Upon the child's eligibility effective date, the child shall
be assigned to a health or dental plan using the department's passive
enrollment process. The enrollee may change plans only at the time of the
annual review unless the provisions of paragraph 86.6(1) "a"
or subrule 86.6(2) apply.
(1)
Period of enrollment. Once enrolled in a health or dental
plan, the child shall remain enrolled in the health or dental plan for a period
of 12 months.
a.
Exceptions. A child may be enrolled in a plan for less than 12 months
if:
(1) The child is disenrolled in
accordance with the provisions of rule
441-86.7 (5141). If a child is
disenrolled from the health or dental plan and subsequently reapplies before
the end of the original 12-month enrollment period, the child shall be enrolled
in the health or dental plan from which the child was originally
disenrolled.
(2) The child is added
to an existing enrollment. When a family requests to add an eligible child, the
child shall be enrolled for the months remaining in the current enrollment
period.
(3) A request to change
plans is accepted in accordance with paragraph 86.6(1)"b."
b.
Request to
change plan. An
enrollee may ask to change the health or dental plan
either verbally or in writing to the
enrollment broker:
(1) Within 90 days following the date of the
enrollee's initial enrollment with the health or dental plan for any
reason.
(2) At any time for cause.
"Cause" as defined in 42 CFR
438.56(d)(2) as amended to May 6, 2016, includes,
but is not limited to:
1. The enrollee moves
out of the plan's service area.
2.
Because of moral or religious objections, the plan does not cover the services
the enrollee seeks.
3. The enrollee
needs related services (for example, a cesarean section and a tubal ligation)
to be performed at the same time, not all related services are available within
the network, and the enrollee's primary care provider or another provider
determines that receiving the services separately would subject the enrollee to
unnecessary risk.
4. Other reasons
including but not limited to poor quality of care, lack of access to services
covered under the
contract, or lack of access to providers experienced in
dealing with the
enrollee's health care needs.
All approved changes shall be made prospectively and shall be
effective no later than the first day of the second month beginning after the
date on which the change request is received.
(2)
Child moves from the service
area. The child may be disenrolled from the health or dental plan when
the child moves to an area of the state in which the health or dental plan does
not have a provider network established. If the child is disenrolled, the child
shall be enrolled in a participating health or dental plan in the new location.
The period of enrollment shall be the number of months remaining in the
original certification period.
(3)
Change at annual review. If more than one health or dental
plan is available at the time of the annual review of eligibility, the family
may designate another plan either verbally or in writing to the enrollment
broker. The child shall remain enrolled in the current health or dental plan if
the family does not notify the enrollment broker of a new health or dental plan
choice by the end of the current 12-month enrollment period.
Notes
Iowa Admin. Code
r. 441-86.6
ARC 8478B, IAB 1/13/10,
effective 3/1/10; ARC 9084B, IAB 9/22/10, effective 9/1/10; ARC 0837C, IAB
7/24/2013, effective 10/1/2013
Amended by
IAB
November 20, 2019/Volume XLII, Number 11, effective
12/25/2019
