gsa17

Enrollee ability to change plans

AZ | CO | CT | DE | FLMH | HI | IL | IN | IA | KS | ME | MD | MA | MI | MN | MO | MT | NE | NV
NH | NJ | NM | NY | NC | OH | OK | PA | RI | SC | TN | TX | UT | VA | WA | WV | WI

"6. ENROLLMENT AND DISENROLLMENT…
Health Plan Choice...
When a member is transferred from Title XIX to Title XXI and has not made a health plan choice for Title XXI, the member will stay with the title XIX health plan and a choice notice will be sent to the member. The member may then change plans no later than 16 days from the date the choice notice is sent...

Newborns: ...
Newborns of FES mothers are auto-assigned to a health plan and mothers of these newborns are sent a letter advising them of their right to choose a different health plan for their child.

Native Americans: ...
Native Americans may change from HIS to a Contractor or from a contractor to HIS at any time…" Arizona Contract, pages 19-20.

"11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual anniversary date. AHCCCSA may hold an open enrollment on a limited basis as deemed necessary. During AEC, members may change contractors subject to the availability of other contractors within their Geographic Service Area…" Arizona Contract, page 23.

"II. ELIGIBILITY AND ENROLLMENT…
C. Disenrollment
l. The following are acceptable reasons for Disenrollment: ...
h. Voluntary request to disenroll without cause during the first thirty 30 days of Enrollment." Colorado Contract, page 15.

"Part II: General Contract Terms for MCOs
1. Definitions...
Z. Lock-in: Limitations on Member changes of managed care plans for a period of time, not to exceed twelve (12) months…" Connecticut Contract, pages 11-13.

"4.5 Lock-in
a. Upon renewal approval of the DEPARTMENT's 1915(b) managed care waiver, the DEPARTMENT will implement a lock-in period of up to 12 months for managed care Members. Members will not be allowed to change plan enrollment during the lock-in period except for cause.
The lock-in period is subject to the following provisions and exceptions:
1. The first 90 days of enrollment into a new MCO will be designated as the free-look period during which time the Member may change plans.
2. The last 60 days of the lock-in period will be an open enrollment period, during which Members may change plans.
3. Plan changes made during the open enrollment period will go into effect on the first day of the month following the end of the lock-in period...

b. The following shall constitute good cause for a Member to disenroll from the plan during the lock-in period:
1. Unfavorable resolution of the MCO's internal complaint process and continued dissatisfaction due to repeated incidents of any of the following:
a. documented long waiting times for appointments
* more than 45 days for well care visit;
* more than 2 days for non-urgent, symptomatic office visit...
* unavailability of same day office visit or same day referral to an emergency provider for emergency provider for emergency care services

b. documented inaccessibility of health plan by phone or mail
* phone calls not answered promptly;
* caller placed on hold for extended periods of time;
* phone messages and letters not responded to promptly
* repeated rude and demeaning treatment by MCO staff.

2. Prior to pursuing the MCO's internal complaint process and without filing a grievance through the plan, dissatisfaction due to any of the following:
a. discriminatory treatment as documented in a complaint filed with CHRO or the DEPARTMENT's Affirmative Action Division;
b. primary care provider able to serve client's specific documentable needs (i.e. language or physical accessibility) left health plan and there is no other suitable PCP within reasonable distance to the client; or
c. enrollee has a pending lawsuit against the MCO; verification of pending lawsuit must be provided.

3. Child placed under DCF guardianship whose placement is changed to a location or facility not affiliated with current health plan…" Connecticut Contract, pages 56-57.

"11.3 Internal MCO Enrollment Requirements
3.1 Enrollment Periods
The MCOs will have a continuous open enrollment process for new DSHP and Title XXI members and a specific yearly enrollment/transfer month for members already enrolled in a MCO. A continuous open enrollment process means that as individuals are determined eligible for the DSHP or Title XXI, they can enroll in contracting MCOs without waiting for the annual open enrollment period. During the yearly enrollment/transfer month, members can transfer from their present MCO for any reason, and name a different MCO. After enrollment in an MCO, DSHP and Title XXI members may transfer at any point for ‘good cause,’ and must complete all standard grievance procedures and have the situation deemed good cause for transfer by DSS. Transfers will be received and processed by DSS. DSS will re-determine eligibility based on required regulations for the proper category, and members will be enrolled in a MCO until the yearly enrollment/transfer period...

4.2 Transfers
The transfer process can be initiated by the member, the MCO, or the State. Members will be enrolled in another MCO on the first (1st) day of the next month. MCOs must have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when a member is transferred to or from another MCO. The HBM will process and complete within five (5) business days of receipt all member and State-approved MCO requests to transfer members to another MCO. Appendix F provides an overview of the transfer process.

4.2.1 Member-Initiated Transfers
Members may request transfers between MCOs at any time for good cause, as determined by the DSS. There is no limit on the number of transfer requests that a member can initiate for good cause.

Reasons considered good cause for member transfers are:
(a) Members may initiate a transfer during the annual open enrollment period for any reason; the HBM will inform each member in writing at the time of enrollment and at least thirty (30) calendar days before the start of each open enrollment period of the right to transfer; members must inform the HBM which will process the transfer request and update the enrollment roster whereby both the old and the new MCOs are informed of the transfer

(b) As the result of a formal grievance filed by the member against the MCO; in this case, members must work through the grievance process with the MCO; if the member's grievance is not resolved at the informal and formal levels of the MCO's grievance process, the member may seek resolution through the HBM and the State

(c) The member requires specialized care for a chronic condition, and the member, MCO and State agree that reassignment to another MCO is appropriate." Delaware RFP, pages II.9- II.12.

FLMH

"2.15 Disenrollment Rules and Procedures...
B. In areas where there are no Medicaid HMOs, recipients may disenroll from the plan for reason of just cause only if just cause is related to quality of care." Florida Mental Health RFP, page 39.

“20.130 Quest-Net...
During the entire transitional period, these individuals shall not be eligible for plan changes during the open enrollment period.” Hawaii RFP, pages 5-6.

“40.420 QUEST Enrollment...
Once enrolled, a member will only be allowed to change to another plan during the next annual open enrollment period. The exceptions to this provision include directives resulting from administrative appeal decisions or legal decisions and mutual agreement by the plans involved, the recipient and the State. Another exception to this is a hospitalized recipient. QUEST will follow industry standards on plan changes as it relates to hospitalizations. If a recipient is hospitalized on the date of the plan change, the plan with responsibility at the time of the hospitalization remains financially responsible through discharge.” Hawaii RFP, page 46.

“40.600 Open Enrollment
Recipients will generally not be allowed to change health plans except during open enrollment which will take place once a year...

The recipients will inform DHS of their decision to change health plan by submitting the completed enrollment form. The enrollment of the recipient into the new plan will follow the same procedures as the enrollment of a new recipient...

Recipients may be allowed to change health plan at times other than during open enrollment due to an administrative appeal decision; provisions in administrative rules or statutes; a legal decision; the recipient moves to a service area where the plan does not provide service; or an administrative decision resulting from agreement between DHS, the recipient and the plans involved.” Hawaii RFP, page 50.

“Will the ‘medical home’ philosophy be maintained that supports recipients ability to change plans to access PCPs that they have had relationships in the past, if the PCP is not in the plan that they have either chosen (without knowledge that the PCP is no longer in the ‘returning’ plan) or been assigned to?

ANSWER:
The State is considering a limited time period in which persons who inadvertently find themselves in the ‘wrong’ plan will have an opportunity to change. If a decision is made to do this, the process and procedures will be developed.” Hawaii RFP, Q&A, page 29.

“a) If there are ‘new’ plans that are awarded contracts, will a recipient be allowed to change plan once (if the recipient has selected or been assigned to a ‘returning’ plan) in order to access a ‘new’ plan that may have unique programs that better meet the recipient's specific medical/social needs (regardless of whether PCP is available in both 'new' and ‘returning’ plan)?

ANSWER:
a) During open enrollment a person is able to select a new plan because of its unique programs...” Hawaii RFP, Q&A, page 33.

"Article IV
Enrollment, Coverage and Termination of Coverage...
(e) Termination of Coverage...
(D)… Beneficiaries may elect to disenroll at any time." Illinois Contract, pages 11-12.

"4.2.2 Disenrollment
MCO members may terminate or change their enrollment at any time for cause, as defined by OMPP. 'For cause' changes will be handled by the enrollment broker with oversight by the OMPP. Recipients may disenroll from the MCO without cause at any time during the 90 day period beginning on the date the member receives notice of enrollment with the MCO, and at least every 12 months thereafter…

4.5.2.1 Disenrollment From Hoosier Healthwise RBMC
The recipient will be allowed to disenroll from the RBMC component of Hoosier Healthwise at any time with cause. These recipients may be required, however, to participate in the PrimeStep component of the program, unless certain conditions are identified and approved for disenrollment from Hoosier Healthwise entirely. Requests for disenrollment are made through the Hoosier Healthwise Helpline or Benefit Advocate and are documented, tracked, and monitored. OMPP has the ultimate authority for allowing eligible recipients to disenroll from the program. Recipients who disenroll and switch programs frequently will be monitored and such activity will be discouraged.

Without cause disenrollment is permitted at any time during the 90 day period beginning on the date the individual receives notice of enrollment with the MCO and every twelve (12) months thereafter, assuming eligibility has been continuous. The OMPP will notify enrollees 60 days prior to the end of the 12-month enrollment period, of the opportunity to disenroll without cause." Indiana RFP, pages 4-2, 4-13.

"8.2 Extended Plan Participation (EPP)
After the initial 90 days from the notice of enrollment, Enrollees shall remain enrolled in the selected HMO for a period of 6 months (EPP) as long as they otherwise qualify for Medicaid unless: ...
(2) a previously unavailable, Managed Care Entity becomes available. In this circumstance, the Enrollee shall be allowed to enroll with the newly available Managed Care Entity for the remainder of their current EPP period...

8.4 Request for Disenrollment by the Enrollee
During the 90 days from the initial notice of enrollment and during the 90 days from the notice of the disenrollment option prior to the end of EPP, Enrollees may request disenrollment from the HMO pursuant to 42 CFR 434.27(b)(1). Disenrollment shall be effective no later than the first day of the second month after the month in which disenrollment was requested. If at any time the Enrollee establishes a good cause for disenrollment, the disenrollment shall be effective no later than the first day of the second month after the month in which disenrollment was requested…" Iowa Contract, page 49.

"A. ENROLLMENT PROCESS
Enrollment of Medicaid beneficiaries in managed care will include the following components: ...
• Annual enrollment process for those beneficiaries currently enrolled in a managed care program:
o The Medicaid fiscal agent will facilitate the annual enrollment of beneficiaries. An enrollment packet will be mailed to all identified beneficiaries qualified to participate in managed care, informing them they have 30 days to change their assignment without cause…" Kansas Contract, pages 44-45.

"SRS Responsibilities
Notification will be sent to each Medicaid beneficiary after 6 months enrollment in a managed care program stating that he or she may change programs or plans within the next thirty (30) days without good cause…" Kansas Contract, page 50.

"Members may voluntarily disenroll from the HMO's health plan without cause at any time if the HMO is not federally qualified. These disenrollments will be effective on the last day of the calendar month in which they are requested whenever possible. At any other time members of federally qualified HMOs may request SRS to disenroll them from the HMO's health plan if the following requirements are met:

• A member requests disenrollment in writing to SRS and the HMO, for good cause;
• The request cites the reason(s) why he or she wishes to disenroll such as poor quality of care, lack of access to specialty services or other reasons satisfactory to SRS;
• The HMO provides information that SRS may require; and
• SRS determines that good cause for disenrollment exists. Good cause includes:
o Adequate transportation to primary care services is not available
o Unresolved language barriers
o The beneficiary has an established family doctor in another managed care plan or the PCCM program
o The beneficiary requests all family members be assigned to the same provider
o Lack of referral to necessary specialty services covered in the State Plan." Kansas Contract, page 55.

"D. SELECTION/ASSIGNMENT OF PRIMARY CARE PROVIDER (PCP)
3. Exemption. If an otherwise eligible recipient requests an exemption to enrollment, and the request for exemption is approved by the Department, the Contractor shall allow the Enrollee to disenroll so that his or her continuity of care is not interrupted." Maine Contract, page 11.

"G. DISENROLLMENT FROM INITIATIVE...
2. Voluntary Disenrollment. The Contractor shall permit Enrollees to voluntarily disenroll without restriction for the purpose of enrolling in a different HMO. Voluntary disenrollment shall be effective at the end of the month in which the disenrollment is requested, or five (5) days from the date of request, whichever is later." Maine Contract, pages 12-13.

"10.09.63.05...
.05 Reassignment.
A. Annually, upon the anniversary date of initial enrollment in an MCO, a Program recipient may elect to: ...
(2) Enroll in another MCO in the recipient's local access area; or
(3) Enroll in an MCO outside the recipient's local access area, upon the approval of the Department and the MCO located outside the recipient's local access area.

B. Before an enrollee's anniversary date of enrollment, the Department shall notify the enrollee that the enrollee has 21 days to notify the Department of a decision to enroll in a new MCO...

.06 Disenrollment.
A. Enrollee-Initiated Disenrollment for Cause.
(1) Examples of Cause.
   (a) During the first year of the Maryland Medicaid Managed Care Program only, an enrollee may elect one time, for any reason, to disenroll from an MCO and to enroll in another MCO.
   (b) An enrollee may disenroll from an MCO and enroll in another MCO if the enrollee moves to a county that is not served by the enrollee's present MCO.
   (c) A group of enrollees comprising a family, the members of which are enrolled in different MCOs, may, at the request of an adult enrollee, be disenrolled and reassigned so that all family members are assigned to one MCO.
   (d) An enrollee who moves or becomes homeless, creating a transportation hardship that may be resolved by enrollment into another MCO serving the enrollee's new local access area, may request to be disenrolled and enrolled into another MCO.
(2) Enrollees shall apply to the Department's enrollment agent for disenrollment.
(3) The Department shall interpret cause liberally in determining whether to permit disenrollment of a member of a special needs population during the first year of the Maryland Medicaid Managed Care Program." Maryland COMAR 10.09.63.05-.06.

"Section 3.2 Enrollment, Assignment, and Disenrollment Processes...
B. Enrollment
The Division shall:
1… The Division shall present all options available to Members under MassHealth in an unbiased manner and shall inform each member at the time of enrollment, of the right to terminate enrollment at any time...

E. Disenrollment
1. Disenrollment Conditions...
b. Except as otherwise provided under federal law or Waiver, an Enrollee may disenroll voluntarily at any time. Such voluntary disenrollments shall take effect one business day after such request...

2. Disenrollment Information
The Division shall: ...
b. Provide the Contractor with information related to the following voluntary disenrollment reasons as received from Enrollees by the Division's enrollment vendor on a monthly basis. Such disenrollment reasons may include, but are not limited to:
   1) difficult to contact PCP;
   2) takes too long to obtain an appointment;
   3) did not like the PCP;
   4) dissatisfaction with BH services;
   5) did not like office staff's personal manner;
   6) received poor medical treatment; and
   7) any other specified causes…" Massachusetts Contract, pages 97-101.

"II-G ENROLLMENT IN THE CHCP...
3. Enrollment Lock-in
Enrollment into a Contractor's plan will be for a period of 12 months. The 12-month enrollment period will be in effect from July 1 through June 30 of the following year with the following conditions:

*At least 60 days before the start of each enrollment period and at least once a year, DCH, or the Enrollment Services contractor, will notify Enrollees of their right to disenroll;
*Enrollees will be provided with an opportunity to select any Contractor approved for their area during this open enrollment period;
*Enrollees will be notified that if they do nothing, their current enrollment will continue;
*Enrollees who choose to remain with the same Contractor will be deemed to have had their opportunity for disenrollment without cause and declined that opportunity;
*New Enrollees, those who have changed from one Contractor to another or are new to Medicaid eligibility, will have 90 days within which they may change Contractors without cause;
*Enrollees who change enrollment within the 90-day period will have another 90 days within which they may change Contractors without cause and this may continue throughout the year;
*An Enrollee who has already had a 90-day period with a particular Contractor will not be entitled to another 90-day period within the year with the same Contractor...

7. Open Enrollment
Open enrollment will occur for all Beneficiaries at least once every 12 months. Enrollees will be offered the choice to stay in the health plan they are in or to change to another Contractor within their county at the end of the 12-month lock-in...

13. Disenrollment for Cause Initiated by the Enrollee
The Enrollee may request a disenrollment for cause from a Contractor's plan at any time during the enrollment period. Reasons cited in a request for disenrollment for cause may include poor quality care or lack of access to necessary specialty services covered under the Contract. Enrollees who are granted a disenrollment for cause will be required to change enrollment to another Contractor." Michigan Contract, pages 17-20.

"Section 3.1.2. Enrollment...
E. Enrollee Change of Health Plan. Enrollees may change to a different health plan during the open enrollment period, and as required under Minnesota Rules, Part 9500.1453, Subparts 5 and 7. Also see Section 3.4.L(C) and (G)." Minnesota Contract, page 20.

"Section 3.4. Termination of Enrollee Coverage.
Section 3.4.1. Termination by STATE. An Enrollee's coverage in the HEALTH PLAN may be terminated by the STATE for one of the following reasons: ...

C. The Enrollee is permitted to change health plans pursuant to Minnesota Rules, Part 9500.1453 because of problems with access or service delivery, or other good cause...

F. Pursuant to Minnesota Rules, Part 9500.1453, Subpart 5, the Enrollee elects to change health plans once during the first year of initial enrollment in the HEALTH PLAN or during the first 60 days after a change in enrollment from a health plan that no longer participates in PMAP, PGAMC or MinnesotaCare.

G. Pursuant to Minnesota Rules, Part 9500.1453, Subparts 7 or 8, the Enrollee elects to change health plans due to substantial travel time or Local Agency error.

H. The Enrollee elects to change health plans during the annual open enrollment period.

I. The Enrollee elects to change health plans within 120 days following notice of a Material Modification of the HEALTH PLAN's Provider Network under Section 3.2.4.A.2." Minnesota Contract, pages 29-30.

"2.41. Health Plan Lock-In: ...Once a member chooses a health plan or is assigned to a health plan, the member will have ninety (90) days from the date the member's enrollment is effective with the health plan in which to change health plans for an reason. After the ninety (90) day period, the member will be allowed to change health plans for any reason every twelve (12) months thereafter. A notice will be provided at least sixty (6) days before each annual enrollment opportunity. Members will have the right to change health plans for good cause as determined by the state agency at any time within the twelve (12) month lock-in" Missouri RFP, page 34.

"e. Transfers and Disenrollments: Members, as part of the complaint and grievance system, may request…disenrollment from one health plan and subsequent enrollment in another health plan...
f. All transfers among health plans that members request during the first ninety (90) calendar days following initial enrollment will be granted without review by the State…" Missouri RFP, page 74.

"Children in state custody or foster care placement will be allowed automatic and unlimited changes in health plan and provider choice as often as circumstances necessitate…" Missouri RFP, page 75.

"2.3.2 Voluntary Disenrollment All ENROLLEES shall have the right to request disenrollment from the CONTRACTOR pursuant to 42 CFR 434.27(b)(1). A voluntary disenrollment shall be effective no later than the first DAY of the second month after the month in which the ENROLLEE'S request is received and processed. The CONTRACTOR shall forward to the State's ADMINISTRATIVE CONTRACTOR FOR MANAGED CARE all requests from EN-ROLLEES for disenrollment within three (3) working days. This requirement only applies to ENROLLEES on BASIC Medicaid if the ENROLLEE is switching to another HMO, moves out of the enrollment area, or for good cause.

2.3.3 Disenrollment for FAIM Enrollees FAIM adults on BASIC Medicaid may only disenroll if they move from the enrollment area, request disenrollment from one HMO in order to enroll in another HMO or for good cause. An adult FAIM ENROLLEE on BASIC Medicaid is considered to have good cause if the person:
(1) has a terminal illness;
(2) meets one of the conditions for exemption of or the PASSPORT to Health program as defined in ARM 46.12.5003(2); or
(3) is under treatment by a physician or mid-level practitioner who is not affiliated with a Medicaid HMO and both patient and PROVIDER believe that a disruption of the patient/PROVIDER relationship may adversely affect treatment or cause unnecessary hardship to the patient; provided that good cause to disenroll for this reason shall exist only until the end of treatment or until the PROVIDER contracts with an HMO, whichever occurs first, and in no event for more than 4 months.

The DEPARTMENT shall once a year notify adults 21 years of age or older on BASIC Medicaid about the right to request disenrollment for good cause." Montana Contract, page 34.

"2.2 Scope: ...
If any of the plans that the Department currently contracts with are not offered a continuing contract, the Department shall afford the client the right to transfer to any of the available plans effective July, 1999." Nebraska Contract, page 3.

"9.4 Reenrollment for the Basic Benefits Package
9.4.1 Reenrollment Rules Within Two Months of Disenrollment: ...
The client is free to choose a different PCP/plan; however, the reenrollment process shall be 'automatic' and shall be activated prospectively unless the client contacts the EBS. The client’s choice shall take precedence over the systematic process, if the choice is made prior to system cutoff." Nebraska Contract, page 34.

"9.6.2 Enrollment of a Pregnant Woman and Her Unborn Child for the Basic Benefits Package: ...
Enrollment changes (i.e., to a different plan or PCP) may be made as often as allowed for any other client participating in the NHC, as long as mother and unborn/newborn are both enrolled with the same plan…" Nebraska Contract, page 36.

"9.15 Client Requested Transfers
9.15.1 Definition of a Transfer: A transfer is a change in a client’s enrollment from one PCP to another PCP or from one plan to another. A transfer may be made at the client’s request pursuant to Section 9.15 of this contract or at the PCP/plan’s request pursuant to 9.16 of this contract.

9.15.2 Client Transfer Requests: The client shall contact the EBS to request a transfer. A client may request a transfer at any time. The transfer shall be effective the month following the request but no later than the second month following the request. The EBS shall assist the client in selecting a new PCP or plan by:
(a) Discussing the reasons for transfer with the client and attempting to resolve any conflicts, when in the client’s best interest; and
(b) Reviewing the client’s needs to facilitate the client’s choice of PCP or plan...

9.15.5 Exception to the Transfer Rules: The following rules apply for a mother and her unborn/newborn:
(a) When requested by the client, the mother and unborn/newborn may be enrolled in separate plans based on good cause. Good cause includes, but is not limited to, situations in which one plan is unable to meet the needs of both clients despite reasonable efforts to accommodate their needs; and
(b) The request for enrollment in separate plans must be submitted to the EBS, who shall gather any additional information needed. The request shall be submitted to the Department within two (2) working days. The Department shall approve or deny the request within five (5) working days. The Department shall notify the client and PCP/plans of the approval or denial of the request." Nebraska Contract, pages 40-41.

"9. Section II. Medicaid Participants, Paragraph C. Enrollment Lock-In, on page 28 of the Contract is changed as follows:
'Members will be locked into an enrollment with a Contractor for up to 12 months as determined by DHCFP. The members will be notified of their option to change Contractors during the annual open enrollment period at least 60 days prior to the end of the lock-in period'...

6. Section II. Enrollment, Paragraph B. Date of Enrollment on page 47 of the Contract is changed to include as follows: …
'Once enrolled, a member will remain with their chosen plan until the annual enrollment period unless the participant is disenrolled from Nevada Check Up in accordance with Paragraph G. and H. There will be an annual open enrollment process coinciding with the eligibility redetermination process during which families can change their plan. The enrollment period will be from October 1 through September 30 of the current year.'

7. Section II. Enrollment, Paragraph C. Lock-In on page 47 of the Contract is changed as follows:
'All members will be locked into enrollment with a Contractor for up to 12 months. Members will be notified of their option to change Contractors at the time of the annual open enrollment period at least 60 days prior to the end of the lock-in period.'" Nevada Amendment #1, pages 5-8.

"Article VI
Enrollment and Disenrollment...

6.4 VOLUNTARY DISENROLLMENT--Any Enrollee under this Agreement may voluntarily disenroll at any time for any reason by following the proper procedures as agreed upon by the State and Contractor in accordance with Section 6.8. Disenrollment will be allowed if unresolvable difficulties arise, subject to Section 2.12." New Hampshire General Service Agreement, page 23.

"ARTICLE 9
TRANSFERS
9.1 An enrollee may transfer from one plan to another at any time for any reason during the first ninety (90) days after the latter of the date the individual is enrolled or the date they receive notice of enrollment and at least every 12 months thereafter without cause. Enrollees may transfer for cause at any time…" New Jersey Contract, page 49.

"2.B.2 Enrollment Process for Members:
Because CONTRACTOR is not a federally qualified HMO, members who join CONTRACTOR may request a change in enrollment during any month.

2.B.2.c Member Selection:
A new MCO mandatory enrollee has the opportunity to select an MCO within fourteen (14) calendar days. A current MCO member has the opportunity to change MCO during the first 30 days of a six month enrollment period." New Mexico Contract, page 24.

"2.b.4 Member Initiated Disenrollment:
A Medicaid member who is required to participate in managed care may request to be disenrolled from the CONTRACTOR ‘for cause' at anytime, even during a lock-in period. This request shall be submitted in writing to HSD for review. HSD shall complete the review and furnish a written decision to the member and the CONTRACTOR in a timely manner. Members who voluntarily enroll may choose to disenroll at any time." New Mexico Contract, page 26.

"7. Article 2, Section 2.B.2., is amended as follows:
2.B.2.c… A new MCO member has the opportunity to change MCOs during the first 90 days of a twelve month enrollment period. Members will be notified by HSD of the ability to change MCOs at least 60 days before the end of an enrollment period." New Mexico Contract, Amendment #1, pages 2-3.

"7. LOCK-IN PROVISIONS
7.1 Lock-In Provisions in Voluntary Counties
All Enrollees in local social service districts where enrollment in managed care is voluntary shall be subject to a Lock-In Period under this Agreement if so required by the LDSS as indicated by an x below:

Enrollees are subject to a twelve (12) month Lock-In Period following the Effective Date of Enrollment in the Contractor's plan with an initial ninety (90) day grace period to disenroll from the Contractor's plan without cause...

7.2 Lock-In Provisions in Mandatory Counties
All Enrollees in local social service districts, except New York City, where enrollment in managed care is mandatory, are subject to a twelve (12) month Lock-In period following the Effective Date of Enrollment in the Contractor's plan, with an initial thirty (30) day grace period in which to disenroll from the Contractor's plan without cause, or a sixty (60) day grace period in which to disenroll from the Contractor's plan without cause, if the Enrollee was auto-assigned by the LDSS to the Contractor's plan.

7.3 Lock-In Provisions in New York City
All Enrollees residing in New York City are subject to a twelve (12) month Lock-In Period following the Effective Date of Enrollment in the Contractor's plan with an initial ninety (90) day grace period in which to disenroll without cause from the Contractor's Plan, regardless of zip code of residence, and regardless of whether the Enrollee selected or was auto-assigned to the Contractor's plan…" New York Contract, page 7-1.

"8. Disenrollment...
8.7 Enrollee Initiated Disenrollment
a) Disenrollment For Good Cause
   i) An Enrollee subject to Lock-In may initiate disenrollment from the Contractor's plan for 'good cause' as defined in 18 NYCRR ' 360-10.13 at any time during the Lock-In period and may disenroll for any reason at any time after the twelfth (12th) month following the Effective Date of Enrollment...
   iii) Enrollees granted disenrollment for 'good cause' in a voluntary county may join another plan, if one is available, or participate in Medicaid fee-for-service program. In mandatory counties, unless the Enrollee becomes exempt or excluded, he/she may be required to enroll with another MCO...
   v) Once the Lock-In Period has expired, an Enrollee may disenroll from the Contractor's plan at any time, for any reason…" New York Contract, pages 8-1-8-3.

"APPENDIX H
New York State Department of Health Guidelines for the Processing of Enrollments and Disenrollments...
E. Disenrollment: ...
LDSS Responsibilities: ...

2. Enrollees may initiate a request for an expedited disenrollment to the LDSS or SDOH. The LDSS will expedite the disenrollment process in those cases where a Enrollee's request for disenrollment involves an urgent medical need or a complaint of non-consensual enrollment. If approved, the LDSS will manually process the disenrollment through the PCP Subsystem...

5. Where the LDSS has the authority to operate a mandatory program, the LDSS will promptly disenroll Enrollees who request disenrollment upon determination that they meet exemption criteria (e.g. individuals who are newly diagnosed with HIV infection)...

8. The LDSS is responsible for informing Enrollees of their right to change MCOs including any applicable lock-in restrictions. For those LDSSs that have implemented a mandatory enrollment program, families or members of a case wishing to change MCOs will be required to do so as a unit, unless the LDSS determines a 'good cause' reason to waive this requirement...

F. Expedited Disenrollments
An expedited disenrollment process is available in those cases where there is an urgent medical need to disenroll or where there is a complaint of non-consensual enrollment. Enrollees may submit a request for expedited disenrollment to the LDSS or SDOH as stated in Section 8.7 (b) of this Agreement…" New York Contract, Appendix H, pages H-1-H-11.

"4.9 Plan Transfers
Members may voluntarily disenroll from the Plan, and transfer to another Plan at any time without cause...

4.10 County Transfers
When Members transfer to another county, they must report the change of residence to the Department of Social Services (DSS). Section 4.2 of the Contract also requires the Plan to report a Member's change of residence to DSS. Upon notification of such change, the Member will be disenrolled from the Plan. The effective date of the disenrollment is subject to data processing deadlines. The Plan is responsible for all medically necessary services to the Member until the disenrollment occurs." North Carolina Contract, page 7.

"B. Background...
Program Characteristics...
Enrollees are currently permitted to change MCPs during their first month of MCP enrollment or during semi-annual open enrollment months. At other times, only the loss of program eligibility or the existence of circumstances (certain enrollment limitations as described in RFP Appendix D) can result in MCP disenrollment..." Ohio RFP, page 5.

"APPENDIX C...
Enrollment Change Opportunities...
MCP enrollees may voluntarily disenroll from a MCP, however, the enrollees' ability to initiate disenrollment from an MCP is limited. Enrollees are permitted to change MCPs at any time during their initial month of enrollment in an MCP or during semi-annual open enrollment months…" Ohio RFP, Appendix C, page 1.

"APPENDIX D
ENROLLMENT LIMITATIONS
Effective July 2000, enrollees of Medicaid-serving MCPs in counties designated as Open Enrollment counties will be able to change MCPs in the initial three months of enrollment in an MCP, as well as during an annual Open Enrollment month designated by ODHS for their county of residence...

Just Cause Disenrollment
Enrollees may request to change MCPs (enrollees in voluntary enrollment counties may also request a change to fee-for-service Medicaid) outside of designated Open Enrollment periods for specific reasons. Requests are made through the Consumer Hotline. The following are acceptable reasons for requesting a change:

1. The Primary Care Physician (PCP) that was selected is no longer on the MCP's panel and there
is no other PCP that is available or located within a reasonable travel time.

2. The PCP that was selected is no longer on the MCP's panel and was the only physician with that MCP that spoke the member's primary language; an another MCP has an available physician that speaks the member's language.

3. The PCP that an assistance group member needs to see because of a special medical condition is not available through the MCP or does not have an office located within a reasonable travel time from the member.

4. The assistance group no longer lives within a reasonable travel time to any PCPs in the MCP, and another MCP has a PCP available and located within a reasonable travel time from the member's home.

5. A situation exists where, in the judgement of ODHS, continued enrollment in the current MCP would be harmful to the enrollee. (Applicants selecting this option must provide a written explanation of why they believe they meet this criteria.)" Ohio RFP, Appendix D, page 1.

"5101:3-26-021 Managed care plan: Disenrollment...
(B) The following applies to all automatic disenrollments in both voluntary and mandatory counties: ...
(9) Enrollees may initiate disenrollment in other than open enrollment months or IN the first month of MCP enrollment for just cause.
(a) Disenrollment for just cause includes the following:
   (i) The PCP selected by an assistance group member leaves the MCP's panel or is no longer available or accessible within the travel time requirement and there is no other PCP available or accessible within the travel time requirement as specified by ODHS;
   (ii) The PCP selected by an assistance group member leaves the MCP's panel and was only available and accessible PCP speaking the primary language of the enrollee, and another PCP speaking the language is available and accessible in another MCP in the county;
   (iii) The onset of an illness, or an accident, or an addition to the assistance group requires the PCP for an assistance group member outside the travel time requirement as specified by ODHS;
   (iv) The enrolled assistance group moves within the county and no PCP on the MCP's panel is available or accessible within the travel time requirements as specified by ODHS;
   (v) A situation in which, in the judgement of ODHS, continued enrollment would be harmful to the interests of the enrollee...
(c) All requests for just cause disenrollment will be reviewed by ODHS within three working days of receipt. ODHS may request documentation as necessary from both the enrollee and the MCP. A decision will be made within five working days of receipt of all necessary documentation..." Ohio RFP, Appendix E, OAC 5101:3-26-021, pages 1-5.

"2.4.4 Health Plan Lock-in
Health Plan enrollees will be permitted to change Health Plans, without showing cause, during their first month of enrollment, including those previously enrolled in a Plan who have elected to remain with that Plan. After the first month of enrollment, Health Plan members will be ‘locked into’ their Health Plan until the next annual open enrollment period, unless:
• Member files an appeal and is disenrolled by the Authority for cause, as described in Section 2.4.12 of the Contract or,
• Member loses eligibility for more than ninety (90) days and then regains eligibility (See also, Section 2.4.5).

Health Plan lock-in provisions apply to individual members or families…" Oklahoma RFP, page 17.

"2.4.12 Member Disenrollment from Plan
2.4.12.1 At Request of Member
Health Plan must permit members to disenroll from a Plan, without cause, during the first thirty (30) days of enrollment.
After the first thirty (30) days, members will be ‘locked-into’ their Health Plan until the next annual open enrollment period…" Oklahoma RFP, page 23.

"14. Member Disenrollment...
b. Reason for Disenrollment
The HMO member may disenroll from the HMO for any of the following reasons:
• Request to change from his/her current HMO to a new HMO (this change may be initiated at any time)…" Pennsylvania RFP, page 33.

"2.04.05 Health Plan Lock-In
Following their initial enrollment into a Health Plan, Rite Care families shall be restricted to that Health Plan until the next open enrollment period…" Rhode Island RFP, page 11.

"6.6 Member Initiated Disenrollment and Change of Managed Care Plans
The Contractor shall ensure that the Medicaid HMO Program member's right to disenroll voluntarily is not restricted in any way. Medicaid HMO Program members shall be disenrolled from the Contractor's plan or have their managed care plan changed when they submit a written request to disenroll or change plans. The request must be made to SCDHHS…" South Carolina Contract, page 37.

"2-6. Enrollment
a. Enrollment Guidelines...
13...New enrollees becoming eligible for TennCare shall have one (1) opportunity, anytime during the forty-five (45) day period immediately following enrollment in a MCO plan, to request to change MCO plans without regard to whether such enrollment is the result of selection or assignment. Once the initial forty-five (45) day period has expired, the individual shall remain a member of the designated plan until the following change period, until the enrollee moves outside the designated plan's service area or until they lose eligibility for TennCare. All enrollees that are in a plan on October 1, 1994 and each subsequent October 1st will be given an additional opportunity to change their managed care organization. These changes will be made subject to the capacity of the selected MCO to accept additional enrollees and any restrictions limiting enrollment levels established by TENNCARE. The change selected by these enrollees will be made effective January 1, 1995 and each subsequent January 1st. Enrollees who move outside the designated plan's service area shall be allowed to immediately transfer to a plan serving the service area where the enrollee has moved…" Tennessee Contract, pages 34-37.

"6.3.3 Plan Change. A Member cannot change from one health plan to another health plan during an inpatient hospital stay." Texas Contract, page 36.

"D. Disenrollment by Enrollee
1. Enrollee's Right to Disenrollee
Enrollees will have the right to disenroll from this MCO at any time with or without cause." Utah Contract, Attachment B, page 9.

"5. Enrollment Period
Following their initial enrollment into an HMO, Medallion II enrollees shall be restricted to that HMO until the next open enrollment period, unless disenrolled under one of the conditions described in Article II and pursuant with Section 1932 (a)(4)(A) of Title XIX.

For the initial ninety (90) calendar days following the effective date of enrollment, the recipient will be permitted to disenroll from one HMO to another without cause...

In addition, within sixty (60) days prior to the end of the enrollment period, the Department will inform the recipient of the opportunity to remain with the current HMO, or change to another HMO without cause...

However, the recipient may disenroll from any HMO to another at any time, for good cause as defined by the Department.

6. Disenrollment
a. Voluntary Disenrollment

All enrollees shall have the right to disenroll from the Contractor's plan to another plan pursuant to 42 C.F.R. 434, 27 (b), as amended...

During the first ninety (90) calendar days following the effective date of enrollment, an enrollee may disenroll for any reason...

Consistent with 1932(A)(4) of the Social Security Act, as amended (42 U.S.C. 1396u-2), the Department must permit an enrollee to disenroll at any time for good cause. The request must be in writing to the Department and cite the reason(s) why he or she wish to disenroll. The Department will define the reasons under which good cause for disenrollment may exist. The Department will establish procedures for 'good cause' disenrollment." Virginia Contract, pages 24-25.

"2.5 Enrollment Period: Subject to the provisions of section 2.8(a), enrollment is continuously open. Members shall have the right to change enrollment prospectively, from one managed care plan to another without cause, each month (42 CFR 434.27)." Washington Contract, page 6.

"2.10 Termination of Enrollment:
a. Voluntary Termination - Members shall request termination of enrollment by submitting a written request to terminate enrollment to DSHS or by calling the DSHS toll-free enrollment number and requesting termination of enrollment. Requests for termination of enrollment may be made to enroll with another Healthy Options contractor, or to disenroll from Healthy Options as provided in WAC 388-538-130…" Washington Contract, page 8.

"2.24 After the first sixty days of enrollment in CHIP, clients will not be permitted to change plans except during an annual open enrollment period. Exceptions will be made for 'good cause'. The 'good cause' reasons include:
• To get all family members enrolled with one plan
• If the client moves out of a plan's service area
• The client's plan has to stop providing services in the client's county because of network adequacy problems
• If the client is AI/AN
• To protect a client from a perpetrator of domestic violence, abuse, or neglect
• To correct a department error
• If directed to do so by an Administrative Law Judge as a result of a fair hearing." Washington CHIP RFQQ, page 7.

"4.2.4 Transfers from MCPs
The term 'transfer' will be used to refer to enrollees who leave one MCP to enroll in another MCP, all under Medicaid.

The transfer process can be initiated by the enrollee, the MCP or DHHR. Recipients will be enrolled in another MCP no later than the first day of the second month after the transfer was requested… The MCP must have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when an enrollee is transferred to or from another MCP.

4.2.4.1 Enrollee-Initiated Transfers
MCP enrollees may request transfers between MCPs at any time for any reason. There is no limit on the number of transfer requests that an enrollee can initiate. The enrollee should contact the HBM to transfer from one MCP to another MCP. However, if an enrollee informs the MCP that he or she wants to transfer to another MCP, the MCP must work with the HBM to facilitate the process." West Virginia RFA, page 29.

"J. VOLUNTARY DISENROLLMENT - All enrollees shall have the right to disenroll from the HMO pursuant to 42 CFR 434.27(b)(1) unless otherwise limited by a section 1915(b) waiver of federal laws, or pursuant to Addendum II. A voluntary disenrollment shall be effective no later than the first day of the second month after the month in which the enrollee requests termination. The HMO will promptly forward to the Department or its designee all requests from enrollees for disenrollment. Wisconsin currently has a 1915(b) waiver which allows the Department to 'lock-in' enrollees to an HMO for a period of six months in mandatory HMO service areas, except that disenrollment is allowed for good cause as described in sections B. through Fn. above... Addendum II allows voluntary exemptions and disenrollment from HMOs for a variety of reasons. Because of these two Department policies, voluntary disenrollment is limited to the situations described in sections B. through I. of Article VII. and Addendum II.

K. SECTION 1915(b) WAIVER - Should the Department, at any time during the Contract, obtain a waiver or revised waiver authority under section 1915(b) of the Social Security Act (as amended), the conditions of enrollment described in the Contract, including but not limited to voluntary enrollment and the right to voluntary disenrollment, shall be amended by the terms of said waiver...

N. ENROLLEE LOCK-IN PERIOD - Under the Department's waiver authority of section 1915(b) of the Social Security Act (as amended), in mandatory HMO service areas enrollees will be locked in to an HMO for six months. The first month of the six month lock-in period will be an open enrollment month in which the enrollee may change their HMO. The conditions of disenrollment as specified in VII. B - J still apply during this lock-in period." Wisconsin Contract, pages 56-57.