28 CA ADC § 1300.65.1


      28 CCR s 1300.65.1

      Cal. Admin. Code tit. 28, s 1300.65.1


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 6. APPEALS ON CANCELLATION
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.65.1. Cancellation Complaint Form.

      (a) A request that the Director review cancellation of, or refusal to 
      renew, an enrollment or subscription pursuant to subdivision (b) of 
      Section 1365 of the Act shall be made in writing, signed by the subscriber 
      or enrollee or the legal representative of the subscriber or enrollee and 
      it shall be in the following form (or in letter form containing the 
      information specified in the form below):

      DEPARTMENT OF MANAGED HEALTH CARE STATE OF CALIFORNIA


      TO:                                     Health Plan Division          
      Date:____
                                              Department of Managed Care
                                              320 West 4th Street, Suite
                                              750
                                              Los Angeles, CA 90013-1105
                                              RE: COMPLAINT ON
                                              CANCELLATION OF,
                                              OR REFUSAL TO RENEW, HEALTH
                                              CARE
                                              SERVICE PLAN BENEFITS.
      The undersigned requests that the
        Director review the cancellation
        or refusal to renew the
        subscription or enrollment for
        health plan benefits pursuant to
        Section 1365 of the Knox-Keene
        Health Care Service Plan Act of
        1975, as follows:

       
      1. Name of person whose benefits were cancelled or not renewed: __________

      2. Name of subscriber, if different than "1" above: __________

      3. Name of plan: __________

      4. Subscriber or Enrollee Account or Identification Number: __________

      5. If applicable, the Group Identification Number: __________

      6. Date notice of cancellation or refusal to renew was received: 
__________

      7. Attach copies of:

      (a) The notice of cancellation or refusal to renew received from the plan.

      (b) Any correspondence with the plan regarding such cancellation or 
      refusal to renew.

      8. State why such cancellation or refusal to renew is believed to be an 
      improper action by the plan: __________ __________ __________

      9. Are you aware of the existence of any grounds for cancellation or 
      refusal to renew under the terms of the agreement with the plan? 
      __________ __________ __________

      10. Explain why you believe that the cause or causes for cancellation 
      enumerated in the notice of cancellation received from the Plan are 
      inadequate or untrue. Attach copies of any documents which are relevant to 
      your explanation. __________ __________ __________

      11. Does such cancellation or refusal to renew prevent or interfere with 
      providing medical care to any person currently in need of such care? 
      __________ __________ __________

      12. Has the person named in item 1 above whose benefits were cancelled 
      received any medical or health care since the cancellation? If so, what 
      services have been received and how much did they cost?

      __________ Signature of Complainant

      (b) Upon receipt of a complaint pursuant to subsection (b) of Section 1365 
      of the Act, the Director will immediately forward a copy of such complaint 
      to the plan, together with a request that the plan furnish the Director 
      with

      (1) a copy of the notice of cancellation or refusal to renew,

      (2) a copy of any correspondence relating thereto,

      (3) a statement of the reason for such cancellation or refusal to renew 
and

      (4) a response to the complainant's allegations pursuant to Item 9 of the 
      complaint form in subsection (a). Such information shall be returned to 
      the Director by the plan within 10 business days following its receipt of 
      the Director's request.

      (c) Following examination of the information provided pursuant to 
      subsection (a) and (b), the Director will notify the complainant and the 
      plan of the determination of whether or not a proper complaint exists 
      under the provisions of subdivision (b) of Section 1365 of the Act.


      


      Note: Authority cited: Section 1344, Health and Safety Code. Reference: 
      Section 1365, Health and Safety Code. 


       HISTORY 
         
      1. Amendment of subsection (a) filed 1-12-83; effective thirtieth day
      thereafter (Register 83, No. 3).

      2. Change without regulatory effect amending form filed 5-24-99 pursuant 
      to 
      section 100, title 1, California Code of Regulations (Register 99, No.
      22).

      3. Change without regulatory effect amending section filed 7-18-2000 
      pursuant
      to section 100, title 1, California Code of Regulations (Register 2000, 
      No. 29).

      4. Change without regulatory effect amending subsection (a) filed 
      11-21-2002
      pursuant to section 100, title 1, California Code of Regulations (Register
      2002, No. 47).
      28 CA ADC s 1300.65.1

      END OF DOCUMENT

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