- Participating Physician Groups (PPG)
Member Disenrollment Process
A member may request disenrollment from Cal MediConnect in any month and for any reason, or they may enroll into another Medicare Advantage (MA) HMO plan, or an MA stand-alone prescription drug (Part D) plan, which automatically disenrolls them from Cal MediConnect. A member may disenroll by:
- Contacting the Department of Health Care Services' (DHCS') enrollment broker, Health Care Options (HCO).
- Calling 1-800-633-4227.
- Sending a signed written disenrollment notice to HCO.
- Enrolling in an MA HMO plan or MA prescription drug plan by calling 1-800-633-4227 or using the Centers for Medicare & Medicaid Services (CMS) online enrollment center.
- Enrolling in another health plan participating in Cal MediConnect.
Health Net forwards any requests to disenroll to HCO. Members who verbally request disenrollment from Health Net are instructed to make the request in one of the ways outlined above.
After the member submits a request to disenroll, DHCS provides the member with a disenrollment notice within 10 calendar days of receipt of the request to disenroll. Members have until the last calendar day of the month to request disenrollment. The effective date for all voluntary disenrollments is the first day of the month following DHCS' receipt of the disenrollment request.
DHCS or CMS can initiate involuntary disenrollment requests. DHCS disenrolls members for the following reasons:
- Member moves outside the service area (including incarceration) or resides temporarily outside the service area for more than six consecutive months.
- Member loses entitlement to either Medicare Part A or B.
- Member loses Medi-Cal eligibility.
- Information is materially misrepresented regarding reimbursement for third-party coverage.
- The health plan's contract with CMS is terminated, or the member is within an area excluded by the health plan due to the health plan reducing its service area.
- Member is deceased.
- Member is not lawfully present or loses lawful presence status.
DHCS may request Contract Management Team (CMT) approval to disenroll a member from a Cal MediConnect plan if:
- The member engages in disruptive behavior, which is so disruptive, uncooperative or abusive that continuing membership seriously impairs Health Net's or its participating providers' ability to provide services to the member or other members. Disruptive behavior includes threats of violence by the member to employees of Health Net or its participating providers. The member's behavior must be determined to be unrelated to an adverse change in the member's health status, diminished mental capacity, uncooperative or disruptive behavior resulting from special needs or because the member sued for medical services. Members are disenrolled only after serious efforts to resolve the problem have been made.
- The member provides fraudulent information on an enrollment request, or permits abuse of the Health Net identification (ID) card.
Disenrollment is generally effective the first day of the calendar month after the month in which DHCS sends the final notice to the member indicating the intended action.