1 Tex. Admin. Code § 353.403

Current through Register Vol. 49, No. 48, November 29, 2024

Section 353.403 - Enrollment and Disenrollment

(a) Enrollment by HHSC. HHSC will conduct enrollment and disenrollment activities. Except as provided in subsection (d)(2) and (5) of this section, regarding dental home assignments, HHSC may not contract with a participating MCO to serve as the administrator for enrollment or disenrollment activities in any area of the state.

(b) Procedures for enrollment. HHSC will establish procedures for enrollment into participating MCOs, primary care providers (PCPs), and dental homes, including enrollment periods and time limits within which enrollment must occur. Beneficiaries will have at least 15 calendar days from the date notification is mailed to choose an MCO, PCP, and dental home.

(c) Default assignment. Beneficiaries who fail to select an MCO, PCP, or dental home within the timeframe specified in subsection (b) of this section will have an MCO, PCP, or dental home selected for them by HHSC using the default assignment methodology described in subsection (d) of this section.

(d) Default assignment methodology. HHSC's default assignment methodology will include the following criteria, to the maximum extent possible:

(1) Automated PCP assignment. If a beneficiary has not selected a PCP, HHSC or its administrative services contractor will assign one using an automated algorithm that considers:

(A) the beneficiary's established history with a PCP, as demonstrated by Medicaid claims or encounter history with the provider in the preceding year, if available;

(B) the geographic proximity of the beneficiary's home address to the PCP;

(C) whether the provider serves as a PCP to other members of the beneficiary's household;

(D) limitations on default assignment, such as PCP restrictions on age, gender, and capacity; and

(E) other criteria determined by HHSC.

(2) Automated dental home assignment. If a beneficiary has not selected a dental home, the dental MCO will assign one using an automated algorithm that considers:

(A) the beneficiary's established history with a dental home, as demonstrated by Medicaid claims or encounter history with the provider in the preceding year, if available;

(B) the geographic proximity of the beneficiary's home address to the dental home;

(C) whether the provider serves as the dental home to other members of the beneficiary's household;

(D) limitations on default assignment, such as dental home restrictions on age and capacity; and

(E) other criteria approved by HHSC.

(3) Automated MCO assignment. If a beneficiary has not selected a health care MCO or dental MCO, HHSC or its administrative services contractor will assign one using an automated algorithm that considers the beneficiary's history with a PCP or dental home when possible. If this is not possible, HHSC or its administrative services contractor will equitably distribute beneficiaries among qualified MCOs, using an automated algorithm that considers one or more of the following factors:

(A) whether other members of the beneficiary's household are enrolled in the MCO;

(B) MCO performance;

(C) the greatest variance between the percentage of elective and default enrollments (with the percentage of default enrollments subtracted from the percentage of elective enrollments);

(D) capitation rates;

(E) market share; and

(F) other criteria determined by HHSC.

(4) Automatic re-enrollment. Notwithstanding subsection (d) of this section, HHSC will automatically re-enroll a beneficiary in the same MCO if there is a loss of Medicaid eligibility of six months or less.

(5) Use of manual default processes. A beneficiary who cannot be assigned to a PCP, dental home, health care MCO, or dental MCO on the basis of an automated default process may be assigned through a manual default process determined by HHSC. Beneficiaries with special medical needs may be defaulted on the basis of a manual default methodology if such beneficiaries can be identified and if the automated default process cannot be administered for such beneficiaries.

(e) Modified default enrollment process. HHSC has the option to implement a modified default enrollment process for MCOs when contracting with a new MCO or implementing managed care in a new service area, or when it has placed an MCO on full or partial enrollment suspension.

(f) Request to change dental home or PCP. There is no limit on the number of times a member can request to change his or her dental home or PCP. A member can request a change in writing or by calling the MCO's toll-free member hotline.

(g) Disenrollment from Medicaid managed care.

(1) Disenrollment at a member's request.

(A) Members will be informed of disenrollment opportunities no less than annually.

(B) Members who are enrolled in a managed care program on a voluntary basis may request disenrollment from the managed care model and transfer to fee-for-service Medicaid at any time for any reason.

(C) Members who are enrolled in a managed care program on a mandatory basis may request, in writing to HHSC, disenrollment from the managed care model and transfer to fee-for-service Medicaid. HHSC considers disenrollment from the managed care model only if medical documentation establishes that the MCO cannot provide the needed services. An authorized HHSC representative reviews all disenrollment requests and processes approved requests for disenrollment from an MCO.

(D) Disenrollment will take place no later than the first day of the second month after the month in which the member has requested a change.

(2) Disenrollment at an MCO's request.

(A) An MCO may submit a request to HHSC that a member be disenrolled without the member's consent in the following limited circumstances:

(i) the member misuses or loans his or her MCO membership card to another person to obtain services;

(ii) the member's behavior is disruptive or uncooperative to the extent that the member's continued enrollment in the MCO seriously impairs the MCO's or a provider's ability to provide services to either the member or other members, and the member's behavior is not related to a developmental, intellectual, or physical disability, or behavioral health condition; or

(iii) the member steadfastly refuses to comply with managed care restrictions (such as repeatedly using the emergency room in combination with a refusal to allow treatment for the underlying medical condition).

(B) An MCO must take reasonable measures to correct a member's behavior prior to requesting disenrollment. Reasonable measures may include providing education and counseling regarding the offensive acts or behaviors.

(C) An MCO cannot request a disenrollment based on adverse change in the member's health status or utilization of medically necessary services.

(D) HHSC will review all requests for disenrollment. HHSC will grant a request if it determines that all reasonable measures taken by the MCO have failed to correct the member's behavior.

(E) If HHSC grants a request, it will notify the member of the disenrollment decision and the availability of HHSC's fair hearings process for an appeal of the disenrollment.

(h) MCO Transfer. A beneficiary may request transfer to another MCO in the service area through the enrollment broker at any time for any reason.

1 Tex. Admin. Code § 353.403

The provisions of this §353.403 adopted to be effective December 18, 1996, 21 TexReg 11822; Amended to be effective October 6, 1997, 22 TexReg 9673; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; Amended to be effective August 10, 2005, 30 TexReg 4466; Amended to be effective September 1, 2006, 31 TexReg 6629; Amended to be effective March 1, 2012, 37 TexReg 1283; Amended to be effective July 8, 2012, 37 TexReg 4851; Amended to be effective September 1, 2014, 39 TexReg 5879