Cancellation

Section 5421 Section 4521.111  Cancellation a)         No HMO shall cancel a group or individual contract or evidence of coverage except for one or more of the following reasons: 1)         Failure of the enrollee to pay the amount due under the contract or evidence of coverage, for which the enrollee is legally responsible; 2)         Fraud or material misrepresentation in enrollment or in the use of services or facilities; 3)         Material violation of the terms of the contract or evidence of coverage; 4)         Failure of the enrollee and the primary care physician to establish a satisfactory patient-physician relationship if the enrollee has repeatedly refused to follow the plan of treatment ordered by the physician; it is shown that the HMO has in good faith provided the enrollee with the opportunity to select an alternative primary care physician; and the enrollee has been notified in writing at least 31 days in advance that the HMO considers such patient-physician relationship to be unsatisfactory; 5)         Under the Basic Outpatient Preventive and Primary Care Services for Children Program, failure to meet or continue to meet eligibility requirements as required by Section 4521.131 of this Part; or 6)         Other good cause agreed upon in the contract and approved by the Director pursuant to Section 4-13 of the Act. b)         A group contract, evidence of coverage or individual contract may not be cancelled for any of the following reasons: 1)         The status of the enrollee's health; 2)         The enrollee has exercised his or her rights under the HMO's grievance system.