108D-5.3. Enrollee requests for disenrollment.

(a) In General. - An enrollee, or the enrollee's authorized representative, who is requesting disenrollment from a PHP, shall submit an oral or written request for disenrollment to the enrollment broker.

(b) Without Cause Enrollee Requests for Disenrollment. - An enrollee shall be allowed to disenroll from the PHP without cause only during the times specified in 42 C.F.R. 438.56(c)(2), except that enrollees who are in any of the following groups may disenroll at any time:

(1) Beneficiaries who meet the definition of Indian under 42 C.F.R. 438.14(a).

(2) Beneficiaries who are enrolled in the foster care system.

(3) Beneficiaries who are in the former foster care Medicaid eligibility category.

(4) Beneficiaries who receive Title IV-E adoption assistance.

(5) Beneficiaries who are receiving long-term services and supports in institutional or community-based settings.

(6) Any other beneficiaries who are not required to enroll in a PHP under G.S. 108D-40.

(c) With Cause Enrollee Requests for Disenrollment. - An enrollee, or the enrollee's authorized representative, may submit a request to disenroll from a PHP for cause at any time. For cause reasons for disenrollment from a PHP include the following:

(1) The enrollee moves out of the PHP's service area.

(2) The PHP, because of the PHP's moral or religious objections, does not cover a service the enrollee seeks.

(3) The enrollee needs concurrent, related services that are not all available within the PHP's network and the enrollee's provider determines that receiving services separately would subject the enrollee to unnecessary risk.

(4) An enrollee who receives long-term services and supports will be required to change residential, institutional, or employment supports providers due to the enrollee's provider's change from in-network to out-of-network status with the PHP and, as a result, the enrollee would experience a disruption in residence or employment.

(5) The enrollee's complex medical conditions could be better served under a different PHP. For purposes of this subsection, an enrollee is considered to have a complex medical condition if the enrollee has a condition that could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function.

(6) A family member of the enrollee becomes, or is determined, eligible for Medicaid or NC Health Choice and the family member is, or becomes, enrolled in a different PHP.

(7) Poor performance by the PHP, as determined by the Department. The Department shall not make a determination of poor performance by any PHP until the Department has completed an annual PHP performance evaluation following the first year of that PHP's contract.

(8) Poor quality of care, lack of access to services covered under the PHP's contract, lack of access to providers experienced in addressing the enrollee's health care needs, or any other reasons established by the Department in the PHP's contract or in rule.

(d) Expedited Enrollee Requests for Disenrollment. - An enrollee, or the enrollee's authorized representative, may submit an expedited request for disenrollment to the enrollment broker when the enrollee has an urgent medical need that requires disenrollment from the PHP. For purposes of this subsection, an urgent medical need means that continued enrollment in the PHP could jeopardize the enrollee's life, health, or ability to attain, maintain, or regain maximum function. (2019-81, s. 1(a); 2021-62, s. 4.8(a).)