{"data":{"id":"us-nc/n.c.-gen.-stat.-108d-5.3","jurisdiction":"us-nc","citation":"N.C. Gen. Stat. § 108D-5.3","heading":"Enrollee requests for disenrollment.","body":"(a)\tIn 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.\n(b)\tWithout Cause Enrollee Requests for Disenrollment. - An enrollee shall be allowed to request disenrollment 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 request to disenroll at any time:\n(1)\tBeneficiaries who meet the definition of Indian under 42 C.F.R. § 438.14(a).\n(2)\tBeneficiaries who are described in G.S. 108D-40(a)(14).\n(3)\tRepealed by Session Laws 2023-134, s. 9E.22(d), effective October 3, 2023.\n(4)\tRepealed by Session Laws 2023-134, s. 9E.22(d), effective October 3, 2023.\n(5)\tBeneficiaries who are receiving long-term services and supports in institutional or community-based settings.\n(6)\tAny other beneficiaries who are not required to enroll in a PHP under G.S. 108D-40.\n(7)\tBeneficiaries who are described in G.S. 108D-40(a)(12).\n(c)\tWith 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:\n(1)\tThe enrollee moves out of the PHP's service area.\n(2)\tThe PHP, because of the PHP's moral or religious objections, does not cover a service the enrollee seeks.\n(3)\tThe 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.\n(4)\tAn 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.\n(5)\tThe 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.\n(6)\tA family member of the enrollee becomes, or is determined, eligible for Medicaid and the family member is, or becomes, enrolled in a different PHP.\n(7)\tPoor 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.\n(8)\tPoor 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.\n(d)\tExpedited 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); 2022-74, s. 9D.15(z); 2023-134, s. 9E.22(d).)","path":["Chapter 108D. Medicaid Managed Care Program.","Article 1A. Disenrollment from Prepaid Health Plans."],"source_url":"https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_108D/GS_108D-5.3.html","current_through":"S.L. 2026-30","vintage":"","retrieved_at":"2026-08-27T18:16:37Z","sha256":"8b14fb631d2229083fc900e43cde7853a8ee469bec66ad7d11b097e37a7104dd","source_id":"us-nc","stale":false,"prev":"us-nc/n.c.-gen.-stat.-108d-5.1","next":"us-nc/n.c.-gen.-stat.-108d-5.5"},"notice":"GroundRules: Original legal text. Not legal advice."}