Prohibited Disenrollment

Contracts with managed care organizations (MCOs) generally limit their ability to disenroll members involuntarily.  Prohibited reasons for MCO-initiated disenrollment include a consumer’s adverse change in health status, utilization of medical services, or diminished mental capacity.

Prohibited reasons for disenrollment by MCO

  • Adverse change in the consumer’s health status: Arizona a, Florida b, Hawaii c, New Mexico d, New York e, Tennessee f
  • Capitation rate payable to MCO: New York g
  • Consumer’s utilization of medical services: Arizona h, Florida i, Hawaii j, New Mexico k, New York l, Tennessee m
  • Diminished mental capacity of consumer: Florida n, Hawaii o, New Mexico p, New York q, Tennessee r
  • Pre-existing medical condition: Florida s, Hawaii t, Tennessee u
  • Consumer’s attempt to exercise rights under the MCO grievance system: Florida v
  • Missed appointments: Hawaii w
  • Uncooperative or disruptive behavior resulting from a consumer’s special needs: Arizona x, Florida y, New York ``
  • Uncooperative or disruptive behavior resulting from a consumer’s special needs except where member’s continued enrollment in MCO seriously impairs MCO ability to furnish services: Hawaii aa, New Mexico bb, Tennessee cc, Wisconsin dd
  • High cost of medical or behavioral health bills: Tennessee ee
  • Failure to pay applicable cost sharing responsibilities, except when this results in loss of eligibility for Medicaid managed care: Tennessee ff
  1. Ariz. Contract, p. 15.  (back)
  2. Fla. Contract, Atch. II, p. 46.  (back)
  3. Haw. RFP, p. 184.  (back)
  4. N.M. Contract, p. 24.  (back)
  5. N.Y. Partnership Contract, p. 17.  (back)
  6. Tenn. Contract, p. 38.  (back)
  7. N.Y. Partnership Contract, p. 17.  (back)
  8. Ariz. Contract, p. 15.  (back)
  9. Fla. Contract, Atch. II, p. 46.  (back)
  10. Haw. RFP, p. 184.  (back)
  11. N.M. Contract, p. 24.  (back)
  12. N.Y. Partnership Contract, p. 17.  (back)
  13. Tenn. Contract, p. 39.  (back)
  14. Fla. Contract, Atch. II, p. 46.  (back)
  15. Haw. RFP, p. 184.  (back)
  16. N.M. Contract, p. 24.  (back)
  17. N.Y. Partnership Contract, p. 17.  (back)
  18. Tenn. Contract, p. 39.  (back)
  19. Fla. Contract, Atch. II, p. 46.  (back)
  20. Haw. RFP, p. 184.  (back)
  21. Tenn. Contract, p. 38.  (back)
  22. Fla. Contract, Atch. II, p. 46.  (back)
  23. Haw. RFP, p. 184.  (back)
  24. Ariz. Contract, p. 15-16.  (back)
  25. Fla. Contract, Atch. II, p. 46.  (back)
  26. N.Y. Partnership Contract, p. 17.  (back)
  27. Haw. RFP, p. 184.  (back)
  28. N.M. Contract, p. 24.  (back)
  29. Tenn. Contract, p. 39.  (back)
  30. Wis. Contract, p. 42.  (back)
  31. Tenn. Contract, p. 39.  (back)
  32. Tenn. Contract, p. 39.  (back)

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