Section 210-RICR-30-05-2.48 - MCO Initiated DisenrollmentA. 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.210 R.I. Code R. 210-RICR-30-05-2.48
Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024