Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING
Division 1 - ENROLLMENT AND DISENROLLMENT
Section 370.311 - Disenrollment
Universal Citation: 1 TX Admin Code ยง 370.311
Current through Reg. 49, No. 38; September 20, 2024
(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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