- Participating Physician Groups (PPG)
This section contains general information and procedures regarding member disenrollment requirements.
The following document applies only to Participating Physician Groups (PPG), Hospitals, and Ancillary Providers.
A member may disenroll at any time and without cause by contacting the Health Care Options (HCO) enrollment contractor, who then issues disenrollment forms directly to the member.
Members in a mandatory aid code must simultaneously re-enroll in another health plan or the HCO enrollment contractor assigns them a health plan. Members in non-mandatory aid codes may choose a new health plan or return to the Medi-Cal fee-for-service (FFS) program.
The disenrollment process may take 15 to 45 days to complete. Health Net continues to be responsible for the member's health care until disenrollment is approved. The Department of Health Care Services (DHCS), not the plan, approves all such requests.
Disenrollment is mandatory under the following conditions:
- Member loses Medi-Cal eligibility.
- Member moves out of the plan's approved service area.
- Member's Medi-Cal aid code changes to an aid code not covered under the health plan.
- Member's enrollment violated state marketing and enrollment laws.
- Member requests disenrollment as a result of plan merger or reorganization.
- Member is eligible for certain carve-out or waiver programs that require disenrollment (for example, long-term care for the month of admission and the following month, major organ transplants with the exception of adult kidney transplants and certain waiver programs).
To request disenrollment of a member, providers must contact the Health Net Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or CalViva Health Medi-Cal Member Services Department (for Fresno, Kings and Madera counties). Providers are asked to describe the circumstances leading them to request the disenrollment and may be asked to submit documentation regarding their requests.
On notification, the Medi-Cal Member Services Department contacts the member and provides counseling. If necessary, the department reassigns the member to a new primary care physician (PCP) within the plan. If reassignment is not possible and the member requires disenrollment based on the guidelines outlined below, the Medi-Cal Member Services Department sends the information to the Department of Health Care Services (DHCS) for approval or disapproval of the disenrollment request. Once the disenrollment has been approved, a letter is sent to the member.
A provider-initiated disenrollment request based on the breakdown of the provider-member relationship is considered good cause and is approved by DHCS only if one or more of the following circumstances occur:
- The member is repeatedly verbally abusive to plan providers, ancillary or administrative staff, or other plan members.
- The member physically assaults a plan provider, staff person or plan member, or threatens another person with a weapon. In this instance, the provider is expected to file a police report and bring charges against the member.
- The member is disruptive to provider operations in general.
- The member habitually uses providers not affiliated with Health Net for non-emergency services without required authorizations.
- The member has allowed fraudulent use of the Health Net identification card to receive services from Health Net providers.
Failure to follow prescribed treatment, including failure to keep appointments, is not, in itself, good cause for disenrollment, unless Health Net and the provider can demonstrate to DHCS that, as a result of such failure, the plan or provider is exposed to a substantially greater and unforeseeable risk than otherwise contemplated.
If a member refuses to transfer from an out-of-network hospital to an in-network hospital when it is medically safe to do so, a temporary plan-initiated disenrollment may be obtained through DHCS.