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-30-05-2.39 - MCO Lock-In

Universal Citation: 210 RI Code of Rules 30 05 2.39

Current through March 25, 2025

A. Following initial enrollment into an MCO, Medicaid members are restricted to that MCO until the next open enrollment period. During this health plan lock-in, a Medicaid member may request to be reassigned to another MCO only under one of a set of specific allowed conditions.

1. Allowed conditions for reassignment requests - Members may request to be reassigned to another MCO for any of the following reasons:
a. Substandard or poor quality care;

b. Inadequate access to necessary specialty services;

c. Lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the enrollee's care needs;

d. The MCO does not, because of moral or religious objections, cover the services the enrollee seeks;

e. The enrollee needs related services 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;

f. Insufficient transportation;

g. Discrimination;

h. Member relocation;

i. Good cause as defined in § 2.48(A)(4) of this Part.

j. Without cause during the ninety (90) days following the effective date of the Medicaid member's initial enrollment with the MCO.

2. Process for requesting reassignment - Medicaid members seeking MCO reassignment during the lock-in period must file a formal request with EOHHS.

3. Agency review - MCO reassignment can only be ordered by EOHHS after administrative review of the facts of the case. In the course of the review, EOHHS must examine the evidence it has compiled about the grounds that are the basis for the Medicaid member's request for disenrollment.

4. Notice of agency action - EOHHS must provide the member with written notice of the action taken on the request for MCO reassignment. If EOHHS determines that there is sufficient evidence to reassign the Medicaid member, the notice must be sent to the member at least ten (10) days prior to the date the proposed reassignment would be effective. The Medicaid member must submit a plan change form to select another MCO.

Disclaimer: These regulations may not be the most recent version. Rhode Island may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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