PHC Florida

Robert Heglar
AHF Provider

If You Want to Disenroll

You may ask to cancel your membership during the open enrollment period.  You may also ask to disenroll for “good cause” at any time during your enrollment.  Call the Enrollment Broker Helpline at (877) 711-3662, TTY (866) 467-4970.  Agents are available Monday through Thursday, 8:00 a.m. to 8:00 p.m. and Friday, 8:00 a.m. to 7:00 p.m.

Disenrollment will not affect your Medicaid eligibility.  After you disenroll from PHC Florida, you will receive benefits through Medicaid.  You can still file an appeal or grievance with PHC Florida for when you were a member even if you have disenrolled from the plan.

If you are a mandatory enrollee and you want to change plans after the initial 120-day period ends or after your open enrollment period ends, you must have a state-approved good-cause reason to change plans. The following are state-approved cause reasons to change Managed Care Plans:

  • The enrollee does not live in a region where the Managed Care Plan is authorized to provide services, as in Florida Medicaid Management Information System (FMMIS).
  • The provider is no longer with the Managed Care Plan.
  • The enrollee is excluded from enrollment.
  • A substantiated marketing or community outreach violation has occurred.
  • The enrollee is prevented from participating in the development of his/her treatment plan/plan of care.
  • The enrollee has an active relationship with a provider who is not on the Managed Care Plan’s panel, but is on the panel of another Managed Care Plan. “Active relationship” is defined as having received services from the provider within the six months preceding the disenrollment request.
  • The enrollee is in the wrong Managed Care Plan as determined by the Florida Agency for Health Care Administration (the Agency).
  • The Managed Care Plan no longer participates in the region.
  • The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR 438.702(a) (3).
  • The enrollee needs related services to be performed concurrently, but not all related services are available within the Managed Care Plan’s network or the enrollee’s primary care provider (PCP) has determined that receiving the services separately would subject the enrollee to unnecessary risk.
  • The Managed Care Plan does not, because of moral or religious objections, cover the service the enrollee seeks.
  • The enrollee missed open enrollment due to a temporary loss of eligibility.
  • Other reasons per 42 CFR 438.56(d) (2) and s. 409.969(2), F.S.,, including, but not limited to:
    • Poor quality of care
    • Lack of access to services covered under the Contract;
    • Inordinate or inappropriate changes of PCPs;
    • Service access impairments due to significant changes in the geographic location of services;
    • An unreasonable delay or denial of service;
    • Lack of access to providers experienced in dealing with the enrollee’s health care needs; or
    • Fraudulent enrollment.

If you want to disenroll from the plan for any of the above good-cause reasons, please call the Enrollment Broker Helpline at (877) 711-3662, TTY (866) 467-4970. Agents are available Monday through Thursday, 8:00 a.m. to 8:00 p.m. and Friday, 8:00 a.m. to 7:00 p.m

 

AHCA 062614 PHC MMA Form 17.0