means an organization which is a nonprofit organization as determined by the Internal Revenue Service and comprised of a group of individuals or employers who associate based solely on participation in a specified profession or industry, accepting for membership any individual or employer meeting its membership criteria which (1) includes one or more small employers, (2) does not condition membership directly or indirectly on the health or claims history of any person, (3) uses membership dues solely for and in consideration of the membership and membership benefits, except that the amount of the dues shall not depend on whether the member applies for or purchases insurance offered by the association, (4) is organized and maintained in good faith for purposes unrelated to insurance, (5) has been in active existence on January 1, 1992, and for at least five years prior to that date, (6) has been offering health insurance to its members for at least five years prior to January 1, 1992, (7) has a constitution and bylaws, or other analogous governing documents that provide for election of the governing board of the association by its members, (8) offers any health benefits plan that is purchased to all individual members and employer members in this state, (9) includes any member choosing to enroll in a health benefits plan offered to the association provided the member has agreed to make the required premium payments, and (10) covers at least 1,000 persons with each carrier with which it contracts. The requirement of 1,000 persons may be met if component chapters of a statewide association contracting separately with the same carrier cover at least 1,000 persons in the aggregate. This definition applies regardless of whether a contract issued by a plan is with an association or a trust formed for, or sponsored by, an association to administer benefits for guaranteed association members. For purposes of this definition, an association formed by a merger of two or more associations after January 1, 1992, and otherwise meeting the criteria of this definition shall be deemed to have been in active existence on January 1, 1992, if its predecessor organization(s) had been in active existence on January 1, 1992, and for at least five years prior to that date and otherwise met the criteria of this definition.(v) "Guaranteed association member" means an individual member or member employee of a qualified guaranteed association.(w) "Health Benefits Plan" means a policy or contract written or administered by a participating carrier that arranges or provides health care benefits for enrollees.(x) "Health maintenance organization" means either of the following:(1) Comprehensive group practice prepayment plans which offer benefits, in whole or in substantial part, on a prepaid basis, with professional services thereunder provided by physicians or other providers of health services practicing as a group in a common center or centers. This group shall include physicians representing at least three major medical specialties who receive all or a substantial part of their professional income from the prepaid funds.(2) Individual practice prepayment plans or network model prepayment plans which offer health services in whole or in part on a prepaid basis, with professional services thereunder provided by individual physicians or groups of physicians or other providers of health services who agree to accept the payment provided by the plans as full payment for covered services rendered by them.(y) "Indemnity plan" means health benefit plans under which retrospective payment is made by a carrier on a fee-for-service basis for health care benefits and services.(z) "Individual member" means a person who is sponsored for coverage by a qualified guaranteed association and who is not a member employee.(aa) "Individual member premium" means either:(1) For individual members whose guaranteed association has an effective date of coverage prior to September 1, 1998, and did not make an election pursuant to Section 2699.6116, the dollar amount owed each month to the program for coverage of an enrolled individual member and an individual member's enrolled dependents. It includes the amount for dental benefits coverage if the individual member's guaranteed association has elected to participate for dental benefits. It includes program participation fees, any required late fees, any required reinstatement fees, and any required agent or broker fees; or(2) For individual members whose guaranteed association has an effective date of coverage on or after September 1, 1998, or made an election pursuant to Section 2699.6116, the amount owed each month to the program by the individual member. It includes the comprehensive individual medical premium and the comprehensive individual dental premium if the individual member's guaranteed association has elected to participate for dental benefits. In includes any required late fees and any required reinstatement fees.(bb) "Individual premium" means the dollar amount owed to the program for health or health and dental coverage of an enrolled employee and the employee's enrolled dependents.(cc) "Late applicant" means either: (1) An eligible employee or dependent who declined health coverage in the program at the time it was last offered to them by the small employer sponsoring their coverage, and who subsequently applies for enrollment in the program. Otherwise eligible employees or dependents who previously certified to their employer that they had other employer sponsored health coverage or coverage under the federal Medicare program pursuant to Title XVIII of the Social Security Act and waived coverage in the program and who apply for coverage in the program within thirty (30) calendar days of a loss of the other coverage will not be considered to be late applicants; or(2) An individual member or dependent who did not apply for health coverage at the time it was offered by the guaranteed association and subsequently applies for enrollment in the program. Individual members or dependents who did not apply for health coverage at the time it was last offered by the guaranteed association but at that time had other employer sponsored health coverage or coverage under the federal Medicare program pursuant to Title XVIII of the Social Security Act, who apply for coverage in the program within thirty (30) calendar days of a loss of the other coverage will not be considered to be a late applicant if the member or dependent can demonstrate that he or she had other coverage at the time the guaranteed association offered coverage.(dd) "Member employee" means any permanent employee employed by a member employer for at least thirty (30) consecutive calendar days who is actively engaged on a full-time basis in the conduct of the business of the member employer with a normal workweek of at least thirty (30) hours, at the member employer's regular place or places of business. The term includes sole proprietors or partners in a partnership, if they are actively engaged on a full time basis with a normal work week of at least 30 hours in the member employer's business and included as employees under a health care plan contract of a member employer, but does not include employees who work on a part-time, temporary, or substitute basis. To be considered a member employee an employee shall be paid by the member employer as a permanent employee. An employee who has been on paid leave for more than ninety (90) days in a year from the effective date of coverage in the program or more than ninety (90) days in any subsequent twelve month period of coverage in the program shall cease to be considered a member employee unless on leave pursuant to the federal Family and Medical Leave Act of 1993 (P.L. 103-3), and/or California Government Code Sections 12945 and 12945.2. An employee on unpaid leave shall not be considered a member employee unless on leave pursuant to the federal Family and Medical Leave Act of 1993 and/or California Government Code Sections 12945 and 12945.2. Employees who waive coverage on the grounds that they have other employer sponsored health coverage or coverage under the federal Medicare program pursuant to Title XVIII of the Social Security Act shall not be considered or counted as member employees.(ee) "Member employer" means either a sole employer which purchases coverage in the program as a member of a qualified guaranteed association or an employer which would be a sole employer if it had no more than 50 eligible employees which purchases coverage in the program as a member of a qualified guaranteed association.(ff) "Participating carrier" means a carrier that has entered into a contract with the program to provide health benefits coverage.(gg) "Participating dental carrier" means a dental carrier that has entered into a contract with the program to provide dental benefits coverage.(hh) "Participating employer" means a small employer who has been accepted into the program.(ii) "Preexisting condition" means a condition for which medical advice, diagnosis, care, or treatment, including the use of prescription medications, was recommended or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage.(jj) "Preexisting condition provision" means a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage for any preexisting condition.(kk) "Preferred provider organization" means health benefits plans under which retrospective payment is made by a carrier under contracts that define rates of payment with physicians, hospitals, or other providers of health services rendered to subscribers.(ll) "Pre-paid dental organization" means individual practice prepayment plans or network model prepayment plans which offer dental services in whole or in part on a prepaid basis, with professional services thereunder provided by individual dentists or groups of dentists or other providers of dental services who agree to accept the payment provided by the plans as full payment for covered services rendered by them.(mm) "Program participation fee" means the amount charged to a small employer or individual member to participate in the program pursuant to Section 2699.6307.(nn) "Program" means the Voluntary Alliance Uniting Employers Purchasing Program which shall be known as "The Health Insurance Plan of California."(oo) "Qualified guaranteed association" means an association that has been determined to be in compliance with the participation requirements of Section 2699.6109 of this part.(pp) "Qualified individual member" means an individual member that has been determined to be in compliance with the participation requirements of Section 2699.6113 of this part.(qq) "Qualified member employer" means a member employer that has been determined to be in compliance with the participation requirements of Section 2699.6111.(rr) "Qualified sole employer" means a sole employer that has been determined to be in compliance with the participation requirements of Section 2699.6107 of this part.(ss) "Qualifying prior coverage" means: (1) Any individual or group policy, or contract, or program, this is written or administered by a disability insurer, nonprofit hospital service plan, health care service plan, fraternal benefits society, self insured employer plan, or any other entity, in this state or elsewhere, and that arranges or provides medical, hospital, and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage but does not include accident only, credit, disability income, Medicare supplement, long term care, dental, vision, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self insurance.(2) The federal Medicare program pursuant to Title XVIII of the Social Security Act.(3) The Medicaid program pursuant to Title XIX of the Social Security Act.(4) Any other publicly sponsored program, provided in this state or elsewhere, of medical, hospital and surgical care.(tt) "Qualifying prior dental coverage" means:(1) Any individual or group policy, or contract, or program, that is written or administered by a disability insurer, nonprofit dental service plan, dental service plan, fraternal benefits society, self-insured employer dental plan, or any other entity, in this state or elsewhere, and that arranges or provides dental coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage but does not include accident only, credit, disability income, Medicare supplement, longterm care, vision, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.(2) Any other publicly sponsored program, provided in this state or elsewhere, of dental care.(uu) "Rating period" means the period for which premium rates for a participating carrier are in effect.(vv) Rounding of percentage. Whenever in this part a percentage is calculated or referenced the resulting number will be rounded to the nearest whole integer.(ww) "Small employer" means a sole employer or member employer.(xx) "Sole employee" means any permanent employee employed by a qualified sole employer for at least thirty (30) consecutive calendar days who is actively engaged on a full-time basis in the conduct of the business of the qualified sole employer with a normal workweek of at least thirty (30) hours, at the qualified sole employer's regular place or places of business. The term includes sole proprietors or partners in a partnership, if they are actively engaged on a full time basis with a normal work week of at least 30 hours in the qualified sole employer's business and included as employees under a health care plan contract of a qualified sole employer, but does not include employees who work on a part-time, temporary, or substitute basis. To be considered a sole employee an employee shall be paid by the sole employer as a permanent employee. An employee who has been on paid leave for more than ninety (90) days in a year from the effective date of coverage in the program or for more than ninety (90) days in any subsequent twelve month period shall cease to be considered a sole employee unless on leave pursuant to the federal Family and Medical Leave Act of 1993 (P.L. 103-3), and/or California Government Code Sections 12945 and 12945.2. An employee on unpaid leave shall not be considered a member employer unless on leave pursuant to the federal Family and Medical Leave Act of 1993 and/or California Government Code Sections 12945 and 12945.2. Employees who waive coverage on the grounds that they have other employer sponsored health coverage or coverage under the federal Medicare program pursuant to Title XVIII of the Social Security Act shall not be considered or counted as sole employees.(yy) "Sole employer" means any person, firm, proprietary or nonprofit corporation, partnership, public agency, or association that is actively engaged in business or service that, on at least 50% of its working days during the preceding calendar quarter employed at least two, but no more than 50, eligible employees, the majority of whom were employed within this state, which was not formed primarily for the purposes of buying health coverage and in which a bona fide employer-employee relationship exists. However, the definition shall include employers with at least four eligible employees until July 1, 1995, three eligible employees until July 1, 1997 and two eligible employees thereafter. In determining the number of eligible employees, companies that are affiliated companies and that are eligible to file a combined tax return for purposes of state taxation shall be considered one employer. For purposes of these regulations sole employers who participate in the program as member employers will be considered member employers.(zz) "Social Security Number" means the account number assigned to an individual by the United States Social Security Administration in order to make payments and obtain benefits under the Social Security Act. The Social Security Number is necessary for use by the program as a unique identifier in order to track an enrollee's status in the program, and for ongoing administration. The Social Security Number will be shared with the program's central enroller contractor and with the carrier contractor selected by the enrollee. The use of the Social Security Number in the program is protected under The Federal Privacy Act of 1974 (Public Law 93-579) and the State Information Practices Act of 1977 (Civil Code Section 1798 et seq.).(aaa) "Tenses, and Number." The present tense includes the past and future, and the future the present; the singular includes the plural and the plural the singular.(bbb) "Time." Whenever in this chapter a time is stated in which an act is to be done, the time is computed by excluding the first day and including the last day. If the last day is a holiday it is also excluded.Cal. Code Regs. Tit. 10, § 2699.6000
1. Relocating of article heading and renumbering and amendment of former section 2699.610 to section 2699.6000 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
4. Amendment of subsection (k), new subsection (l), subsection relettering, and amendment of newly designated subsections (o)(1), (q), (r), (s), (x), (mm), (oo)(2), (pp)(1) and (uu) filed 12-29-94 as an emergency; operative 12-29-94 (Register 94, No. 52). A Certificate of Compliance must be transmitted to OAL 4-28-95 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 12-29-94 order including amendment of subsections (r) and (oo)(1) transmitted to OAL 4-12-95 and filed 5-22-95 (Register 95, No. 21).
6. Amendment of subsections (z) and (tt) filed 6-16-95 as an emergency; operative 6-16-95 (Register 95, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-16-95 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 6-16-95 order transmitted to OAL 9-26-95 and filed 10-18-95 (Register 95, No. 42).
8. New subsection (p) and subsection relettering filed 5-2-96; operative 6-1-96 (Register 96, No. 18).
9. Amendment of subsections (i) and (vv) filed 5-5-97; operative 7-1-97 (Register 97, No. 19).
10. Amendment filed 7-3-98 as an emergency; operative 7-3-98 (Register 98, No. 27). A Certificate of Compliance must be transmitted to OAL by 11-2-98 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 7-3-98 order, including amendment of section, transmitted to OAL 10-2-98 and filed 11-16-98 (Register 98, No. 47).
12. Editorial correction (Register 99, No. 6). Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
1. Relocating of article heading and renumbering and amendment of former section 2699.610 to section 2699.6000 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
4. Amendment of subsection (k), new subsection (l), subsection relettering, and amendment of newly designated subsections (o)(1), (q), (r), (s), (x), (mm), (oo)(2), (pp)(1) and (uu) filed 12-29-94 as an emergency; operative 12-29-94 (Register 94, No. 52). A Certificate of Compliance must be transmitted to OAL 4-28-95 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 12-29-94 order including amendment of subsections (r) and (oo)(1) transmitted to OAL 4-12-95 and filed 5-22-95 (Register 95, No. 21).
6. Amendment of subsections (z) and (tt) filed 6-16-95 as an emergency; operative 6-16-95 (Register 95, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-16-95 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 6-16-95 order transmitted to OAL 9-26-95 and filed 10-18-95 (Register 95, No. 42).
8. New subsection (p) and subsection relettering filed 5-2-96; operative 6-1-96 (Register 96, No. 18).
9. Amendment of subsections (i) and (vv) filed 5-5-97; operative 7-1-97 (Register 97, No. 19).
10. Amendment filed 7-3-98 as an emergency; operative 7-3-98 (Register 98, No. 27). A Certificate of Compliance must be transmitted to OAL by 11-2-98 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 7-3-98 order, including amendment of section, transmitted to OAL 10-2-98 and filed 11-16-98 (Register 98, No. 47).
12. Editorial correction (Register 99, No. 6).