Federal
regulations allow Medicaid members to change their MCO through a process
called, “Good Cause Disenrollment”. This process is for members who want to
change their current MCO and are not within their 90-day window to change. If
you request good cause disenrollment, you must continue to receive all medical
care from your current MCO until the effective date of disenrollment. Contact
the Division of Health Care Financing and Policy (DHCFP) District Office
Southern Nevada: (702) 668-4200 or Northern Nevada: (775) 687-1900 or TTY 7-1-1
to verify your disenrollment before you seek medical services outside of your
MCO’s network or for any other questions.
In
accordance with 42 CFR 438.56(d)(2), the following
are cause for disenrollment:
- The enrollee moves out of the MCO's service area.
- The plan does not, because of moral or religious
objections, cover the service the enrollee seeks.
- The enrollee needs related services (for example, a
cesarean section and a tubal ligation) to be performed at the same time;
not all related services are available within the provider network; and
the enrollee's primary care provider or another provider determines that
receiving the services separately would subject the enrollee to
unnecessary risk.
- For enrollees that use MLTSS, the enrollee would have
to change their residential, institutional, or employment supports
provider based on that provider's change in status from an in-network to
an out-of-network provider with the MCO and, as a result, would experience
a disruption in their residence or employment.
- 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 enrollee's care needs.
Please
note that switching MCOs to access a particular facility or provider will
generally not be considered good cause.