Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3810 - Disenrollment from MCEs

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Member-initiated requests for disenrollment.
(a) All member-initiated requests for
			 disenrollment from an MCE shall be initiated orally or in writing by the
			 primary person in the benefit group enrolled with an MCE where primary person
			 and benefit group are defined in OAR 461-001-0000, 461-001-0035, and
			 461-110-0750, respectively. For members who are not able to request
			 disenrollment on their own, the request may be initiated by the member's
			 representative. Some disenrollment requests may not be applicable to all MCEs.
			 In instances where that is the case, the type of MCE is specified within the
			 applicable section or subsection of this rule;
(b) The Authority or MCE shall honor a member
			 or representative request for disenrollment for the following reasons:
(A) Without cause:
(i) Members may request to change their MCE
			 enrollment within thirty (30) calendar days of the Authority's automatic or
			 manual enrollment error. If approved, the change would occur on the next
			 available enrollment date;
(ii)
			 Members may request to change their MCE enrollment within ninety (90) calendar
			 days of the initial MCE enrollment. If approved, the change would occur on the
			 next available enrollment date;
(iii) Members may request to change their MCE
			 enrollment after they have been enrolled with the MCE for at least six (6)
			 months. If approved, the change would occur at the end of the month;
(iv) Members may request to change their MCE
			 enrollment at their OHP eligibility renewal. If approved, the change would
			 occur at the end of the month;
(v)
			 Members have one additional opportunity to request a plan change during the
			 eligibility period if none of the above options can be applied. If a request
			 for disenrollment is approved under this section, the change would occur at the
			 end of the month.
(B)
			 With cause, at any time as follows:
(i) The
			 member moves out of the MCE service area; or
(ii) Due to moral or religious objections the
			 MCE does not cover the service the member seeks;
(iii) When the member needs related services
			 (for example a Caesarean section and a tubal ligation) to be performed at the
			 same time, not all related services are available within the network, and the
			 member's primary care provider or another provider determines that receiving
			 the services separately would subject the member to unnecessary risk.
(C) Medicare and Medicaid fully
			 dual eligible members may change plans or disenroll to FFS at any time subject
			 to the provisions set forth in OAR 410-141-3805(14)(c)  based on enrollment
			 options in the member's service area and to ensure continuity of care during a
			 transition;
(D) Other reasons
			 including, but not limited to, poor quality of care, lack of access to services
			 covered under the contract, or lack of access to participating providers who
			 are experienced in dealing with the specific member's health care needs.
			 Examples of sufficient cause include but are not limited to:
(i) The member is an American Indian or
			 Alaskan Native with proof of Indian Heritage who wishes to obtain primary care
			 services from their Indian Health Service facility, tribal health
			 clinic/program, or urban clinic and the FFS delivery system;
(ii) The member is at risk of experiencing a
			 lack of continuity of care. Continuity of care for the purpose of this rule
			 means the ability to sustain services necessary for a person's treatment. A
			 request for disenrollment based on continuity of care shall be denied if the
			 basis for this request is primarily for the convenience or preference of a
			 member for a provider of a treatment, service, or supply:
(I) A request for disenrollment based on
			 continuity of care shall be deemed by the Authority a request for an open card
			 for continuity of care and a temporary MCE exemption;
(II) Authority decisions to approve or deny
			 the member's request shall be communicated in a written notice to the member. A
			 Copy of the notice shall be sent, if applicable, to the providers that
			 participated in the member's request. The notice to the member shall include
			 the regulatory or clinical criteria, or both, relied upon to make the decision
			 cited in the notice. If the Authority's decision is a denial of a request for
			 disenrollment, the notice shall include information about the member's right
			 to, and how to, file a grievance and other information related to the member's
			 administrative hearing rights;
(E) If thirty (30) calendar days pass without
			 a decision from the Authority on a member's disenrollment request, the request
			 becomes effective on the first calendar day of the following calendar month
			 (unless the Authority takes action before that date).
(c) A member may request a temporary
			 enrollment exception during pregnancy as follows:
(A) A temporary enrollment request shall be
			 granted if a member is at any point in the third trimester of pregnancy and:
(i) The member is newly determined eligible
			 for OHP; or
(ii) The member is
			 newly re-determined eligible for OHP and not enrolled in a MCE within the past
			 three (3) months; or
(iii) The
			 member is enrolled with a new MCE that does not contract with the member's
			 current OB provider and the member wishes to continue obtaining maternity
			 services from that non-participating OB provider.
(B) The enrollment exemption shall remain in
			 place until sixty (60) calendar days postdate of either the delivery of the
			 member's child or the pregnancy otherwise ends, at which time the member shall
			 be enrolled in the appropriate MCE in their service area. Where there is a
			 choice among multiple MCEs in the member's service area the member may choose
			 an open plan; however, if the member does not express preference, the Authority
			 shall auto assign on a next weekly basis.
(d) Upon approval of a member's disenrollment
			 from a MCE, the member shall join another MCE unless:
(A) The member resides in a service area
			 where enrollment is voluntary;
(B)
			 The member meets the exemptions to enrollment set forth in OAR
			 410-141-3805;
(C) The member meets
			 disenrollment criteria stated in this rule; or
(D) There is not another MCE available and
			 open to new enrollment in the service area.