Current through Register 2025 Notice Reg. No. 13, March 28, 2025
(a) A subscriber shall be transferred from
one participating health, dental, or vision plan to another if any of the
following occurs:
(1) The applicant so
requests in writing because the subscriber no longer resides in an area served
by the participating plan in which the subscriber is enrolled, and there is at
least one other participating plan serving the area in which the subscriber now
resides.
(A) If the program learns that the
subscriber no longer resides in an area served by the participating health plan
in which the subscriber is enrolled, but the applicant does not choose a new
health plan within thirty (30) days of a written notice from the program, the
program will enroll the subscriber in the Community Provider Plan in the
subscriber's county of residence.
(B) If the program learns that the subscriber
no longer resides in an area served by the participating dental plan in which
the subscriber is enrolled, but the applicant does not choose a new dental plan
within thirty (30) days of a written notice from the program, the program will
enroll the subscriber in a participating dental plan in the subscriber's county
of residence. If there is more than one (1) participating dental plan in the
subscriber's county of residence, the program will alternate assignments
between the participating dental plans so that the transfers are evenly
distributed among the participating dental plans.
(C) If the program learns that the subscriber
no longer resides in an area served by the participating vision plan in which
the subscriber is enrolled, but the applicant does not choose a new vision plan
within thirty (30) days of a written notice from the program, the program will
enroll the subscriber in a participating vision plan in the subscriber's county
of residence. If there is more than one (1) participating vision plan in the
subscriber's county of residence, the program will alternate assignments
between the participating vision plans so that the transfers are evenly
distributed among the participating vision plans.
(2) The applicant or the participating plan
so requests in writing because of failure to establish a satisfactory
subscriber-plan relationship and the Executive Director of the Board or
designee determines that the transfer is in the best interests of the
subscriber and the program, and there is at least one other participating plan
serving the area in which the subscriber resides.
(3) The program contract with the
participating plan in which the subscriber is enrolled is canceled or not
renewed.
(A) If the applicant does not choose
a new health plan in response to two (2) written notices and three (3) phone
calls from the program by the necessary date of transfer, the program will
enroll the subscriber in the Community Provider Plan in the subscriber's county
of residence.
(B) If the applicant
does not choose a new dental plan in response to two (2) written notices and
three (3) phone calls from the program by the necessary date of transfer, the
program will enroll the subscriber in a participating dental plan in the
subscriber's county of residence. If there is more than one (1) participating
dental plan in the subscriber's county of residence, the program will alternate
assignments between the participating dental plans so that the transfers are
evenly distributed among the participating dental plans.
(C) If the applicant does not choose a new
vision plan in response to two (2) written notices and three (3) phone calls
from the program by the necessary date of transfer, the program will enroll the
subscriber in a participating vision plan in the subscriber's county of
residence. If there is more than one (1) participating vision plan in the
subscriber's county of residence, the program will alternate assignments
between the participating vision plans so that the transfers are evenly
distributed among the participating vision plans.
(4) An open enrollment request is submitted
pursuant to Section
2699.6621.
(5) An AIM infant subscriber has a sibling(s)
that is enrolled in a different health plan and is transferred pursuant to
subsection (e).
(b) A
subscriber shall be transferred from one participating health, dental, or
vision plan to another once for any reason upon the applicant's request as
follows:
(1) Within the first three (3)
months from the effective date of coverage after original enrollment into the
program or re-enrollment into the program after a period of
disenrollment.
(2) Within the first
thirty (30) days from the effective date of coverage in a new plan following
open enrollment.
(c) If a
subscriber is transferred pursuant to (a) or (b) above, all other subscribers
of the same applicant who live in the same household will also be transferred,
unless the subscriber was transferred because the subscriber moved from the
household.
(d) Transfer of
enrollment shall take effect on the first day of a month and shall be within
forty (40) days of approval of the request, or, if the transfer is pursuant to
subsection (a)(3) above, shall take effect prior to the end of the contract.
However, subscribers in inpatient facilities on the scheduled date of transfer
shall not be transferred to a new health plan until the first day of the month
following completion of their inpatient stay.
(e) The following provisions apply to the
transfer of AIM infants from one participating health, dental, or vision plan
to another:
(1) An AIM infant subscriber will
be automatically transferred to the same health, dental, and vision plan that
his or her sibling(s) is enrolled in, effective on the first day of the
infant's third calendar month of birth, unless one of the following occurs:
(A) The applicant submits a letter stating
that the infant has a physical, developmental, behavioral, or emotional
condition that requires continuity of care, and requests that the infant's
sibling(s) be transferred to the infant's health plan, or
(B) The applicant submits a letter stating
that the infant has a physical, developmental, behavioral, or emotional
condition that requires continuity of care, and requests that the infant remain
with the current health plan and the sibling(s) remain with his or her current
health plan. For siblings enrolled in different health plans, the applicant
must choose the same health plan for all children living in the household
during the Open Enrollment period after the AIM infant's first
birthday.
(2) An AIM
infant subscriber shall be transferred from one participating health, dental,
or vision plan to another if the applicant so requests in writing once within
the first three (3) months from the date of the infant's birth and the infant
subscriber has no sibling(s) in the program. The transfer of enrollment shall
take effect on the first day of a month and shall be within forty (40) days
after the approval of the request but not earlier than the third calendar month
of the infant's enrollment in the program.
(f) The transfers of enrollment shall comply
with Sections
2699.6600(c)(1)(BB)1.
and 2699.6623.
1. New section
filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A
Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency
language will be repealed by operation of law on the following
day.
2. Certificate of Compliance as to 2-20-98 order transmitted to
OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).
3. Amendment of
section and NOTE filed 10-23-2001; operative 11-22-2001 (Register 2001, No.
43).
4. New subsections (a)(5) and (f)-(f)(2) filed 7-1-2004 as an
emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80,
A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be
transmitted to OAL by 12-28-2004 or emergency language will be repealed by
operation of law on the following day.
5. Certificate of Compliance
as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register
2005, No. 1).
6. Amendment of subsections (a)(5)-(b), repealer of
subsection (c), subsection relettering and amendment of newly designated
subsection (c) filed 9-15-2008; operative 10-15-2008 (Register 2008, No.
38).
7. Repealer of subsection (b), new subsections (b)-(b)(2) and
(f)(3) and amendment of NOTE filed 10-29-2009; operative 11-1-2009 pursuant to
Government Code section
11346.1(d)
(Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL
by 4-30-2010 or emergency action will be repealed by operation of law on the
following day. This regulatory action is deemed to meet the emergency standard
and is exempt from OAL review pursuant to Insurance Code section
12693.22.
8.
Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010
and filed 6-9-2010 (Register 2010, No. 24).
Note: Authority cited: Sections
12693.21
and
12693.22,
Insurance Code. Reference: Sections
12693.21,
12693.22,
12693.326
and
12693.51,
Insurance Code.
