12693.01. For purposes of this part, the definitions contained in
this chapter shall govern the construction of this part, unless the
context requires otherwise.
12693.02. (a) "Applicant" means a person over the age of 18 years
who is a natural or adoptive parent; a legal guardian; or a caretaker
relative, foster parent, or stepparent with whom the child resides,
who applies for coverage under the program on behalf of a child.
(b) "Applicant" also means any of the following:
(1) A person 18 years of age who is applying on his or her own
behalf for coverage under the program.
(2) A person who is under 18 years of age and is an emancipated
minor who is applying on his or her own behalf for coverage under the
program.
(3) A minor who is not living in the home of a natural or adoptive
parent, a legal guardian, or a caretaker relative, foster parent or
stepparent, who is applying on his or her own behalf for coverage
under the program.
(4) A minor who applies for coverage under the program on behalf
of his or her child.
12693.03. "Board" means the Managed Risk Medical Insurance Board.
12693.04. "Child" means a person who is under 19 years of age who
is eligible for the program pursuant to Chapter 9 (commencing with
Section 12693.70).
12693.045. "Community provider plan" means that participating
health plan in each geographic area that has been designated by the
board as having the highest percentage of traditional and safety net
providers in its provider network.
12693.05. "County organized health system" means a health care
organization that contracts with the State Department of Health
Services to provide comprehensive health care to all eligible
Medi-Cal beneficiaries residing in the county, and that is operated
directly by a public entity established by a county government
pursuant to Section 14087.51 or 14087.54 of the Welfare and
Institutions Code, or Chapter 3 (commencing with Section 101675) of
Part 4 of Division 101 of the Health and Safety Code.
12693.06. "Family contribution" means the cost to an applicant to
enable herself or himself or an eligible child or children to enroll
in and participate in the program. Family contribution does not
include copayments for insured services. The family contribution may
be paid by a family contribution sponsor pursuant to Section
12693.17.
12693.065. "Family value package" means the combination of
participating health, dental, and vision plans available to
subscribers in each geographic area offering the lowest prices to the
program. The board may define the family value package to include
not only the combination of participating health, dental, and vision
plans offering the absolute lowest price to the program but also the
combination of health, dental, and vision plans within a fixed
percentage or dollar amount of the absolute lowest price.
12693.07. "Fund" means the Healthy Families Fund.
12693.08. "Local initiative" means a prepaid health plan that is
organized by, or designated by, a county government or county
governments, or organized by stakeholders, of a region designated by
the department to provide comprehensive health care to eligible
Medi-Cal beneficiaries. The entities established pursuant to the
following sections of the Welfare and Institutions Code are local
initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96.
12693.09. "Participating dental plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal dental services under insurance
policies or contracts, or membership contracts, in consideration of
premiums or other periodic charges payable to it, and that contract
with the board to provide coverage to program subscribers:
(a) A dental insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.10. "Participating health plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal health care services under
insurance policies or contracts, medical and hospital service
arrangements, or membership contracts, in consideration of premiums
or other periodic charges payable to it, and that contracts with the
board to provide coverage to program subscribers:
(a) A private health insurer holding a valid outstanding
certificate of authority from the commissioner.
(b) A health care service plan as defined under subdivision (f) of
Section 1345 of the Health and Safety Code.
(c) A county organized health system.
(d) A local initiative.
12693.105. A health care service plan, as defined in subdivision
(b) of Section 12693.10, shall include a plan operating as a
geographic managed care plan.
12693.11. "Participating vision care plan" means any of the
following plans that is lawfully engaged in providing, arranging,
paying for, or reimbursing the cost of personal vision services under
insurance policies or contracts, or membership contracts, in
consideration of premiums or other periodic charges payable to it,
and that contract with the board to provide coverage to program
subscribers:
(a) A vision insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.12. "Program" means the Healthy Families Program, which
includes a purchasing pool providing health coverage for children in
families without access to affordable employer based dependent
coverage and a purchasing credit mechanism through which families
with access to employer based dependent coverage can receive
financial assistance with the cost of dependent coverage for
children.
12693.13. "Purchasing credit member" means an applicant 18 years of
age or a child who is eligible for and participates in the
purchasing credit component of the program.
12693.14. "Subscriber" means an applicant 18 years of age or a
child who is eligible for and participates in the purchasing pool
component of the program.
12693.15. "Supplemental coverage" means coverage purchased by the
program from (a) a private health insurer holding a valid outstanding
certificate of authority from the Insurance Commissioner, or (b) a
health care service plan as defined under subdivision (f) of Section
1345 of the Health and Safety Code to bring the coverage available to
purchasing credit members into at least 95 percent actuarial
equivalence with the coverage provided to subscribers through the
purchasing pool component of the program. The coverage shall provide
for any necessary adjustment of the cost-sharing levels charged to
purchasing credit members to be equivalent to those charged to
subscribers through the purchasing pool component of the program.
Subscriber costs and benefits for the purchasing credit members shall
be at least 95 percent actuarially equivalent to subscriber costs
and benefits in the purchasing pool component.
12693.16. "Geographic managed care plan" means an entity that is
operating pursuant to a contract entered into under Article 2.91
(commencing with Section 14089) of Chapter 7 of Part 3 of Division 9
of the Welfare and Institutions Code.
12693.17. "Family contribution sponsor" means a person or entity
that pays the family contribution on behalf of an applicant for any
period of 12 consecutive months and, notwithstanding Section
12693.70, if the sponsor is paying for the initial 12 months of
eligibility, the payment for 12 months is made with the application.
12693.01. For purposes of this part, the definitions contained in
this chapter shall govern the construction of this part, unless the
context requires otherwise.
12693.02. (a) "Applicant" means a person over the age of 18 years
who is a natural or adoptive parent; a legal guardian; or a caretaker
relative, foster parent, or stepparent with whom the child resides,
who applies for coverage under the program on behalf of a child.
(b) "Applicant" also means any of the following:
(1) A person 18 years of age who is applying on his or her own
behalf for coverage under the program.
(2) A person who is under 18 years of age and is an emancipated
minor who is applying on his or her own behalf for coverage under the
program.
(3) A minor who is not living in the home of a natural or adoptive
parent, a legal guardian, or a caretaker relative, foster parent or
stepparent, who is applying on his or her own behalf for coverage
under the program.
(4) A minor who applies for coverage under the program on behalf
of his or her child.
12693.03. "Board" means the Managed Risk Medical Insurance Board.
12693.04. "Child" means a person who is under 19 years of age who
is eligible for the program pursuant to Chapter 9 (commencing with
Section 12693.70).
12693.045. "Community provider plan" means that participating
health plan in each geographic area that has been designated by the
board as having the highest percentage of traditional and safety net
providers in its provider network.
12693.05. "County organized health system" means a health care
organization that contracts with the State Department of Health
Services to provide comprehensive health care to all eligible
Medi-Cal beneficiaries residing in the county, and that is operated
directly by a public entity established by a county government
pursuant to Section 14087.51 or 14087.54 of the Welfare and
Institutions Code, or Chapter 3 (commencing with Section 101675) of
Part 4 of Division 101 of the Health and Safety Code.
12693.06. "Family contribution" means the cost to an applicant to
enable herself or himself or an eligible child or children to enroll
in and participate in the program. Family contribution does not
include copayments for insured services. The family contribution may
be paid by a family contribution sponsor pursuant to Section
12693.17.
12693.065. "Family value package" means the combination of
participating health, dental, and vision plans available to
subscribers in each geographic area offering the lowest prices to the
program. The board may define the family value package to include
not only the combination of participating health, dental, and vision
plans offering the absolute lowest price to the program but also the
combination of health, dental, and vision plans within a fixed
percentage or dollar amount of the absolute lowest price.
12693.07. "Fund" means the Healthy Families Fund.
12693.08. "Local initiative" means a prepaid health plan that is
organized by, or designated by, a county government or county
governments, or organized by stakeholders, of a region designated by
the department to provide comprehensive health care to eligible
Medi-Cal beneficiaries. The entities established pursuant to the
following sections of the Welfare and Institutions Code are local
initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96.
12693.09. "Participating dental plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal dental services under insurance
policies or contracts, or membership contracts, in consideration of
premiums or other periodic charges payable to it, and that contract
with the board to provide coverage to program subscribers:
(a) A dental insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.10. "Participating health plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal health care services under
insurance policies or contracts, medical and hospital service
arrangements, or membership contracts, in consideration of premiums
or other periodic charges payable to it, and that contracts with the
board to provide coverage to program subscribers:
(a) A private health insurer holding a valid outstanding
certificate of authority from the commissioner.
(b) A health care service plan as defined under subdivision (f) of
Section 1345 of the Health and Safety Code.
(c) A county organized health system.
(d) A local initiative.
12693.105. A health care service plan, as defined in subdivision
(b) of Section 12693.10, shall include a plan operating as a
geographic managed care plan.
12693.11. "Participating vision care plan" means any of the
following plans that is lawfully engaged in providing, arranging,
paying for, or reimbursing the cost of personal vision services under
insurance policies or contracts, or membership contracts, in
consideration of premiums or other periodic charges payable to it,
and that contract with the board to provide coverage to program
subscribers:
(a) A vision insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.12. "Program" means the Healthy Families Program, which
includes a purchasing pool providing health coverage for children in
families without access to affordable employer based dependent
coverage and a purchasing credit mechanism through which families
with access to employer based dependent coverage can receive
financial assistance with the cost of dependent coverage for
children.
12693.13. "Purchasing credit member" means an applicant 18 years of
age or a child who is eligible for and participates in the
purchasing credit component of the program.
12693.14. "Subscriber" means an applicant 18 years of age or a
child who is eligible for and participates in the purchasing pool
component of the program.
12693.15. "Supplemental coverage" means coverage purchased by the
program from (a) a private health insurer holding a valid outstanding
certificate of authority from the Insurance Commissioner, or (b) a
health care service plan as defined under subdivision (f) of Section
1345 of the Health and Safety Code to bring the coverage available to
purchasing credit members into at least 95 percent actuarial
equivalence with the coverage provided to subscribers through the
purchasing pool component of the program. The coverage shall provide
for any necessary adjustment of the cost-sharing levels charged to
purchasing credit members to be equivalent to those charged to
subscribers through the purchasing pool component of the program.
Subscriber costs and benefits for the purchasing credit members shall
be at least 95 percent actuarially equivalent to subscriber costs
and benefits in the purchasing pool component.
12693.16. "Geographic managed care plan" means an entity that is
operating pursuant to a contract entered into under Article 2.91
(commencing with Section 14089) of Chapter 7 of Part 3 of Division 9
of the Welfare and Institutions Code.
12693.17. "Family contribution sponsor" means a person or entity
that pays the family contribution on behalf of an applicant for any
period of 12 consecutive months and, notwithstanding Section
12693.70, if the sponsor is paying for the initial 12 months of
eligibility, the payment for 12 months is made with the application.
12693.01. For purposes of this part, the definitions contained in
this chapter shall govern the construction of this part, unless the
context requires otherwise.
12693.02. (a) "Applicant" means a person over the age of 18 years
who is a natural or adoptive parent; a legal guardian; or a caretaker
relative, foster parent, or stepparent with whom the child resides,
who applies for coverage under the program on behalf of a child.
(b) "Applicant" also means any of the following:
(1) A person 18 years of age who is applying on his or her own
behalf for coverage under the program.
(2) A person who is under 18 years of age and is an emancipated
minor who is applying on his or her own behalf for coverage under the
program.
(3) A minor who is not living in the home of a natural or adoptive
parent, a legal guardian, or a caretaker relative, foster parent or
stepparent, who is applying on his or her own behalf for coverage
under the program.
(4) A minor who applies for coverage under the program on behalf
of his or her child.
12693.03. "Board" means the Managed Risk Medical Insurance Board.
12693.04. "Child" means a person who is under 19 years of age who
is eligible for the program pursuant to Chapter 9 (commencing with
Section 12693.70).
12693.045. "Community provider plan" means that participating
health plan in each geographic area that has been designated by the
board as having the highest percentage of traditional and safety net
providers in its provider network.
12693.05. "County organized health system" means a health care
organization that contracts with the State Department of Health
Services to provide comprehensive health care to all eligible
Medi-Cal beneficiaries residing in the county, and that is operated
directly by a public entity established by a county government
pursuant to Section 14087.51 or 14087.54 of the Welfare and
Institutions Code, or Chapter 3 (commencing with Section 101675) of
Part 4 of Division 101 of the Health and Safety Code.
12693.06. "Family contribution" means the cost to an applicant to
enable herself or himself or an eligible child or children to enroll
in and participate in the program. Family contribution does not
include copayments for insured services. The family contribution may
be paid by a family contribution sponsor pursuant to Section
12693.17.
12693.065. "Family value package" means the combination of
participating health, dental, and vision plans available to
subscribers in each geographic area offering the lowest prices to the
program. The board may define the family value package to include
not only the combination of participating health, dental, and vision
plans offering the absolute lowest price to the program but also the
combination of health, dental, and vision plans within a fixed
percentage or dollar amount of the absolute lowest price.
12693.07. "Fund" means the Healthy Families Fund.
12693.08. "Local initiative" means a prepaid health plan that is
organized by, or designated by, a county government or county
governments, or organized by stakeholders, of a region designated by
the department to provide comprehensive health care to eligible
Medi-Cal beneficiaries. The entities established pursuant to the
following sections of the Welfare and Institutions Code are local
initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96.
12693.09. "Participating dental plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal dental services under insurance
policies or contracts, or membership contracts, in consideration of
premiums or other periodic charges payable to it, and that contract
with the board to provide coverage to program subscribers:
(a) A dental insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.10. "Participating health plan" means any of the following
plans that is lawfully engaged in providing, arranging, paying for,
or reimbursing the cost of personal health care services under
insurance policies or contracts, medical and hospital service
arrangements, or membership contracts, in consideration of premiums
or other periodic charges payable to it, and that contracts with the
board to provide coverage to program subscribers:
(a) A private health insurer holding a valid outstanding
certificate of authority from the commissioner.
(b) A health care service plan as defined under subdivision (f) of
Section 1345 of the Health and Safety Code.
(c) A county organized health system.
(d) A local initiative.
12693.105. A health care service plan, as defined in subdivision
(b) of Section 12693.10, shall include a plan operating as a
geographic managed care plan.
12693.11. "Participating vision care plan" means any of the
following plans that is lawfully engaged in providing, arranging,
paying for, or reimbursing the cost of personal vision services under
insurance policies or contracts, or membership contracts, in
consideration of premiums or other periodic charges payable to it,
and that contract with the board to provide coverage to program
subscribers:
(a) A vision insurer holding a valid outstanding certificate of
authority from the commissioner.
(b) A specialized health care service plan as defined under
subdivision (o) of Section 1345 of the Health and Safety Code.
12693.12. "Program" means the Healthy Families Program, which
includes a purchasing pool providing health coverage for children in
families without access to affordable employer based dependent
coverage and a purchasing credit mechanism through which families
with access to employer based dependent coverage can receive
financial assistance with the cost of dependent coverage for
children.
12693.13. "Purchasing credit member" means an applicant 18 years of
age or a child who is eligible for and participates in the
purchasing credit component of the program.
12693.14. "Subscriber" means an applicant 18 years of age or a
child who is eligible for and participates in the purchasing pool
component of the program.
12693.15. "Supplemental coverage" means coverage purchased by the
program from (a) a private health insurer holding a valid outstanding
certificate of authority from the Insurance Commissioner, or (b) a
health care service plan as defined under subdivision (f) of Section
1345 of the Health and Safety Code to bring the coverage available to
purchasing credit members into at least 95 percent actuarial
equivalence with the coverage provided to subscribers through the
purchasing pool component of the program. The coverage shall provide
for any necessary adjustment of the cost-sharing levels charged to
purchasing credit members to be equivalent to those charged to
subscribers through the purchasing pool component of the program.
Subscriber costs and benefits for the purchasing credit members shall
be at least 95 percent actuarially equivalent to subscriber costs
and benefits in the purchasing pool component.
12693.16. "Geographic managed care plan" means an entity that is
operating pursuant to a contract entered into under Article 2.91
(commencing with Section 14089) of Chapter 7 of Part 3 of Division 9
of the Welfare and Institutions Code.
12693.17. "Family contribution sponsor" means a person or entity
that pays the family contribution on behalf of an applicant for any
period of 12 consecutive months and, notwithstanding Section
12693.70, if the sponsor is paying for the initial 12 months of
eligibility, the payment for 12 months is made with the application.
