From: HEALTH PLAN FAX

MCORequestforMemberDisenrollment

To:FAX: 1-888-858-3875

From: HEALTH PLAN FAX:

PrinttheNameofMember(Last,First,MiddleInitial) / BirthDate / MedicaidIDNumberorSocialSecurityNumber

☐Memberhasdemonstratedapatternofdisruptive,unruly,abusiveoruncooperativebehaviortotheextentthatenrollmentintheMCOseriouslyimpairstheorganization’sabilitytofurnishservicestoeitherthememberorothermembersandthemember’sbehaviorisnotcausedbyaphysicalormentalcondition.(Attachseparatenarrativewithadditionalinformationincludingmeasurestaken bytheMCOtocorrectthemember’sbehaviorpriortosubmittingtherequestfordisenrollment)

☐Member’sutilizationofservicesisfraudulentorabusive(e.g.memberloanstheMCOissuedIDcardtoanotherpersontoobtainservices).(AttachnarrativewithadditionalinformationincludingdateofreferraltoMedicaidProgramIntegrity’sFraudHotline)

☐Memberisplacedinalong-termcarenursingfacility,ICF/DDfacility,orbecomeseligibleforaMedicaidHomeandCommunity-BasedServicesWaiverorhospice.Indicatewhich______

☐Memberexpired Date: ______

☐Member incarceratedDate:______Facility:______

☐ Member has moved out of state. New Address: ______

☐Other______

Health Plan Signature:Date:______

The LouisianaDepartmentof Health andHospitalswilldetermineiftheMCOhas showna goodcausetodisenrolltheMedicaid/CHIP member.TheEnrollmentBrokerwill givewrittennotificationtothe MCOofthedecision. Medicaid/CHIP membershavethe rightto appealdisenrollmentdecisionsandrequestastate fairhearing withtheDivision ofAdministrativeLaw. All requests will be reviewed on a case-by-case basis and are subject to the sole discretion of DHH or its designee (Enrollment Broker). All decisions are final and not subject to the dispute resolution process by the MCO. (MCO Request for Proposals, 11.11.4)

The MCOshallnotdiscriminateagainst any Medicaid/CHIPmemberon the basisof theirhealth status,needforhealthcare servicesorany otheradverse reasonwith regardtothemember’shealth,race, sex,handicap,age,religionornationalorigin.

☐Disenrollment Approved Effective Date: ______☐Disenrollment Denied/Reason:______

DHH Signature:Date: ______

EB Signature:Date: ______

Health Plan notified of decision.