An official State of Texas website.
Revision 24-1; Effective Feb. 22, 2024
A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of noncompliance listed in the Texas Health and Human Services Commission (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5 (PDF). These reasons for noncompliance include:
- misusing or loaning the member’s MCO membership card to another person to obtain services;
- disruptive, unruly, threatening or uncooperative behavior unrelated to a physical or behavioral health condition to the extent that the member’s membership seriously impairs the MCO’s ability to provide services to the member or to get new members;
- steadfast refusal to comply with managed care restrictions such as repeatedly using the emergency room along with refusing to allow the MCO to treat the underlying medical condition; or
- a member’s failure to pay room and board (R&B) or copayment charges.
A member may also request to be disenrolled from managed care. Disenrollment from managed care means the member wants to remove themselves from managed care and receive services by fee-for-service (FFS) only. The member must receive approval from HHSC to disenroll from managed care.
Disenrollment is not the same as voluntarily withdrawing from the program. A member may voluntarily withdraw from the STAR+PLUS Home and Community Based Services (HCBS) program without HHSC approval. Examples where a member may request to voluntarily withdraw from the STAR+PLUS HCBS program voluntarily include the:
- member’s name came to the top of another Medicaid waiver program’s interest list and the member chose to pursue the other Medicaid waiver program and withdraw from the STAR+PLUS HCBS program; or
- member states they no longer want the STAR+PLUS HCBS program because they do not use any STAR+PLUS HCBS program services.
Members who receive HHSC approval to disenroll from managed care and maintain Medicaid eligibility, such as Supplemental Security Income (SSI) or SSI-related Medicaid, may continue receiving non-waiver services available through FFS Medicaid. Medical assistance only (MAO) members will lose Medicaid eligibility as well as waiver services.
Program Support Unit (PSU) staff must refer a member who requests disenrollment from managed care to the HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 to request to disenroll.
PSU staff must refer MCOs requesting a member be disenrolled from managed care to follow the policy outlined in UMCM Chapters 11.5 and 11.6.
PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Compliance & Operations (MCCO) Unit staff and the HHSC Disenrollment Committee will review each member and MCO request to disenroll. MCCO Unit staff will notify Program Enrollment & Support (PES) state office staff of an approved disenrollment request. PES state office staff will notify the appropriate PSU supervisor and request disenrollment. The notification will include the Medicaid Managed Care Member Disenrollment form and the disenrollment date.
The PSU supervisor will email the disenrollment request to the assigned PSU staff for processing. PSU staff must complete the following activities within two business days of PSU supervisor assignment:
- create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record selecting “Disenrollment” in the Action Type field;
- select “Disenrollment. HPM Request. Add Never Not” as the Issue Type in the HEART case record;
- manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) using the effective date provided by the MCCO Unit and the termination reason, “Member requests service termination”;
- for MAO members, complete Form H1746-A, MEPD Referral Cover Sheet and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist requesting Medicaid termination effective the date of disenrollment provided by the MCCO Unit;
- upload applicable documents to the HEART case record;
- document that the member disenrolled in the HEART case record; and
- close the HEART case record.
PSU staff must not generate Form H2065-D, Notification of Managed Care Program Services, for an approved disenrollment. PSU staff are not required to notify Enrollment Resolution Services (ERS) Unit staff or the member of the approved disenrollment. MCCO Unit staff will send a Notice of Ineligibility to the member and work with ERS Unit staff to disenroll the member from managed care.