California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 14 - Miscellaneous Provisions › Section 1300.99 - Application to Surrender License

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An application to surrender a license as a health plan
					 shall be filed with the Director, in the following form:
DEPARTMENT OF MANAGED HEALTH CARE
STATE OF CALIFORNIA
APPLICATION FOR SURRENDER OF LICENSE
PURSUANT TO
SECTION
					 1399, HEALTH AND SAFETY
					 CODE
Date of Application
Dept. of Managed
							 Care
___________________________
___________________________File No.
____________________
1. Name of Licensee (as appearing in license)
___________________________
2. Person to be contacted regarding this
				  application.
___________________________
Name
___________________________
Address
___________________________
___________________________
Telephone Number
					 __________________________
3. Reason for Surrender of License (explain
				  briefly):
4. Date upon which
				  licensee proposes to terminate business:
___________________________
If the date is subject to contingencies or will be
					 determined hereafter, explain briefly below:
5. Complete the following:
a. Attach a copy of the balance sheet and a
				  statement of income and expense for the plan, prepared as of a date within 30
				  days of the filing of this application. Such financial statements need not be
				  certified.
b. State whether the
				  licensee is required to file certain reports pursuant to Section
				  1384 of the Knox-Keene Health Care
				  Service Plan Act of 1975. If so, state the date by which the licensee will
				  forward such reports to the Director:
___________________________
c. Section
				  1300.85.1. of the rules pursuant
				  to the Knox-Keene Health Care Service Plan Act of 1975 requires that the books
				  and records of a plan be preserved for a period of five years. State the name
				  and address of the custodian of the plan's books and records and the address at
				  which such records will be located:
Custodian: ___________________________
___________________________
Location: ___________________________
___________________________
d. Describe in an attachment hereto the
				  licensee's plans for the termination of its business as a health care service
				  plan or specialized health care service plan, including the following
				  information:
1. The provision for payment of
				  any amounts due to subscribers and enrollees and the aggregate amount owed
				  thereto.
2. The provision for
				  payment of any amounts due to providers of health care services, the aggregate
				  owed thereto and a schedule showing the persons to whom such amounts are owed,
				  the amount due each such person, and the date such liability first became due
				  and payable.
3. The final date for
				  payment of periodic payments by or on behalf of subscribers for health care
				  services, and the final date which the plan will be obligated to furnish health
				  care services by reason of such payments.
4. If an insurer assumes obligations as to
				  the plans subscribers and enrollees, attach a detailed statement of the plan
				  for the assumption of business by the subsequent provider or insurer, including
				  the provision being made for notice to subscribers and enrollees, group
				  representatives and providers of health care services who contract with the
				  plan.
5. If the plan or any
				  provider of health care services to the plan holds medical records as to any
				  subscriber or enrollee, indicate the disposition to be made of such records,
				  including the provision made for its subsequent availability to persons
				  providing health care services to such subscribers and
				  enrollees.
e. Is the
				  plan's application pursuant to Section
				  1351 of the Knox-Keene Health Care
				  Service Plan Act of 1975 current, reflecting all matters which require an
				  amendment to such application pursuant to Rules 1300.52, 1300.52.1 or
				  1300.52.2?
Yes [] No []
If "no" attach an amendment(s) to such application in
					 conformance with such rules
f. Is the plan currently involved in any
				  civil or administrative proceeding?
Yes [] No []
If "yes" furnish full details, including the court or
					 administrative action before which such matter is
					 pending.