Section 17-1720.1-18 - Change of a health plan for an individual prior to the annual plan change period(a) Except for changes made by a newly eligible individual during the fifteen (15) or sixty (60) calendar days grace periods, an enrolled individual shall only be allowed to change enrollment from one health plan to another during the annual plan change period.(b) Exceptions to (a) can occur for cause, which include the following circumstances: (1) A decision from an administrative appeals office allowing participating health plan change;(2) A court order allowing participating health plan change;(3) Provisions in federal or State statutes or administrative rules;(4) A non-returning plan or termination of the individual's health plan's contract or the start of a new contract;(5) Mutual agreement by the participating health plans involved, the enrolled individual and the department;(6) Violations by a participating health plan specified in chapter 17-1735.2;(7) Change in foster placement if necessary for the best interest of the child;(8) The individual's PCP or long-term care residential facility is not in the health plan's provider network and is in the provider network of a different participating health plan provided the health plan is not at its maximum enrollment;(9) The individual is eligible to receive HCBS or personal assistance services level I and is enrolled in a health plan with a waiting list for HCBS or personal assistance services level I and another health plan does not have a waiting list for the necessary service(s);(10) The participating health plan's refusal, because of moral or religious objections, to cover the service the individual seeks as allowed for in the department's contract with the participating health plan;(11) The individual's need for related services(e.g., a cesarean section and a tubal ligation) to be performed at the same time and not all related services are available within the network and the individual's primary care physician or another provider determines that receiving the services separately would subject the individual's to unnecessary risk;(12) Lack of direct access to women's health care specialists for breast cancer screening, pap smears and pelvic exams;(13) Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the individual's health care needs, lack of direct access to certified nurse midwives, pediatric nurse practitioners, family nurse practitioners, if available in the geographic area in which the individual resides;(14) Relocation of the individual to a service area where the health plan in which they were enrolled does not provide services;(15) The individual missed the annual plan change period due to a temporary loss of Medicaid eligibility and was re-enrolled in their previous health plan; or(16) Other special circumstances as determined by the department.(c) When changing health plans, an individual shall select among health plans participating in the service area in which the individual resides that are open to new members except as described in section 171720.1-19.(d) In the absence of choice of health plans participating in the service area in which the individual resides and open to new members, except as described in section 17-1720.1-19, the individual shall be enrolled in the available health plan accepting new members. Haw. Code R. § 17-1720.1-18
[Eff 09/30/13] (Auth: HRS § 346-14; 42 C.F.R. §§430.25, 438.50 ) (Imp: HRS § 346-14; 42 C.F.R. §§430.25, 438.50 )