Federal statute 42 CFR 438.56 requires any Medicaid program that uses multiple managed care organizations (MCOs) must allow beneficiaries to dis-enroll or switch MCOs at under specific circumstances.
There are two types of disenrollment: disenrollment without cause and disenrollment for cause.
Disenrollment without Cause
Disenrollment without cause may occur at any of the following times:
- During the 90 days following the date of initial enrollment in the MCO or during the 90 days following the date the state sends notice of enrollment, whichever is later.
- At least once every 12 months during open enrollment
- In the event of temporary loss of Medicaid that caused you to miss the annual open enrollment.
Disenrollment with Cause
Disenrollment with cause may happen any time for a specific reason to request the change. The following are reasons you may request a disenrollment with cause:
- The beneficiary moves out of the MCOs service area;
- The MCO does not, because of moral or religious objections, cover the service the beneficiary needs;
- The beneficiary needs related services (i.e., a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the MCO network; and the beneficiary’s physician determines that receiving the services separately would be an unnecessary risk; or
- Other reasons, including poor quality of care, lack of access to services covered under the contract or lack of access to providers experienced in dealing with the beneficiary’s special needs.
Request a Hearing
The request for disenrollment for cause is reviewed by the Department for Medicaid Services, Division of Provider and Member Services. If you, your authorized representative, your legal guardian or your provider acting on your behalf are not satisfied with Medicaid’s decision, you may ask for a state fair hearing. You have 30 days from the date on the letter advising you of the decision to make a request for a state fair hearing. Your request must be in writing. Please send the request to:
Cabinet for Health and Family Services
Department for Medicaid Services
Division of Provider and Member Services
275 East Main Street, 6E-C
Frankfort KY 40621
You may represent yourself at the hearing or be represented by legal counsel, relative, friend or other spokesperson. You may provide additional information to support your request and you may ask to see any information used by the Department for Medicaid Service to make its decision.