§ 438.56 Disenrollment Requirements for FMOLHS OLOL: Mark Zielinski, Michael Robinson (LPG) & (Bienvenidos)  Benjamin Levron (BRGeneral), Pro se LSU Board of Supervisors, LSUHSC-BR Professors, Dept. Heads, Senior Administrative Management, Esteemed Foundation, Stakeholders, Family, Lady Counselors, CEO President Richard Vath - Sister Barbara Arceneaux, Scott Wester, Ordinaries, Sisters, & JP Funes) Provisions apply to all [MCO, PIHP, PAHP, PCCM]  '50 Shot Patron + Midazolam Charism Chug'

§ 438.56 Disenrollment: Requirements and limitations. (a) Applicability. The provisions of this section apply to all managed care arrangements whether enrollment is mandatory or voluntary and whether the contract is with an MCO, a PIHP, a PAHP, or a PCCM (b) Disenrollment requested by the MCO, PIHP, PAHP, or PCCM. All MCO, PIHP, PAHP, and PCCM contracts must— (1) Specify the reasons for which pairs the entity’s ability to furnish the MCO, PIHP, PAHP, or PCCM may request disenrollment of an enrollee; (2) Provide that the MCO, PIHP, PAHP, or PCCM 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 disrup- tive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, or PCCM seriously impairs the entity’s ability to furnish228 42 CFR Ch. IV (10–1–10 Edition) § 438.56 services to either this particular en- rollee or other enrollees); and (3) Specify the methods by which the MCO, PIHP, PAHP, or PCCM assures the agency that it does not request disenrollment for reasons other than those permitted under the contract. (c) Disenrollment requested by the en- rollee. If the State chooses to limit disenrollment, its MCO, PIHP, PAHP, and PCCM contracts must provide that a recipient may request disenrollment as follows: (1) For cause, at any time. (2) Without cause, at the following times: (i) During the 90 days following the date of the recipient’s initial enroll- ment with the MCO, PIHP, PAHP, or PCCM, or the date the State sends the recipient notice of the enrollment, whichever is later. (ii) At least once every 12 months thereafter. (iii) Upon automatic reenrollment under paragraph (g) of this section, if the temporary loss of Medicaid eligi- bility has caused the recipient to miss the annual disenrollment opportunity. (iv) When the State imposes the in- termediate sanction specified in § 438.702(a)(3). (d) Procedures for disenrollment—(1) Request for disenrollment. The recipient (or his or her representative) must sub- mit an oral or written request— (i) To the State agency (or its agent); or (ii) To the MCO, PIHP, PAHP, or PCCM, if the State permits MCOs, PIHP, PAHPs, and PCCMs to process disenrollment requests. (2) Cause for disenrollment. The fol- lowing are cause for disenrollment: (i) The enrollee moves out of the MCO’s, PIHP’s, PAHP’s, or PCCM’s service area. (ii) The plan does not, because of moral or religious objections, cover the service the enrollee seeks. (iii) The enrollee needs related serv- ices (for example a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the enrollee’s primary care provider or another provider determines that re- ceiving the services separately would subject the enrollee to unnecessary risk. (iv) Other reasons, including but not limited to, poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the enroll- ee’s health care needs. (3) MCO, PIHP, PAHP, or PCCM action on request. (i) An MCO, PIHP, PAHP, or PCCM may either approve a request for disenrollment or refer the request to the State. (ii) If the MCO, PIHP, PAHP, PCCM, or State agency (whichever is respon- sible) fails to make a disenrollment de- termination so that the recipient can be disenrolled within the timeframes specified in paragraph (e)(1) of this sec- tion, the disenrollment is considered approved. (4) State agency action on request. For a request received directly from the re- cipient, or one referred by the MCO, PIHP, PAHP, or PCCM, the State agen- cy must take action to approve or dis- approve the request based on the fol- lowing: (i) Reasons cited in the request. (ii) Information provided by the MCO, PIHP, PAHP, or PCCM at the agency’s request. (iii) Any of the reasons specified in paragraph (d)(2) of this section. (5) Use of the MCO, PIHP, PAHP, or PCCM grievance procedures. (i) The State agency may require that the en- rollee seek redress through the MCO, PIHP, PAHP, or PCCM’s grievance sys- tem before making a determination on the enrollee’s request. (ii) The grievance process, if used, must be completed in time to permit the disenrollment (if approved) to be effective in accordance with the time- frame specified in § 438.56(e)(1). (iii) If, as a result of the grievance process, the MCO, PIHP, PAHP, or PCCM approves the disenrollment, the State agency is not required to make a determination. (e) Timeframe for disenrollment deter- minations. (1) Regardless of the proce- dures followed, the effective date of an approved disenrollment must be no later than the first day of the second month following the month in which the enrollee or the MCO, PIHP, PAHP, or PCCM files the request. VerDate Mar2010 11:19 Oct 28, 2010 Jkt 220182 PO 00000 Frm 00238 Fmt 8010 Sfmt 8010 :\42\42V4 ofr150 PsN: PC150229 Centers for Medicare & Medicaid Services, HHS § 438.100 (2) If the MCO, PIHP, PAHP, or PCCM or the State agency (whichever is responsible) fails to make the deter- mination within the timeframes speci- fied in paragraph (e)(1) of this section, the disenrollment is considered ap- proved. (f) Notice and appeals. A State that restricts disenrollment under this sec- tion must take the following actions: (1) Provide that enrollees and their representatives are given written no- tice of disenrollment rights at least 60 days before the start of each enroll- ment period. (2) Ensure access to State fair hear- ing for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (g) Automatic reenrollment: Contract re- quirement. If the State plan so specifies, the contract must provide for auto- matic reenrollment of a recipient who is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less. § 438.58 Conflict of interest safeguards. (a) As a condition for contracting with MCOs, PIHPs, or PAHPs, a State must have in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have respon- sibilities relating to the MCO, PIHP, or PAHP contracts or the default enroll- ment process specified in § 438.50(f). (b) These safeguards must be at least as effective as the safeguards specified in section 27 of the Office of Federal Procurement Policy Act (41 .S.C. 423). § 438.60 Limit on payment to other providers. The State agency must ensure that no payment is made to a provider other than the MCO, PIHP, or PAHP for serv- ices available under the contract be- tween the State and the MCO, PIHP, or PAHP, except when these payments are provided for in title XIX of the Act, in 42 CFR, or when the State agency has adjusted the capitation rates paid under the contract, in accordance with § 438.6(c)(5)(v), to make payments for graduate medical education. § 438.62 Continued services to recipi-ents. The State agency must arrange for Medicaid services to be provided with- out delay to any Medicaid enrollee of an MCO, PIHP, PAHP, or PCCM whose contract is terminated and for any Medicaid enrollee who is disenrolled from an MCO, PIHP, PAHP, or PCCM for any reason other than ineligibility