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