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-30-05-2.48 - MCO Initiated Disenrollment

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:

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.