gsa22

Enrollee ability to change plans

AZ | CT | FL | HI | MA | MO | MT | NV | NJ | NY | OH | OK | VA | WV

"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.

"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 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.

"Amendment # 003...
6. Attachment I, B. 17. is amended to include:
c. Upon the agency's implementation of open enrollment, new eligibles and existing recipients subject to open enrollment who change from their current Medicaid managed health care plan will remain enrolled in their plan for 12 months. Additionally, recipients who are reinstated or regain eligibility within 10 months of their 12 month enrollment period will remain 'locked-in' until the date for the next open enrollment period. Members that move to a new county shall remain a member of their current plan if the plan operates in the new county. These recipients will only be allowed to disenroll form plans outside of the annual open enrollment period if they meet a 'good cause change' reason…" Florida Contract, page 4.

“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 the recipient does not select a plan and is enrolled in a ‘returning’ plan, and finds out that the recipient’s PCP is no longer in the ‘returning’ plan, will the recipient be allowed to change plan to retain their medical home relationship with their PCP (that’s in a different plan)?
b) If the recipient does not select a plan and is not currently enrolled in a ‘returning’ plan and is auto assigned, will the recipient be allowed to change plan to access their PCP (if the PCP is not in the plan that they have been auto-assigned to)?
c) If the recipient does select a plan and finds out that their PCP is no longer in the plan selected, will the recipient be allowed to change plan to access their PCP?

ANSWER:
a) As noted previously, the State is considering a limited time period in which a recipient may change plans if he or she discovers that PCP is no longer with the plan.
b) See answer above.
c) See answer above.” Hawaii RFP, Q&A, pages 32-33.

“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.

"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 nay 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.

"2.4.1 Health-Plan Lock-In: … Once a member... 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… 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.

"2.2.1 Enrollment limits...
If capacity is decreased because of a reduction in the number of PARTICIPATING PROVIDERS available to Medicaid ENROLLEES then the DEPARTMENT will give the ENROLLEES of those PROVIDERS leaving the network the option to voluntarily disenroll from the plan. This option will not be offered to ENROLLEES on BASIC Medicaid unless:
a. all ENROLLEES on FULL Medicaid disenroll, and
b. ENROLLEES on FULL Medicaid need to disenroll drop actual caseload below new maximum." Montana Contract, page 32.

"All voluntary participants may disenroll from the Contractor at any time.
E. Disenrollment For Cause at the Request of the Participant. Mandatory participants may disenroll from a Contractor for cause at any time. Cause may be considered to exist when it is found that irreparable damage has been done or undo hardship exists within the Contractor/participant relationship. Whether cause exists for a participant's disenrollment from the Contractor shall be determined through the Contractor's internal dispute resolution process. The Contractor shall advise the participant seeking disenrollment in the post 90 day period that he/she may pursue Contractor internal dispute resolution to determine if cause exists for disenrollment. The participant and Contractor are encouraged to resolve these disputes internally, and where possible attempt to solve the underlying issue or issues. The DHCFP shall also advise the participant of their State hearing rights which may be exercised if the Contractor denies disenrollment through the Contractor's internal dispute resolution process.

Only if cause is found through the dispute resolution process will a participant be permitted to disenroll and select another Contractor during the lock-in period. If the Contractor's dispute resolution process determines that no cause exists to allow the participant to disenroll, then the Contractor shall in all cases forward this decision to the Medicaid managed care unit for review and disenrollment determination.

The request may contain the participant's signature unless the participant is not available for signature and/or is unable to sign the request for disenrollment." Nevada Contract, pages 28-29.

"E. Disenrollment Without Cause. Participants may disenroll without cause for the first 90 days after enrollment with a Contractor. DHCFP will be responsible for effecting the disenrollment by the first day of the second month after the request is made and enrolling the participant in another Contractor.

All voluntary participants may disenroll without cause at any time.

F. Disenrollment for Cause. Participants may disenroll from a Contractor for cause at any time. Cause may be considered to exist when it is found that irreparable damage has been done or undo hardship exists within the Contractor/participant relationship. Whether cause exists for a participant's disenrollment from the Contractor shall be determined through the Contractor's internal dispute resolution process. The DHCP shall advise the participant seeking disenrollment in the post 90 day period that he/she may pursue Contractor internal dispute resolution to determine if cause exists for disenrollment. The participant and Contractor are encouraged to resolve these disputes internally, and where possible attempt to solve the underlying issue or issues. The DHCFP shall also advise the participant of their State hearing rights which may be exercised if the Contractor denies disenrollment through the Contractor's internal dispute resolution process.

In rare cases, the DHCFP may disenroll a participant for cause without first referring the participant to the Contractor for resolution through the Contractor internal dispute resolution process." Nevada Contract, page 48.

"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 enrolment and at least every 12 months thereafter without cause. Enrollees may transfer for cause at any time...
B. NJ KidCare B, C, or D enrollees will be subject to a 12-month lock-in period…" New Jersey Contract, page 49.

"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.

"5101:3-26-02 Managed care plan: Eligibility, enrollment and automatic enrollment...
(B) Enrollment.
(1) The following applies to enrollment in MCPs…
(m) No eligible individual's choice of enrollment in an MCP may be processed until three working days after completion of the initial enrollment or enrollment change form in order to allow eligible individuals the opportunity to make changes. During this time, changes may be made without regard to the disenrollment and enrollment provisions of rule 5101:3-26-021 of the Administrative Code. Eligible individuals must be informed of this provision when an initial enrollment or enrollment change form is requested or completed." Ohio RFP, Appendix E, OAC 5101:3-26-02, pages 1-4.

"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.

"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.

" 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.