![]() ![]() (3) MCO, PIHP, PAHP, PCCM, or PCCM entity action on request. (v) 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. (iv) 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, PIHP, or PAHP and, as a result, would experience a disruption in their residence or employment. (iii) 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. ![]() ![]() (ii) The plan does not, because of moral or religious objections, cover the service the enrollee seeks. (i) The enrollee moves out of the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's service area. The following are cause for disenrollment: (ii) To the MCO, PIHP, PAHP, PCCM, or PCCM entity, if the State permits MCOs, PIHP, PAHPs, PCCMs, and PCCM entities to process disenrollment requests. The beneficiary (or his or her representative) must submit an oral or written request, as required by the State. (iv) When the State imposes the intermediate sanction specified in § 438.702(a)(4). (iii) Upon automatic reenrollment under paragraph (g) of this section, if the temporary loss of Medicaid eligibility has caused the beneficiary to miss the annual disenrollment opportunity. (ii) At least once every 12 months thereafter. (i) During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later. (2) Without cause, at the following times: If the State chooses to limit disenrollment, its MCO, PIHP, PAHP, PCCM, and PCCM entity contracts must provide that a beneficiary may request disenrollment as follows: (c) Disenrollment requested by the enrollee. (3) Specify the methods by which the MCO, PIHP, PAHP, PCCM, or PCCM entity assures the agency that it does not request disenrollment for reasons other than those permitted under the contract. (2) Provide that the MCO, PIHP, PAHP, PCCM, or PCCM entity may 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 or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (1) Specify the reasons for which the MCO, PIHP, PAHP, PCCM, or PCCM entity may request disenrollment of an enrollee. All MCO, PIHP, PAHP, PCCM and PCCM entity contracts must: (b) Disenrollment requested by the MCO, PIHP, PAHP, PCCM, or PCCM entity. The provisions of this section apply to all managed care programs whether enrollment is mandatory or voluntary and whether the contract is with an MCO, PIHP, PAHP, PCCM, or PCCM entity. § 438.56 Disenrollment: Requirements and limitations. ![]()
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