Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.4 - Disenrollment

Current through Register Vol. 47, No. 3, July 24, 2024
(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.