La. Admin. Code tit. 50, § I-3105 - Enrollment Process
A. The MCO
shall abide by all enrollment and disenrollment policy and procedures as
outlined in the contract developed by the department.
B. The department will contract with an
enrollment broker who will be responsible for the enrollment and disenrollment
process for MCO participants. The enrollment broker shall be:
1. the primary contact for Medicaid
recipients regarding the MCO enrollment and disenrollment process, and shall
assist the recipient to enroll in an MCO;
2. the only authorized entity, other than the
department, to assist a Medicaid recipient in the selection of an MCO;
and
3. responsible for notifying
all MCO members of their enrollment and disenrollment rights and
responsibilities within the timeframe specified in the contract.
C. Enrollment Period. The annual
enrollment of an MCO member shall be for a period of up to 12 months from the
date of enrollment, contingent upon his/her continued Medicaid and MCO
eligibility. A member shall remain enrolled in the MCO until:
1. DHH or its enrollment broker approves the
members written, electronic or oral request to disenroll or transfer to another
MCO for cause; or
2. the annual
open enrollment period or after the lock-in period; or
3. the member becomes ineligible for Medicaid
and/or the MCO program.
D. Special Open Enrollment Period for
Specialized Behavioral Health Integration
1.
The department, through its enrollment broker, will provide an opportunity for
all populations to be mandatorily enrolled into Bayou Health for specialized
behavioral health services. These populations will be given a 60-day choice
period to proactively choose an MCO.
2. Each potential MCO member shall receive
information and the offer of assistance with making informed choices about the
participating MCOs and the availability of choice counseling.
3. During the special enrollment period,
current members who do not proactively request reassignment will remain with
their existing MCO.
4. These new
members will be encouraged to make a choice among the participating MCOs. When
no choice is made, auto-assignment will be used as outlined in
§3105. G.2 a
E. Special Enrollment Provisions
for Mandatory, Opt-In Population Only
1.
Mandatory, opt-in populations may request participation in Bayou Health for
physical health services at any time. The effective date of enrollment shall be
no later than the first day of the second month following the calendar month
the request for enrollment is received. Retroactive begin dates are not
allowed.
2. The enrollment broker
will ensure that all mandatory, opt-in populations are notified at the time of
enrollment of their ability to disenroll for physical health at any time. The
effective date will be the first day of a month, and no later than the first
day of the second month following the calendar month the request for
disenrollment is received.
3.
Following an opt-in for physical health and selection of an MCO and subsequent
90-day choice period, these members will be locked into the MCO for 12 months
from the effective date of enrollment or until the next annual enrollment
period unless they elect to disenroll from physical health.
F. Enrollment of Newborns.
Newborns of Medicaid eligible mothers, who are enrolled at the time of the
newborn's birth, will be automatically enrolled with the mothers MCO,
retroactive to the month of the newborns birth.
1. If there is an administrative delay in
enrolling the newborn and costs are incurred during that period, the member
shall be held harmless for those costs and the MCO shall pay for these
services.
2. The MCO and its
providers shall be required to:
a. report the
birth of a newborn within 48 hours by requesting a Medicaid identification (ID)
number through the departments online system for requesting Medicaid ID
numbers; and
b. complete and submit
any other Medicaid enrollment form required by the department.
G . Selection of an MCO
1. As part of the eligibility determination
process, Medicaid and LaCHIP applicants, for whom the department determines
eligibility, shall receive information and assistance with making informed
choices about participating MCOs from the enrollment broker. These individuals
will be afforded the opportunity to indicate the plan of their choice on their
Medicaid financial application form or in a subsequent contract with the
department prior to determination of Medicaid eligibility.
2. All new recipients who have made a
proactive selection of an MCO shall have that MCO choice transmitted to the
enrollment broker immediately upon determination of Medicaid or LaCHIP
eligibility. The member will be assigned to the MCO of their choosing unless
the plan is otherwise restricted by the department.
a. Recipients who fail to choose an MCO shall
be automatically assigned to an MCO by the enrollment broker, and the MCO shall
be responsible to assign the member to a primary care provider (PCP) if a PCP
is not selected at the time of enrollment into the MCO.
b. For mandatory populations for all covered
services as well as mandatory, specialized behavioral health populations, the
auto-assignment will automatically enroll members using a hierarchy that takes
into account family/household member enrollment, or a round robin method that
maximizes preservation of existing specialized behavioral health
provider-recipient relationships.
3. All new recipients shall be immediately,
automatically assigned to an MCO by the enrollment broker if they did not
select an MCO during the financia l eligibility determination process.
a. Special Provisions for Medicaid Expansion.
Individuals enrolled in the Take Charge Plus and/or the Greater New Orleans
Community Health Connection (GNOCHC) Waiver program upon implementation of the
new adult group will be auto assigned to an MCO by the enrollment broker as
provided for in the automatic assignment process defined in
§3105 H-H.3.
4. All new recipients will be given 90 days
to change plans if they so choose.
a. Special
Provisions for Medicaid Expansion. Individuals transferred from Take Charge
Plus and/or GNOCHC will be given 90 days to change plans without cause
following auto assignment to an MCO upon implementation of the new adult group.
5. The following
provisions will be applicable for recipients who are mandatory participants.
a. If there are two or more MCOs in a
department designated service area in which the recipient resides, they shall
select one.
b. Recipients may
request to transfer out of the MCO for cause and the effective date of
enrollment into the new plan shall be no later than the first day of the second
month following the calendar month that the request for disenrollment is
filed.
H.
Automatic Assignment Process
1. The following
participants shall be automatically assigned to an MCO by the enrollment broker
in accordance with the departments algorithm/formu la and the provisions of
§3105 E:
a. mandatory MCO participants, with the
exceptions noted in
§3105. G.2.a i;
b. pregnant women with Medicaid eligibility
limited to prenatal care, delivery and post-partum services; and
c. other recipients as determined by the
department.
2. MCO
automatic assignments shall take into consideration factors including, but not
limited to:
a. assigning members of family
units to the same MCO;
b. existing
provider-enrollee relationships;
c.
previous MCO-enrollee relationship;
d. MCO capacity; and
e. MCO performance outcome
indicators.
3. MCO
assignment methodology shall be available to recipients upon request to the
enrollment broker.
I.
Selection or Automatic Assignment of a Primary Care Provider for Mandatory
Populations for All Covered Services
1. The
MCO is responsible to develop a PCP automatic assignment methodology in
accordance with the departments requirements for the assignment of a PCP to an
enrollee who:
a. does not make a PCP
selection after being offered a reasonable opportunity by the MCO to select a
PCP;
b. selects a PCP within the
MCO that has reached their maximum physician/patient ratio; or
c. selects a PCP within the MCO that has
restrictions/limitations (e.g. pediatric only practice).
2. The PCP automatically assigned to the
member shall be located within geographic access standards, as specified in the
contract, of the member's home and/or who best meets the needs of the member.
Members for whom an MCO is the secondary payor will not be assigned to a PCP by
the MCO, unless the member requests that the MCO do so.
3. If the enrollee does not select an MCO and
is automatically assigned to a PCP by the MCO, the MCO shall allow the enrollee
to change PCP, at least once, during the first 90 days from the date of
assignment to the PCP. Effective the ninety-first day, a member may be locked
into the PCP assignment for a period of up to nine months beginning from the
original date that he/she was assigned to the MCO.
4. If a member requests to change his/her PCP
for cause at any time during the enrollment period, the MCO must agree to grant
the request.
J. Lock-In
Period
1. Members have 90 days from the
initial date of enrollment into an MCO in which they may change the MCO for any
reason. Medicaid enrollees may only change MCOs without cause within the
initial 90 days of enrollment in an MCO. After the initial 90-day period,
Medicaid enrollees/members shall be locked into an MCO until the annual open
enrollment period, unless disenrolled under one of the conditions described in
this Section, with the exception of the mandatory, opt-in populations, who may
disenroll from Bayou Health for physical health and return to legacy Medicaid
at any time.
K. Annual
Open Enrollment
1. The department will
provide an opportunity for all MCO members to retain or select a new MCO during
an annual open enrollment period. Notification will be sent to each MCO member
and voluntary members who have opted out of participation in Bayou Health at
least 60 days prior to the effective date of the annual open enrollment. Each
MCO member shall receive information and the offer of assistance with making
informed choices about MCOs in their area and the availability of choice
counseling.
2. Members shall have
the opportunity to talk with an enrollment broker representative who shall
provide additional information to assist in choosing the appropriate MCO. The
enrollment broker shall provide the individual with information on each MCO
from which they may select.
3.
During the open enrollment period, each Medicaid enrollee shall be given the
option to either remain in their existing MCO or select a new MCO.
Notes
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