Section 482-2-003 - ENROLLMENT ACTIVITIES IN A HERITAGE HEALTH PLAN The enrollment broker has the responsibility to enroll a member in a Heritage Health plan.
003.01MEMBER CHOICE. A member may choose a Heritage Health plan and primary care provider or the member may be auto-assigned by the enrollment broker to a Heritage Health plan. The member must have the opportunity to choose the health plan and primary care provider of their choice, to the extent possible and appropriate. (A) The Heritage Health plan is responsible for the assignment of the primary care provider for members who do not voluntarily enroll.003.02HEALTH PLAN ACCEPTANCE. The Heritage Health plan must accept members in the order in which they are enrolled through the enrollment broker.003.03INITIAL ENROLLMENT PLAN CHANGE. A member has ninety (90) days after the effective date of their initial Heritage Health plan enrollment to choose another Heritage Health plan. Family members may select a different primary care provider and Heritage Health plan but are encouraged to choose the same Heritage Health plan.003.04DEPARTMENT NOTIFICATION. Enrollment activities must be completed and communicated to the Department by the enrollment broker following the date of the notice sent to the member informing the member of the Heritage Health plan assignment.003.05REENROLLMENT. A member will automatically be enrolled with the previous Heritage Health plan effective the first day of the next possible month if the member is identified as mandatory for enrollment into a Heritage Health plan no later than two months of losing Medicaid eligibility. 003.05(A)REENROLLMENT EXCEPTIONS. During reenrollment the member may choose a different Heritage Health plan in the following circumstances only: (i) If the reenrollment is during the initial ninety (90) day period;(ii) If the reenrollment is during the open enrollment period; or(iii) For cause, per Title 482 NAC 2-004.02(C), by contacting the enrollment broker and completing a plan transfer request.003.06DEPARTMENTAL WARDS AND FOSTER CARE MEMBERS. The enrollment broker must coordinate enrollment activities for departmental wards or foster children with the Department staff responsible for the case management of the member.003.07ENROLLMENT OF AN UNBORN AND NEWBORN CHILD. Unborns will be pre-enrolled into a Heritage Health plan prior to birth if the unborn has either a mother or sibling enrolled. If the Department is notified after a live birth, the newborn will be immediately enrolled in either the mother's Heritage Health plan or an eligible sibling's Heritage Health plan. The mother's Heritage Health plan supersedes the sibling's plan, in the event that both mother and sibling are enrolled in a Heritage Health plan. Enrollment changes may be made as allowed for any other member participating in a Heritage Health plan per Title 482 NAC 2-004.02.003.08MEMBER ENROLLMENT REQUIREMENTS. The member must complete the enrollment process. For purposes of completing the enrollment process, the following rules apply: (A) Any individual with sufficient knowledge of the member's health status may complete the informational portion of the enrollment process;(B) The member must make the choice of the Heritage Health plan and primary care provider; and(C) The Departmental staff or designee must act on a Department ward's behalf. The child's foster parents must be involved in the selection of the Heritage Health plan and primary care provider.003.09HEALTH PLAN CONTACT. The Heritage Health plans must not have any direct contact with the member or the member's legal representative, family, or friends prior to the client becoming enrolled with that Heritage Health plan, unless the contact is initiated by the enrollment broker.003.10EFFECTIVE DATE OF HERITAGE HEALTH PLAN AND DENTAL BENEFITS MANAGER COVERAGE. The effective date of coverage is the first calendar day of the month of the Heritage Health plan or Dental Benefits Manager enrollment. The date of enrollment will match the Medicaid eligibility date. This date may occur up to three (3) months prior to the date of enrollment. The Heritage Health plan and Dental Benefits Manager are responsible for benefits and services in the core benefits package and dental benefits package from and including the effective date of an enrolled member's Medicaid eligibility. The Heritage Health plan and Dental Benefits Manager must reimburse a provider for appropriate covered services and that provider must reimburse a member for any payments made by the member. 003.10(A)SERVICES RECEIVED BEFORE ENROLLMENT. Medicaid-coverable services received before the Heritage Health or Dental Benefits Manager coverage becomes effective will be paid on a fee-for-service basis under the rules and regulations of the Department Title 471 NAC.003.11NOTIFICATION OF COVERAGE. Members will be notified of their coverage within the first month of enrollment. 003.11(A)HERITAGE HEALTH PLAN NOTIFICATION. The Heritage Health plan must provide each member a member handbook that includes general information about the member's integrated health coverage and the Heritage Health plan itself.003.11(B)DENTAL BENEFITS MANAGER NOTIFICATION. The Dental Benefits Manager must provide each member a member handbook that includes general information about the Dental Benefits Manager.003.11(C)PROVIDER NOTIFICATION. Providers must verify a member's coverage through: (i) Medicaid's internet access for enrolled providers;(ii) The Medicaid inquiry line; or(iii) The standard electronic health care eligibility benefit inquiry and response transaction (ASC X12N 270/271).003.12COVERAGE WHEN THERE IS A DISCREPANCY. The Heritage Health plan is responsible for providing the services in the core benefits package to members listed on the enrollment report generated for the month of enrollment. Any discrepancies between the member notification and the enrollment report must be reported to the Department for resolution. The Heritage Health plan must continue to provide and authorize services until the discrepancy is resolved. 003.12(A)DISCREPANCY REVIEW. In case of a discrepancy, the eligibility and enrollment databases used to build the enrollment file serves as the official source of validation. Once the cause for the discrepancy is identified, the Department will work cooperatively with the Heritage Health plan to identify responsibility for the member's services until the cause for the discrepancy is corrected.003.13DENTAL BENEFITS MANAGER NOTIFICATION. The Dental Benefits Manager will notify its members, through written materials and notice, of the member's enrollment and right to change dental homes.003.14CONTINUITY OF CARE. The Heritage Health plan and Dental Benefits Manager must continue all services authorized by Medicaid fee-for-service prior to the member becoming enrolled in the Heritage Health plan or Dental Benefits Manager. These services must be continued until the Heritage Health plan or Dental Benefits Manager determines the service no longer meets the definition of medical necessity.003.15HOSPITALIZATION. When a Medicaid client is admitted to an acute care medical or rehabilitation facility prior to the client's enrollment in a Heritage Health plan, Medicaid fee-for-service remains responsible for the hospitalization until the client is discharged from the facility, transferred to a lower level of care, or sixty (60) days, whatever is earliest. 003.15(A)HOSPITALIZATION IN MONTH OF ASSIGNMENT. In the event that a client is admitted as an inpatient in an acute care medical or rehabilitation facility and is assigned to a Heritage Health plan in the same month, the Heritage Health plan is responsible for that hospitalization.003.16AUTOMATIC ASSIGNMENT FOR HERITAGE HEALTH. If a choice of a Heritage Health plan is not made at the time of application, the member will be automatically assigned to a Heritage Health plan based on criteria established by the Department.482 Neb. Admin. Code, ch. 2, § 003
Amended effective 7/29/2020Amended effective 9/27/2021