Page 273

Becoming eligible for Medicare Depending on when notification of Medicare eligibility was received and the Medicare eligibility start date, if the notification is received:

Prior to the Medicare eligibility begin date, the disenrollment date is the end of the month in which notification was received.

After the Medicare eligibility begin date, the disenrollment date is the end of the month prior to the month of notification. Mail was returned for the member’s household with no forwarding address, and an up-to-date address has not been received. End of the month in which it is determined an up- to-date address cannot be received. 38.4.4.2 Voluntary Disenrollment The member may voluntarily disenroll from the HMO for any reason as long as they are no longer in their lock-in period. If the member is still in the lock-in period, the member, the member’s family, or the legal guardian must request a voluntary disenrollment based on a qualifying reason. Qualifying reasons for voluntary disenrollments may include but are not limited to:

A temporary loss of eligibility caused the member to miss their open enrollment period.

The HMO does not cover the service the member seeks, due to moral or religious objections.

The member needs related services (for example, a cesarean section and tubal ligation) to be performed at the same time and not all related services are within the provider network and the member’s primary care provider, or another provider determines the risk of receiving services separately would subject the member to unnecessary risk.

Other reasons, including poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the member’s care needs Voluntary disenrollments are effective no later than the first day of the month following the month in which the disenrollment was requested. 38.4.4.3 Involuntary Disenrollment The Department of Health Services may approve involuntary disenrollments with an effective date of the following month, if approved with the exception of a just cause disenrollment, which may require additional review of the effective date of disenrollment based on the circumstances. The HMO must submit a disenrollment request to the Department and include evidence attesting to the reason. The HMO must direct all members for whom an involuntary disenrollment request has been made to the HMO Enrollment Specialist for assistance and/or for choice counseling. Involuntary disenrollments may include but are not limited to:

Just Cause – A situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with medically necessary services for reasons beyond the HMO’s control. An HMO cannot request just cause disenrollment because of an