Member Initiated Disenrollment

Justifications for a member’s voluntary disenrollment include the inability of the managed care organization (MCO) to provide necessary services or the MCO providing a low quality of care.

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  • Member who is required to participate in Medicaid managed care may request to be disenrolled “for cause” at any time, even during lock-in period: New Mexico a
  • State or enrollment broker can perform disenrollment for cause at any time: Florida b
  • Member may request disenrollment from MCO for cause at any time: Arizona c

  • Member becomes ineligible for the program: Arizona d, Tennessee e
  • Member excluded from enrollment: Florida f
  • Member enters state hospital, PACE program, organ and transplant program, or Medicare Special Savings Program: Hawaii g
  • Member in wrong MCO as determined by state: Florida h, Tennessee i
  • Death or incarceration of member: Hawaii j
  • Member no longer qualifies for Medicaid or leaves program: Hawaii k
  • Consumer missed open enrollment due to a temporary loss of eligibility: Florida l

  • In certain situations when member out of service area: Arizona m, Tennessee n
  • Member does not live in region where MCO is authorized to provide services: Florida o, Hawaii p, New Mexico q
  • MCO no longer participates: Tennessee r
  • Member in foster care has been moved out of state: Hawaii s

  • Provider no longer with MCO: Florida t
  • Member has active relationship with a provider who is not on MCO panel, but is on the panel of another MCO: Florida u
  • Not all related services are available with MCO network and member needs related services to be performed concurrently or provider has determined that receiving services separately would subject consumer to unnecessary risk: Florida v, Hawaii w, New Mexico x
  • MCO does not, because of moral or religious objections, cover service member needs: Arizona y, Florida ``, Hawaii aa, New Mexico bb
  • Lack of access to services: Florida cc, New Mexico dd
  • Lack of access to providers experienced in dealing with member’s health care needs: Florida ee, Hawaii ff, New Mexico gg
  • Lack of direct access to certified nurse midwives, pediatric nurse practitioners, family nurse practitioners (if available in geographic area): Hawaii hh
  • Lack of access to women’s healthcare specialists: Hawaii ii
  • Unreasonable delay or denial of service: Florida jj
  • Inappropriate changes of primary care physicians: Florida kk
  • Long-term care facility of member is not in provider network and is in the network of another health plan that is not capped: Hawaii ll
  • Service access impairments due to significant changes in location of services: Florida mm

  • Member changes MCOs during open enrollment: Arizona nn
  • Member approved for MCO change after MCO has followed the procedures outlined in 42 CFR 438.56: Arizona oo
  • Member who elects to join and/or receive services from another MCO, HCBS waiver program, OPWDD Day Treatment, or a CMCM is considered to have initiated disenrollment: New York pp
  • Opportunity to change MCO anytime during 45 day period immediately following enrollment, and every 12 months: Tennessee qq
  • Members may change MCO based on hardship criteria: Tennessee rr
  • Member chooses another health plan that is not capped: Hawaii ss
  • Member selects another MCO during annual choice period: Tennessee tt

  • Fraudulent enrollment: Florida uu
  • Marketing or community outreach violation has occurred: Florida vv

  • Member prevented from participating in his or her treatment plan/plan of care: Florida ww
  • Poor quality of care: Florida xx, Hawaii yy, New Mexico ```

  • MCO may not restrict member’s right to disenroll voluntarily: Florida aaa
  • Member may request disenrollment at any time: New York bbb
  • Voluntary members may disenroll from MCO at any time: Florida ccc
  • Mandatory members may disenroll for cause at any time: Florida ddd
  • Member may request disenrollment for cause at any time: Hawaii eee

  • MCO subject to intermediate sanction of disenrollment of members: Tennessee fff
  • Administrative appeal decision, provision in rules or statute, legal decision, or administrative decision for foster children: Hawaii ggg
  1. N.M. Contract, p. 24.  (back)
  2. Fla. Contract, Atch. II, p. 44.  (back)
  3. Ariz. Contract, p. 16.  (back)
  4. Ariz. Contract, p. 16.  (back)
  5. Tenn. Contract, p. 38.  (back)
  6. Fla. Contract, Atch. II, p. 44.  (back)
  7. Haw. RFP, p. 57.  (back)
  8. Fla. Contract, Atch. II, p. 45.  (back)
  9. Tenn. Contract, p. 38.  (back)
  10. Haw. RFP, p. 57.  (back)
  11. Haw. RFP, p. 57.  (back)
  12. Fla. Contract, Atch. II, p. 45.  (back)
  13. Ariz. Contract, p. 16.  (back)
  14. Tenn. Contract, p. 38.  (back)
  15. Fla. Contract, Atch. II, p. 44.  (back)
  16. Haw. RFP, p. 58.  (back)
  17. N.M. Contract, p. 25  (back)
  18. Tenn. Contract, p. 38  (back)
  19. Haw. RFP, p. 57.  (back)
  20. Fla. Contract, Atch. II, p. 44.  (back)
  21. Fla. Contract, Atch. II, p. 44-45.  (back)
  22. Fla. Contract, Atch. II, p. 45.  (back)
  23. Haw. RFP, p. 58.  (back)
  24. N.M. Contract, p. 25.  (back)
  25. Ariz. Contract, p. 16.  (back)
  26. Fla. Contract, Atch. II, p. 45.  (back)
  27. Haw. RFP, p. 58.  (back)
  28. N.M. Contract, p. 25.  (back)
  29. Fla. Contract, Atch. II, p. 45.  (back)
  30. N.M. Contract, p. 25.  (back)
  31. Fla. Contract, Atch. II, p. 45.  (back)
  32. Haw. RFP, p. 58.  (back)
  33. N.M. Contract, p. 25.  (back)
  34. Haw. RFP, p. 58.  (back)
  35. Haw. RFP, p. 58.  (back)
  36. Fla. Contract, Atch. II, p. 45.  (back)
  37. Fla. Contract, Atch. II, p. 45.  (back)
  38. Haw. RFP, p. 57.  (back)
  39. Fla. Contract, Atch. II, p. 45.  (back)
  40. Ariz. Contract, p. 16.  (back)
  41. Ariz. Contract, p. 16.  (back)
  42. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 3.  (back)
  43. Tenn. Contract, p. 35.  (back)
  44. Tenn. Contract, p. 35.  (back)
  45. Haw. RFP, p. 57.  (back)
  46. Tenn. Contract, p. 38.  (back)
  47. Fla. Contract, Atch. II, p. 45.  (back)
  48. Fla. Contract, Atch. II, p. 44.  (back)
  49. Fla. Contract, Atch. II, p. 44.  (back)
  50. Fla. Contract, Atch. II, p. 45.  (back)
  51. Haw. RFP, p. 58.  (back)
  52. N.M. Contract, p. 25.  (back)
  53. Fla. Contract, Atch. II, p. 43.  (back)
  54. N.Y. Medicaid Advantage Plus Contract, Sect. 8, p. 2; N.Y. Partnership Contract, p. 18.  (back)
  55. Fla. Contract, Atch. II, p. 45.  (back)
  56. Fla. Contract, Atch. II, p. 44.  (back)
  57. Haw. RFP, p. 57.  (back)
  58. Tenn. Contract, p. 38.  (back)
  59. Haw. RFP, p. 58.  (back)

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