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 512 - ALTERNATIVE BENEFIT PLAN (ABP) AND PREMIUM ASSISTANCE PROGRAM
Section He-W 512.04 - Enrollment

Universal Citation: NH Admin Rules He-W 512.04

Current through Register No. 40, October 3, 2024

(a) For individuals who are eligible for PAP, enrollment in a QHP shall be mandatory unless the individual is determined to be exempt as described in (b) below or voluntary as described in (c) and (d) below.

(b) Individuals who are determined to be medically frail as defined in 42 CFR § 440.315(f) shall be exempt from mandatory enrollment with a QHP.

(c) The following individuals shall be considered voluntary for enrollment with a QHP:

(1) Individuals who are members of a federally recognized Indian tribe or Alaskan natives; and

(2) Individuals who are enrolled in PAP who identify as pregnant after the point of application for medicaid.

(d) The following shall apply to voluntary individuals described in (c) above:

(1) Voluntary individuals shall be enrolled in a QHP unless the individual identifies to the department that he or she is in a voluntary eligibility group as noted in (c) above; and

(2) If, after identifying as being in a voluntary eligibility group, a voluntary individual chooses not to enroll in a QHP, the individual shall be notified by the department and required to choose a medicaid managed care organization (MCO) as described in He-W 506.

(e) The department shall send a notice of QHP plan selection to all individuals eligible for PAP enrollment as indicated in (a) above except those who are exempted from enrollment.

(f) PAP participants shall have 30 days from the date of the QHP plan selection notice in (e) above to select a QHP and to respond to the department's notice by using the on-line portal NH Electronic Application System (NH EASY) at www.nheasy.nh.gov, calling via telephone at 1-888-901-4999, or contacting the department in person.

(g) Except for voluntary individuals described in (c) and (d) above, PAP participants who fail to select a QHP within 30 days from the date of the notice in (f) above shall be auto-assigned to a QHP.

(h) Auto-assignments with a QHP shall be based on the following criteria:

(1) Personal or family affiliation to a QHP or MCO, if the MCO offers a complementary QHP;

(2) Primary care provider affiliation with a QHP; or

(3) If no assignment can be made utilizing (1) -(2) above, assignment shall be equally distributed among the available QHPs.

(i) PAP participants may request to change the QHP selection without cause, by making a written or oral request to the department at any of the following times:

(1) During the first 30 days following the date of the member's initial selection of or the auto-assignment to the QHP, or the date the department sends the member confirmation of the individual's selection or auto-assignment, whichever is later; and

(2) During annual open enrollment.

(j) PAP participants may request to change the QHP selection for cause, by making a written or oral request to the department within 60 days of the occurrence of one of the following events:

(1) PAP participant loses access to the QHP he or she is currently enrolled in because of a permanent move to a county where that QHP is not available;

(2) PAP participant gains or becomes a dependent through marriage, birth, adoption, foster care, child support order, or court order;

(3) PAP participant loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee's dependent dies;

(4) The department confirms based on a PAP participant's complaint that the QHP in which the PAP participant is enrolled violated a material provision of its contract in relation to the PAP participant; or

(5) PAP participant's enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the department, its instrumentalities, or a non-departmental entity providing enrollment assistance or conducting enrollment activities.

(k) PAP participants shall be dis-enrolled from the PAP program if they identify as medically frail after they were previously determined eligible.

(l) Medically frail individuals shall have the option to enroll with a medicaid MCO to receive the ABP benefit or the state plan medicaid benefit.

(m) Individuals who are voluntary as described in (c) and (d) above shall be enrolled as follows:

(1) Individuals who are enrolled in PAP and identify as pregnant after the point of application for medicaid shall elect to receive either state plan medicaid benefits delivered through a medicaid MCO or remain enrolled in the PAP with a QHP; and

(2) Individuals who are members of a federally recognized Indian tribe or Alaskan natives who elect to disenroll from their QHP shall receive ABP benefits delivered through a medicaid MCO.

(n) For PAP participants eligible for medicaid after October 1, 2015, the PAP participant shall receive coverage through fee-for-service medicaid from the date of the eligibility determination until the individual's enrollment in the QHP becomes effective.

(o) If a PAP participant selects or is auto-assigned to a QHP on or before the 15th of the month, coverage in the QHP shall be begin the first day of the month following the month in which the selection or auto-assignment was made.

(p) If a PAP participant selects or is auto-assigned to a QHP any time after the 15th of the month, coverage in the QHP shall be begin the first day of the second month following the month in which the selection or auto-assignment was made.

#10656, eff 8-15-14

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