Federal regulation 42 CFR 438.56 requires any Medicaid program that contracts with multiple managed care organizations (MCOs) to allow beneficiaries to disenroll or switch MCOs under specific circumstances.
Disenrollment is permitted both without cause and for cause.
Disenrollment without Cause
Disenrollment without cause is allowed at 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 any of the following reasons:
- 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 (e.g., 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.
- 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.
A request for disenrollment for cause should be sent to your MCO. If you, your authorized representative, your legal guardian or your provider acting on your behalf are not satisfied with the MCO’s decision, you may contact:
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