Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 482 - NEBRASKA MEDICAID MANAGED CARE
Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT
Section 482-2-004 - DISENROLLMENT OR TRANSFERS

Universal Citation: 482 NE Admin Rules and Regs ch 2 ยง 004

Current through September 17, 2024

A disenrollment or transfer may be made at the member's request (Title 482 NAC 2-004.01) or at the primary care provider's or Heritage Health plan's request (Title 482 NAC 2-004.04). A transfer may also be made because the member requires an interim primary care provider (Title 482 NAC 2-004.03E).

004(A) TRANSFERS. Transfer for the purposes of this section is a change in a member's assignment from one primary care provider to another primary care provider or one dental home to another dental home.

004(B) DISENROLLMENT. Disenrollment for the purposes of this section is a change in a member's enrollment from one Heritage Health plan to another.

004.01 TRANSFER REQUESTS. The member must contact the Heritage Health plan or Dental Benefits Manager to request a primary care provider or dental home transfer, respectively. A member may request a transfer from one primary care provider to another primary care provider or from one dental home to another dental home at any time. The health plan must document all member transfer requests and the reason.

004.01(A) ASSISTANCE WITH SELECTING A NEW PRIMARY CARE PROVIDER. The Heritage Health plan must assist the member in selecting a new primary care provider by:
(i) Discussing the reasons for transfer with the member and attempting to resolve any conflicts when in the member's best interest;

(ii) Reviewing the member's needs to facilitate the member's choice of primary care provider;

(iii) Processing the member request; and

(iv) Notifying the Department of the primary care provider transfer via the primary care provider transfer file. The primary care provider transfer will be updated on the member's managed care file,

004.01(B) TRANSFER UNDER RESTRICTED SERVICES. Any transfer for a Heritage Health plan member under a restricted services provision must be completed per restricted services procedures (see 482-000-7).

004.02 DISENROLLMENT REQUESTS. A Heritage Health plan member may request a change from one Heritage Health plan to another. The effective date will be the first day of the month following the month of the approval determination.

004.02(A) DISENROLLMENT REASONS. The enrollment broker will allow for a disenrollment as follows:
(i) With cause, at any time;

(ii) During the ninety (90) days following the date of the member's initial enrollment with the Heritage Health plan, or the date the Department sends the member's notice of enrollment, whichever is later;

(iii) During the designated open enrollment period;

(iv) Upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the member to miss the annual disenrollment opportunity; or

(v) If the Department imposes the established intermediate sanctions on the Heritage Health plan.

004.02(B) CAUSE FOR DISENROLLMENT. The following are cause for disenrollment:
(i) The Heritage Health plan does not, because of moral or religious objections, cover the service the member seeks;

(ii) The member needs related services (for example a cesarean section and a total ligation) to be performed at the same time; not all related services are available within the network; and the member's primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk;

(iii) Other reasons, including but not limited to, poor quality of care, lack of access to providers experienced in dealing with the member's health care needs or lack of access to services covered under the contract; or

(iv) The Department and Heritage Health plan contract termination.

004.02(C) DETERMINATION OF DISENROLLMENT FOR CAUSE. When the disenrollment request is for cause, the enrollment broker must complete a Plan Disenrollment Member Request Form with the member and forward the request to the Department staff for a decision. The Department will approve or deny the request based on the following:
(i) Reasons cited in the request;

(ii) Information provided by the Heritage Health plan at the Department's request; and

(iii) Any of the reasons cited in Title 482 NAC 2-004.02A.

004.02(D) COERCEMENT OR ENTICEMENT. The Heritage Health plan may work with the enrollment broker to resolve any issues raised by the member at the time of request for disenrollment but may not coerce or entice the member to remain with them as a member.

004.02(E) DISENROLLMENT UNDER RESTRICTED SERVICES. Any disenrollment for a Heritage Health plan member under a restricted services provision must be completed per restricted services procedures (see 482-000-7).

004.03 PRIMARY CARE PROVIDER TRANSFER REQUESTS. The primary care provider may request that the Heritage Health plan member be transferred to another primary care provider. The primary care provider must provide the services in the core benefits package to the Heritage Health plan member until a transfer is completed.

004.03(A) TRANSFER REASONS. Transfers will be allowed based on the following situations:
(i) The primary care provider has sufficient documentation to establish that the member's condition or illness would be better treated by another primary care provider;

(ii) The primary care provider has sufficient documentation to establish that the member or provider relationship is not mutually acceptable. This may include when the member is uncooperative, disruptive, does not follow medical treatment, or does not keep appointments;

(iii) The individual provider retired, left the practice, died, or is no longer available to provide services; or

(iv) Travel distance substantially limits the member's ability to follow through the primary care provider services and referrals.

004.03(B) REASONABLE ACCOMMODATIONS. The Heritage Health plan must assist the primary care providers and specialists in their efforts to provide reasonable accommodations. This may include additional funding and support to obtain the services of consultative physicians for Heritage Health plan members with special needs.

004.03(C) PROCEDURE FOR PRIMARY CARE PROVIDER TRANSFER REQUESTS. The following procedure applies when a primary care provider requests a transfer:
(i) The primary care provider must contact the Heritage Health plan for which the member is enrolled and provide documentation of the reason(s) for the transfer. The Heritage Health plan must investigate and document the reason for the request. Where possible, the Heritage Health plan must provide the primary care provider with assistance to try to maintain the medical home;

(ii) The Heritage Health plan must review the documentation and conduct any additional inquiry to clearly establish the reason(s) for transfer;

(iii) The Heritage Health plan must submit the request to the Department for approval within ten (10) business days of the request;

(iv) If a primary care provider transfer is approved, the Heritage Health plan will contact and assist the member in choosing a new primary care provider;

(v) If the member does not select a primary care provider within fifteen (15) calendar days after the decision, the Heritage Health plan will automatically assign a primary care provider; and

(vi) The Heritage Health plan must enter the approved transfer of primary care provider on the primary care provider file for the information to be reflected in the managed care system.

004.03(D) TRANSFER CRITERIA. The criteria for terminating a member from a practice must not be more restrictive than the primary care provider's general office policy regarding terminations for non-Medicaid members. The Heritage Health plan must provide documentation to the Department prior to submitting the primary care provider transfer request that attempts were made to resolve the primary care provider member issues (see 482-000-3).

004.03(E) INTERIM PRIMARY CARE PROVIDER ASSIGNMENT. The Heritage Health plan will be responsible for assigning an interim primary care provider in the following situations:
(i) The primary care provider has terminated the member's participation with the Heritage Health plan;

(ii) The primary care provider is still participating with the Heritage Health plan but is not participating at a specific location and the member requests a new primary care provider; or

(iii) A primary care provider or Heritage Health plan initiated transfer has been approved (see Title 482 NAC 2-004.03C) but the member does not select a new primary care provider.

004.03(F) MEMBER NOTIFICATION. The Heritage Health plan must immediately notify the member, by mail or by telephone, that the member is being temporarily assigned to another primary care provider within the same health plan and that the new primary care provider must meet the member's health care needs until a transfer can be completed.

004.04 HERITAGE HEALTH DISENROLLMENT REQUESTS. The Heritage Health plan may request that the member be disenrolled from the plan and re-enrolled in another plan.

004.04(A) DOCUMENTATION. The Heritage Health plan must provide documentation showing attempts were made to resolve the reason for the disenrollment request through contact with the member, the primary care provider, or other appropriate sources.

004.04(B) COVERAGE OF SERVICES. The Heritage Health plan must provide the services in the core benefits package to the member until a disenrollment is completed. The Heritage Health plan is prohibited from requesting disenrollment because of a change in the member's health status or because of the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member's special needs.

004.04(C) DISENROLLMENT REASONS. Disenrollment will be allowed based on the following situations:
(i) The Heritage Health plan has sufficient documentation to establish that the member's condition or illness would be better treated by another Heritage Health plan; or

(ii) The Heritage Health plan has sufficient documentation to establish fraud, forgery, or evidence of unauthorized use or abuse of services by the member.

004.04(D) PROCEDURE FOR HERITAGE HEALTH PLAN DISENROLLMENT REQUESTS. The following procedure applies when the Heritage Health plan requests a member disenrollment:
(i) The Heritage Health plan for which the member is enrolled must provide documentation to the Department which clearly establishes the reason(s) for the disenrollment request;

(ii) The Heritage Health plan must submit the request to the Department;

(iii) The health plan must send notification of the disenrollment request to the member at the same time the request is made to the Department. The member notification must include the member's grievance and appeal rights;

(iv) The member, primary care provider and health plan are notified of the approval or denial of the disenrollment request and information will be made available electronically; and

(v) If approved, the disenrollment will become effective the first day of the following month, given system cut-off.

004.05 HOSPITALIZATION DURING TRANSFER. When a Heritage Health plan member is admitted to an inpatient for acute or rehabilitation services on the first day of the month a transfer to another Heritage Health plan is effective, the Heritage Health plan that admitted the member to the hospital is responsible for the member (hospitalization and the related services in the core benefits package) until an appropriate discharge from the hospital, transfer to a lower level of care, or for sixty days, whatever is earliest.

(A) The Heritage Health plan the member is transferring to is responsible for the member (hospitalization and the related services in the core benefits package) beginning the day of discharge, the day of transfer to a lower level of care, or on the sixty-first (61st) day of hospitalization following the Heritage Health plan transfer, whatever is earliest.

(B) The Heritage Health plans must work cooperatively with the enrollment broker and the Department to coordinate the member's transfer between the Heritage Health plans.

Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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