California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53891 - Disenrollment of Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Health Care Options Program shall disenroll any member from a plan when one of
					 the following conditions is met:
(1) A
					 member's eligibility for enrollment as a Medi-Cal beneficiary is
					 terminated.
(2) The Health Care
					 Options Program incorrectly enrolled or assigned a member to a plan not of
					 his/her choosing, as indicated on the enrollment request form completed by
					 beneficiary.
(3) A member was
					 enrolled in the plan due to incorrect information provided by the Health Care
					 Options Program or due to prohibited marketing practices by the plan as
					 specified in sections
					 53880 or
					 53881.
(4) A member's request for disenrollment is
					 due to plan merger or reorganization.
(5) There is a change of a member's place of
					 residence to outside the plan's service area.
(6) A member requests the disenrollment for
					 any reason and the request is not made during any restricted disenrollment
					 period for that member.
(7) The
					 member or the plan requests disenrollment for good cause, as specified below,
					 when the request is made during any restricted disenrollment period for the
					 member. For the purposes of this subsection, good cause for disenrollment means
					 one of the following:
(A) The member requires
					 Medi-Cal services that are excluded under the terms of the plan's contract and
					 which can be obtained only if the member disenrolls from the plan.
(B) The plan requests disenrollment because
					 the member uses or permits to be used fraudulently the member's Medi-Cal
					 coverage under the plan, as defined in Welfare and Institutions Code section
					 14043.1(d).
					 Fraudulent use includes allowing others to use the member's plan membership
					 card to receive services from the plan or to submit claims for services which
					 were not provided to the member.
(C) The plan or member requests the
					 disenrollment because of an irreconcilable breakdown in the physician-patient
					 relationship, specified in section
					 53889(j)(2)(I).
(D) The member or plan requests the
					 disenrollment for any other reasons determined by the department to constitute
					 good cause.
(8) The
					 member requests disenrollment for one of the reasons specified for exemption
					 from plan enrollment in section
					 53887 and meets the criteria
					 specified in that section.
(9) The
					 member meets the criteria for expedited disenrollment in accordance with
					 section 53889(j).
(10) The member becomes enrolled in one of
					 the following forms of other health coverage, except when dual enrollment is
					 permitted as specified in Section
					 53845(f):
(A) Medicare HMO
(B) CHAMPUS Prime HMO
(C) Kaiser HMO
(D) Any other HMO/Prepaid Health Plan in
					 which the enrollee is limited to a prescribed panel of providers for
					 comprehensive service.