Involuntary Disenrollment

Enrollment in Medicaid managed care is generally mandatory, with consumers allowed to disenroll only under specified conditions.  In general, states are responsible for processing disenrollments from Managed Care Organizations (MCO).  Contracts with MCOs specify the form disenrollment requests must take, the procedure of processing requests, effective dates, and notice requirements.

Contents – To access the full text, please click each sub-topic.

  • Member’s behavior is disruptive, unruly, abusive or uncooperative to the extent that enrollment in MCO seriously impairs the ability to furnish services to either the member or other members, but not if the member’s behavior is attributable to member’s medical or mental health diagnosis: Florida a
  • Disenrollment request related to member behavior must include at least one oral warning and one written warning, an attempt to educate the member or rights and responsibilities, an offer of assistance through care coordination, and a determination behavior not related to medical or mental condition: Florida b, Texas c
  • MCO must take reasonable measures to correct member behavior prior to requesting disenrollment: Texas d
  • Member, family member, or informal caregiver engages in conduct or behavior that seriously impairs MCO’s ability to furnish services, provided MCO has made and documented reasonable efforts to resolve the problems: New York e
  • Member has engaged in disruptive behavior, and request for disenrollment meets requirements of 42 CFR § 422.74(d)(2): Minnesota f
  • Member conduct makes it not feasible, safe, or prudent to provide covered services: New Mexico g
  • Member has threatened or attempted to intimidate MCO or providers: New Mexico h, Wisconsin i
  • Member refuses to participate in care planning: Wisconsin j

  • Fraudulent use of member ID card: Florida k, Minnesota l, New York m, Texas n
  • Member provided fraudulent information on enrollment form: Minnesota o, New York p
  • Falsification of prescription by a member: Florida q
  • Fraudulent conduct with respect to any substantive aspect of membership: New York r

  • Loss of Medicaid eligibility: Massachusetts s
  • Member remains out of service area for more than 6 consecutive months: Massachusetts t
  • Member is temporarily out of MCO service area: Wisconsin u

  • Member will not relocate from an assisted living or adult care home that does not, and will not, conform to HCB requirements in contract: Florida v
  • MCO ability to furnish services to member or other members is seriously impaired, if approved in advance by state: Massachusetts w
  • MCO made good faith effort to accommodate member’s health care, but efforts have been unsuccessful: New Mexico x
  • MCO has offered member opportunity to utilized the grievance process: New Mexico y
  • Member fails to pay amount owed to MCO within 30 days after amount first becomes due, providing reasonably efforts to collect: New York ``
  • Member knowingly fails to complete any necessary consent or release: New York aa
  • Member steadfastly refuses to comply with managed care restrictions (e.g. repeatedly using emergency room in combination with refusing to allow MCO to treat the underlying medical condition): Texas bb
  • Member totally dependent on a ventilator or has been diagnosed with end stage renal disease: Texas cc

  • Change in residence makes member ineligible: New York dd
  • Consumer no longer a member, no longer eligible for Medicaid Advantage Plus Product, or dies: New York ee
  • Member absent from service area for more than 90 consecutive days: New York ff
  • Member absent from service area for more than 30 consecutive days: New York gg
  • Member no longer eligible for nursing home level of care, unless termination of services could reasonably be expected to result in member becoming eligible for nursing home level of care: New York hh
  • Member is hospitalized or enters other facility for 45 consecutive days: New York ii
  • Member requires nursing facility care, but is not eligible for such care under Medicaid: New York jj
  • Member no longer meets nursing home level of care: New York kk
  • Incarcerated member: New York ll

  • Member fails to enroll or stay enrolled with MCO: New York mm
  • Member no longer eligible for Medicaid benefits: New York nn
  • Member becomes ineligible for enrollment: New York oo
  • Members taking into conservatorship by Department of Family and Protective Services will be disenrolled from MCO: Texas pp
  • State or enrollment broker may disenroll members without cause at specific times depending on initial enrollment, loss of Medicaid eligibility, or referral for hospice: Florida qq

  • Consumers who are dissatisfied with a disenrollment determination may request a Medicaid fair hearing: Florida rr
  • All members have the right to file an appeal on disenrollment except for disenrollment because of moving out of the region, loss of Medicaid eligibility, member part of excluded population, or member death: Florida ss
  • Access to a fair hearing will be provided to a member who is dissatisfied with state’s determination denying a request to transfer or disenroll: New Mexico tt
  • State is responsible for providing members with a notice of their right to request a fair hearing: New York uu
  • MCO must notify members who receive an adverse appeal resolution of their right to a fair hearing and/or an external appeal through the department of financial services: New York vv
  • Where state approves request to disenroll, and member requests a fair hearing, member will remain in MCO until the disposition of the fair heing if aid to continue is ordered by the Office of Administrative Hearings: New York ww
  • If member disagree with decision, state must notify member of complaint procedure and fair hearing process: Texas xx

  • Once member disenrolled at MCO’s request, MCO may reject re-enrollment request: New York yy
  • If disenrollment due to disruptive conduct, MCO may not reject enrollment request without first substantiating that circumstance have not been remedied: New York ```
  1. Fla. Contract, Atch. II, p. 45.  (back)
  2. Fla. Contract, Atch. II, p. 45-46.  (back)
  3. Tex. Contract, p. 24.  (back)
  4. Tex. Contract, p. 24.  (back)
  5. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3; N.Y. Partnership Contract, p. 20.  (back)
  6. Minn. Contract, p. 42.  (back)
  7. N.M. Contract, p. 24.  (back)
  8. N.M. Contract, p. 24.  (back)
  9. Wis. Contract, p. 42.  (back)
  10. Wis. Contract, p. 42.  (back)
  11. Fla. Contract, Atch. II, p. 45.  (back)
  12. Minn. Contract, p. 42.  (back)
  13. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  14. Tex. Contract, p. 24.  (back)
  15. Minn. Contract, p. 42.  (back)
  16. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  17. Fla. Contract, Atch. II, p. 46.  (back)
  18. N.Y. Partnership Contract, p. 20.  (back)
  19. Mass. Contract, p. 12.  (back)
  20. Mass. Contract, p. 12.  (back)
  21. Wis. Contract, p. 42.  (back)
  22. Fla. Contract, Atch. 11, Exh. 3, p. 9.  (back)
  23. Mass. Contract, p. 12.  (back)
  24. N.M. Contract, p. 24.  (back)
  25. N.M. Contract, p. 24.  (back)
  26. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4; N.Y. Partnership Contract, p. 20.  (back)
  27. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4; N.Y. Partnership Contract, p. 20.  (back)
  28. Tex. Contract, p. 24.  (back)
  29. Tex. Contract, p. 24.  (back)
  30. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3; N.Y. Partnership Contract, p. 19.  (back)
  31. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  32. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  33. N.Y. Partnership Contract, p. 19.  (back)
  34. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  35. N.Y. Partnership Contract, p. 19.  (back)
  36. N.Y. Partnership Contract, p. 19.  (back)
  37. N.Y. Partnership Contract, p. 19.  (back)
  38. N.Y. Partnership Contract, p. 19.  (back)
  39. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4.  (back)
  40. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4.  (back)
  41. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4.  (back)
  42. Tex. Contract, p. 24.  (back)
  43. Fla. Contract, Atch. II, p. 44.  (back)
  44. Fla. Contract, Atch. II, p. 37.  (back)
  45. Fla. Contract, Atch. II, p. 43.  (back)
  46. N.M. Contract, p. 25.  (back)
  47. N.Y. Medicaid Advantage Plus Contract, App. 8, p. 10.  (back)
  48. N.Y. Partnership Contract, p. 20.  (back)
  49. N.Y. Medicaid Advantage Plus Contract, App. 8, p. 13.  (back)
  50. Tex. Contract, p. 24.  (back)
  51. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4.  (back)
  52. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 4.  (back)

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