Fillable Nevada Medicaid Managed Care Organization (MCO) Change Form (State of Nevada, Department of Information Technology)

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Nevada Medicaid Managed Care Organization (MCO) Change Form (State of Nevada, Department of Information Technology)

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Nevada Medicaid – Managed Care Organization (MCO) Change
Form
MCO Change Form (E) Rev 03.2018
If you would like to request a change to your MCO, please complete the following information and
return this letter to the address listed below. Contact your Medicaid District Office at the number
below if you need help determining if you are eligible to switch your MCO. Please be aware of any
deadlines associated with your initial 90 day switch period or the Annual Open Enrollment
period. Requests received outside of your switch period or the Annual Open Enrollment period
may not be processed.
MCO Choice:
Anthem Blue Cross and Blue Shield Healthcare Solutions (formerly Amerigroup)
(844) 396-2329
Health Plan of Nevada (800) 962-8074
SilverSummit Healthplan (844) 366-2880
Name: ____________________________________________________________________________
Medicaid ID (Head of Household):__________________________________________________
Signature: ________________________________________________________________________
Date: __________________________
Mail your request to:
Nevada Medicaid
Attn. MCO Changes
P.O. Box 30042
Reno, NV, 89520
Any recipient wishing to change their MCO plan outside of the annual open enrollment period
must contact the MCO at the telephone number above and show good cause. The MCO will
evaluate the cause and make a determination to allow or deny the switch. If your request is
denied, you have the right to appeal the decision.
Medicaid District Office
Northern Nevada (775) 687-1900
Southern Nevada (702) 668-4200
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Nevada Medicaid – Managed Care Organization (MCO) Change
Form
MCO Change Form(S) Rev 03.2018
Si desea solicitar un cambio a su MCO, complete la siguiente información y devuelva esta carta a la
dirección que está escrita abajo. Comuníquese con la Oficina del Distrito de Medicaid a los
números que están escritos abajo si necesita ayuda para determinar si es elegible para cambiar su
MCO. Por favor, tenga en cuenta los plazos asociados con su período de cambio inicial de 90 días o
el período de inscripción anual. Las solicitudes recibidas fuera del período de cambio o del
período de inscripción anual no se procesaran.
Opción de MCO:
Anthem Blue Cross and Blue Shield Healthcare Solutions (anteriormente Amerigroup)
(844) 396-2329
Health Plan of Nevada (800) 962-8074
SilverSummit Healthplan (844) 366-2880
Nombre: __________________________________________________________________________
Número de identificación de Medicaid (Jefe de familia): _______________________________
Firma: ____________________________________________________________________________
Fecha: _________________________
Envié su solicitud por correo a:
Nevada Medicaid
Attn. MCO Changes
P.O. Box 30042
Reno, NV, 89520
Cualquier destinatario que desee cambiar su plan de MCO fuera del período anual de inscripción
abierta debe comunicarse con la MCO al número de teléfono que aparece arriba y mostrar una
buena causa. El MCO evaluará la causa y tomará una determinación para permitir o denegar el
cambio. Si su solicitud es denegada, tiene derecho a apelar la decisión.
Medicaid District Office
Norte de Nevada (775) 687-1900
Sur de Nevada (702) 668-4200
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Nevada Medicaid Managed Care Organization (MCO) Change Form (State of Nevada, Department of Information Technology)

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Completed 12 February 2022

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