(a) Disenrollment at a member's request.
(1) Members will be informed of disenrollment opportunities
no less than annually.
(2) During the first 90 days of enrollment in a managed
care organization (MCO), a member may request to move to another MCO
for any reason. After 90 days with an MCO, a member must show good
cause to move to another MCO.
(3) Disenrollment will take place no later than the
first day of the second month after the month in which the member
has requested a change.
(b) Disenrollment at an MCO's request.
(1) An MCO may submit a request to HHSC that a member
be disenrolled without the member's consent in the following limited
circumstances:
(A) the member misuses or loans his or her MCO membership
card to another person to obtain services;
(B) the member is disruptive, unruly, threatening or
uncooperative to the extent that the member's membership seriously
impairs the MCO's or a provider's ability to provide services to the
member or to obtain new members, and member's behavior is not caused
by a physical or behavioral health condition; or
(C) the member steadfastly refuses to comply with managed
care restrictions (such as repeatedly using the emergency room in
combination with a refusal to allow treatment for the underlying medical
condition).
(2) An MCO must take reasonable measures to correct
a member's behavior prior to requesting disenrollment. Reasonable
measures may include providing education and counseling regarding
the offensive acts or behaviors.
(3) HHSC will review all requests for disenrollment.
HHSC will grant a request if it determines that all reasonable measures
taken by the MCO have failed to correct the member's behavior. If
HHSC grants a request, it will notify the member of the disenrollment
decision and the availability of HHSC's fair hearings process for
an appeal of the disenrollment.
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