California Health and Safety Code 1362 – As used in Sections 1363 and 1364:(a) “Benefits and coverage” …
As used in Sections 1363 and 1364:
(a) “Benefits and coverage” means the health care services available under a plan contract.
Terms Used In California Health and Safety Code 1362
- Advertisement: means any written or printed communication or any communication by means of recorded telephone messages or by radio, television, or similar communications media, published in connection with the offer or sale of plan contracts. See California Health and Safety Code 1345
- Contract: A legal written agreement that becomes binding when signed.
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- Plan contract: means a contract between a plan and its subscribers or enrollees or a person contracting on their behalf pursuant to which health care services, including basic health care services, are furnished. See California Health and Safety Code 1345
(b) “Exception” means any provision in a plan contract whereby coverage for a specified hazard or condition is entirely eliminated.
(c) “Reduction” means any provision in a plan contract which reduces the amount of a plan benefit to some amount or period less than would be otherwise payable for medically authorized expenses or services had such a reduction not been used.
(d) “Limitation” means any provision other than an exception or a reduction which restricts coverage under the plan.
(e) “Presenting for examination or sale” means either (1) publication and dissemination of any brochure, mailer, advertisement, or form which constitutes a presentation of the provisions of the plan and which provides a plan enrollment or application form, or (2) consultations or discussions between prospective plan members or their contract agents and solicitors or representatives of a plan, when such consultations or discussions include presentation of formal, organized information about the plan which is intended to influence or inform the prospective member or contract holder, such as brochures, summaries, charts, slides, or other modes of information.
(f) “Disclosure form” means the disclosure form, material, or information required pursuant to Section 1363.
(g) For the purposes of Sections 1363 and 1364, where the definition of the term “hospital” in the plan contract omits care in any “health facility” defined pursuant to subdivision (a) or (b) of Section 1250 of this code, the omitted coverage shall constitute a limitation; and where the definition of the term “nursing home” in the plan omits care in any “health facility” defined pursuant to subdivision (c) or (d) of Section 1250 of this code, the omitted coverage shall constitute a limitation.
(Added by Stats. 1975, Ch. 941.)