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Revision 26-3; Effective Aug. 14, 2026
A managed care organization (MCO) may request a member be disenrolled from managed care for specific noncompliance reasons. The reasons are listed in the Texas Health and Human Services Commission (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5 (PDF). Noncompliance reasons include:
- misusing or loaning the member’s MCO membership card to another person to get services;
- disruptive, unruly, threatening or uncooperative behavior unrelated to a physical or behavioral health condition where the member’s membership seriously impairs the MCO’s ability to provide services to the member or to get new members;
- steadfast refusal to comply with managed care restrictions such as repeatedly using the emergency room and refusing to allow the MCO to treat the underlying medical condition; or
- a member’s failure to pay room and board (R&B) or copayment charges.
A member may also request to be disenrolled from managed care. Disenrollment from managed care means the member wants to remove themselves from managed care and receive services by fee-for-service (FFS) only. The member must receive approval from HHSC to disenroll from managed care.
Disenrollment is not the same as voluntarily withdrawing from the program. A member may voluntarily withdraw from the STAR+PLUS Home and Community Based Services (HCBS) program without HHSC approval. A voluntary withdrawal includes when a member’s name comes to the top of another Medicaid waiver program’s interest list and they chose to pursue that program. Another example is the member requesting a voluntary withdraw because they don’t use any of the program’s services.
Members who:
- receive HHSC approval to disenroll from managed care and maintain Medicaid eligibility, such as:
- Supplemental Security Income (SSI); or
- SSI-related Medicaid; may
- continue receiving non-waiver services available through FFS Medicaid.
Medical assistance only (MAO) members will lose Medicaid eligibility as well as waiver services.
Program Support Unit (PSU) staff must refer a member who requests disenrollment from managed care to the HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 to request to disenroll.
PSU staff must refer MCOs requesting a member be disenrolled from managed care to follow the policy outlined in UMCM Chapters 11.5 and 11.6.
PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Contracts and Oversight (MCCO) unit staff and the HHSC Disenrollment Committee review each member and MCO request to disenroll. MCCO unit staff notify Program Enrollment & Support (PES) state office staff of an approved disenrollment request. PES state office staff notify the appropriate PSU supervisor and request disenrollment. The notification includes the Medicaid Managed Care Member Disenrollment form and the disenrollment date.
The PSU supervisor emails the disenrollment request to the assigned PSU staff for processing. PSU staff must complete the following activities within three business days of PSU supervisor assignment:
- create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record selecting Disenrollment in the Action Type field;
- select Disenrollment. HPM Request. Add Never Not as the Issue Type in the HEART case record;
- manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) using the effective date provided by the MCCO unit and the termination reason, Member requests service termination;
- complete Form H1746-A, MEPD Referral Cover Sheet for MAO members; and
- fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
- request Medicaid termination effective the date of disenrollment provided by the MCCO unit;
- upload all applicable documents to the HEART case record;
- document that the member disenrolled in the HEART case record; and
- close the HEART case record.
PSU staff must not generate Form H2065-D, Notification of Managed Care Program Services, for an approved disenrollment. PSU staff are not required to notify Enrollment Resolution Services (ERS) unit staff or the member of the approved disenrollment. MCCO unit staff will send a Notice of Ineligibility to the member and work with ERS unit staff to disenroll the member from managed care.