Tip for State-specific MCO selection form

Check if your current doctors are in the plan's network BEFORE choosing

Tip for State-specific MCO selection form

Compare plans based on covered benefits, especially dental, vision, and behavioral health

Tip for State-specific MCO selection form

You usually have a 90-day window after enrollment to switch plans without cause

Medicaideasy

Medicaid Managed Care Plan Selection

State-specific MCO selection form · State Medicaid Agencies / Enrollment Brokers

Form to select or change a Medicaid managed care organization. In mandatory managed care states, failure to choose results in auto-assignment.

Form Details

Total fields: 20
Auto-fillable: 15 (75%)
Time without BeneFill: 20 minutes
Time with BeneFill: 5 minutes
Time saved: 15 minutes
Filled by: patient
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Through your state Medicaid managed care enrollment portal

Most states have an online plan selection tool for Medicaid managed care.

📬

Return the plan selection form mailed to you by your state Medicaid agency

🏢

At your local Medicaid office or through an enrollment broker

Many states contract with enrollment brokers who can help you choose a plan.

Filing Deadline

Typically 30-60 days from receiving your plan selection notice. If you do not choose, the state will auto-assign you to a plan.

Required Attachments

📎 Completed plan selection form with your chosen managed care plan
📎 No additional documentation typically required beyond the selection form

Processing Time

Plan selection is usually processed within the enrollment cycle. Coverage in your chosen plan typically begins the first of the following month.

What Happens Next

You will receive a membership card and plan materials from your selected Medicaid managed care organization (MCO). You can change plans during the initial 90-day period.

Tips for This Form

✓ Check if your current doctors are in the plan's network BEFORE choosing
✓ Compare plans based on covered benefits, especially dental, vision, and behavioral health
✓ You usually have a 90-day window after enrollment to switch plans without cause
✓ If auto-assigned to a plan, you can still request a change within the 90-day period

More Medicaid Forms

Medicaid Application

State-specific · State Medicaid Agencies / CMS via HealthCare.gov

Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

HealthCare.gov Marketplace Application

Federal Marketplace Application · CMS / Federal Marketplace

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Emergency Medicaid Application

State-specific (e.g., Form 520) · State Medicaid Agencies

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Presumptive Eligibility Determination

State-specific PE form · State Medicaid Agencies / Qualified Entities

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Medicaid Renewal / Redetermination

State-specific (e.g., CA MC 210 RV) · State Medicaid Agencies

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies / Enrollment Brokers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.