New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 506 - MEDICAID CARE MANAGEMENT (MCM)
Section He-W 506.06 - Selection of a Managed Care Organization

Universal Citation: NH Admin Rules He-W 506.06

Current through Register No. 40, October 3, 2024

(a) Recipients shall be passively enrolled in an MCO if they do not select a plan at application.

(b) Recipients shall select an MCO at application by:

(1) Utilizing the on-line NH Electronic Application System (NH EASY);

(2) A personal interview, as required in He-W 636.01 and He-W 644.01;

(3) A telephone application pursuant to He-W 802.03; or

(4) Calling the medicaid service center.

(c) The department shall send a notice to all recipients not excluded from managed care per He-W 506.05(b) specifying which MCO the recipient has been enrolled into.

(d) Passive enrollment shall be based on the following criteria:

(1) MCO participation of a primary care provider with whom the recipient has a pre-existing relationship as demonstrated by past claims history;

(2) MCO participation of a specialty care provider with whom the enrollee has a pre-existing relationship as demonstrated by past claims history;

(3) Family affiliation to an MCO;

(4) Previous enrollment with an MCO prior to a loss of medicaid eligibility;

(5) Provider-member relationship, to the extent obtainable; or

(6) If enrollment cannot be made utilizing (1)-(5) above, enrollment shall be based on the terms of the contract agreed to by the department and the MCO.

(e) A member may request to change his or her MCO selection without cause, by making a written or oral request to the department at any of the following times:

(1) Once during the 90 days following the date of the member's initial medicaid eligibility;

(2) During the first 12 months of enrollment, if the member has an established relationship with a primary care provider that is only in-network of a non-assigned MCO;

(3) During annual open enrollment periods and enrollments related to renegotiation and re-procurement; and

(4) When the department imposes an intermediate sanction specified in 42 CFR 438.702(a)(3).

(f) A member may request to change his or her MCO with cause after seeking redress through the MCO's grievance system, by making a written or oral request to the department at any time for any of the following reasons:

(1) The member requires related services simultaneously that are not available in the MCO's network and bifurcation of the care creates unnecessary risk to the member as determined by the member's treating provider;

(2) Due to moral or religious objections of the MCO, the MCO does not provide the covered service the member needs;

(3) Poor quality of care;

(4) Lack of access to covered services;

(5) The member has experienced a violation of his or her member rights, as established in 42 CFR 438.100; or

(6) The MCO's network providers are not experienced in the member's unique healthcare needs.

(g) If a request made pursuant to (e) or (f) above does not include the selection of a different MCO, the department shall not act on the request unless there are only 2 MCOs.

(h) A member may request a department fair hearing of a denial of (e) or (f) above in accordance with He-C 200 without first exhausting the MCO appeal process.

(i) A member shall be locked into an MCO for a period of 12 months or until the next open enrollment period, whichever comes first, unless the member changes his or her MCO selection in accordance with (e)(1)-(3) or (f) above.

(j) A member shall disenroll from an MCO when the member has moved out of state and is no longer NH medicaid eligible or becomes exempt as described in He-W 506.05(b).

(k) An MCO may request the department to disenroll a member who is threatening or abusive such that the health or safety of other members, MCO staff, or providers is jeopardized.

(l) The department shall approve a request for disenrollment in (j) above when no other option is available that would ensure the health and safety of other members, MCO staff, or providers.

(m) If the department approves an MCO request for involuntary disenrollment, the member may request a department fair hearing of the disenrollment in accordance with He-C 200 without first exhausting the MCO appeal process.

(n) Members appealing involuntary disenrollment may request a continuation of services pending appeal as outlined in 42 CFR 431.230.

#10410, eff 9-13-13

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