California Code of Regulations
Title 10 - Investment
Chapter 5.5 - Major Risk Medical Insurance Board
Article 2 - Eligibility, Application, and Enrollment
Section 2698.204 - Disenrollment

Universal Citation: 10 CA Code of Regs 2698.204

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Disenrollment shall occur when:

(1) The subscriber requests in writing to be disenrolled or that an enrolled dependent be disenrolled.

(2) The enrolled dependent requests in writing to be disenrolled.

(3) The dependent subscriber requests in writing to be disenrolled.

(4) The subscriber or dependent subscriber fails to make subscriber contributions in accordance with section 2698.403.

(5) The subscriber, enrolled dependent or dependent subscriber no longer meets the residency requirement.

(6) The subscriber, enrolled dependent or dependent subscriber has notified the program in writing of his/her eligibility for Part A and Part B of Medicare or the program becomes aware of his/her eligibility for Part A and Part B of Medicare, except subscribers, enrolled dependents or dependent subscribers on Medicare solely because of end-stage renal disease.

(7) The subscriber, enrolled dependent or dependent subscriber has been enrolled in the program for a period of 36 consecutive months from his/her respective start of coverage date.
(A) If the subscriber, enrolled dependent or dependent subscriber was initially subject to a post-enrollment waiting period, the length of that post-enrollment waiting period shall not be calculated as part of his/her 36 consecutive months of enrollment.

(B) If the subscriber, enrolled dependent or dependent subscriber was initially subject to a pre-existing condition exclusion period, the length of that pre-existing condition exclusion period shall be calculated as a part of his/her 36 consecutive months of enrollment.

(8) The subscriber, enrolled dependent or dependent subscriber has committed an act of fraud to circumvent the statutes or regulations of the program.

(9) Death of a subscriber, enrolled dependent or dependent subscriber.

(b) The subscriber or dependent subscriber shall be notified by the program in writing of the disenrollment of the subscriber and/or enrolled dependents or the dependent subscriber, the reason for the disenrollment, the effective date of the disenrollment, and shall be given an explanation of the appeals process.

(c) Disenrollment pursuant to (a)(1) and (a)(2) and (a)(3) of this section shall be effective on the last day of the month in which the written request was received.

(d) Disenrollment pursuant to (a)(4) of this section shall be retroactive to the last day of the month for which the required subscriber contribution was paid in full.

(e) Disenrollment pursuant to (a)(5) of this section shall be effective on the last day of the month in which the program determines that the subscriber, enrolled dependent or dependent subscriber no longer meets the residency requirement.

(f) Disenrollment pursuant to (a)(6) of this section shall be effective on the last day of the month in which the subscriber's or the dependent subscriber's written notification that the subscriber and/or the enrolled dependent or the dependent subscriber is now eligible for Medicare Part A and Part B was received or on the last day of the month in which the program becomes aware of the subscriber's, enrolled dependent's or dependent subscriber's eligibility for Medicare Part A and Part B.

(g) Disenrollment pursuant to (a)(7) of this section shall be effective on the last day of the subscriber's, enrolled dependent's or dependent subscriber's 36th consecutive month of enrollment.

(1) The subscriber, enrolled dependent or dependent subscriber shall be notified by the program in writing of their disenrollment from the program, pursuant to (a)(7) of this section, 90 days in advance of the end of his/her 36th consecutive month of enrollment. The notice shall contain his/her effective date of disenrollment and shall provide information regarding the availability of guaranteed coverage in the private insurance market pursuant to Health and Safety Code section 1373.62 and Insurance Code section 10127.15.

(2) The program shall mail a second notice to the subscriber, enrolled dependent or dependent subscriber no less than 45 days in advance of the end of his/her 36th consecutive month of enrollment. The notice shall contain his/her effective date of disenrollment and a Certificate of Program Completion.

(h) Disenrollment pursuant to (a)(8) of this section shall be effective on the last day of the month in which the program determines that the subscriber, enrolled dependent or dependent subscriber has committed an act of fraud to circumvent the statutes or regulations of the program.

(i) Disenrollment pursuant to (a)(9) of this section shall be effective on the last day of the month in which death occurred.

(j) If disenrolled for any reason, a subscriber and enrolled dependent, if any, or a dependent subscriber shall not be eligible for enrollment in the program for 12 months from the date of disenrollment.

(k) Subscribers, enrolled dependents or dependent subscribers disenrolled pursuant to (a)(7) of this section who are eligible for the Pilot Program and elect that coverage, shall not be eligible for enrollment in the program for a period of 12 months from the date of disenrollment from the Pilot Program standard benefit plan if the disenrollment from the Pilot Program standard benefit plan was a result of:

(1) A request to voluntarily disenroll; or

(2) Non-payment of premiums due for the Pilot Program standard benefit plan; or

(3) An act of fraud.

1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order transmitted to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Editorial correction of printing error (Register 91, No. 27).
4. Amendment of subsections (a), (a)(3)-(a)(3)(B) and NOTE filed 12-19-91 as an emergency; operative 12-19-91 (Register 92, No. 19). A Certificate of Compliance must be transmitted to OAL 4-17-92 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 12-19-91 order including amendment of subsection (a)(3)(B) transmitted to OAL 4-8-92 and filed 5-12-92 (Register 92, No. 23).
6. New subsection (a)(5) and amendment of NOTE filed 8-11-92; operative 9-11-92 pursuant to Government Code section 11346.2(d) (Register 92, No. 34).
7. Amendment of subsection (a)(3)(B) filed 5-19-95; operative 6-19-95 (Register 95, No. 20).
8. Amendment of subsections (a)(2) and (b) filed 4-23-96; operative 5-23-96 (Register 96, No. 17).
9. Amendment of section and NOTE filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).

Note: Authority cited: Sections 12711 and 12712, Insurance Code; and ASSEM. Bill No. 1401 (Stats. 2002, ch. 794 Sec. 21). Reference: Sections 10127.15, 12711, 12733 and 12735, Insurance Code; and Section 1363.62, Health and Safety Code.

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