§ 53891. Disenrollment of Members.

(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.

(b) The department may restrict disenrollment from a plan during the second through sixth month of a member's initial enrollment in the plan when all of the following apply:

(1) Both plans in a designated area are operational.

(2) Both plans have requested restricted disenrollment.

(3) The department's federal waiver or State Plan amendment authorizing operation of the Two-Plan Model Program authorizes restricted disenrollment.

(c) Each disenrollment request shall be accompanied by an enrollment request for enrollment in the competing plan unless the member has moved out of the plan's service area, meets the criteria in section 53887 for exemption from plan enrollment, will be incarcerated for more than one month, or is eligible for voluntary enrollment. Any member who does not select the competing plan shall be assigned, in accordance with section 53883. If the competing plan is at enrollment capacity, fee-for-service Medi-Cal shall be made available to the eligible beneficiary.

(d) Disenrollment requests shall be processed in accordance with the provisions of section 53889.

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. Amendment of 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, 14407.6 and 14407.8, Welfare and Institutions Code.