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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 365. Insurance Department |
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Chapter 40. Health Maintenance Organizations (HMO) |
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Subchapter 5. Life, Accident & Health Division and Consumer Assistance and Claims Division Rules |
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Part 13. TERMINATION OF MEMBERS, PROVIDERS AND CONTINUATION OF BENEFITS |
SECTION 365:40-5-73. Disenrollment for cause
Latest version.
- An HMO may disenroll an individual member of a group for cause such as failure to pay premiums or copayments, fraud, or misuse of identification card or if the enrollee's behavior is abusive, disruptive, threatening, or uncooperative to the extent that continued membership in the HMO seriously impairs the HMO's ability to furnish services to either the enrollee or other enrollees. Before disenrolling the enrollee, the HMO shall:(1) Make a serious effort to resolve the problem presented by the enrollee, including the use or attempted use of the HMO's grievance procedures;(2) Ascertain that the enrollee's behavior does not directly result from an existing medical condition; and(3) Document the problems, efforts, and medical conditions that demonstrate the HMO's conformity to this section.