§ 53889. Enrollment/Disenrollment Processing.

(a) An eligible beneficiary shall submit an enrollment or disenrollment request on an original, signed enrollment/disenrollment form to the Health Care Options Program by mail or in person at department-approved Health Care Options Program sites. Expedited disenrollment requests may also be submitted by facsimile. An eligible beneficiary also may request expedited disenrollment over the telephone from the Health Care Options Program.

(b) An eligible beneficiary shall provide the following information on the enrollment/disenrollment form when requesting enrollment or disenrollment: first and last name of the beneficiary; sex; date of birth; Social Security Number; Medi-Cal number; complete mailing address; telephone number, if available; plan choice, if requesting enrollment; name and address of doctor or clinic beneficiary is choosing as primary care provider; language of the beneficiary; and the reason for disenrolling, if requesting disenrollment. If the beneficiary is requesting enrollment or disenrollment for any other eligible family member, the same information shall be provided for the other eligible beneficiaries on the same form where indicated. The beneficiary or authorized representative, as specified in (h), shall sign and date the enrollment/disenrollment form.

(c) The Health Care Options Program shall assist with, accept and process enrollment and disenrollment requests regardless of the beneficiary's race, creed, color, religion, age, sex, national origin, ancestry, marital status, sexual orientation, physical or mental disability, or pre-existing medical conditions.

(d) The Health Care Options Program shall ensure that beneficiaries are informed of their right to request a fair hearing in accordance with sections 50951, 51014.1, 51014.2, and 53894.

(e) The Health Care Options Program shall accept and process all completed enrollment and disenrollment requests, including expedited disenrollment requests, from eligible beneficiaries within two working days of receipt if such requests meet the conditions for plan disenrollment specified in section 53891.

(f) Approval of enrollment and disenrollment requests is conditioned upon receipt of a fully completed enrollment/disenrollment form and all required supporting documentation.

(g) The Health Care Option Program shall notify beneficiaries in writing of the approval or disapproval of enrollment and disenrollment requests, including expedited disenrollment requests, within seven working days of receipt of the request. This notice shall include the effective date of the enrollment and/or disenrollment, as specified in (h) below.

(h) Enrollment and disenrollment requests may be submitted by the beneficiary or other authorized individuals listed in (1) through (7) below:

(1) Persons with legal authority to act on the beneficiary's behalf. Such persons include, but are not limited to, parents, legal guardians, publicly appointed guardians, and other legally designated representatives.

(2) Department staff responsible for the administration of the Two-Plan Model Program and Health Care Options Program staff.

(3) County staff, including but not limited to, social workers, probation officers, caseworkers, and other local government personnel responsible for supervision or case management of the beneficiary.

(4) Foster parents or parents adopting a child in the Adoption Assistance Program.

(5) Medi-Cal managed care Two-Plan Model Program contractors.

(6) Case managers, physicians or medical staff of the Medi-Cal home and community-based services waiver programs.

(7) Care coordinators at Regional Centers for the Developmentally Disabled.

(i) The effective date of enrollment or disenrollment is determined as follows:

(1) Enrollment requests and non-expedited disenrollment requests processed before the monthly update to the Medi-Cal Eligibility Data System shall be effective on the first day of the month following the month in which the request is processed.

(2) Enrollment requests and non-expedited disenrollment requests processed after the monthly update to the Medi-Cal Eligibility Data System shall be effective on the first day of the second month following the month in which the request is processed.

(3) Expedited disenrollment requests shall be effective on the first day of the month in which the request is processed, whether submitted before or after the monthly update to the Medi-Cal Eligibility Data System.

(j) The Health Care Options Program shall process all completed disenrollment requests meeting the requirements of section 53891 as expedited disenrollments if they also meet the criteria in (1) and (2) below. Approved expedited disenrollments are effective as specified in (i)(3) in this section.

(1) The beneficiary has not used services for which the plan is contractually obligated to pay during the month for which disenrollment is requested, and

(2) Disenrollment is requested for one of the following reasons, and all required supporting documentation is provided:

(A) The beneficiary is an American Indian, a member of an American Indian household, or chooses to receive health care services through an Indian Health Service facility and has written acceptance from the Indian Health Service facility for care on a fee-for-service basis.

(B) The beneficiary is receiving services under the Foster Care or Adoption Assistance Program or has been placed in the care of Child Protective Services. The disenrollment request must be submitted by the authorized foster parent, the authorized adoptive parent, or the licensed agency providing protective services.

(C) The beneficiary has a complex medical condition, specified in section 53887(a)(2)(A), and the disenrollment request is submitted with verification of the medical condition, treatment plan, and duration of treatment by the Medi-Cal fee-for-service physician.

(D) The beneficiary is enrolled in a Medi-Cal waiver program that allows the individual to receive sub-acute, acute, intermediate or skilled nursing care at home rather than in a sub-acute care facility, acute care hospital, intermediate care facility or skilled nursing facility. Verification of participation in the waiver program must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative as specified in (h).

(E) The beneficiary is participating in a pilot project organized and operated pursuant to sections 14087.3, 14094.3, or 14490 of the Welfare and Institutions Code. Verification of participation in the pilot program must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative as specified in (h).

(F) The Health Care Options Program incorrectly enrolled or assigned the eligible beneficiary to a plan not chosen by the beneficiary, as determined by the Health Care Options Program, the beneficiary or the plan and verified by the Health Care Options Program. An explanation of the incorrect enrollment or assignment must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative as specified in (h).

(G) The beneficiary submitted a non-expedited disenrollment request that meets the requirements for disenrollment or a request for exemption from plan enrollment based upon a qualifying complex medical condition that was not timely processed by the Health Care Options Program. An explanation of the lack of timely processing must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative as specified in (h).

(H) The beneficiary has moved or been placed outside of the plan service area and has notified his or her caseworker of the new address. If the beneficiary's new address is not yet shown in the Medi-Cal Eligibility Data System, the beneficiary is responsible for requesting that the caseworker provide verification of the new address to the Health Care Options Program by telephone, facsimile, or in writing.

(I) The beneficiary or plan has experienced an irreconcilable breakdown in the patient-physician relationship, has used the plan's problem resolution process, and the department has approved the disenrollment. Documentation of the irreconcilable breakdown in the patient-physician relationship, including the use of the plan's problem resolution process, must be submitted with the disenrollment request by the beneficiary, the beneficiary's authorized representative as specified in (h), or the plan. Use of the plan's problem resolution process shall not be required in situations where a beneficiary's behavior presents physical risk to plan staff, a provider, or staff at a provider site, and the plan or provider has filed a police report regarding the physical risk.

(J) The beneficiary 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 determined by the Health Care Options Program, the beneficiary or the plan and verified by the Health Care Options Program. Explanation of the incorrect information or the prohibited marketing practices must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative, as specified in (h).

(K) The beneficiary requires nursing facility services, other than members requesting hospice services, has been admitted to a long-term care facility and will remain in long-term care for more than two consecutive months. The name of the long-term care facility and the date of admission must be submitted with the disenrollment request by the beneficiary or the beneficiary's authorized representative as specified in (h).

(L) The beneficiary is deceased, and the death is not yet reflected in the Medi-Cal Eligibility Data System. A copy of the death certificate must be submitted with the disenrollment request by the beneficiary's authorized representative as specified in (h).

(k) The Health Care Options Program shall notify the plan of enrollment and disenrollment on a weekly basis. However, enrollment and disenrollment is effective only when confirmed by the department's eligibility information contained in the Medi-Cal Eligibility Data System update that is provided monthly to plans.

HISTORY

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

3. Repealer and new section heading, section and Note filed 12-19-2000 as an emergency; operative 12-19-2000. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 2000, No. 51).

Note

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4 and 14495, Welfare and Institutions Code.