Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.3 - Enrollment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Enrollment area.
Counties in a PHP enrollment area shall be
				designated as voluntary or mandatory. In voluntary counties, enrollment is not
				required but eligible recipients may choose to join the PHP. Recipients not
				excluded in rule 441-8 8.1 (249A) may volunteer to enroll in the PHP. In
				mandatory counties, enrollment in managed health care is required for eligible
				recipients.
(2)
Voluntary
				enrollment.
When only one managed health care option is providing
				service in a county, enrollment by recipients is voluntary. The department
				encourages recipients to enroll in a managed health care option. Applicants and
				recipients are offered the option of managed health care enrollment or regular
				Medicaid coverage. Applicants and recipients who do not choose one option or
				the other shall be assigned to a managed health care provider as defined in
				subrule 88.3(6). These persons shall have the right to request disenrollment at
				any time as defined in subrule 88.3(3).
Applicants or recipients may designate their choices of
				  providers on a form designated by the managed health care contractor or in
				  writing to or through a verbal request to the managed health care contractor.
				  The form shall be available through the county office, the PHP office, provider
				  offices, the managed health care contractor, or other locations at the
				  department's discretion. If the PHP (or any entity listed above other than the
				  managed health care contractor) receives the form, it shall be forwarded to the
				  managed health care contractor within three working days.
Recipients shall be accepted by the PHP as they are enrolled
				  by the department unless a maximum limit has been specified in the
				  contract.
Recipients who choose not to enroll in a PHP shall be covered
				  under regular Medicaid.
(3)
Mandatory enrollment.
In a county where the department has a
				contract with more than one PHP, HMO, or other managed health care provider,
				the department shall require whenever it is administratively feasible that all
				eligible recipients enroll with a managed health care provider of their own
				choosing. Administrative feasibility is determined by whether the managed
				health care providers have the capacity to adequately serve all potential
				enrolled recipients. Recipients may enroll by completing the choice form
				designated by the managed health care contractor, in writing to or through
				verbal request to the managed health care offices. Recipients may also contact
				the managed health care contractor by the publicized toll-free telephone number
				for enrollment assistance.
(4)
Effective date.
The effective date of enrollment shall be no
				later than the first day of the second month subsequent to the date on which
				the managed health care contractor receives the form designated by the managed
				health care contractor.
(5)
Identification card.
The PHP may issue an appropriate
				identification card to the enrolled recipient or request the department to do
				so on its behalf. The identification card shall be issued so that the recipient
				receives it prior to the effective date of enrollment.
(6)
Assignment methodology.
When no choice is made, the recipient shall be systematically assigned to,
				between, or among the contracting managed health care providers.
a.
Notification.
Recipients
				who are assigned to a managed health care provider shall receive notification
				of the assignment and the name of the provider in a timely fashion prior to the
				effective date of enrollment.
b.
Limitations.
Contracting providers may specify in the contract
				a limit to the number of recipients who can be assigned under this subrule. If
				a specified limitation is attained, the remaining assignment needs in that
				county shall be met by the other managed health care providers who are
				contracting with the department in that county.
c.
Household member
				enrollment.
Inasmuch as persons within a household are allowed to make
				individual decisions about choosing enrollment in managed health care, it is
				possible that a case may exist where some household members have made a choice
				and some have not (so that assignment is required). In these instances, a
				systematic search of household member choices regarding managed health care
				option shall be completed. Assignment of those who have made no choice shall be
				made whenever possible to the managed health care provider with whom the first
				household member is already enrolled.
d.
Assigned recipients who desire
				another choice.
Recipients who are assigned to a managed health care
				provider as described in this subrule shall have at least 30 days in which to
				request enrollment in a different available managed health care plan. The
				change of plan is subject to provisions in subrules 88.3(4) and 88.4(2) dealing
				with effective date.