Cal. Code Regs. Tit. 22, § 53902 - Definitions

The following definitions shall control the construction of this chapter, unless the context requires otherwise.

(a) Assignment. Assignment means the actions taken by the GMC enrollment contractor to enroll an eligible beneficiary into a GMC plan, in the absence of a selection made by the beneficiary. Assignment also means action by a GMC plan to assign a member to a primary care provider, in the absence of a selection made by the member.

(b) Capitated Service. Capitated service means a medical or dental service for which a GMC plan is compensated in its fixed monthly per member rate.

(c) Dental Plan. Dental plan means a specialized health care service plan, which provides only dental services and is licensed under the Knox-Keene Health Care Services Plan Act of 1975.

(d) Eligible Beneficiary. Eligible beneficiary means a person who resides in an area covered by the GMC program, who has been determined eligible to receive Medi-Cal services, whose scope of Medi-Cal benefits is not limited, and who has been determined to have a share of cost equal to zero, as specified in Section 53906.

(e) Fair Hearing. Fair hearing means an administrative hearing conducted by the state relating to Medi-Cal eligibility or benefits, pursuant to Sections 50951 through 50955.

(f) Federally Qualified Health Maintenance Organization (HMO). Federally qualified HMO means a PHP that has been determined by the federal Health Care Financing Administration to be a qualified HMO under Section 1310(d) of the Public Health Service Act.

(g) Geographic Managed Care (GMC) Program. GMC Program means the program authorized by Section 14089 et seq. of the Welfare and Institutions Code.

(h) GMC Contract. GMC contract means the written agreement entered into between a prepaid health plan, primary care case management plan, or dental plan and the department to provide health care services to GMC plan members.

(i) GMC Enrollment Contractor. GMC enrollment contractor means the entity contracting with the department to provide GMC options presentations, enrollment and disenrollment activities, and problem resolution functions.

(j) GMC Plan. GMC plan means a PHP, PCCM plan, or dental plan that has entered into a GMC contract with the department.

(k) Indian. Indian means any Indian who is eligible under federal law to receive health services provided directly by the United States Indian Health Services (IHS) or by a tribal or urban contractor through contract with IHS.

(l) Indian Health Service Program Facility. Indian Health Service program facility means a tribal or urban Indian Health Service (IHS) organization operating health care programs or facilities with funds from the IHS under the Indian Self-Determination Act and the Indian Health Care Improvement Act, through which services are provided, directly or by contract, to the eligible Indian population within a defined geographic area.

(m) Initial Health Assessment. Initial health assessment means an assessment conducted by the GMC plan of a member's medical or dental health status.

(n) Member. Member means an eligible beneficiary who is enrolled in a GMC plan.

(o) Prepaid Health Plan (PHP). PHP means a health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975, which has entered into a contract with the department on a capitated rate basis to furnish health services to eligible beneficiaries.

(p) Primary Care Case Management (PCCM) Plan. PCCM plan means a primary care provider that has contracted with the department pursuant to Article 2.9, commencing with Section 14088, Welfare and Institutions Code.

(q) Primary Care Provider. Primary care provider means a physician or dentist who has the responsibility for providing initial and primary care to members, for maintaining the continuity of member care, and for initiating referrals for specialist care.

(r) Service Site. Service site means the location designated by a GMC plan at which a member received primary care physician or dentist services.

Notes

Cal. Code Regs. Tit. 22, § 53902

1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15).

Note: Authority cited: Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Sections 10950- 10965, 14088, 14088.05, 14089, 14251 and 14252, Welfare and Institutions Code.

1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15).