Point-of-Service Health Care Service Plan Contracts
Cal. HSC § 1374.67
California Statutes
A health care service plan offering a point-of-service plan contract is subject to the following limitations: (
a) A health care service plan shall limit its offering of point-of-service plan contracts so that no more than percent of the plan’s total premium revenue in any fiscal quarter is earned from point-of-service plan contracts. (
b) A health care service plan offering a point-of-service plan contract shall not expend in any fiscal-year quarter more than percent of its total health care expenditures for all its enrollees for out-of-network services for point-of-service enrollees. (
c) If the amount specified in subdivision (
a) or (
b) is exceeded by percent in any quarter, the health care service plan shall come into compliance with subdivisions (
a) and (
b) by the end of the next following quarter. If compliance with the amount specified in subdivisions (
a) and (
b) is not demonstrated in the health care service plan’s next quarterly report, the director may prohibit the health care service plan from offering a point-of-service plan contract to new groups, or may require the health care service plan to amend one or more of its point-of-service contracts at the time of renewal to delete some or all of the out-of-network coverage or services as may be necessary for the plan to demonstrate compliance to the director’s satisfaction. (
d) The limitation imposed by this
section shall not apply to a plan which in substantial
part indemnified subscribers and enrollees pursuant to contracts issued under such plan’s former registration under the Knox-Mills Health Plan Act in and as of that date, and on September 1, 1993, was offering point-of-service plan contracts previously approved by the director.