Cal. Code Regs. tit. 10 § 2699.207

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2699.207 - Disenrollment

(a) A subscriber shall be disenrolled from the program and from the program's participating health plan when any of the following occur:

(1) The subscriber so requests in writing.

(2) The subscriber becomes ineligible because:

(A) The subscriber fails to meet the residency requirement; or

(B) The subscriber has committed an act of fraud to circumvent the statutes or regulations of the program,

(C) The subscriber is no longer pregnant on her effective date of coverage, based on her self-attestation before the effective date. If notification to the program is received after the effective date, documentation by a licensed or certified healthcare professional must be submitted indicating the date of the miscarriage.

(D) More than 60 days have elapsed since the end of the pregnancy for which the subscriber enrolled in the program. Notwithstanding the previous sentence, beginning January 1, 2014, the program shall provide coverage through the last day of the month in which the 60^th day following the end of the pregnancy occurs. As a condition of receiving the premium reduction described in Section 2699.400(a)(5), documentation by a licensed or certified healthcare professional must be submitted to the program indicating the date the pregnancy ended.

(b) When a subscriber is disenrolled pursuant to subsection (a) of this section, the program shall notify the subscriber of the disenrollment. The notice shall be in writing and include the following information:

(1) The reason for the disenrollment.

(2) The effective date of the disenrollment.

(3) An explanation of the appeals process.

(c) Disenrollment pursuant to (a)(1), shall take effect at the end of the calendar month in which the request was received or at the end of a future calendar month as requested by the subscriber.

(d) Disenrollment pursuant to (a)(2)(A), shall take effect as follows:

1. If the program provides notification to the subscriber on or before the 10th of the month, disenrollment shall take effect at the end of the calendar month.

2. If the program provides notification to the subscriber after the 10th of the month, disenrollment shall take effect at the end of the following calendar month.

(e) Disenrollment pursuant to (a)(2)(B), shall take effect as follows:

1. If the program provides notification to the subscriber on or before the 10th of the month, disenrollment shall take effect at the end of the calendar month.

2. If the program provides notification to the subscriber after the 10th of the month, disenrollment shall take effect at the end of the following calendar month.

(f) Disenrollment pursuant to (a)(2)(C), shall take effect upon the date that would have been the effective date of coverage.

(g) Disenrollment pursuant to (a)(2)(D), shall take effect as follows:

1. Disenrollment shall take effect on the 61st day following the date the subscriber's pregnancy ended. Notwithstanding the previous sentence, beginning January 1, 2014, the program shall provide coverage through the last day of the month in which the 60th day following the end of the pregnancy occurs.

2. In the event that the program is not notified of the end of the pregnancy as specified in Section 2699.209(b), disenrollment shall take effect pursuant to paragraph 1, based on the expected delivery date.

3. The program shall send the subscriber a reminder notice of the period of coverage on or about 30 days prior to the expected delivery date.

(h) Once a subscriber is disenrolled pursuant to Section 2699.207(a), the subscriber cannot be re-enrolled for the same pregnancy.

Cal. Code Regs. Tit. 10, § 2699.207

1. New section filed 12-12-91 as an emergency; operative 12-12-91 (Register 92, No. 10). A Certificate of Compliance must be transmitted to OAL 4-10-92 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-12-91 order transmitted to OAL 4-8-92 and filed 5-20-92 (Register 92, No. 21).
3. New subsections (a)(2)(C) and (d) and amendment of subsection (c) filed 8-29-94 as an emergency; operative 9-1-94 (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-30-94 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 8-29-94 order transmitted to OAL 12-9-94 and filed 1-23-95 (Register 95, No. 4).
5. Amendment filed 5-20-2003; operative 5-20-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 21).
6. Amendment filed 8-14-2008; operative 8-14-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 33).
7. Amendment of subsection (a)(2)(D) filed 11-13-2013 as an emergency; operative 11-13-2013 (Register 2013, No. 46). A Certificate of Compliance must be transmitted to OAL by 5-12-2014 or emergency language will be repealed by operation of law on the following day.
8. Amendment of subsections (a)(1)(C) and (g) and new subsections (g)1.-3. filed 12-27-2013 as an emergency; operative 12-27-2013 (Register 2013, No. 52). A Certificate of Compliance must be transmitted to OAL by 6-25-2014 or emergency language will be repealed by operation of law on the following day. This filing is deemed an emergency and is exempt from review by OAL pursuant to Assembly Bill 82, Chapter 23, Statutes of 2013, section 77.
9. Certificate of Compliance as to 12-27-2013 order transmitted to OAL 5-29-2014 and filed 6-10-2014 (Register 2014, No. 24).
10. Certificate of Compliance as to 11-13-2013 order transmitted to OAL 5-7-2014 and filed 6-16-2014 (Register 2014, No. 25).

Note: Authority cited: Section 12696.05, Insurance Code. Reference: Sections 12696.05 and 12698, Insurance Code.