Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 3 - General Program Information › Part 1 - ELIGIBILITY, ENROLLMENT AND CONTINUITY OF CARE › Section 317:55-3-2 - Enrollment and disenrollment process

Current through Vol. 41, No. 20, July 1, 2024
(a)
Enrollment process.
The OHCA beneficiary support system will
				  provide choice counseling to all potential Enrollees at the time of initial
				  enrollment, during the annual open enrollment period and for Enrollees who
				  disenroll from a CE or DBM for good cause as described in the Contract and in
				  this Section. The OHCA, or its designee, will provide information about
				  individual CE or DBM benefit structures, services, and network providers, as
				  well as information about other Medicaid programs as requested by the Eligible
				  to assist the Eligible in making an informed selection.
(1)
Selection/auto assignment.
During the application process, at OHCA's discretion, an Applicant may have up
				  to sixty (60) days to select a contracted CE and DBM of their choice.
				  Applicants who are Eligible to choose a CE and DBM and fail to make an election
				  on the SoonerCare application, within the allotted timeframe, will be assigned
				  to the CE and DBM that is due next to receive an auto assignment.
(2)
Exemptions to
				  auto-assignments.
(A) The OHCA will
				  not make auto-assignments to the CE if:
(i)
				  The CE's maximum enrollment has been capped and actual enrollment has reached
				  ninety-five percent (95%) of the cap;
(ii) The CE has been excluded from receiving
				  new enrollment due to the application of non-compliance remedies; or
(iii) The CE has failed to meet readiness
				  review requirements.
(B)
				  The OHCA will not make auto-assignments to the DMB if:
(i) The DBM's maximum enrollment has been
				  capped and actual enrollment has reached ninety-five percent (95%) of the
				  cap;
(ii) The DBM has been excluded
				  from receiving new enrollment due to the imposition of administrative remedies;
				  or
(iii) The DBM has failed to meet
				  readiness review requirements.
(3)
Enrollment effective date.
(A) Eligibles, with the exception of deemed
				  newborns, who select or are assigned to a CE and/or DBM from the first day of
				  the month through the fifteenth day of the month shall be enrolled effective on
				  the first day of the following month.
(B) Eligibles who select or are assigned to a
				  CE and/or DBM on the sixteenth (16 th) day of the month through the last day of
				  the month will be enrolled effective on the first day of the second following
				  month.
(C) Prior to these
				  enrollment dates, most Eligibles will be covered by a fee-for-service payment
				  structure administered by OHCA.
(D)
				  Deemed newborns eligible for the CE and/or DBM shall be enrolled effective as
				  of the date of birth, if the newborn's mother also is enrolled in the
				  SoonerSelect program.
(E)
				  Notwithstanding the foregoing, the effective date of enrollment with the CE or
				  DBM shall be the date recorded on the outbound ANSI ASC X 12 834 electronic
				  transaction sent by OHCA.
(4)
Enrollment lock-in period.
An Enrollee may, within the first ninety (90) days of initial enrollment,
				  request to change enrollment without cause from the CE and/or DBM, or during
				  the ninety (90) days following the date OHCA sends the Enrollee notice of
				  initial enrollment, whichever is later. Enrollees will also be permitted to
				  change CEs and/or DBMs, without cause, at least once every twelve (12) months
				  during the open enrollment period. After the disenrollment period from the CE
				  or DBM has lapsed, the Enrollee will remain enrolled with the CE or DBM until
				  the next annual open enrollment period, unless:
(A) The SoonerSelect Medical Enrollee:
(i) Is disenrolled due to loss of SoonerCare
				  eligibility;
(ii) Becomes a foster
				  child under custody of the state;
(iii) Becomes juvenile justice involved under
				  the custody of the state;
(iv) Is a
				  former foster care or child receiving adoption assistance and opts to enroll in
				  the SoonerSelect Children's Specialty program;
(v) Demonstrates good cause under the
				  following conditions:
(I) The Enrollee moves
				  out of the service area;
(II) The
				  Enrollee requires specialized care for a chronic condition and the Enrollee or
				  Enrollee's representative, the CE, OHCA and receiving CE agree that assignment
				  to the receiving CE is in the Enrollee's best interest;
(III) The plan does not cover the service the
				  Enrollee seeks, because of moral or religious objections;
(IV) The Enrollee needs related services to
				  be performed at the same time; not all related services are available within
				  the CE's network; and the Enrollee's primary care provider or another provider
				  determines that receiving the services separately would subject the Enrollee to
				  unnecessary risk;
(V) For other
				  reasons, including a filed and prevailed grievance related to poor quality of
				  care, lack of access to services covered under the Contract, or lack of access
				  to providers experienced in dealing with the Enrollee's oral health care needs
				  or other matters deemed sufficient to warrant disenrollment; and
(VI) The Enrollee has been enrolled in error,
				  as determined by the OHCA.
(vi) Experiences a temporary loss of
				  eligibility or enrollment which caused the Enrollee to miss the annual
				  disenrollment period, then the Enrollee may disenroll without cause upon
				  reenrollment; or
(vii) The OHCA has
				  imposed intermediate sanctions on the CE and allows Enrollees to disenroll
				  without cause.
(B) The
				  SoonerSelect Dental Enrollee:
(i) Is
				  disenrolled due to loss of SoonerCare eligibility;
(ii) Demonstrates good cause under the
				  following conditions:
(I) The Enrollee moves
				  out of the service area;
(II) The
				  plan does not cover the service the Enrollee seeks, because of moral or
				  religious objections;
(III) The
				  Enrollee needs related services to be performed at the same time; not all
				  related services are available within the DBM's network; and the Enrollee's
				  primary care dental provider or another provider determines that receiving the
				  services separately would subject the Enrollee to unnecessary risk;
(IV) For other reasons, including a filed and
				  prevailed grievance related to poor quality of care, lack of access to services
				  covered under the Contract, or lack of access to providers experienced in
				  dealing with the Enrollee's oral health care needs or other matters deemed
				  sufficient to warrant disenrollment; and
(V) The Enrollee has been enrolled in error,
				  as determined by the OHCA.
(iii) Experiences a temporary loss of
				  eligibility or enrollment which caused the Enrollee to miss the annual
				  disenrollment period, then the Enrollee may disenroll without cause upon
				  reenrollment; or
(iv) The DBM is
				  terminated.
(5)
Annual and special enrollment periods.
Sixty (60) days prior to
				  the start of the Enrollee's annual open enrollment period, the Enrollee shall
				  be notified of the option to maintain enrollment with the current CE and/or DBM
				  or to enroll with a different CE and/or DBM. OHCA, at its sole discretion, may
				  schedule a special open enrollment period, under the following circumstances:
(A) In the event of the early termination of
				  a CE or DBM under the process described in the Contract; or
(B) The loss of a major participating
				  provider(s) places the CE or DBM at risk of failing to meet service
				  accessibility standards and the CE or DBM does not have an acceptable plan for
				  mitigating the loss or finding of non-compliance.
(6)
Enrollment caps.
OHCA, at
				  its sole discretion, may impose a cap on the CE or DBM's enrollment, in
				  response to a request by the CE or DBM or as part of a corrective action in
				  accordance to the respective Contract.