Cal. Code Regs. Tit. 22, § 55100 - Definitions

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

(a) County organized health system means a Medi-Cal managed care plan contracting with the department to serve enrolled beneficiaries under the authority of Welfare and Institutions Code, Section 14499.5, or Welfare and Institutions Code, Division 9, Part 3, Chapter 7, Article 2.8, commencing with Section 14087.5.

(b) Disenrollment means the process under which a member's entitlement to receive services from a Medi-Cal managed care plan is terminated.

(c) Federally qualified health center means an entity which:

(1) Is receiving a grant under Section 330 of the Public Health Service Act;

(2) Is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under Section 330 of such Act;

(3) Based on the recommendation of the Health Resources and Services Administration within the Public Health Service, is determined by the Secretary of Health and Human Services to meet the requirements for receiving such a grant; or

(4) Was treated by the Secretary, for purposes of Part B of Title XVIII, as a comprehensive federally funded health center as January 1, 1990; and

(5) May be an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (Public Law 93-638) or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act for the provision of primary health services.

(d) Fee-for-service managed care plan means a Medi-Cal managed care plan that does not assume financial risk for the provision of services to its members.

(e) Fee-for-service managed care program means a single fee-for-service managed care plan contracting in a county to provide or arrange for health care services to mandatorily enrolled Medi-Cal beneficiaries.

(f) Fee-for-service provider means a provider of services as defined in Section 51051 which has been issued a Medi-Cal provider number by the department.

(g) Geographic managed care program means a health care delivery system consisting of Medi-Cal managed care plans contracting with the department under the authority of Welfare and Institutions Code Sections 14089 or 14089.05 to provide services to mandatorily enrolled Medi-Cal beneficiaries.

(h) Health care options program means the program established by the department to inform Medi-Cal beneficiaries of their options for receiving Medi-Cal benefits in areas served by Medi-Cal managed care plans other than county organized health systems.

(i) Indian means any person who is eligible under federal law and regulations (25 U.S.C. Sections 1603c, 1679b, and 1680c and 42 CFR Section 36.12) to receive health services provided directly by the United States Department of Health and Human Services, Indian Health Service, or by a tribal or an urban Indian health program funded by the Indian Health Service to provide health services to eligible individuals either directly or by contract.

(j) Indian Health Service Facility means a tribal or urban Indian organization operating health care programs or facilities with funds from the Department of Health and Human Services, Indian Health Service, appropriated pursuant to the Indian Health Care Improvement Act (25 U.S.C. Section 1601 et. seq.) or the Snyder Act (25 U.S.C. Section 13 et. seq.).

(k) Lock-in means the restriction of a member's right to disenroll from a Medi-Cal managed care plan without good cause.

(l) Medi-Cal managed care plan means an entity contracting with the department to provide health care services to enrolled Medi-Cal beneficiaries under Chapter 7, commencing with Section 14000, or Chapter 8, commencing with Section 14200, of Division 9, Part 3, of the Welfare and Institutions Code.

(m) Medi-Cal managed care program means a program established by the department in which participation requirements for beneficiaries and Medi-Cal managed care plans have been standardized. As used in this article, Medi-Cal managed care programs include the two-plan model, Geographic Managed Care, prepaid health plan, primary care case management, county organized health systems, and fee-for-service managed care programs.

(n) Member means any Medi-Cal beneficiary who has enrolled in a Medi-Cal managed care plan.

(o) Prepaid health plan program means the Medi-Cal managed care program in which beneficiaries may voluntarily enroll in Medi-Cal managed care plans contracting with the department under Welfare and Institutions Code Section 14200 et seq.

(p) Primary care case management program means the Medi-Cal managed care program in which beneficiaries may voluntarily enroll in Medi-Cal managed care plans contracting with the department under Welfare and Institutions Code Section 14088 et seq.

(g) Two-plan model means the health care delivery system described in Section 53800, consisting of two Medi-Cal managed care plans in a county providing services to mandatorily enrolled Medi-Cal beneficiaries.

Notes

Cal. Code Regs. Tit. 22, § 55100

1. New section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only pursuant to section 147, Senate Bill 485 (Ch. 722/92) (Register 98, No. 15).
2. Change without regulatory effect amending NOTE filed 4-9-98 pursuant to section 100, title 1, California Code of Regulations (Register 98, No. 15).

Note: Authority cited: Stats. 1992, Ch. 722; Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Sections 14000, 14016.5, 14087.3, 14087.305, 14087.4, 14087.5, 14088, 14089, 14089.05, 14200 and 14499.5, Welfare and Institutions Code; and Title 25, United States Code, Sections 13 and 1601.

1. New section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only pursuant to section 147, Senate Bill 485 (Ch. 722/92) (Register 98, No. 15).
2. Change without regulatory effect amending Note filed 4-9-98 pursuant to section 100, title 1, California Code of Regulations (Register 98, No. 15).