Iowa Admin. Code r. 441-88.4 - Disenrollment
(1)
Disenrollment request. An enrolled recipient may request
disenrollment at any time. In voluntary counties, this request shall be
approved and acted upon within ten days of receipt without requiring the
recipient to demonstrate good cause. In mandatory counties as defined at
subrule 88.3(3), the disenrollment shall not be acted upon by the health care
contractor unless the request includes an alternate choice of managed health
care .
(2)
Effective
date. Disenrollment will be effective no later than the first day of
the second calendar month after the month in which the department receives a
request for disenrollment. The recipient will remain enrolled in the PHP and
the PHP will be responsible for services covered under the contract until the
effective date of disenrollment which will always be the first day of a
month.
(3)
Disenrollment
process. If the recipient is requesting disenrollment, the recipient
shall complete the choice form designated by the managed health care contractor
which can be obtained through the PHP, the county office, or the managed health
care contractor. If the PHP receives a request from the recipient, the PHP
shall forward the form to the managed health care contractor within three
working days. If the recipient must show good cause for disenrollment, the
determination as to whether disenrollment shall occur shall be made by the
managed health care review committee within 30 days. If the recipient or the
PHP disagrees with the decision of the review committee, an appeal may be filed
under the provisions of 441-Chapter 7. If the PHP is requesting disenrollment,
the PHP shall complete Form 470-2169, Managed Health Care Provider Request for
Disenrollment. If the county office receives a completed Form 470-2169 from the
managed health care provider, the county office shall forward the form to the
managed health care review committee within three working days.
a.
Request for disenrollment by the
recipient . In voluntary counties, the request shall be approved and
acted upon within ten days of receipt by the managed health care contractor. In
mandatory counties, a request for disenrollment shall be denied unless a choice
of another managed health care provider is requested simultaneously or good
cause can be demonstrated to the review committee. Examples of good cause
include services received which were untimely, inaccessible, of insufficient
quality, or inadequately provided by all of the contracting managed health care
providers in the recipient's county of residence. If the recipient has not
experienced the above conditions in all the other available managed health care
programs, enrollment in one of the alternative managed health care programs
shall be a condition of approving disenrollment.
b.
Request for disenrollment by the
PHP. With prior approval of the managed health care review committee,
a request for disenrollment of an enrolled recipient may be approved when:
(1) There is evidence of fraud or forgery in
the use of PHP services or in the choice for PHP services .
(2) There is evidence of unauthorized use of
the PHP identification card.
(3)
Upon documentation, the PHP has been unable after reasonable efforts to
establish or maintain a satisfactory physician-patient relationship with the
recipient .
(4)
Disenrollments by the
department . Disenrollments will occur when:
a. The contract between the department and
the PHP is terminated.
b. The
recipient becomes ineligible for Medicaid. If the recipient becomes ineligible
and is later reinstated to Medicaid, enrollment in the PHP will also be
reinstated.
c. The recipient
permanently moves outside the PHP's enrollment area .
d. The recipient transfers to an eligibility
group excluded from PHP enrollment. See definition of recipient in rule
441-88.1
(249A).
e. The department has
determined that participation in the HIPP (Health Insurance Premium Payment)
program as described in rule
441-75.21
(249A) is more cost-effective than enrollment in managed health care .
(5)
No disenrollment for
health reasons. No recipient shall be disenrolled from a PHP because
of an adverse change in health status.
Notes
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