28 CA ADC § 1300.67.1.3
28 CCR s 1300.67.1.3
Cal. Admin. Code tit. 28, s 1300.67.1.3
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 7. STANDARDS
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.67.1.3. Block Transfer Filings.
(a) Definitions. As used in this section:
(1) "Affected Enrollee" means enrollees of the plan who are assigned to a
Terminated Provider Group or a Terminated Hospital.
(2) "Alternate Hospital" means a hospital that will provide services to
plan enrollees in place of a Terminated Hospital.
(3) "Block Transfer" means a transfer or redirection of two thousand
(2,000) or more enrollees by a plan from a Terminated Provider Group or
Terminated Hospital to one or more contracting providers that takes place
as a result of the termination or non-renewal of a Provider Contract.
(4) "Enrollee Transfer Notice" means a written notice that is sent to
enrollees who are assigned to a Terminated Provider group or Terminated
Hospital.
(5) "Provider Contract" means a contract between a plan and one or more
health care providers, through which the plan arranges to provide health
care services for its enrollees.
(6) "Provider Group" means a medical group, an independent practice
association, or any other similar organization providing services to
enrollees of a plan who are assigned to that provider group.
(7) "Receiving Provider Group" means a provider group that will provide
services to Affected Enrollees in place of the current Provider Group.
(8) "Terminated Hospital" means a general acute care hospital that will no
longer maintain a Provider Contract with the plan following the
termination or non-renewal of a Provider Contract.
(9) "Terminated Provider" means either a Terminated Provider Group or a
Terminated Hospital.
(10) "Terminated Provider Group" means a Provider Group that will no
longer maintain a Provider Contract with the plan following the
termination or non-renewal of a Provider Contract.
(b) For any proposed Block Transfer, a plan shall file with the Department
a Block Transfer filing that includes, at minimum, all the items of
information described in this subsection (b). The Block Transfer filing
must be submitted to the Department at least seventy-five (75) days prior
to the termination or non-renewal of any Provider Contract with a
Terminated Provider Group or a Terminated Hospital.
The Block Transfer filing must be submitted in an electronic format
developed by the Department and made available at the Department's website
at www.hmohelp.ca.gov and must include, at minimum, all of the following
information as appropriate for the type of provider involved:
(1) A form of the written notice that the plan intends to send to Affected
Enrollees. The Enrollee Transfer Notice must include:
(A) The name of the Terminated Provider Group or Terminated Hospital. The
plan may also add the name of the assigned physician, where appropriate.
(B) A brief explanation of why the transfer is necessary due to the
termination of the contract between the plan and the Terminated Provider.
(C) The date of the pending contract termination and transfer.
(D) An explanation to the Affected Enrollee outlining the Affected
Enrollee's assignment to a new Provider Group, options for selecting a
physician within a new Provider Group, and applicable timeframes to make a
new Provider Group selection. The explanation must include a notification
to the Affected Enrollee that he or she may select a different network
provider by contacting the plan as outlined in the plan's written
continuity of care policy and evidence of coverage or disclosure form.
(E) A statement that the plan will send the Affected Enrollee a new member
information card with the name, address and telephone number of the
Receiving Provider Group and assigned physician by a specified later date,
which will occur prior to the date of the contract termination.
Alternatively, the plan may notify the Affected Enrollee of the name,
address and telephone number of the new Provider Group and assigned
physician, or Alternate Hospital, to which the Affected Enrollee will be
assigned in the absence of a selection made by the enrollee.
(F) A statement that the Affected Enrollee may contact the plan's customer
service department to request completion of care for an ongoing course of
treatment from a Terminated Provider. This statement may include either a
statement outlining the specific conditions set forth in California Health
and Safety Code section 1373.96(c), or an explanation to the Affected
Enrollee that his or her eligibility is conditioned upon certain factors
as outlined in the plan's written continuity of care policy and evidence
of coverage or disclosure form.
(G) The telephone number through which the Affected Enrollee may contact
the plan for a further explanation of his or her rights to completion of
care, including the plan's written continuity of care policy; and a link
that an Affected Enrollee may use to obtain of a downloadable copy of the
policy from the plan's website.
(H) A statement informing any enrollee of a point of service product that
the Affected Enrollee may be required to pay a larger portion of costs if
he or she continues to use his or her current providers, if applicable to
the particular Block Transfer.
(I) The following statement in at least 8-point font:
"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." The statement may be
modified to include the health care service plan's name in place of the
phrase "your HMO's."
(J) The plan shall require all contracted providers to include the
statutory language required by California Health and Safety Code section
1373.65(f) in all communications to Affected Enrollees that concern the
termination of a provider or a Block Transfer.
(K) Compliance with all applicable language assistance statues and
regulations, including Section 1367.04 and any regulations based upon
Section 1367.04.
(2) For a Terminated Hospital contract the plan shall also submit the
following information:
(A) A brief explanation of the cause of the hospital redirection including
whether the contract termination or non-renewal was initiated by the plan,
the hospital, or by a contracting Provider Group.
(B) A copy of the notice of termination sent or received by the plan.
(C) If the contract termination will affect 50,000 or more enrollees, the
relevant portions of the Provider Contract(s) that relate to continuity of
care and transition of care.
(D) Either of the following two options:
1. a list of counties in which Affected Enrollees reside and the
corresponding number of Affected Enrollees for each county, or
2. a list of the zip codes in which Affected Enrollees reside and the
corresponding number of Affected Enrollees for each zip code.
(E) The number of Affected Enrollees assigned to the Terminated Hospital,
and the number to be reassigned to each Alternate Hospital, classified by
type of product (for example, commercial, Medi-Cal, Healthy Families,
etc.)
(F) The number of Affected Enrollees within a 15-mile radius of the
Terminated Hospital.
(G) The date that the plan anticipates it will mail the Enrollee Transfer
Notification.
(H) The proposed date or dates of transfer of Affected Enrollees. If the
plan intends to transfer Affected Enrollees on various dates, please
explain the reason for the different transfer dates.
(I) If additional governmental departments or agencies require approval of
enrollee notices regarding the transfer, provide copies of each proposed
notice as well as an explanation of the status of each required approval.
(J) The identity of the Terminated Hospital and Alternate Hospital
including the contract renewal or termination date for each Alternate
Hospital.
(K) A listing identifying any services that are available at the
Terminated Hospital that are not available at an Alternate Hospital. The
plan must discuss the arrangements it has made to ensure that enrollees
have an opportunity to receive those services.
(L) Based upon the data made public on the Office of Statewide Health
Planning and Development's website, for each of the proposed Alternate
Hospitals, provide the available bed occupancy rate for the most recently
completed calendar year. If the rate is at 80% or higher, please provide
justification as to the sufficiency of the Alternate Hospital's capacity
to serve additional plan enrollees.
(M) The number of bed days utilized by plan enrollees at the Terminated
Hospital for the most recently completed calendar year.
(N) An analysis showing the driving distance between the proposed
Alternate Hospital and the Terminated Hospital.
(O) Of the primary care providers to whom Affected enrollees are currently
assigned, the number and percentage of primary care providers with active
admitting privileges at the Alternate Hospital(s) and the number of
Affected Enrollees assigned to these primary care providers and the number
and percentage of primary care providers without active admitting
privileges at the Alternate Hospital(s) and the number of Affected
Enrollees assigned to these primary care providers.
(P) Explain the procedure by which an Affected Enrollee who is assigned to
a primary care provider who does not have active admitting privileges to
the Alternate Hospital(s) will receive needed hospital care.
(Q) Of the specialists available to Affected Enrollees with active
admitting privileges at the Terminated Hospital, the number and percentage
with active admitting privileges at the Alternate Hospital(s). If any of
these specialists will be unable to admit to the Alternate Hospital(s),
disclose the specialty involved, how many specialists of that specialty,
if any, will still be available to admit the Alternate Hospital(s) and
explain how Affected Enrollees will receive care for that specialty at a
proposed Alternate Hospital if there are an insufficient number of
remaining specialists with active admitting privileges.
(R) A disclosure of any anticipated increase in costs that will be
incurred by Affected Enrollees of the plan's point of service products
resulting from termination of the current hospital's contract if they
continue to use the Terminated Provider.
(S) Confirmation that the plan's continuity of care program, as filed with
the Department, will be implemented for any Affected Enrollees.
(3) For a Provider Group contract termination, the plan shall also submit
the following information:
(A) A brief explanation of the cause or circumstances of the Provider
Contract termination or non-renewal, including whether the contract
termination or non-renewal was initiated by the plan or the Provider
Group. If the Provider Contract termination is due to a provider closure,
specify whether the provider closure is due to a bankruptcy, an
insolvency, a sale, ceasing business operations or the closure of a
specific office site.
(B) A copy of the notice of termination sent or received by the plan.
(C) If the contract termination will affect 50,000 or more enrollees, the
relevant portions of the Provider Contract(s) that relate to continuity of
care and transition of care.
(D) Either of the following two options:
(i) a list of counties in which Affected Enrollees reside and the
corresponding number of Affected Enrollees for each county, or
(ii) a list of the zip codes in which Affected Enrollees reside and the
corresponding number of Affected Enrollees for each zip code.
(E) A listing, classified by type of product (for example, commercial,
Medi-Cal, Healthy Families, etc.) that specifies the number of Affected
Enrollees assigned to the Terminated Provider.
(F) The date that the plan anticipates it will mail the Enrollee Transfer
Notice.
(G) The proposed date or dates of transfer. If the plan intends to
transfer Affected Enrollees on various dates, please explain the reason
for the different transfer dates.
(H) The plan's estimate of the percentage of Affected Enrollees who will
remain with the same primary care provider after the transfer to a
Receiving Provider Group.
(I) If additional governmental departments or agencies require approval of
enrollee notices regarding the transfer, please provide copies of each
proposed notice as well as an explanation of the status of each required
approval.
(J) A matrix of proposed Receiving Provider Groups that includes the
following information:
1. the identity of the Receiving Provider Group(s), including its Risk
Bearing Organization (RBO) number as assigned by the Department,
2. the number of Affected Enrollees being transferred to each Receiving
Provider Group listed by type of product. If the plan gives the Affected
Enrollees the choice of selecting a new provider, then the plan must
provide the number of Affected Enrollees to be transferred to each
receiving Provider Group by default if no selections are made by the
Affected Enrollees,
3. a listing of all hospitals to which Receiving Provider Groups refer
Affected Enrollees, if different from the Terminated Provider Group.
(K) Confirmation that the plan's continuity of care program, as filed with
the Department, will be implemented for any Affected Enrollees.
(c) Timing of Notice Requirements. For any termination or non-renewal of a
Provider Contract, a plan shall mail to all Affected Enrollees an Enrollee
Transfer Notice that has been approved by the Department.
(1) The Enrollee Transfer Notice must be mailed to each Affected Enrollee
at least sixty (60) days prior to the date of termination or non-renewal.
(d) Notice Mailing Requirements. The plan shall send an Enrollee Transfer
Notice to Affected Enrollees as follows:
(1) For Affected Enrollees enrollees who are Block Transferred from a
Terminated Provider Group - the plan shall send the notice to all Affected
Enrollees assigned to the Terminated Provider Group.
(2) For Affected Enrollees who are block transferred from a Terminated
Hospital - the plan shall send the notice to all Affected Enrollees who
reside within 15 miles of the Terminated Hospital.
(e) If, for any reason, a plan is unable to send all Enrollee Transfer
Notice required pursuant to subsection 1300.67.1.3(c) of Title 28,
California Code of Regulations, at least sixty (60) days prior to the
termination or non-renewal of a Provider Contract, the plan shall submit
to the Department an application for a waiver of the 60-day requirement.
The application for waiver must include an explanation of the plan's
reasons for being unable to meet the 60-day notice requirement and its
proposal to minimize any disruption that may be caused to Affected
Enrollees by the reduced notice. A waiver application may be based upon
the sudden closure of a contracted provider, a notice-timing conflict with
another jurisdictional agency, or other circumstances for which good-cause
exists. If the Department does not approve or disapprove the waiver
request within seven (7) days of its receipt of the request, the waiver
will be deemed to have been approved by the Department.
(f) If, after sending Enrollee Transfer Notices a plan reaches an
agreement to renew or enter into a new Provider Contract or to not
terminate their Provider Contract with a Terminated Provider to which the
plan had assigned enrollees, then the plan shall promptly inform the
Department and convey an additional enrollee notification, either by
telephone or in writing, to each Affected Enrollee. The additional
enrollee notification must include:
(1) A brief explanation of the fact that the plan has reached an agreement
with the Affected Enrollee's previously assigned provider.
(2) An explanation to the enrollee regarding options for either returning
to the previously assigned provider, keeping the newly assigned provider,
or select another participating provider from the plan's contracting
provider list.
(3) An explanation to the Affected Enrollee of the procedure by which the
enrollee may contact the plan to express his or her desire to return to
the previously assigned provider.
(4) If the additional enrollee notice is given in writing, then the notice
must include the following statement in at least 8-point font:
"If you have any questions regarding this notice please contact [Plan
Name] customer service department. If you have further concerns about your
provider network, you are encouraged to contact the Department of Managed
Health Care by telephone at its toll-free number 1-888-HMO-2219, or at TDD
number for the hearing impaired at 1-877-688-9891, or online at
www.hmohelp.ca.gov."
(5) Compliance with all applicable language assistance statutes and
regulations, including Section 1367.04 and any regulations based upon
Section 1367.04.
Note: Authority cited: Sections 1342, 1344 and 1346, Health and Safety
Code. Reference: Sections 1367.04 and 1373.65, Health and Safety Code.
HISTORY
1. New section filed 8-22-2005; operative 9-21-2005 (Register 2005, No.
34).
28 CA ADC s 1300.67.1.3
END OF DOCUMENT
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