Managed Care Good Cause Disenrollment

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:

  1. The enrollee moves out of the MCO's service area.
  2. The plan does not, because of moral or religious objections, cover the service the enrollee seeks.
  3. 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.
  4. 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.
  5. 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.