Iowa Admin. Code r. 441-73.4

Current through Register Vol. 47, No. 11, December 11, 2024

Rule 441-73.4 - Disenrollment process

(1)Enrollee-requested disenrollment. An enrollee may request disenrollment with an MCP as follows:

a. During the first 90 days following the date of the enrollee's initial enrollment with the MCP, the enrollee may request disenrollment, for any reason, in writing or by a telephone call to the enrollment broker's toll-free member telephone line.

b. After the 90 days following the date of the enrollee's enrollment with the MCP, when an enrollee is requesting disenrollment due to good cause, the enrollee member shall first make a verbal or written filing of the issue through the MCP's grievance system. If the member does not experience resolution, the MCP shall direct the member to the enrollment broker. The enrolled member may request disenrollment in writing or by a telephone call to the enrollment broker's toll-free member telephone line and must request a good-cause change for enrollment. Good-cause changes include the following:

(1) The MCP does not, because of moral or religious objections, cover the service the member seeks.

(2) The member needs related services to be performed at the same time, not all related services are available within the network, and the member's primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.

(3) Other reasons, including but not limited to poor quality of care, lack of access to services covered under the contract, lack of access to providers experienced in dealing with the member's health or dental care needs, or eligibility and choice to participate in a program not available in managed care (for example, PACE).

c. The final decision for disenrollment shall be determined by the department.

(2)Disenrollment by department. Disenrollment will occur when:

a. The contract between the department and the MCP is terminated.

b. The enrollee becomes ineligible for Medicaid, the hawki program, the Iowa health and wellness plan, or the dental wellness plan. If the enrollee becomes ineligible and is later reinstated to these programs, enrollment in the MCP will also be reinstated.

c. The enrollee transfers to an eligibility group excluded from managed care plan enrollment. "Enrollee" is defined in rule 441-73.1 (249A).

d. The department has determined that participation in the HIPP program as described in 441-Chapter 75 is more cost-effective than enrollment in managed health care.

e. The enrollee dies.

f. The enrollee has changed residence to another state.

(3)Managed care plan-requested disenrollment. An MCP shall not disenroll an enrollee or encourage an enrollee to disenroll for any reason, including the enrollee's health or dental care needs or change in health or dental care status or because of the enrollee's utilization of medical services, diminished capacity, or uncooperative or disruptive behavior resulting from the enrollee's special needs (except when the enrollee's continued enrollment seriously impairs the MCP's ability to furnish services to either this particular enrollee or other enrollees). In instances where the exception applies, the MCP shall provide evidence to the department that continued enrollment of an enrollee seriously impairs the MCP's ability to furnish services to either this particular enrollee or other enrollees. The MCP shall have methods by which the department is assured that disenrollment is not requested for another reason.

(4)Disenrollment effective date.

a. The effective date of a department-approved disenrollment shall be no later than the first day of the second calendar month beginning after the month in which:

(1) The enrollee requests disenrollment pursuant to subrule 73.4(1);

(2) The department notifies the enrollee and MCP of disenrollment pursuant to subrule 73.4(2); or

(3) The MCP requests disenrollment pursuant to subrule 73.4(3).

b. The enrollee shall remain enrolled in the MCP and the MCP will be responsible for services covered under the contract until the effective date of disenrollment unless the enrollee is in an inpatient setting at the time of disenrollment. If the enrollee is in an inpatient setting at the time of disenrollment, the managed care organization shall be responsible for the inpatient services for 60 days or until the enrollee is discharged.

Iowa Admin. Code r. 441-73.4

Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB April 5, 2023/Volume XLV, Number 20, effective 6/1/2023