N.M. Admin. Code § 8.308.7.10

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.308.7.10 - DISENROLLMENT

A.Member disenrollment initiated by a MCO The MCO shall not, under any circumstances, disenroll a member. The MCO shall not request disenrollment because of a change in the member's health status, because of his or her utilization of medical or behavioral health services, his or her diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.

B.Other HSD member disenrollment: A member may be disenrolled from a MCO or may lose his or her MAD eligibility if:

(1) he or she moves out of the state of New Mexico;

(2) he or she no longer qualifies for a MAP category of eligibility or has a change to a MAP category of eligibility that is not eligible for managed care enrollment;

(3) he or she requests disenrollment for cause, including but not limited to the unavailability of a specific care requirement that none of the contracted MCOs are able to deliver and disenrollment is approved by HSD;

(4) a member makes a request for disenrollment which is denied by HSD, but the denial is overturned in the member's HSD administrative hearing final decision; or

(5) HSD imposes a sanction on the MCO that warranted disenrollment.

C. Effective date of disenrollment: All HSD-approved disenrollment requests are effective on the first calendar day of the month following the month of the request for disenrollment, unless otherwise indicated by HSD. In all instances, the effective date shall be indicated on the termination record sent by HSD to the MCO.

N.M. Admin. Code § 8.308.7.10

8.308.7.10 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018, Amended by New Mexico Register, Volume XXIX, Issue 23, December 11, 2018, eff. 1/1/2019