28 CA ADC § 1300.45
28 CCR s 1300.45
Cal. Admin. Code tit. 28, s 1300.45
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 2. ADMINISTRATION
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.45. Definitions.
In addition to the definitions contained in Section 1345 of the Act, the
following definitions apply to the interpretation of these rules and the
Act:
(a) "Act" means the Knox-Keene Health Care Service Plan Act of 1975.
(b) "Advertisement" includes the disclosure form required pursuant to
Section 1363 of the Act.
(c) (1) An "affiliate" of a person is a person controlled by, under common
control with, or controlling such person.
(2) A person's relationship with another person is that of an "affiliated
person" if such person is, as to such other person, a director, trustee or
a member of its executive committee or other governing board or committee,
or that of an officer or general partner, or holds any other position
involving responsibility and authority similar to that of a principal
officer or general partner; or who is the holder of 5% or more of its
outstanding equity securities; or who has any such relationship with an
affiliate of such person. An affiliate is also an affiliated person.
(d) The term "control" (including the terms "controlling," "controlled by"
and "under common control with") means the possession, direct or indirect,
of the power to direct or cause the direction of the management and
policies of a person, whether through the ownership of voting shares,
debt, by contract, or otherwise.
(e) The term "certified" or "audited," when used in regard to financial
statements, means examined and reported upon with an opinion expressed by
an independent public or certified public accountant.
(f) "Code" means the California Health and Safety Code.
(g) "Copayment" means an additional fee charged to a subscriber or
enrollee which is approved by the Director, provided for in the plan
contract and disclosed in the evidence of coverage or the disclosure form
used as the evidence of coverage.
(h) "Department" means the California Department of Managed Health Care.
(i) "Facility" means
(1) any premises owned, leased, used or operated directly or indirectly by
or for the benefit of a plan or any affiliate thereof, and
(2) any premises maintained by a provider to provide services on behalf of
a plan.
(j) "Family unit" means a unit composed of a subscriber and each person
whose eligibility for benefits is based upon such person's relationship
with, or dependency upon, such subscriber.
(k) "Hospital based plan" means a health care service plan which owns,
operates or is affiliated with a hospital as an integral part of
delivering health care services.
( l) "Material": A factor is "material" with respect to a matter if it is
one to which a reasonable person would attach importance in determining
the action to be taken upon the matter.
(m) "Primary care physician" means a physician who has the responsibility
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 who has limited
his practice of medicine to general practice or who is a board-certified
or board-eligible internist, pediatrician, obstetrician-gynecologist, or
family practitioner.
(n) "Principal creditor" means
(1) a person who has loaned funds to another for the operation of such
other person's business, and
(2) a person who has, directly or indirectly, 20 percent or more of the
outstanding debts of a person.
(o) "Principal officer" means a president, vice-president, secretary,
treasurer or chairman of the board of a corporation, a sole proprietor,
the managing general partner of a partnership, or a person having similar
responsibilities or functions.
(p) "Surcharge" means an additional fee which is charged to a subscriber
or enrollee for a covered service but which is not approved by the
Director, provided for in the plan contract and disclosed in the evidence
of coverage or the disclosure form used as the evidence of coverage.
(q) The term "generally accepted accounting principles," when used in
regard to financial statements, assets, liabilities and other accounting
items, means generally accepted accounting principles as used by business
enterprises organized for profit. Accordingly, Financial Accounting
Standards Board statements, Accounting Principles Board opinions,
accounting research bulletins and other authoritative pronouncements of
the accounting profession should be applied in determining generally
accepted accounting principles unless such statements, opinions, bulletins
and pronouncements are inapplicable. Section 510.05 of the AICPA
Professional Standards, in and of itself, shall not be sufficient reason
for determining inapplicability of statements, opinions, bulletins and
pronouncements.
Note: Authority cited: Sections 1344 and 1352, Health and Safety Code.
Reference: Sections 1351, 1351.1 and 1352, Health and Safety Code.
HISTORY
1. Amendment of subsection (c) filed 6-2-78; effective thirtieth day
thereafter (Register 78, No. 22).
2. New subsection (q) filed 4-27-79; effective thirtieth day thereafter
(Register 79, No. 17).
3. Amendment of subsection (e) filed 1-12-83; effective thirtieth day
thereafter (Register 83, No. 3).
4. Amendment of subsection (c) filed 12-17-85; effective thirtieth day
thereafter (Register 85, No. 51).
5. Change without regulatory effect amending subsections (g)-(h) and (p)
filed
7-18-2000 pursuant to section 100, title 1, California Code of Regulations
(Register 2000, No. 29).
6. Change without regulatory effect amending subsection (h) filed
11-21-2002
pursuant to section 100, title 1, California Code of Regulations (Register
2002, No. 47).
28 CA ADC s 1300.45
END OF DOCUMENT
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