Current through Register Vol. 35, No. 18, September 24, 2024
A.
General: A medical assistance division (MAD) eligible recipient is
required to enroll in a HSD managed care organization (MCO) unless he or she
is:
(1) a Native American who opts into
managed care. If a Native American is dually eligible or in need of long-term
care services, he or she is required to enroll in a MCO; or
(2) is in an excluded population. See
8.200.400 NMAC and 8.308.6 NMAC. Enrollment in a MCO may be the result of the
eligible recipient's selection of a particular MCO or assignment by HSD. The
MCO shall accept as a member an eligible recipient in accordance with 42 CFR.
434.25 and shall not discriminate against, or use any policy or practice that
has the effect of discrimination against the potential or enrolled member on
the basis of health status, the need for health care services, or race, color,
national origin, ancestry, spousal affiliation, sexual orientation or gender
identity. HSD reserves the right to limit enrollment in a specific
MCO.
B.
Newly
eligible recipients: An individual who applies for a MAP category of
eligibility (COE) and has an approved COE effective date of January 1, 2019, or
later, and who is required to enroll in a MCO, must select a MCO at the time of
his or her application for a MAP COE. An eligible recipient who fails to select
a MCO at such time will be auto assigned to a MCO. See Subsection C of this
Section. Members may choose a different MCO one time during the first three
months of their enrollment.
C.
Auto assignment: HSD will auto-assign an eligible recipient to a
MCO in specific circumstances, including but not limited to:
a) the eligible recipient is not exempt from
managed care and does not select a MCO at the time of his or her application
for MAD eligibility;
b) the
eligible recipient cannot be enrolled in the requested MCO pursuant to the
terms of this rule (e.g., the MCO is subject to and has reached its enrollment
limit). HSD may modify the auto-assignment algorithm, at its discretion, when
it determines it is in the best interest of the program, including but not
limited to, sanctions imposed on the MCO, consideration of quality measures,
cost or utilization management performance criteria.
(1) The HSD auto-assignment process will
consider the following:
(a) if the eligible
recipient was previously enrolled with a MCO and lost his or her eligibility
for a period of six months or less, he or she will be re-enrolled with that
MCO, provided he or she is eligible for reenrollment in that MCO at the time of
auto assignment;
(b) if the
eligible recipient has a family member enrolled in a specific MCO, he or she
will be enrolled with that MCO;
(c)
if the eligible recipient has family members who are enrolled with different
MCOs, he or she will be enrolled with the MCO that the majority of other family
members are enrolled with;
(d) if
the eligible recipient is a newborn, he or she will be assigned to the mother's
MCO for the month of birth, at a minimum; see Subsection A of
8.308.6.10
NMAC; or
(e) if none of the above
applies, the eligible recipient will be assigned to an MCO using the default
logic that auto assigns an eligible recipient to a MCO.
D.
Effective date for a newly eligible recipient's enrollment in managed
care: In most instances, the effective date of enrollment with a MCO
will be the same as the effective date of eligibility approval.
E. Retroactive MCO enrollment is limited to
up to six months prior to the current month for the following reasons:
(1) retroactive medicare enrollment;
or
(2) retroactive changes in
eligibility; or
(3) retroactive
nursing facility coverage; or
(4)
changes in race code from Native American to non-Native American.
F.
Eligible recipient member
lock-in: A member's enrollment with a MCO is for a 12-month lock-in
period. During the first three months of his or her initial MCO enrollment,
either by the member's choice or by auto-assignment, he or she shall have one
option to change MCOs for any reason, except as described below.
(1) If the member does not choose a different
MCO during his or her first three months of enrollment, the member will remain
with this MCO for the full 12-month lock-in period before being able to switch
MCOs.
(2) If during the member's
first three months of enrollment in the initially or annually-selected or a HSD
assigned MCO, and he or she chooses a different MCO, he or she is subject to a
new 12-month lock-in period and will remain with the newly selected MCO until
the lock-in period ends. After that time, the member may switch to another
MCO.
(3) At the conclusion of the
12-month lock-in period, the member shall have the option to select a new MCO,
if desired. The member shall be notified of the option to switch MCOs two
months prior to the expiration date of the member's lock-in period, the
deadline by when to choose a new MCO.
(4) If an inmate, as defined at
8.200.410.17
NMAC, becomes a newly eligible recipient during incarceration and remains
eligible at the time of their release, he or she will be enrolled with the MCO
of their choice or auto-assigned to a MCO, unless they are Native American.
Their initial 12-month lock-in period will begin on the first of the month of
their release from incarceration.
(5) If a member misses what would have been
his or her annual switch enrollment period due to incarceration,
hospitalization or incapacitation, the member will have two months to choose a
new MCO.
G.
Eligible recipient MCO open enrollment period: The open enrollment
period is the last two months of an eligible recipient's 12-month lock-in
period, and is the time period during which a member can change his or her MCO
without having to provide a specific reason to HSD. The open enrollment period
may be initiated at HSD's discretion in order to support program
needs.
H.
Mass transfers from
another MCO: A MCO shall accept any member transferring from another MCO
as authorized by HSD. The transfer of membership may occur at any time during
the year.
I.
Change of
enrollment initiated by a member during a MCO lock-in period:
(1) A member may select another MCO during
his or her annual renewal of eligibility, or re-certification period.
(2) A member may request to be switched to
another MCO for cause, even during a lock-in period. The member may submit the
request to HSD's consolidated customer service center or the medical assistance
division. Examples of "cause" include, but are not limited to:
(a) the MCO does not, because of moral or
religious objections, cover the service the member seeks;
(b) the member requires related services (for
example a cesarean section and a tubal ligation) to be performed at the same
time, not all of the related services are available within the network, and his
or her PCP or another provider determines that receiving the services
separately would subject the member to unnecessary risk; and
(c) poor quality of care, lack of access to
covered benefits, or lack of access to providers experienced in dealing with
the member's health care needs.
(d)
continuity of care (for example, a member's physician or specialist is no
longer in the MCO's provider network or a member lives in a rural area and the
closest physician that accepts their current MCO is too far away);
(e) family continuity (for example, a switch
that is requested so that all family members are enrolled with the same
MCO);
(f) administrative error (for
example, a member chooses an MCO at initial enrollment or requests to change
MCOs during an allowable switch period but the request was not
honored).
(3) No later
than the first calendar day of the second month following the month in which
the request is filed by the member, HSD must respond in writing. If HSD does
not respond timely, the request of the member is deemed approved. If the member
is dissatisfied with HSD's determination, he or she may request a HSD
administrative hearing; see 8.352.2 NMAC for detailed description.
(4) Native American opt-in and opt-out:
(a) Native American members in
fee-for-service (FFS) may opt-in to managed care at any time during the year.
MCO enrollment begins on the first calendar day of the month following HSD's
receipt of the member's MCO opt-in request.
(b) Native American members may opt-out of
managed care at any time during the year. MCO enrollment ends on the last
calendar day of the enrollment month in which HSD receives the opt-out
request.
(c) Native Americans who
opt-in to managed care are not retroactively enrolled into managed care for
prior months.
(d) A Native American
who is approved for a category of eligibility that is required to be enrolled
with a MCO must follow Subsection E, F and H of 8.308.7.9 NMAC regarding MCO
enrollment.
