Section 1373.65 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1373.65
. (a) At least 75 days prior to the termination date of its
contract with a provider group or a general acute care hospital, the
health care service plan shall submit an enrollee block transfer
filing to the department that includes the written notice the plan
proposes to send to affected enrollees. The plan may not send this
notice to enrollees until the department has reviewed and approved
its content. If the department does not respond within seven days of
the date of its receipt of the filing, the notice shall be deemed
approved.
(b) At least 60 days prior to the termination date of a contract
between a health care service plan and a provider group or a general
acute care hospital, the plan shall send the written notice described
in subdivision (a) by United States mail to enrollees who are
assigned to the terminated provider group or hospital. A plan that is
unable to comply with the timeframe because of exigent circumstances
shall apply to the department for a waiver. The plan is excused from
complying with this requirement only if its waiver application is
granted by the department or the department does not respond within
seven days of the date of its receipt of the waiver application. If
the terminated provider is a hospital and the plan assigns enrollees
to a provider group with exclusive admitting privileges to the
hospital, the plan shall send the written notice to each enrollee who
is a member of the provider group and who resides within a 15-mile
radius of the terminated hospital. If the plan operates as a
preferred provider organization or assigns members to a provider
group with admitting privileges to hospitals in the same geographic
area as the terminated hospital, the plan shall send the written
notice to all enrollees who reside within a 15-mile radius of the
terminated hospital.
(c) The health care service plan shall send enrollees of a
preferred provider organization the written notice required by
subdivision (b) only if the terminated provider is a general acute
care hospital.
(d) If an individual provider terminates his or her contract or
employment with a provider group that contracts with a health care
service plan, the plan may require that the provider group send the
notice required by subdivision (b).
(e) If, after sending the notice required by subdivision (b), a
health care service plan reaches an agreement with a terminated
provider to renew or enter into a new contract or to not terminate
their contract, the plan shall offer each affected enrollee the
option to return to that provider. If an affected enrollee does not
exercise this option, the plan shall reassign the enrollee to another
provider.
(f) A health care service plan and a provider shall include in all
written, printed, or electronic communications sent to an enrollee
that concern the contract termination or block transfer, the
following statement in not less than 8-point type: "If you have been
receiving care from a health care provider, you may have a right to
keep your provider for a designated time period. Please contact your
HMO's customer service department, and if you have further questions,
you are encouraged to contact the Department of Managed Health Care,
which protects HMO consumers, by telephone at its toll-free number,
1-888-HMO-2219, or at a TDD number for the hearing impaired at
1-877-688-9891, or online at www.hmohelp.ca.gov."
(g) For purposes of this section, "provider group" means a medical
group, independent practice association, or any other similar
organization.