Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.48 - MCO Initiated Disenrollment

Current through June 14, 2024
A. The MCO may seek
				  disenrollment of a member who is habitually non-compliant or poses a threat to
				  MCO employees or other members. An MCO initiated disenrollment, is subject to
				  an administrative review process by EOHHS and must follow the following
				  requirements:
1. MCO disenrollment requests -
				  For an MCO to disenroll a Medicaid member, the MCO must send a request, along
				  with accompanying documentation, to EOHHS. When the request is received, EOHHS
				  sends a notice to the Medicaid member informing him or her that the MCO is
				  seeking to take a disenrollment action and explaining the reason given by the
				  MCO for taking such an action. The notice also informs the member that of the
				  right to submit within ten (10) days any evidence establishing a good cause
				  appeal rejecting the disenrollment action.
2. Additionally, the MCO must:
a. Specify the reasons for which the MCO is
				  requesting disenrollment of an enrollee;
b. Not request disenrollment because of an
				  adverse change in the enrollee's health status, or because of the enrollee's
				  utilization of medical services, diminished mental capacity, or uncooperative
				  or disruptive behavior resulting from his/her special needs (except when
				  his/her continued enrollment in the MCO seriously impairs the MCO's ability to
				  furnish services to either this particular enrollee or other
				  enrollees).
c. Specify the methods
				  by which the MCO assures EOHHS that it does not request disenrollment for
				  reasons other than those permitted under the managed care contract.
3. EOHHS action - EOHHS must
				  investigate and render a decision within ten (10) days of receipt of evidence
				  from both parties. EOHHS's decision is subject to appeal. If, based upon the
				  evidence submitted by the health plan, EOHHS determines that the Medicaid
				  member should be disenrolled from the health plan, a notice is sent to the
				  Medicaid member by EOHHS stating the decision and the basis thereof at least
				  ten (10) days prior to the date the proposed disenrollment would be
				  effective.
4. Good Cause appeal - A
				  Medicaid member subject to a health plan request for disenrollment has the
				  right to present evidence establishing good cause. Good cause must be filed
				  prior to the end of the ten (10) day advance notice period. The filing of good
				  cause is submitted in writing to EOHHS. Good cause includes circumstances
				  beyond the Medicaid member's control sufficiently serious to prevent
				  compliance; an unanticipated household emergency; a court-required appearance;
				  incarceration; breakdown in transportation arrangements; or inclement weather
				  which prevented the Medicaid member and other persons similarly situated from
				  traveling to, or participating in, the required appointment. A member's
				  preference to remain in fee-for-service does not constitute good cause for an
				  appeal of the request for disenrollment.