(a) The department has the sole authority to
enroll and disenroll an individual in a participating health plan.
(b) An eligible individual shall be enrolled
in a health plan for purposes of providing the individual with covered services
effective the date of eligibility as described in 17-1722.3-11.
(c) After the individual is in a
participating health plan, the individual shall be:
(1) Sent an enrollment letter identifying the
assigned plan and the option to remain in the assigned plan or to select a
different health plan;
(2) Allowed
ten days from the date of the enrollment letter to select from among the
participating health plans available in the service area in which the
individual resides that are accepting new members. This provision shall not
apply to an individual identified in subsection (h).
(d) If an individual does not select a
different health plan within ten days from the date of the enrollment letter,
enrollment shall continue in the health plan assigned by the
department.
(e) If an individual
chooses to enroll in a different health plan within ten days, a confirmation
notice will be mailed to the enrollee on the first day of the following month
when enrollment in the new health plan becomes effective.
(f) An enrollee shall only be allowed to
change enrollment from one health plan to another that is open to receiving new
members during the open enrollment period. The exceptions to this provision
include:
(1) Decisions from administrative
hearings;
(3) Termination of the
enrollee's health plan's contract or the start of a new contract;
(4) Mutual agreement by the health plans
involved, the enrollee, and the department;
(5) Violations by a health plan as specified
in sections 17-1727-61 and 17-1727-62;
(6) Relocation of the enrollee to a service
area where the health plan does not provide service;
(7) Change in foster placement if necessary
for the best interest of the child;
(8) The individual missed the open enrollment
period due to temporary loss of Medicaid eligibility and shall be re-enrolled
in their previous assigned health plan within sixty (60) days of losing
eligibility;
(9) The enrollee
chooses a health plan during the open enrollment period and that health plan's
enrollment is capped;
(10)
Provisions in federal or state statutes or administrative rules;
(11) Member's PCP is not in the health plan's
provider network and is in the provider network of a different health
plan;
(12) The health plan's
refusal, because of moral or religious objections, to cover the service the
enrollee seeks as allowed for in the contract with the health plan;
(13) The enrollee's need for related services
(i.e., 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
enrollee's primary care physician or another provider determines that receiving
the services separately would subject the enrollee to unnecessary
risk;
(14) Lack of direct access to
women's health care specialists for breast cancer screening, pap smears and
pelvic exams;
(15) 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
enrollee'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 enrollee resides; or
(16) Other special circumstances as
determined by the department.
(g) An individual who is disenrolled from a
health plan shall be allowed to select a plan of their choice that is open to
receiving new members:
(1) If disenrollment
extends for more than sixty calendar days in a benefit period;
(2) If disenrollment occurred in a period
involving the open enrollment period; or
(3) If disenrollment includes the first day
of a new benefit period.
(h) In the absence of a choice of
participating health plans in a service area, an eligible individual who
resides in that particular service area shall be enrolled in the participating
health plan.
(i) An individual who
is disenrolled from a participating health plan or a health plan contracted to
provide federal or state medical assistance shall be allowed to select a plan
of their choice:
(1) If disenrollment extends
for more than sixty calendar days in a benefit year;
(2) If disenrollment occurred in a period
involving the open enrollment period; or
(3) If disenrollment includes the first day
of a new benefit year.
