Section 210-RICR-30-05-2.36 - Initiating Enrollment: No Wrong DoorA. The enrollment process begins at the point in which an eligibility determination has been made and the applicant is notified. Once determined eligible, a Medicaid member must select an MCO at the time a determination is made if applying online through the web-portal either alone or with assistance. Notice of eligibility provided by EOHHS, whether electronically or on paper, must inform the Medicaid member of whether enrollment in a RIte Care versus Rhody Health Partners plan is required. The Medicaid coverage group that is the basis of eligibility for an individual or family determines the delivery system - RIte Care or RHP - in which a person must enroll (see Subchapter 00 Part 1 of this Chapter). 1. Enrollment channels - Once determined eligible, a Medicaid eligible person may enroll in a RIte Care or Rhody Health Partners Plan, as appropriate:a. Online through the eligibility portal independently or with a navigator's assistance;b. Over the phone with a Contact Center representative; orc. In-person at the Contact Center or a DHS office. (Contact information located in § 2.67 of this Part).2. Information on enrollment options - The EOHHS and the RIte Care and RHP MCOs share responsibility for ensuring Medicaid applicants and prospective and current enrollees have access to accurate up-to-date information about their enrollment options. This information is available online if applying through the eligibility web portal, as well as through the Contact Center, EOHHS, DHS and the participating MCOs. The information available must include:a. Materials describing the Medicaid managed care delivery system.b. A written explanation of enrollment options including information about the applicable service delivery system - RIte Care versus RHP - and choice of participating MCOs therein.c. Upon requested, an indication of whether a prospective enrollee's existing physician is a participant in each of the respective MCOs.d. Non-biased enrollment counseling through the Contact Center or a Navigator.e. A chart comparing participating MCOs.f. Detailed instructions on how to enroll.g. Full disclosure of any time limits and consequences for failing to meet those time limits.h. Access to interpreter services.i. Notification in writing of the right to challenge auto-assignment for good cause through EOHHS.3. Non-biased enrollment counseling - Non-biased enrollment navigators who are not affiliated with any participating MCO help enrollees choose an MCO and a primary care provider (PCP) capable of meeting their needs. Factors that may be considered when making this choice are whether an existing PCP participates in a particular MCO, as well as language preferences or limitation, geographic proximity, and so forth. Enrollment navigators are available by telephone or in-person at the Contact Center and DHS offices during regular hours of operation. They also are available in-person and by telephone at these locations to assist enrollees who would like to change MCO, such as, during open enrollment or due to good cause).4. Voluntary selection of MCO - Prospective enrollees are given fourteen (14) calendar days from the completion of their eligibility determination to select an MCO. All members of a family must select the same MCO. If an individual or family does not select an MCO within the time allowed, the individual or family is automatically assigned to an MCO.5. Automatic assignment into an MCO - The State employs a formula, or algorithm, to assign prospective enrollees who do not make a voluntary selection into an MCO. This algorithm considers quality and financial performance.6. Requests for reassignment - Medicaid enrollees who have selected an MCO voluntarily or have been auto-assigned may request to be reassigned within certain limits. Such requests are categorized as follows:a. Requests made within ninety (90) days of enrollment. Medicaid members may be reassigned to the MCO of their choice if their oral or written request for reassignment and their choice of an alternative MCO is received by EOHHS within ninety (90) days of the voluntary or auto-assigned enrollment and the MCO selected is open to new members. The effective date of an approved enrollment must be no later than the last day of the second (2nd) month following the month in which the enrollee requests disenrollment or the MCO requests.b. Requests made ninety (90) days or more after enrollment. Medicaid enrollees who challenge an auto-assignment decision or seek to change MCOs more than ninety (90) days after enrollment in the health plan must submit an oral or written request to EOHHS and show good cause, as provided in § 2.48(A)(4) of this Part, for reassignment to another MCO. A written decision must be rendered by EOHHS within ten (10) days of receiving the request and is subject to appeal.c. Open Enrollment. A Medicaid enrollee may request to be reassigned to another MCO once every twelve (12) months without good cause shown.7. Auto-assignment and resumption of eligibility - Medicaid members who are disenrolled from an MCO due to loss of eligibility and who regain eligibility within sixty (60) calendar days of disenrollment are automatically re-enrolled, or assigned, into the same MCO if they do not make an MCO selection upon reinstatement of their Medicaid eligibility. If more than sixty (60) days has elapsed and the Medicaid member does not make an MCO selection at the time eligibility was reinstated, the Medicaid member will be auto-assigned to an MCO based on EOHHS's algorithm referenced in § 2.36(A)(5) of this Part.8. Open-enrollment - To the extent feasible, EOHHS must coordinate open enrollment periods with those established for affordable care more generally through the State's health insurance exchange - HealthSource RI.9. EOHHS reserves the discretion to provide Medicaid wrap around coverage, as an alternative to coverage in a Medicaid MCO to any eligible individual who has comprehensive health insurance through a liable third party, including (but not limited to) absent parent coverage. Such wrap around coverage must be equivalent in scope, amount and duration to that provided to Medicaid eligible individuals enrolled in in a qualified health plan, including ESI, through the RIte Share program. See Part 3 of this Subchapter.210 R.I. Code R. 210-RICR-30-05-2.36
Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024