The purpose of this proposed rule is to incorporate in administrative rule the reasons for which a recipient may disenroll from a managed care plan. The effect of the rule will be to incorporate the reasons in administrative rule for which a ...

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO: RULE TITLE
59G-8.500: Cause of Disenrollment from Health Plans
PURPOSE AND EFFECT: The purpose of this proposed rule is to incorporate in administrative rule the reasons for which a recipient may disenroll from a managed care plan. The effect of the rule will be to incorporate the reasons in administrative rule for which a recipient may disenroll from a managed care plan.
SUBJECT AREA TO BE ADDRESSED: Cause for Disenrollment from Health Plans.
SPECIFIC AUTHORITY: 409.91211, 409.9122, 409.919 FS.
LAW IMPLEMENTED: 409.912, 409.91211, 409.9122 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: Tuesday, March 11, 2008, 2:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building #3, Conference Room C, Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Karen Girard, Agency for Health Care Administration, Bureau of Medicaid Services, 2727 Mahan Drive, MS 20, Tallahassee, Florida 32308, [phone], [e-mail]

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-8.500 Cause for Disenrollment from Health Plans.

(1) Recipients subject to the 12-month enrollment period may request disenrollment from the health plan for cause at any time during their no-change period. Recipients making such requests must submit the request to the call center representative for a determination.

(2) Changes without Cause. The following are reasons a recipient may change without cause at any time:

(a) The recipient missed his 60-day Open Enrollment period due to a temporary loss of eligibility, defined as sixty (60) days or less; or

(b) The State has imposed intermediate sanctions upon the health plan, as specified in 42 CFR 438.702(a)(3) for violations consistent with 42 CFR 438.700.

(3) For Cause Reasons. Recipients subject to the 12-month enrollment period may request disenrollment from the health plan for cause at any time during their no-change period. Recipients making such requests must submit the request to the call center representative for a determination. The following reasons constitute cause for disenrollment from the health plan:

(a) The recipient moves out of the county, or the recipient’s address is incorrect and the recipient does not live in the county.

(b) The provider is no longer with the health plan.

(c) The recipient is excluded from enrollment.

(d) A substantiated marketing violation occurred with the individual recipient.

(e) The recipient is prevented from participating in the development of his treatment plan.

(f) The recipient has an active relationship with a provider who is not on the health plan's network, but is in the network of another health plan.

(g) The recipient is ineligible for enrollment in the health plan.

(h) The health plan no longer participates in the county.

(i) The recipient needs related services to be performed concurrently, but not all related services are available within the health plan network; or the recipient's primary care provider (PCP) has determined that receiving the services separately would subject the recipient to unnecessary risk.

(j) The health plan does not, because of moral or religious objections, cover the service the recipient seeks.

(k) Other reasons per 42 CFR 438.56(d)(2), including poor quality of care; lack of access to services covered under the contract; inordinate or inappropriate changes of PCPs; an unreasonable delay or denial of service, service access impairments due to significant changes in the geographic location of services; lack of access to providers experienced in dealing with the recipient’s health care needs; or fraudulent enrollment.

(l) Recipients otherwise locked in who request enrollment in a specialty plan and appear to meet the eligibility requirements for the specialty plan.

(m) Recipient received a notice from their plan of the reduction in required benefits at the end of the plan’s annual contract year (for the next year).

(4) Recipients whose request to disenroll from plans outside of their open enrollment period are denied will be mailed a Disenrollment Denial Letter, AHCA-HSD Form #XX, April 2007, incorporated by reference.

Specific Authority 409.91211, 409.9122, 409.919 FS. Law Implemented 409.912, 409.91211, 409.9122 FS. History–New ________.