Section 17-1722.3-13 - Enrollment in and choice of a participating health plan(a) The department has the sole authority to enroll and disenroll an individual in a participating health plan.(b) An eligible individual shall be enrolled in a health plan for purposes of providing the individual with covered services effective the date of eligibility as described in 17-1722.3-11.(c) After the individual is in a participating health plan, the individual shall be: (1) Sent an enrollment letter identifying the assigned plan and the option to remain in the assigned plan or to select a different health plan;(2) Allowed ten days from the date of the enrollment letter to select from among the participating health plans available in the service area in which the individual resides that are accepting new members. This provision shall not apply to an individual identified in subsection (h).(d) If an individual does not select a different health plan within ten days from the date of the enrollment letter, enrollment shall continue in the health plan assigned by the department.(e) If an individual chooses to enroll in a different health plan within ten days, a confirmation notice will be mailed to the enrollee on the first day of the following month when enrollment in the new health plan becomes effective.(f) An enrollee shall only be allowed to change enrollment from one health plan to another that is open to receiving new members during the open enrollment period. The exceptions to this provision include: (1) Decisions from administrative hearings;(3) Termination of the enrollee's health plan's contract or the start of a new contract;(4) Mutual agreement by the health plans involved, the enrollee, and the department;(5) Violations by a health plan as specified in sections 17-1727-61 and 17-1727-62;(6) Relocation of the enrollee to a service area where the health plan does not provide service;(7) Change in foster placement if necessary for the best interest of the child;(8) The individual missed the open enrollment period due to temporary loss of Medicaid eligibility and shall be re-enrolled in their previous assigned health plan within sixty (60) days of losing eligibility;(9) The enrollee chooses a health plan during the open enrollment period and that health plan's enrollment is capped;(10) Provisions in federal or state statutes or administrative rules;(11) Member's PCP is not in the health plan's provider network and is in the provider network of a different health plan;(12) The health plan's refusal, because of moral or religious objections, to cover the service the enrollee seeks as allowed for in the contract with the health plan;(13) The enrollee's need for related services (i.e., 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 enrollee's primary care physician or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk;(14) Lack of direct access to women's health care specialists for breast cancer screening, pap smears and pelvic exams;(15) 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 enrollee'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 enrollee resides; or(16) Other special circumstances as determined by the department.(g) An individual who is disenrolled from a health plan shall be allowed to select a plan of their choice that is open to receiving new members: (1) If disenrollment extends for more than sixty calendar days in a benefit period;(2) If disenrollment occurred in a period involving the open enrollment period; or(3) If disenrollment includes the first day of a new benefit period.(h) In the absence of a choice of participating health plans in a service area, an eligible individual who resides in that particular service area shall be enrolled in the participating health plan.(i) An individual who is disenrolled from a participating health plan or a health plan contracted to provide federal or state medical assistance shall be allowed to select a plan of their choice: (1) If disenrollment extends for more than sixty calendar days in a benefit year;(2) If disenrollment occurred in a period involving the open enrollment period; or(3) If disenrollment includes the first day of a new benefit year. Haw. Code R. § 17-1722.3-13
[Eff 04/01/10; am 04/12/13 ] (Auth: HRS § 346-14) (Imp: HRS § 346-14)