Current through Reg. 49, No. 38; September 20, 2024
(a)
Enrollment by HHSC. HHSC will conduct enrollment and disenrollment activities.
Except as provided in subsection (d)(2) and (5) of this section, regarding
dental home assignments, HHSC may not contract with a participating MCO to
serve as the administrator for enrollment or disenrollment activities in any
area of the state.
(b) Procedures
for enrollment. HHSC will establish procedures for enrollment into
participating MCOs, primary care providers (PCPs), and dental homes, including
enrollment periods and time limits within which enrollment must occur.
Beneficiaries will have at least 15 calendar days from the date notification is
mailed to choose an MCO, PCP, and dental home.
(c) Default assignment. Beneficiaries who
fail to select an MCO, PCP, or dental home within the timeframe specified in
subsection (b) of this section will have an MCO, PCP, or dental home selected
for them by HHSC using the default assignment methodology described in
subsection (d) of this section.
(d)
Default assignment methodology. HHSC's default assignment methodology will
include the following criteria, to the maximum extent possible:
(1) Automated PCP assignment. If a
beneficiary has not selected a PCP, HHSC or its administrative services
contractor will assign one using an automated algorithm that considers:
(A) the beneficiary's established history
with a PCP, as demonstrated by Medicaid claims or encounter history with the
provider in the preceding year, if available;
(B) the geographic proximity of the
beneficiary's home address to the PCP;
(C) whether the provider serves as a PCP to
other members of the beneficiary's household;
(D) limitations on default assignment, such
as PCP restrictions on age, gender, and capacity; and
(E) other criteria determined by
HHSC.
(2) Automated
dental home assignment. If a beneficiary has not selected a dental home, the
dental MCO will assign one using an automated algorithm that considers:
(A) the beneficiary's established history
with a dental home, as demonstrated by Medicaid claims or encounter history
with the provider in the preceding year, if available;
(B) the geographic proximity of the
beneficiary's home address to the dental home;
(C) whether the provider serves as the dental
home to other members of the beneficiary's household;
(D) limitations on default assignment, such
as dental home restrictions on age and capacity; and
(E) other criteria approved by
HHSC.
(3) Automated MCO
assignment. If a beneficiary has not selected a health care MCO or dental MCO,
HHSC or its administrative services contractor will assign one using an
automated algorithm that considers the beneficiary's history with a PCP or
dental home when possible. If this is not possible, HHSC or its administrative
services contractor will equitably distribute beneficiaries among qualified
MCOs, using an automated algorithm that considers one or more of the following
factors:
(A) whether other members of the
beneficiary's household are enrolled in the MCO;
(B) MCO performance;
(C) the greatest variance between the
percentage of elective and default enrollments (with the percentage of default
enrollments subtracted from the percentage of elective enrollments);
(D) capitation rates;
(E) market share; and
(F) other criteria determined by
HHSC.
(4) Automatic
re-enrollment. Notwithstanding subsection (d) of this section, HHSC will
automatically re-enroll a beneficiary in the same MCO if there is a loss of
Medicaid eligibility of six months or less.
(5) Use of manual default processes. A
beneficiary who cannot be assigned to a PCP, dental home, health care MCO, or
dental MCO on the basis of an automated default process may be assigned through
a manual default process determined by HHSC. Beneficiaries with special medical
needs may be defaulted on the basis of a manual default methodology if such
beneficiaries can be identified and if the automated default process cannot be
administered for such beneficiaries.
(e) Modified default enrollment process. HHSC
has the option to implement a modified default enrollment process for MCOs when
contracting with a new MCO or implementing managed care in a new service area,
or when it has placed an MCO on full or partial enrollment
suspension.
(f) Request to change
dental home or PCP. There is no limit on the number of times a member can
request to change his or her dental home or PCP. A member can request a change
in writing or by calling the MCO's toll-free member hotline.
(g) Disenrollment from Medicaid managed care.
(1) Disenrollment at a member's request.
(A) Members will be informed of disenrollment
opportunities no less than annually.
(B) Members who are enrolled in a managed
care program on a voluntary basis may request disenrollment from the managed
care model and transfer to fee-for-service Medicaid at any time for any
reason.
(C) Members who are
enrolled in a managed care program on a mandatory basis may request, in writing
to HHSC, disenrollment from the managed care model and transfer to
fee-for-service Medicaid. HHSC considers disenrollment from the managed care
model only if medical documentation establishes that the MCO cannot provide the
needed services. An authorized HHSC representative reviews all disenrollment
requests and processes approved requests for disenrollment from an
MCO.
(D) Disenrollment will take
place no later than the first day of the second month after the month in which
the member has requested a change.
(2) Disenrollment at an MCO's request.
(A) An MCO may submit a request to HHSC that
a member be disenrolled without the member's consent in the following limited
circumstances:
(i) the member misuses or
loans his or her MCO membership card to another person to obtain
services;
(ii) the member's
behavior is disruptive or uncooperative to the extent that the member's
continued enrollment in the MCO seriously impairs the MCO's or a provider's
ability to provide services to either the member or other members, and the
member's behavior is not related to a developmental, intellectual, or physical
disability, or behavioral health condition; or
(iii) the member steadfastly refuses to
comply with managed care restrictions (such as repeatedly using the emergency
room in combination with a refusal to allow treatment for the underlying
medical condition).
(B)
An MCO must take reasonable measures to correct a member's behavior prior to
requesting disenrollment. Reasonable measures may include providing education
and counseling regarding the offensive acts or behaviors.
(C) An MCO cannot request a disenrollment
based on adverse change in the member's health status or utilization of
medically necessary services.
(D)
HHSC will review all requests for disenrollment. HHSC will grant a request if
it determines that all reasonable measures taken by the MCO have failed to
correct the member's behavior.
(E)
If HHSC grants a request, it will notify the member of the disenrollment
decision and the availability of HHSC's fair hearings process for an appeal of
the disenrollment.
(h) MCO Transfer. A beneficiary may request
transfer to another MCO in the service area through the enrollment broker at
any time for any reason.
