Section 17-1720.1-29 - Disenrollment An individual may be disenrolled for reasons that include, but are not limited to, the following:
(1) A decision by an administrative appeals office for disenrollment from a participating health plan;(2) A court order for disenrollment from a participating health plan;(3) Provisions in federal or State statutes or administrative rules;(4) A non-returning plan or termination of the health plan's contract or the start of a new contract;(5) Mutual agreement by the participating health plans involved, the individual and the department;(6) Violations by a participating health plan specified in chapter 17-1735.2;(7) Change in foster placement if necessary for the best interest of the child;(8) The individual selects a health plan that is not capped during the annual plan change period;(9) The individual's PCP or long-term care residential facility is not in the health plan's provider network and is in the provider network of a different health plan, provided the health plan is not at its maximum enrollment;(10) The individual is eligible to receive HCBS or personal assistance services level I and is enrolled in a health plan with a waiting list for HCBS or personal assistance services level I and the other health plan does not have a waiting list for the necessary service(s);(11) The participating health plan's refusal, because of moral or religious objections, to cover the service the individual seeks as allowed for in the contract with health plan;(12) The individual's need for related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time and not all related services are available within the network and the individual's primary care physician or another provider determines that receiving the services separately would subject the individual to unnecessary risk;(13) Lack of direct access to women's health care specialists for breast cancer screening, pap smears and pelvic exams;(14) Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the individual's health care needs, lack of direct access to certified nurse midwives, pediatric nurse practitioners, family nurse practitioners, if available in the geographic area in which the individual resides;(15) Relocation to a service area where the health plan in which the individual was enrolled does not provide services;(16) The individual missed the annual plan change period due to a temporary loss of Medicaid eligibility and was re-enrolled in the previous health plan;(17) Voluntary withdrawal from participation in the medical assistance program by the individual or a authorized representative;(18) Not meeting the eligibility requirements;(19) Death of the enrolled individual;(20) The enrolled individual is a medically needy individual who is two full months in arrears in the payment of the designated enrollment fee, unless the failure to pay occurs because: (A) The individual is not in control of the individual's personal finances, and the arrearage is caused by the party responsible for the individual's finances, and action is being taken to remediate the situation, including but not limited to: (i) Appointment of a new responsible party for the individual's finances; or(ii) Recovery of the individual's funds from the responsible party which will be applied to the individual's enrollment fee obligation.(B) The individual is in control of the individual's finances, and the arrearage is due to the unavailability of the individual's funds due to documented theft or financial exploitation, and action is being taken to: (i) Ensure that theft or exploitation does not continue; or(ii) Recover the individual's funds to pay the individual's enrollment fee obligation;(21) Incarceration of an enrolled individual into a public facility;(22) Admission to the State hospital;(23) Enrollment into the State of Hawaii Organ and Tissue Transplantation (SHOTT) program;(24) Relocation out-of-state by the State;(25) Provision of false information with the intent of enrolling in the medical assistance program under false pretenses;(26) Eligible for Medicare Special Savings benefits;(27) Other special circumstances as determined by the department; or(28) An individual disenrolled for cause.Haw. Code R. § 17-1720.1-29
[Eff 09/30/13] (Auth: HRS § 346-14; 42 C.F.R. §§430.25, 438.56 ) (Imp: HRS § 346-14; 42 C.F.R. §§430.25, 438.56 )