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 Texas Administrative Code (Last Updated: March 27,2024)
 TITLE 1. ADMINISTRATION
 PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
 CHAPTER 370. STATE CHILDREN'S HEALTH INSURANCE PROGRAM
 SUBCHAPTER C. ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING
 DIVISION 1. ENROLLMENT AND DISENROLLMENT

  SECTION 370.311. Disenrollment

Latest version.
  • (a) Disenrollment at a member's request.

    (1) Members will be informed of disenrollment opportunities no less than annually.

    (2) During the first 90 days of enrollment in a managed care organization (MCO), a member may request to move to another MCO for any reason. After 90 days with an MCO, a member must show good cause to move to another MCO.

    (3) Disenrollment will take place no later than the first day of the second month after the month in which the member has requested a change.

    (b) Disenrollment at an MCO's request.

    (1) An MCO may submit a request to HHSC that a member be disenrolled without the member's consent in the following limited circumstances:

    (A) the member misuses or loans his or her MCO membership card to another person to obtain services;

    (B) the member is disruptive, unruly, threatening or uncooperative to the extent that the member's membership seriously impairs the MCO's or a provider's ability to provide services to the member or to obtain new members, and member's behavior is not caused by a physical or behavioral health condition; or

    (C) the member steadfastly refuses to comply with managed care restrictions (such as repeatedly using the emergency room in combination with a refusal to allow treatment for the underlying medical condition).

    (2) An MCO must take reasonable measures to correct a member's behavior prior to requesting disenrollment. Reasonable measures may include providing education and counseling regarding the offensive acts or behaviors.

    (3) HHSC will review all requests for disenrollment. HHSC will grant a request if it determines that all reasonable measures taken by the MCO have failed to correct the member's behavior. If HHSC grants a request, it will notify the member of the disenrollment decision and the availability of HHSC's fair hearings process for an appeal of the disenrollment.

Source Note: The provisions of this §370.311 adopted to be effective March 1, 2012, 37 TexReg 1301; amended to be effective January 1, 2014, 38 TexReg 9477