NEVADA MEDICAID AND NEVADA CHECK UP - MANAGED CARE ORGANIZATION (MCO) GOOD CAUSE
DISENROLLMENT FORM
Federal regulations allow Medicaid members to change their MCO through a process called, “Disenrollment for Cause”. This
process is for members who want to change their current MCO and are not within their 90-day window to change. If you
request good cause disenrollment, you must continue to receive all medical care from your current MCO until the effective
date of disenrollment. Contact the Division of Health Care Financing and Policy (DHCFP) District Office Southern
Nevada: (702) 668-4200 or Northern Nevada: (775) 687-1900 or TTY 7-1-1 to verify your disenrollment before you seek
medical services outside of your MCO’s network or for any other questions.
Head of Household Information
Name:
Address:
Medicaid ID:
Date of Birth:
Phone #:
Reason for Disenrollment Per 42 CFR 438.56(d)(2) (Check all that apply):
1. The recipient moves out of the MCO service area.
Note: Contact the Division of Welfare and Supportive Services (DWSS) for Southern Nevada: (702) 486-1646 or
Northern Nevada: (775) 684-7200 or Toll Free: 1(800) 992-0900 or TTY 7-1-1 or log into the Access NV web
portal to update your address at https://accessnevada.dwss.nv.gov/public/landing-page. You may also submit
an address change at the following link https://dhcfp.nv.gov/UpdateMyaddress/.
2. The MCO does not, because of moral or religious objections, cover the service the recipient seeks.
3. The recipient needs related services (for example a cesarean section and a tubal ligation) to be performed at the same
time; not all related services are available within the network; and the recipient's primary care provider or another
provider determines that receiving the services separately would subject the recipient to unnecessary risk.
4. Other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access
to providers experienced in dealing with the recipients care needs.
(Explain)______________________________________________________________________________________
Please include the name of your Primary Care Physician, Specialist and/or the Hospital you use.
_________________________________________________
Primary Care Physician Phone#
____________________
Specialist
___________________________________________________________
Phone #
____________________
Hospital
_____________________________________________________________
Phone #
____________________
Current MCO: (please only check one)
Anthem Blue Cross and Blue Shield Healthcare
Solutions (844) 396-2329
Health Plan of Nevada (800) 962-8074
Molina Healthcare of Nevada (833) 685-2109
SilverSummit Healthplan (844) 366-2880
New MCO Choice: (please only check one)
☐ ☐ Anthem Blue Cross and Blue Shield Healthcare
Solutions (844) 396-2329
Health Plan of Nevada (800) 962-8074
Molina Healthcare of Nevada (833) 685-2109
SilverSummit Healthplan (844) 366-2880
Fax completed form to (775) 684-3773 or mail to Attn: DHCFP MCQA Unit, 1100 E William St Suite 101, Carson City NV
89701. You may also drop off the form at your local Medicaid District office.
You may also submit the completed form via email [email protected] or by clicking the “SUBMIT” button below.
After clicking “SUBMIT” check the Default email application (Microsoft Outlook) circle in the Send Email box that displays,
then click Continue and it will direct you to an email to send the form.
Atención: si habla español, dispone de servicios gratuitos de asistencia lingüística, llame al 1(866) 569-1746 (TTY: 7-1-1)
NMO-5008 (08/22)
