1. (a) Definitions. As used in this section:

   1. (1) “Affected Enrollee” means enrollees of the plan who are assigned to a Terminating Provider Group or a Terminating Hospital.
   2. (2) “Alternate Hospital” means a hospital that will provide services to plan enrollees in place of a Terminating Hospital.

   3. (3) “Block Transfer” means one of the following:

      1. (A) a pending transfer or reassignment of two thousand (2,000) or more enrollees by a plan or Plan-Contracted Entity from a Terminating Provider Group to one or more Receiving Provider Groups that takes place as a result of a Contract Termination. An enrollee who is not assigned to a Terminating Provider Group but is assigned, matched, associated with, or otherwise currently connected to a primary care physician and who will no longer be able to maintain assignment, match, association, or connection with the primary care physician as a result of the Contract Termination is transferred or reassigned, for purposes of ascertaining the 2,000 threshold under this subsection.
      2. (B) a pending Contract Termination between the plan or Plan-Contracted Entity and the Terminating Hospital.
   4. (4) “Contract Termination” means the whole or Partial Termination, constructive termination, novation, non-renewal, or contract assignment of a Provider Contract.
   5. (5) “Enrollee Transfer Notice” means a written notice that is sent to enrollees to inform them of a Contract Termination.
   6. (6) “Partial Termination” means a change to the terms of an existing contract that results in the reassignment of enrollees to a new Receiving Provider Group or the loss of a specific service from a Terminating Provider.
   7. (7) “Plan-Contracted Entity” means a “Provider Group,” as defined in subsection (a)(9) of this Rule, a general acute care hospital, a “Limited health care service plan,” as defined in Rule 1300.49(a)(3), a “Restricted health care service plan,” as defined in Rule 1300.49(a)(6), or a “Health care service plan,” as defined in Health and Safety Code section 1345(f), that arranges to provide health care services to plan enrollees directly or indirectly.
   8. (8) “Provider Contract” means a contract between a plan or Plan-Contracted Entity and one or more health care providers, through which the plan or Plan-Contracted Entity arranges to provide health care services for its enrollees.
   9. (9) “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.
   10. (10) “Receiving Provider Group” means a provider group that will provide services to Affected Enrollees in place of the Terminating Provider Group.
   11. (11) “Terminating Hospital” means a general acute care hospital that will no longer maintain a Provider Contract with the plan or Plan-Contracted Entity following a Contract Termination.
   12. (12) “Terminating Provider” means either a Terminating Provider Group or a Terminating Hospital.
   13. (13) “Terminating Provider Group” means a Provider Group that will no longer maintain a Provider Contract with the plan or Plan-Contracted Entity following a Contract Termination.

2. (b) For any Block Transfer, the primary plan, as defined in Rule 1300.67.2.2(b)(13)(A), 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 seventy-five (75) business days prior to a Contract Termination with a Terminating Provider. The plan shall not remove the Terminating Provider from its network until the Block Transfer filing is approved by the Department.

   1. (1) A form of the written notice that the plan intends to send to Affected Enrollees. The Enrollee Transfer Notice must include:

      1. (A) The name of the Terminating Provider Group or Terminating Hospital. The plan may also add the name of the assigned physician, where appropriate.
      2. (B) A brief explanation of why the transfer is necessary due to the Contract Termination between the plan and the Terminating Provider.
      3. (C) The date of the pending Contract Termination and transfer.
      4. (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.
      5. (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.
      6. (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 Terminating Provider. This statement may include either a statement outlining the specific conditions set forth in 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.
      7. (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 a downloadable copy of the policy from the plan's website.
      8. (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.

      9. (I) The following statement in at least 12-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 health plan's customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects consumers, by telephone at its toll-free number, 1-888-466-2219, or at a TDD number for the hearing and speech impaired at 1-877-688-9891, or online at www.dmhc.ca.gov.”

      10. (J) The plan shall require all contracted providers to include the statutory language required by 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.
      11. (K) Compliance with all applicable language assistance statues and regulations, including Health and Safety Code section 1367.04 and any regulations based upon Health and Safety Code section 1367.04.

   2. (2) For a Terminating Hospital Contract Termination the plan shall also submit the following information:

      1. (A) A brief explanation of the cause of the hospital redirection including whether the Contract Termination was initiated by the plan, the hospital, or by a contracting Provider Group.
      2. (B) A copy of the notice of termination sent or received by the plan.
      3. (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.

      4. (D) Either of the following two options:

         1. (i) a list of counties in which Affected Enrollees reside and the corresponding number of Affected Enrollees for each county, or
         2. (ii) a list of the zip codes in which Affected Enrollees reside and the corresponding number of Affected Enrollees for each zip code.
      5. (E) The number of Affected Enrollees assigned to the Terminating Hospital, and the number to be reassigned to each Alternate Hospital, classified by type of product (for example, commercial, Medi-Cal, Healthy Families, etc.)
      6. (F) The number of Affected Enrollees within a 15-mile radius of the Terminating Hospital.
      7. (G) The date that the plan anticipates it will mail the Enrollee Transfer Notice.
      8. (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.
      9. (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.
      10. (J) The identity of the Terminating Hospital and Alternate Hospital including the contract renewal or termination date for each Alternate Hospital.
      11. (K) A listing identifying any services that are available at the Terminating 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.
      12. (L) Based upon the data made public on the California Department of Health Care Access and Information 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.
      13. (M) The number of bed days utilized by plan enrollees at the Terminating Hospital for the most recently completed calendar year.
      14. (N) An analysis showing the driving distance between the proposed Alternate Hospital and the Terminating Hospital.
      15. (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.
      16. (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.
      17. (Q) Of the specialists available to Affected Enrollees with active admitting privileges at the Terminating 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.
      18. (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 Terminating Hospital's Provider Contract if they continue to use the Terminating Provider.
      19. (S) Confirmation that the plan's continuity of care program, as filed with the Department, will be implemented for any Affected Enrollees.

   3. (3) For a Terminating Provider Group Contract Termination, the plan shall also submit the following information:

      1. (A) A brief explanation of the cause or circumstances of the Contract Termination, including whether the Contract Termination was initiated by the plan or the Provider Group. If the 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.
      2. (B) A copy of the notice of termination sent or received by the plan.
      3. (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.

      4. (D) Either of the following two options:

         1. (i) a list of counties in which Affected Enrollees reside and the corresponding number of Affected Enrollees for each county, or
         2. (ii) a list of the zip codes in which Affected Enrollees reside and the corresponding number of Affected Enrollees for each zip code.
      5. (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 Terminating Provider.
      6. (F) The date that the plan anticipates it will mail the Enrollee Transfer Notice.
      7. (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.
      8. (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.
      9. (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.

      10. (J) A matrix of proposed Receiving Provider Groups that includes the following information:

          1. (i) the identity of the Receiving Provider Group(s), including its Risk Bearing Organization (RBO) number as assigned by the Department,
          2. (ii) 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. (iii) a listing of all hospitals to which Receiving Provider Groups refer Affected Enrollees, if different from the Terminating Provider Group.
      11. (K) Confirmation that the plan's continuity of care program, as filed with the Department, will be implemented for any Affected Enrollees.

   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.dmhc.ca.gov and must include, at minimum, all of the following information as appropriate for the type of provider involved:

3. (c) Timing of Notice Requirements. For any Contract Termination, a plan shall mail to all Affected Enrollees an Enrollee Transfer Notice that has been approved by the Department.

   1. (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.

4. (d) Notice Mailing Requirements. The plan shall send an Enrollee Transfer Notice to Affected Enrollees as follows:

   1. (1) For Affected Enrollees who are Block Transferred from a Terminating Provider Group -- the plan shall send the notice to all Affected Enrollees assigned to the Terminating Provider Group.
   2. (2) For Affected Enrollees who are block transferred from a Terminating Hospital -- the plan shall send the notice to all Affected Enrollees who reside within 15 miles of the Terminating Hospital.
5. (e) If, for any reason, a plan is unable to send all Enrollee Transfer Notices required pursuant to subsection (c) of this Rule, 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.
6. (f) If, for any reason, a plan is unable to file with the Department, a proposed Block Transfer filing, 75 business days prior to a Contract Termination with a Terminating Provider, the plan shall submit to the Department an exemption request from the 75-business day filing requirement. The application for exemption must include an explanation of the plan's reasons for being unable to meet the 75-business day filing requirement. If the Department does not approve or disapprove the exemption request within seven (7) days of its receipt of the request, the exemption will be deemed to have been approved by the Department.

7. (g) 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 Terminating 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. (1) A brief explanation of the fact that the plan has reached an agreement with the Affected Enrollee's previously assigned provider.
   2. (2) An explanation to the enrollee regarding options for either returning to the previously assigned provider, keeping the newly assigned provider, or selecting another participating provider from the plan's contracting provider list.
   3. (3) An explanation to the Affected Enrollee of the procedure by which the enrollee may contact the plan to express their desire to return to the previously assigned provider.

   4. (4) If the additional enrollee notice is given in writing, then the notice must include the following statement in at least 12-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 1-888-466-2219, or at TDD number for the hearing and speech impaired at 1-877-688-9891, or online at www.dmhc.ca.gov.”

   5. (5) Compliance with all applicable language assistance statutes and regulations, including Health and Safety Code section 1367.04 and any regulations based upon Health and Safety Code 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).

2. Amendment filed 3-18-2026; operative 3-18-2026. Submitted to OAL for filing and printing only pursuant to Government Code section 11343.8. Exempt from the APA pursuant to Health and Safety Code section 1367.03, subsection (f)(5) (Register 2026, No. 12).