Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.02 - Maryland Medicaid Managed Care Program: Eligibility and Enrollment › Section 10.67.02.06 - Disenrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A.
				  Enrollee-Initiated Disenrollment for Cause.
(1) An enrollee may disenroll from an MCO and
				  enroll into another MCO if:
(a) The enrollee
				  moves to a county that is not served by the enrollee's present MCO;
(b) The family members are enrolled in
				  different MCOs and the adult enrollee requests that other family members be
				  enrolled in one of the MCOs in which another family member is currently
				  enrolled;
(c) The enrollee requests
				  enrollment into the MCO that contracts with the PCP of any other family member
				  who is not a HealthChoice enrollee;
(d) The enrollee moves or becomes homeless,
				  creating a transportation hardship that may be resolved by enrollment into
				  another MCO serving the enrollee's new local access areas;
(e) The enrollee requests a change of MCO
				  within 90 days after the termination of the enrollee's primary care provider's
				  (PCP's) contract if the PCP's contract with the enrollee's MCO, MCO's medical
				  management group, or its subcontractors is terminating for the following
				  reasons:
(i) By the MCO for reasons other
				  than the quality of care or the PCP's failure to comply with contractual
				  requirements related to quality assurance activities; or
(ii) The MCO's reduction of PCP's
				  reimbursement to the extent that the reduction in rate is greater than the
				  actual change in capitation paid to the MCO by the Department, and the MCO and
				  PCP's inability to negotiate a mutually acceptable rate;
(f) The enrollee is automatically assigned to
				  an MCO or it is the enrollee's initial enrollment in an MCO as follows:
(i) Only one request during the first 90 days
				  of automatic assignment or initial enrollment into an MCO; and
(ii) The enrollee is not hospitalized at the
				  time of the request;
(g)
				  The MCO terminates its contract with the Department in which case:
(i) The MCO shall provide written notice to
				  the recipient at least 60 days before the date on which the MCO will exit the
				  HealthChoice Program;
(ii) The MCO
				  shall include in the notice the name and provider number of the PCP assigned to
				  the recipient and the telephone number of the enrollment broker;
(iii) The Department shall send a notice to
				  every enrollee of the MCO regarding the MCO's termination of its contract with
				  the Department, at least 30 days before the effective date of the termination
				  of the contract;
(iv) An enrollee
				  shall have at least 30 days before the effective date of the MCO's contract
				  termination with the Department to choose another MCO, or will be assigned to
				  another MCO; and
(v) An enrollee
				  may choose another MCO one additional time within at least 90 days after
				  reenrollment into the new MCO;
(h) The MCO is acquired by another entity in
				  which case:
(i) The MCO shall provide written
				  notice to the recipient at least 60 days before the date on which the MCO will
				  exit the HealthChoice Program;
(ii)
				  The MCO shall include in the notice the name and provider number of the PCP
				  assigned to the recipient and the telephone number of the enrollment
				  broker;
(iii) The Department shall
				  send a notice to every enrollee of the MCO regarding the change in ownership,
				  30 days before the effective date of the change of ownership;
(iv) An enrollee shall have 30 days before
				  the change of ownership to disenroll from the MCO into another participating
				  MCO;
(v) If an enrollee does not
				  choose to disenroll in accordance with §A(1)(f)(ii) of this regulation,
				  the enrollee will be reenrolled in the newly purchased MCO; and
(vi) An enrollee may choose another MCO one
				  additional time within at least 90 days after reenrollment in the newly
				  purchased MCO;
(i) The
				  MCO does not, because of moral or religious objections, cover the service the
				  enrollee seeks;
(j) All of the
				  following apply:
(i) The enrollee needs
				  related services to be performed at the same time;
(ii) Not all related services are available
				  within the network; and
(iii) The
				  enrollee's PCP or other provider determines that receiving the services
				  separately would subject the enrollee to unnecessary risk; or
(k) The Department imposes the
				  intermediate sanction specified in
				  42 CFR §
													438.702(a) and (b), as
				  amended.