Disenrollment

A health maintenance organization (HMO) must disclose in the policy and certificate any circumstances under which an enrollee may be disenrolled. Disenrollment proceedings may be initiated only for the following reasons:

  • The enrollee has failed to pay required premiums by the end of the grace period.
  • The enrollee has committed acts of physical or verbal abuse, which pose a threat to providers or other members of the organization.
  • The enrollee has allowed a nonmember to use the HMO's certification card to obtain services or has knowingly provided fraudulent information in applying for coverage.
  • The enrollee has moved outside of the geographical service area of the organization.
  • The enrollee is unable to establish or maintain a satisfactory physician-patient relationship with the physician responsible for the enrollee's care.

Enrollees have the right to file a grievance when a disenrollment proceeding is initiated.