10906 DISENROLLMENT

10906.1 Beneficiaries shall have the right to disenroll from their MCO upon request, for the reasons described under § 10906.4 and pursuant to the requirements under 42 C.F.R. § 438.56(c).

10906.2 An MCO may request beneficiary disenrollment in accordance with the requirements set forth in its contract with the Department.

10906.3 Except when a beneficiary's continued enrollment in the MCO seriously impairs the entity's ability to furnish services to either the particular enrollee or other enrollees, an MCO may not request disenrollment because of:

(a) An adverse change in the enrollee's health status;

(b) The beneficiary's utilization of services;

(c) The beneficiary's diminished mental capacity; or

(d) The beneficiary's uncooperative or disruptive behavior resulting from his or her special needs.

10906.4 Disenrollment may occur, at the beneficiary's request, for the following reasons:

(a) For cause, at any time, which shall include the following:

(1) The beneficiary moves out of the MCO's service area;

(2) The plan does not, because of moral or religious objections, cover the service the beneficiary seeks;

(3) The beneficiary 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 beneficiary's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk;

(4) 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;

(5) The beneficiary needs services from a Psychiatric Residential Treatment Facility (PRTF). The MCO shall provide coverage for the beneficiary prior to disenrollment for a limited time period specified in the managed care contract; or

(6) All family members are not assigned to the same MCO and the beneficiary is requesting disenrollment to ensure family enrollment alignment; or

(b) Without cause, at the following times:

(1) During the ninety (90) calendar days following the date of the beneficiary's enrollment into the MCO, or during the ninety (90) calendar days following the date the Department sends the beneficiary notice of that enrollment, whichever is later;

(2) At least once every twelve (12) months after the period described under § 10906.4(b)(1);

(3) Upon automatic reenrollment under 42 C.F.R. § 438.56(g), if the loss of Medicaid eligibility for two (2) months or less has caused the beneficiary to miss the annual disenrollment opportunity; and

(4) When the Department imposes an intermediate sanction that suspends all new enrollment, including default enrollment, into a MCO, as described in 42 C.F.R. § 438.702(a)(4).

10906.5 The Department must approve or disapprove disenrollment no later than the first (1st) day of the second (2nd) month following the month in which the beneficiary requests disenrollment, the MCO refers the request to the Department, or the MCO requests disenrollment of the beneficiary.

(a) Upon approval of a disenrollment, the effective date of the disenrollment shall be the first (1st) day of the second (2nd) month following the month in which the beneficiary requests disenrollment or the MCO refers the request to the Department.

(b) Upon approval of a disenrollment, the beneficiary shall have thirty (30) days from the date of the notice of the approval of disenrollment to select an MCO, pursuant to § 10905.3. If the beneficiary does not select an MCO in the allotted thirty (30) days, the beneficiary will be automatically assigned to an MCO, pursuant to § 10906.4.

10906.6 If the Department fails to make the determination of whether the disenrollment is approved within the timeframes specified in § 10906.5, the disenrollment shall be considered approved for the effective date that would have been established had the Department complied with 29 DCMR § 5502.5.

10906.7 Beneficiaries who are dissatisfied with the Department’s determination that there is not good cause for disenrollment shall be entitled to request a fair hearing in accordance with the requirements set forth under § 10908 of this Chapter.

SOURCE: Final Rulemaking published at 72 DCR 013183 (November 28, 2025).