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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.7 Managed Care Plan Changes : 2.7.2 Plan Administrator-Initiated Changes

Each health plan and dental plan has a limited right to request that a client be disenrolled without the client’s consent. HHSC must approve any request for such disenrollment.
Health plans and dental plans may request that a client be disenrolled for the following reasons:
Client is disruptive, unruly, threatening, or uncooperative to the extent that client’s membership seriously impairs MCO’s, dental plan’s, or provider’s ability to provide services to the client or to obtain new patients, and the client’s behavior is not caused by a physical or behavioral health condition.
Client refuses to comply with managed care restrictions (e.g., repeatedly using emergency room in combination with refusing to allow MCO to treat the underlying medical condition).
For STAR+PLUS MCOs, under limited conditions, the MCO may request disenrollment of members who are totally dependent on a ventilator or who have been diagnosed with End Stage Renal Disease.
Before a request for disenrollment can be initiated, reasonable measures must be taken to correct the client’s behavior. Reasonable measures may include education or counseling conducted by health plan or dental plan staff. HHSC will notify the client in writing of the disenrollment if all attempts to remedy the situation have failed. HHSC will also notify the client in writing of the availability of appeal procedures and the HHSC fair hearing process.
Health plans, dental plans, and providers can not request a client’s disenrollment because of an adverse change in the client’s health or the utilization of services that are medically necessary for the treatment of a client’s condition.

Texas Medicaid & Healthcare Partnership
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