Illinois Administrative Code
Title 50 - INSURANCE
Part 4521 - HEALTH MAINTENANCE ORGANIZATION
Section 4521.111 - Cancellation
Universal Citation: 50 IL Admin Code ยง 4521.111
Current through Register Vol. 48, No. 12, March 22, 2024
a) No HMO shall cancel a group or individual contract or evidence of coverage except for one or more of the following reasons:
1) Failure of
the enrollee to pay the amount due under the contract or evidence of coverage,
for which the enrollee is legally responsible;
2) Fraud or material misrepresentation in
enrollment or in the use of services or facilities;
3) Material violation of the terms of the
contract or evidence of coverage;
4) Failure of the enrollee and the primary
care physician to establish a satisfactory patient-physician relationship if
the enrollee has repeatedly refused to follow the plan of treatment ordered by
the physician; it is shown that the HMO has in good faith provided the enrollee
with the opportunity to select an alternative primary care physician; and the
enrollee has been notified in writing at least 31 days in advance that the HMO
considers such patient-physician relationship to be unsatisfactory;
5) Under the Basic Outpatient Preventive and
Primary Care Services for Children Program, failure to meet or continue to meet
eligibility requirements as required by Section
5421.131
of this Part; or
6) Other good
cause agreed upon in the contract and approved by the Director pursuant to
Section 4-13 of the Act.
b) A group contract, evidence of coverage or individual contract may not be cancelled for any of the following reasons:
1) The status of the enrollee's
health;
2) The enrollee has
exercised his or her rights under the HMO's grievance system.
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