- Participating Physician Groups (PPG)
This section contains general information and procedures regarding member disenrollment requirements.
Health Net does not, either verbally or in writing or by any action or inaction, request or encourage a Medicare member to disenroll. However Health Net must disenroll a member from a Medicare Advantage plan due to death, failure to pay the Part D-Income Related Monthly Adjustment Amount (IRMAA), a move outside of the plan's service area, including incarceration, loss of Medicare Part A or Part B, loss of special needs status (if the member is enrolled in a Special Needs Plan (SNP)), or a non-renewal or service area reduction. Health Net may disenroll a member if the member engages in disruptive behavior, provides fraudulent information on an enrollment request or if the member permits abuse of an identification card (ID).
Health Net has the right to disenroll a Health Net Medicare Advantage (MA) member under the following circumstances, for instance:
- When a member fails to pay Part D-IRMAA. Centers for Medicare & Medicaid Services (CMS) will report the disenrollment to Health Net if the member fails to pay the Part-D IRMAA within a 3-month grace period.
- When Health Net confirms that the member has permanently moved outside the plan's service area, Health Net must disenroll the member. Health Net is required to send a written notice informing the member of its intent to disenroll and explain the member's right to file a grievance against this action.
- When a member is temporarily outside the Health Net MA plan service area for a period of six months or longer, Health Net is required to disenroll the member. Only emergency services, out-of-area urgent care, and out-of-area renal dialysis are covered while the member is temporarily out of the plan's service area.
- Disruptive behavior by a member, which is so disruptive, unruly, abusive, or uncooperative to the extent that continuing membership seriously impairs Health Net 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. Health Net disenrolls members for disruptive behavior only after serious efforts to resolve the problem, including the use of internal grievance procedures, consideration of extenuating circumstances, and the Centers for Medicare & Medicaid Services' (CMS') advance approval of the proposed disenrollment, have been made. Disenrollment is effective the first day of the calendar month after the month in which final notice is sent to the member of the intended action.
A member may disenroll by:
- Enrolling in another plan (during a valid enrollment period).
- Giving or faxing assigned written notice to Health Net or through their employer or union.
- Calling 1-800-633-4227 (1-800-MEDICARE).
The election period during which Health Net receives a valid request to disenroll will determine the member's effective date of disenrollment. After the member submits a request, Health Net must provide the member with a disenrollment notice within ten calendar days of the request to disenroll. The notice will provide the effective date of disenrollment. If Health Net receives a disenrollment request that must be denied, the member will be notified within ten calendar days of the receipt of the request. The notice will include the reason for the denial. Health Net continues to be responsible for the member's health care until disenrollment is approved by Centers for Medicare and & Medicaid Services (CMS).
To request disenrollment of a Medicare member, providers may contact the Medicare Programs Provider Services Department. Providers are asked to describe the circumstances leading them to request the disenrollment and may be asked to submit documentation regarding their requests. If necessary, Health Net 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, then Health Net sends the information to Centers for Medicare & Medicaid Services (CMS) for approval or disapproval of the disenrollment request. Health Net cannot terminate Medicare members without CMS approval. 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 CMS 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 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.
Disenrollment for Disruptive Behavior
Health Net may request to disenroll a member if their behavior is disruptive to the extent that they continued enrollment in the Medicare Advantage (MA) plan substantially impairs Health Net's ability to arrange for or provide services to either that particular member or other members of the plan. However, Health Net may disenroll a member for disruptive behavior only after Health Net has met the requirements outlined in chapter 2 of the Medicare Managed Care Manual, Section 50.3.2 and obtained CMS approval.
Before requesting CMS approval of disenrollment for disruptive behavior, Health Net must make a serious effort to resolve the problems presented by the member. Such efforts must include providing reasonable accommodations, as determined by CMS, for individuals with mental or cognitive conditions, including mental illness and developmental disabilities. Health Net must also inform the individual of their right to use Health Net's grievance procedures.
The Centers for Medicare & Medicaid Services (CMS) can approve retroactive disenrollment in the following instances:
- System problems with CMS, the Social Security Administration (SSA) or Health Net Medicare Advantage (MA)
- SSA errors in processing disenrollment requests made by Health Net MA plan members at the SSA district office
- Beneficiary did not intend to enroll in a Health Net MA plan
- Death of a member
- Requests for disenrollment relating to marketing misrepresentations
A written request for retroactive disenrollment must be submitted to the Health Net Medicare Programs Member Services Department by the member. Depending on the circumstances, CMS may approve a partial disenrollment.
Disenrollment of Employer Group Members
When a Health Net Medicare Advantage (MA) plan member disenrolls through an employer group, there may be a delay in processing the disenrollment request. In these cases, the CMS allows a retroactive disenrollment not to exceed 90 days.
A member may only disenroll from a plan during one of the specified election periods. The member must submit a written request to the Member Services Department or through his or her employer. The written request must be signed by the member or member representative before the disenrollment date. The member may choose an effective date of up to three months after the month in which the individual completed a disenrollment request; however the effective date of disenrollment may not be earlier than the first of the month following the month in which the request was made.
When a member enrolls in another MA plan, the member is automatically disenrolled from Health Net's MA plan at the time the membership in the new MA plan becomes effective. In these situations, the member should not submit a written request for disenrollment to his or her health plan.