Leaving the Plan (Disenrollment)
1. If you want to leave the plan
- You can try us out for 90 days. You may leave AmeriHealth Caritas North Carolina and join another health plan at any time during the first 90 days of your membership with us.
- You can switch health plans once every 12 months. Some members can change their health plan at any time.
- If you want to leave AmeriHealth Caritas North Carolina at any other time, you can do so only with a good reason (good cause). Some examples of good cause include:
- You move out of our service area
- We do not offer a Medicaid Managed Care service that you can get from another health plan in your area.
- You need a service that is related to a benefit we have chosen not to cover and getting the service separately would put your health at risk.
- You have a complex medical condition and another health plan can better meet your needs.
- We have not been able to provide services to you as we are required to under our contract with the North Carolina Department of Health and Human Services.
2. How to change plans
You can ask to change plans by phone, mail, in person or electronically. You will receive help and information to choose a new plan.
You will get a notice that the change will take place by a certain date. AmeriHealth Caritas North Carolina will provide the care you need until then.
You can ask for faster action if you believe the timing of the regular process will cause risk to your health. In that case, you will get a notice about your request to leave the plan within three days of making the request that you want to leave the plan.
You could become ineligible for Medicaid Managed Care
You may have to leave AmeriHealth Caritas North Carolina if you:
- Are no longer eligible for Medicaid Managed Care
- If you stay in a nursing home for more than 90 days in a row
- If you become eligible for and are transferred for treatment to a state-owned Neuro-Medical Center or a Department of Military and Veteran Affairs-operated Veterans Home
- If you begin receiving Medicare.
3. We can ask you to leave AmeriHealth Caritas North Carolina
You can lose your AmeriHealth Caritas North Carolina membership, if you:
- Abuse or harm plan members, providers or staff
- Do not fill out forms honestly or do not give true information (commit fraud)
4. You can appeal a disenrollment decision
You, or your authorized representative, may ask for a State Fair Hearing if you disagree with a decision to:
- Deny your request to change plans; or
- Approve a request made by AmeriHealth Caritas North Carolina for you to leave the plan.
A State Fair Hearing is your opportunity to give more information and facts, and to ask questions about your decision before an administrative law judge. The judge in your Fair Hearing is not a part of your health plan in any way.
You can ask for a State Fair Hearing within 30 days from the day you receive a notice informing you of the decision about your request to change plans or AmeriHealth Caritas North Carolina's request for you to leave the health plan.
When you request a State Fair Hearing, you will receive an opportunity to mediate your disagreement. Mediation is an informal voluntary process to see if an agreement can be made on your case. Mediation is guided by a professional mediator who does not take sides. If you do not reach an agreement at mediation, you can still have a State Fair Hearing. You can also decide not to go through mediation and just ask for a State Fair Hearing.
You can use one of the following ways to request a State Fair Hearing:
Department of Health and Human Services (DHHS)
Attention: Appeals Section
2501 Mail Service Center
Raleigh, NC 27699-2501
Office of Administrative Hearings (OAH)
Attention: Clerk of Court
6714 Mail Service Center
Raleigh, NC 27699-6700