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Effective: December 1, 2006 |
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28.15.15ar1 - Health Plan Changes (Archive) |
Archived: June 1, 2009 |
People enrolled in managed care may change health plans (or ) for a variety of reasons.
When a household changes health plans the change is effective the first day of the after receipt of the new enrollment form, unless otherwise noted in this section.
First 90 Days of Initial Enrollment.
Primary Care Provider Inaccessible.
Change in Program Eligibility.
Termination of Health Plan Contract.
People may change health plans once during the first year after initial enrollment in managed care. The first day of enrollment is the initial effective date of health plan enrollment. The 12-month period runs continuously from that date regardless of whether the enrollee remains eligible during that time.
Note: Apply the first year change option to households, not individuals.
Example:
The Browns exercise their first year change option. They return their enrollment form for the plan they wish to select on August 10. All information is entered before capitation in August.
Action:
Enroll the Browns in the new plan effective September 1.
Enrollees may change health plans within 90 days of initial enrollment into an MCO .
There is an annual open enrollment period for all managed care enrollees. Enrollees receive open enrollment materials approximately 90 days before the due date for returning enrollment forms. If enrollees choose a different plan, enrollment in the new plan will begin on January 1 of the following year.
Enrollees may change health plans when the distance from their residence to their primary care provider makes the provider inaccessible to the enrollee.
l For MA and GAMC, inaccessibility is defined as:
n In the Twin Cities metropolitan area, if the travel time to the primary care provider exceeds 30 minutes, or is 30 miles from the enrollee's residence.
n In the rest of the state, it is when travel time is considered excessive by community standards. The DHS Managed Care Ombudsman must approve the change. See Complaints and Appeals.
l For MinnesotaCare, the DHS Managed Care Ombudsman decides inaccessibility to the primary care provider on a case-by-case basis.
If an enrollee changes health care program eligibility between MA, GAMC and MinnesotaCare:
l The system will re-assign the enrollee to the same plan with the new product ID if the same health plan is available with the new program.
l If the same health plan is not available for the new program:
n Code the MMIS RPPH screen with exclusion code YY (Delayed Decision) and an Exclusion Begin date.
n Code a closing date for the previous enrollment span.
n Initiate the managed care education and enrollment process. Begin tracking on the MMIS RTRK screen. Refer the client to a managed care presentation or mail the information.
n Health care services may be covered on a fee-for-service basis until the client is enrolled in a new health plan.
Note: If there is a change in eligibility group or basis of eligibility with no change in major program, do not allow a change in health plan.
See the MMIS User Manual for specific coding information.
If a household moves to another county and the plan they are enrolled in is:
l Available - They may choose a new health plan if they request the change within 60 days of the move date. The receiving worker must initiate the education and enrollment process.
l Not available - They must choose a new health plan. The system will initiate the education and enrollment process.
See Managed Care County Transfers.
Example:
The Greens move to a new county where their health plan is not available. They return their enrollment form on August 26 (after capitation).
Action:
Enroll the Greens in the new plan effective October 1. If DHS has paid a capitation to their previous health plan for September, they must receive health care services through the previous health plan or make arrangements with their old health plan to receive services elsewhere.
If a household has a break in eligibility of more than two full calendar months, they may request a change in health plans. They must request the change within 90 days of being reenrolled.
If a health plan terminates its contract with DHS, enrollees will be notified of the need to choose a new health plan. For further information, see the PMHCP Manual, section 3.03.
Do not change the enrollment status or health plan of an enrollee who is hospitalized in an acute care facility on the effective date of the change. Follow these procedures:
l Delay initial enrollment of a hospitalized enrollee into managed care until the first of the next available month after discharge.
Exception: Enroll hospitalized MSHO enrollees for the first available month. The health plan is not responsible for hospital charges before the effective date of enrollment.
l Delay changing health plans for a hospitalized MA or GAMC managed care enrollee who is eligible to change until the first of the next available month after discharge.
l Disenroll a hospitalized GAMC managed care enrollee who becomes excluded from managed care for the next available month.
If you discover after an enrollment change that a household member was in the hospital on the effective date, refer the case to your managed care unit or DHS for an adjustment.
Document dates the person went into and out of the hospital and how you verified the dates in MMIS case notes. Explain the delay in changing the health plan or enrollment status in MMIS case notes.