D.C. Mun. Regs. tit. 29, r. 29-5502

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-5502 - DISENROLLMENT

5502.1 Eligibility groups enrolled on both a mandatory and voluntary basis (as described under §§ 5501.1(a)-(b)) shall have the right to disenroll from their DC Health Families MCO upon request, for the reasons described under § 5502.4 and pursuant to the requirements under 42 CFR § 438.56(c).

5502.2 A DC Healthy Families MCO may request beneficiary disenrollment in accordance with the requirements set forth in its contract with the Department.

5502.3 Except when a beneficiary's continued enrollment in the DC Healthy Families MCO seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees, a DC Healthy Families MCO may not request disenrollment because of:

(a) An adverse change in the enrollee's health status;

(b) The beneficiary's utilization of services;

(c) The beneficiary's diminished mental capacity; or

(d) The beneficiary's uncooperative or disruptive behavior resulting from his or her special needs.

5502.4 Disenrollment, as described under § 5502.1, shall mean the following:

(a) For beneficiaries enrolled on a mandatory basis (as described under § 5501.1(a)), a beneficiary would no longer be enrolled in the beneficiary's current DC Healthy Families MCO, and would need to enroll or be automatically enrolled into a different DC Healthy Families MCO that is contracted with the Department; and

(b) For beneficiaries enrolled on a voluntary basis (as described under § 5501.1(b)), a beneficiary may elect to either receive services through an alternative delivery system or to switch enrollment to a different DC Healthy Families MCO of their choice.

5502.5 Disenrollment may occur for the following reasons:

(a) For cause, at any time, which shall include the following:

(1) The beneficiary moves out of the DC Healthy Families MCO's service area;

(2) The plan does not, because of moral or religious objections, cover the service the beneficiary seeks;

(3) The beneficiary needs related services (for example, a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the beneficiary's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk;

(4) Other reasons, including 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 care needs;

(5) The beneficiary needs services from a Psychiatric Residential Treatment Facility; or

(6) All family members are not assigned to the same DC Healthy Families MCO and the beneficiary is requesting disenrollment to ensure family enrollment alignment.

(b) Without cause, at the following times:

(1) During the ninety (90) days following the date of the beneficiary's enrollment into the DC Healthy Families MCO, or during the ninety (90) days following the date the Department sends the beneficiary notice of that enrollment, whichever is later;

(2) At least once every twelve (12) months after the period described under § 5502.4(b)(1);

(3) Upon automatic reenrollment under 42 CFR § 438.56(g), if the loss of Medicaid eligibility for two (2) months or less has caused the beneficiary to miss the annual disenrollment opportunity; and

(4) When the Department imposes an intermediate sanction that suspends all new enrollment, including default enrollment, into a DC Healthy Families MCO, as described in 42 CFR § 438.702(a)(4).

5502.6 The Department must approve or disapprove disenrollment no later than the first (1st) day of the second (2nd) month following the month in which the beneficiary requests disenrollment, the DC Healthy Families MCO refers the request to the Department, or the DC Healthy Families MCO request disenrollment of the beneficiary. Upon approval of any disenrollment, the effective date of the disenrollment will be the first (1st) day of the second (2nd) month following the month in which the beneficiary requests disenrollment or the DC Healthy Families MCO refers the request to the Department.

5502.7 If the Department fails to make the determination of whether the disenrollment is approved within the timeframes specified in § 5502.6, the disenrollment shall be considered approved for the effective date that would have been established had the Department complied with § 5502.6.

5502.8 Beneficiaries who are dissatisfied with the Department's determination that there is not good cause for disenrollment shall be entitled to request a fair hearing in accordance with the requirements set forth under § 9508 of Title 29 DCMR.

D.C. Mun. Regs. tit. 29, r. 29-5502

Final Rulemaking published at 69 DCR 2149 (3/18/2022)