Md. Code Regs. 10.67.02.06

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.02.06 - Disenrollment

A. Enrollee-Initiated Disenrollment for Cause.

(1) An enrollee may disenroll from an MCO and enroll into another MCO if:

(a) The enrollee moves to a county that is not served by the enrollee's present MCO;

(b) The family members are enrolled in different MCOs and the adult enrollee requests that other family members be enrolled in one of the MCOs in which another family member is currently enrolled;

(c) The enrollee requests enrollment into the MCO that contracts with the PCP of any other family member who is not a HealthChoice enrollee;

(d) The enrollee moves or becomes homeless, creating a transportation hardship that may be resolved by enrollment into another MCO serving the enrollee's new local access areas;

(e) The enrollee requests a change of MCO within 90 days after the termination of the enrollee's primary care provider's (PCP's) contract if the PCP's contract with the enrollee's MCO, MCO's medical management group, or its subcontractors is terminating for the following reasons:

(i) By the MCO for reasons other than the quality of care or the PCP's failure to comply with contractual requirements related to quality assurance activities; or

(ii) The MCO's reduction of PCP's reimbursement to the extent that the reduction in rate is greater than the actual change in capitation paid to the MCO by the Department, and the MCO and PCP's inability to negotiate a mutually acceptable rate;

(f) The enrollee is automatically assigned to an MCO or it is the enrollee's initial enrollment in an MCO as follows:

(i) Only one request during the first 90 days of automatic assignment or initial enrollment into an MCO; and

(ii) The enrollee is not hospitalized at the time of the request;

(g) The MCO terminates its contract with the Department in which case:

(i) The MCO shall provide written notice to the recipient at least 60 days before the date on which the MCO will exit the HealthChoice Program;

(ii) The MCO shall include in the notice the name and provider number of the PCP assigned to the recipient and the telephone number of the enrollment broker;

(iii) The Department shall send a notice to every enrollee of the MCO regarding the MCO's termination of its contract with the Department, at least 30 days before the effective date of the termination of the contract;

(iv) An enrollee shall have at least 30 days before the effective date of the MCO's contract termination with the Department to choose another MCO, or will be assigned to another MCO; and

(v) An enrollee may choose another MCO one additional time within at least 90 days after reenrollment into the new MCO;

(h) The MCO is acquired by another entity in which case:

(i) The MCO shall provide written notice to the recipient at least 60 days before the date on which the MCO will exit the HealthChoice Program;

(ii) The MCO shall include in the notice the name and provider number of the PCP assigned to the recipient and the telephone number of the enrollment broker;

(iii) The Department shall send a notice to every enrollee of the MCO regarding the change in ownership, 30 days before the effective date of the change of ownership;

(iv) An enrollee shall have 30 days before the change of ownership to disenroll from the MCO into another participating MCO;

(v) If an enrollee does not choose to disenroll in accordance with §A(1)(f)(ii) of this regulation, the enrollee will be reenrolled in the newly purchased MCO; and

(vi) An enrollee may choose another MCO one additional time within at least 90 days after reenrollment in the newly purchased MCO;

(i) The MCO does not, because of moral or religious objections, cover the service the enrollee seeks;

(j) All of the following apply:

(i) The enrollee needs related services to be performed at the same time;

(ii) Not all related services are available within the network; and

(iii) The enrollee's PCP or other provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or

(k) The Department imposes the intermediate sanction specified in 42 CFR § 438.702(a) and (b), as amended.

(2) The Department shall provide timely notification to the affected MCO of an enrollee's intention to disenroll under §A of this regulation.

(3) The Department shall allow disenrollments, subject to the Department's approval, for other reasons, including but not limited to:

(a) Poor quality of care;

(b) Lack of access to services covered under the contract; or

(c) Access to providers experienced in dealing with the enrollee's health care needs.

(4) Enrollees shall make an oral or written request to the Department's enrollment agent for disenrollment.

B. Department-Initiated Disenrollment. The Department shall disenroll from an MCO an enrollee:

(1) Subject to the MCO or long-term care facility obtaining the Department's determination that the enrollee's institutionalization has been medically necessary, who has been continuously institutionalized for a period of more than 90 successive days in a long-term care facility;

(2) Upon admission to an intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID);

(3) Determined eligible for rare and expensive case management pursuant to COMAR 10.67.69;

(4) Who loses Medicaid eligibility or who changes to an assistance category not eligible for MCO enrollment, subject, however, to Regulation .01 of this chapter;

(5) Upon the termination of the contract between the enrollee's MCO and the Department;

(6) Who has died;

(7) Who has not been validly enrolled in the MCO;

(8) Who is 65 years old or older;

(9) Who is an inmate of a public institution, including a State operated institution or facility; or

(10) Who is eligible to receive Medicare benefits.

C. The Department may disenroll individuals from an MCO which the Maryland Insurance Administration has put into rehabilitation or liquidation pursuant to Health-General Article, §15-102.2, Annotated Code of Maryland.

D. MCO Initiated Disenrollment.

(1) An MCO may request disenrollment of an enrollee who has:

(a) Moved outside of the MCO's service area; or

(b) Become ineligible for continued enrollment for one of the reasons specified in §B of this regulation.

(2) An MCO may not request disenrollment as specified in 42 CFR § 438.56(b)(2), as amended.

E. Effective Date of Disenrollment.

(1) Except as specified in §E(2)-(6) of this regulation, an enrollee's disenrollment is effective on the 10th calendar day after the enrollee selects a new MCO.

(2) An enrollee's disenrollment shall take effect:

(a) Immediately when the enrollee dies;

(b) From the first day of the month following the month that the enrollee lost Medicaid eligibility;

(c) On the first day of the month following the month in which the Department receives the required notification, when the enrollee permanently relocates outside of the State; or

(d) From the first day of the month following the month in which the Department verifies an enrollee is an inmate.

(3) When an enrollee becomes eligible for Medicare, the enrollee's disenrollment from the MCO is effective on the:

(a) First day of the month following the month in which the Program receives notice of Medicare eligibility; or

(b) Last day of the month in which the enrollee turns 65 years old.

(4) Termination of enrollment resulting from termination of the contract between the Department and an MCO shall be effective on the date the Department terminates the contract.

(5) Termination of enrollment resulting from the MCO being placed into rehabilitation or liquidation by the Maryland Insurance Administration shall be effective on the date the Department notifies the MCO of the disenrollment.

(6) In the case of an enrollee's death, the Department has the right to recover any capitation payments made on behalf of an enrollee for the period beginning on the date of death.

F. An MCO shall:

(1) Make a good faith effort to give written notice to the Department when enrollees have the right to change MCOs under §A(1)(e) of this regulation 90 days before the effective date of the termination;

(2) Provide the Department with a list of the affected enrollees in a format specified by the Department; and

(3) If applicable, provide the termination survey required under COMAR 10.67.65.17B(4).

G. The Department shall notify enrollees who may change MCOs under §A(1)(e) of this regulation.

H. At the Department's discretion, an MCO may be required to reimburse the Department for the costs associated with the mailing of the notifications in §G of this regulation.

Md. Code Regs. 10.67.02.06

Regulations .06 recodified from 10.09.63.06 effective 46:22 Md. R. 976, eff. 11/1/2019; amended and recodified from 10.09.63.06 effective 46:23 Md. R. 1065, eff. 11/18/2019