Section 405 IAC 14-2-59 - Enrollment and disenrollmentAuthority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11
Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2
Sec. 59.
(a) Individuals applying for Medicaid coverage who are not receiving SSI benefits will have an opportunity to select their choice of MCO on their Medicaid application or through the enrollment broker, while SSI recipients are automatically eligible for Indiana Medicaid coverage without a separate application.(b) The office's enrollment broker shall provide information and assistance with MCO selection to enrollees who do not select an MCO at the time of application, and SSI recipients who are not required to submit a Medicaid application, under 42 CFR 438.810(b).(c) The enrollment broker must be conflict free and meet all applicable state and federal law requirements, including 42 CFR 438.810 as amended May 6, 2016.(d) Individuals who do not select an MCO are auto-assigned to an MCO under auto-assignment methodology.(e) Contracted MCOs for each of the office's managed care programs shall accept individuals eligible for enrollment in the order in which they apply without restriction, and shall not, based on health status or needing for health care services, discriminate against individuals eligible to enroll.(f) Contracted MCOs for each of the office's managed care programs shall not discriminate against, or use a policy or practice that causes discrimination against, individuals eligible to enroll based on the following: (g) Members who become eligible for coverage through any of the office's managed care programs may be eligible for coverage retroactive for up to three (3) months after their application date as set forth in 405 IAC 2. Retroactive coverage periods will be in the FFS program. Members in any of the office's managed care programs receive FFS coverage through the effective eligibility approval date, at which time they are assigned to an MCO.(h) Except as provided in subsection (g), a newborn whose mother is enrolled with an MCO on the date of the child's birth is assigned to the mother's MCO, retroactively effective to the newborn's date of birth.(i) Members in any of the office's managed care programs may request to change MCOs they are enrolled in as follows: (1)405 IAC 10-8-2 provides the requirements for a HIP member changing MCOs.(2) HCC members may request to change MCOs at the following times: (A) Without cause during the initial enrollment period, which is within ninety (90) days after enrollment.(B) Without cause at least one (1) time each calendar year after the initial enrollment period.(C) At any time for cause under 42 CFR 438.56(d)(2).(3) HHW members may request to change MCOs at the following times: (A) Without cause during the initial enrollment period, which is within ninety (90) days after enrollment.(B) Without cause at least one (1) time each calendar year after the initial enrollment period.(C) At any time for cause under 42 CFR 438.56(d)(2).(4) PathWays members may request to change MCOs at the following times: (A) Without cause during the initial enrollment period, which is within ninety (90) days of enrollment.(B) Without cause at least one (1) time each calendar year after the initial enrollment period.(C) At any time for cause under 42 CFR 438.56(d)(2).(D) At any time the member's Medicare and Medicaid plans become unaligned.(E) During the plan selection period aligned with the annual Medicare open enrollment window held mid-October through mid-December, with the change to be effective the following calendar year.(j) The following are reasons members of a managed care program operated by the office are disenrolled from the program:(1) Individuals are disenrolled from HIP, HCC, HHW, or PathWays if the individual: (A) loses eligibility for the program;(B) is no longer a resident of Indiana; or(2) In addition to the reasons in subdivision (1), individuals are disenrolled from the respective managed care program based on the following program specific factors: (A)405 IAC 10-4-10 sets forth the reasons individuals are disenrolled from the HIP program.(B) An individual is disenrolled from HCC if: (i) the individual is admitted for a long term stay in an institutional setting;(ii) the individual is admitted to an ICF/IID;(iii) the individual becomes enrolled in an HCBS waiver operated by the office;(iv) the individual begins receiving psychiatric treatment in a state hospital; or(v) unless covered by an EPSDT exception, the individual is receiving treatment in a psychiatric residential treatment facility.(C) An individual is disenrolled from HHW if:(i) the individual is admitted for a long term stay in an institutional setting;(ii) the individual is admitted to an ICF/IID;(iii) the individual begins receiving hospice services;(iv) the individual becomes enrolled in an HCBS waiver operated by the office;(v) the individual begins receiving psychiatric treatment in a state hospital; or(vi) unless covered by an EPSDT exception, the individual is receiving treatment in a psychiatric residential treatment facility.(D) An individual is disenrolled from PathWays if: (i) the individual begins receiving psychiatric treatment in a state hospital;(ii) the individual is admitted to an ICF/IID; or(iii) the individual begins receiving services under an HCBS waiver operated by the office other than the PathWays 1915(c) waiver.Office of the Secretary of Family and Social Services; 405 IAC 14-2-59; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA