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7.1.5.2 Health Plan Managed Care Administrator-Initiated Changes
Each health plan has a limited right to request that a client be disenrolled without the client's consent. HHSC must approve any request for such disenrollment.
A health plan may request that a client be disenrolled for the following reasons:
• The client loans his or her Medicaid Identification Form (Form H3087) to another person to obtain services.
•The client continually disregards the advice of his primary care provider.
•The client repeatedly uses the ER inappropriately.
Before a request for disenrollment can be initiated, reasonable measures must be taken to correct the client's behavior. Reasonable measures may include education or counseling conducted by health plan staff. HHSC will notify the client of the disenrollment if all attempts to remedy the situation have failed. HHSC will also notify the client of the availability of appeal procedures and the HHSC fair hearing process.
Neither the health plan nor a provider may request a disenrollment based on an adverse change in the client's health or the utilization of services which are medically necessary for the treatment of a client's condition.
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