(a) Except for
changes made by a newly eligible individual during the fifteen (15) or sixty
(60) calendar days grace periods, an enrolled individual shall only be allowed
to change enrollment from one health plan to another during the annual plan
change period.
(b) Exceptions to
(a) can occur for cause, which include the following circumstances:
(1) A decision from an administrative appeals
office allowing participating health plan change;
(2) A court order allowing participating
health plan change;
(3) Provisions
in federal or State statutes or administrative rules;
(4) A non-returning plan or termination of
the individual's health plan's contract or the start of a new
contract;
(5) Mutual agreement by
the participating health plans involved, the enrolled individual and the
department;
(6) Violations by a
participating health plan specified in chapter 17-1735.2;
(7) Change in foster placement if necessary
for the best interest of the child;
(8) The individual's PCP or long-term care
residential facility is not in the health plan's provider network and is in the
provider network of a different participating health plan provided the health
plan is not at its maximum enrollment;
(9) The individual is eligible to receive
HCBS or personal assistance services level I and is enrolled in a health plan
with a waiting list for HCBS or personal assistance services level I and
another health plan does not have a waiting list for the necessary
service(s);
(10) The participating
health plan's refusal, because of moral or religious objections, to cover the
service the individual seeks as allowed for in the department's contract with
the participating health plan;
(11)
The individual's need for related services(e.g., a cesarean section and a tubal
ligation) to be performed at the same time and not all related services are
available within the network and the individual's primary care physician or
another provider determines that receiving the services separately would
subject the individual's to unnecessary risk;
(12) Lack of direct access to women's health
care specialists for breast cancer screening, pap smears and pelvic
exams;
(13) Other reasons,
including but not limited to, poor quality of care, lack of access to covered
services, or lack of access to providers experienced in dealing with the
individual's health care needs, lack of direct access to certified nurse
midwives, pediatric nurse practitioners, family nurse practitioners, if
available in the geographic area in which the individual resides;
(14) Relocation of the individual to a
service area where the health plan in which they were enrolled does not provide
services;
(15) The individual
missed the annual plan change period due to a temporary loss of Medicaid
eligibility and was re-enrolled in their previous health plan; or
(16) Other special circumstances as
determined by the department.
(c) When changing health plans, an individual
shall select among health plans participating in the service area in which the
individual resides that are open to new members except as described in section
171720.1-19.
(d) In the absence of
choice of health plans participating in the service area in which the
individual resides and open to new members, except as described in section
17-1720.1-19, the individual shall be enrolled in the available health plan
accepting new members.
