Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1720.1 - FREEDOM OF CHOICE, ENROLLMENT AND DISENROLLMENT › Subchapter 4 - DISENROLLMENT › Section 17-1720.1-29 - Disenrollment

Current through June, 2024
An individual may be disenrolled for reasons that include,
					 but are not limited to, the following:
(1) A decision by an administrative appeals
				  office for disenrollment from a participating health plan;
(2) A court order for disenrollment from a
				  participating health plan;
(3)
				  Provisions in federal or State statutes or administrative rules;
(4) A non-returning plan or termination of
				  the health plan's contract or the start of a new contract;
(5) Mutual agreement by the participating
				  health plans involved, the individual and the department;
(6) Violations by a participating health plan
				  specified in chapter 17-1735.2;
(7)
				  Change in foster placement if necessary for the best interest of the
				  child;
(8) The individual selects a
				  health plan that is not capped during the annual plan change period;
(9) The individual's PCP or long-term care
				  residential facility is not in the health plan's provider network and is in the
				  provider network of a different health plan, provided the health plan is not at
				  its maximum enrollment;
(10) The
				  individual is eligible to receive HCBS or personal assistance services level I
				  and is enrolled in a health plan with a waiting list for HCBS or personal
				  assistance services level I and the other health plan does not have a waiting
				  list for the necessary service(s);
(11) The participating health plan's refusal,
				  because of moral or religious objections, to cover the service the individual
				  seeks as allowed for in the contract with health plan;
(12) The individual's need for related
				  services (e.g., a cesarean section and a tubal ligation) to be performed at the
				  same time and not all related services are available within the network and the
				  individual's primary care physician or another provider determines that
				  receiving the services separately would subject the individual to unnecessary
				  risk;
(13) Lack of direct access to
				  women's health care specialists for breast cancer screening, pap smears and
				  pelvic exams;
(14) Other reasons,
				  including but not limited to, poor quality of care, lack of access to covered
				  services, or lack of access to providers experienced in dealing with the
				  individual's health care needs, lack of direct access to certified nurse
				  midwives, pediatric nurse practitioners, family nurse practitioners, if
				  available in the geographic area in which the individual resides;
(15) Relocation to a service area where the
				  health plan in which the individual was enrolled does not provide
				  services;
(16) The individual
				  missed the annual plan change period due to a temporary loss of Medicaid
				  eligibility and was re-enrolled in the previous health plan;
(17) Voluntary withdrawal from participation
				  in the medical assistance program by the individual or a authorized
				  representative;
(18) Not meeting
				  the eligibility requirements;
(19)
				  Death of the enrolled individual;
(20) The enrolled individual is a medically
				  needy individual who is two full months in arrears in the payment of the
				  designated enrollment fee, unless the failure to pay occurs because:
(A) The individual is not in control of the
				  individual's personal finances, and the arrearage is caused by the party
				  responsible for the individual's finances, and action is being taken to
				  remediate the situation, including but not limited to:
(i) Appointment of a new responsible party
				  for the individual's finances; or
(ii) Recovery of the individual's funds from
				  the responsible party which will be applied to the individual's enrollment fee
				  obligation.