69O-191.042. Reasons for Cancellation of Eligibility of a Subscriber Member

Upon written notice, an HMO may cancel or terminate the coverage of a subscriber for the following reasons:

(1) The HMO may disenroll a subscriber if the subscriber’s behavior is disruptive, unruly, abusive, unlawful, fraudulent or uncooperative to the extent that his continuing membership in the HMO seriously impairs the HMO’s ability to furnish services to either the subscriber or other subscribers. Prior to disenrolling a member, the following are required:

(a) An effort to resolve the problem. The HMO shall make a reasonable effort to resolve the problem presented by the subscriber, including the use or attempted use of subscriber grievance procedures.

(b) Consideration of extenuating circumstances. The HMO should ascertain, to the extent possible, that the subscriber’s behavior is not related to the use of medical services or mental illness.

(c) Documentation. The HMO shall document the problems, efforts, and medical conditions as described in this rule chapter;

(2) Fraud or material misrepresentation in applying for or presenting any claim for benefits under the health maintenance contract;

(3) Misuse of the HMO identification membership card by the subscriber;

(4) Furnishing to the HMO, by the subscriber, incorrect or incomplete information for the purpose of fraudulently obtaining coverage by the HMO;

(5) The subscriber leaves the geographical service area of the HMO with the intent to relocate or establish a new residence outside of the HMO’s geographic service area;

(6) A dependent of the subscriber reaches the limiting age under the HMO contract, provided that the termination shall only apply to coverage of the dependent.

Specific Authority 641.36 FS. Law Implemented 641.3108, 641.31(3)(b)5., 641.3921 FS. History–New 2-22-88, Amended 10-25-89, Formerly 4-31.042, Amended 5-28-92, Formerly 4-191.042.