Enrollment; disenrollment

409.969

Enrollment; disenrollment.

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(1)

ENROLLMENT. — All Medicaid recipients shall be enrolled in a managed care plan unless specifically exempted under this part. Each recipient shall have a choice of plans and may select any available plan unless that plan is restricted by contract to a specific population that does not include the recipient. Medicaid recipients shall have 30 days in which to make a choice of plans.

(2)

DISENROLLMENT; GRIEVANCES. — After a recipient has enrolled in a managed care plan, the recipient shall have 90 days to voluntarily disenroll and select another plan. After 90 days, no further changes may be made except for good cause. For purposes of this section, the term “good cause” includes, but is not limited to, poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service, or fraudulent enrollment. The agency must make a determination as to whether good cause exists. The agency may require a recipient to use the plan’s grievance process before the agency’s determination of good cause, except in cases in which immediate risk of permanent damage to the recipient’s health is alleged.

(a)

The managed care plan internal grievance process, when used, must be completed in time to permit the recipient to disenroll by the first day of the second month after the month the disenrollment request was made. If the result of the grievance process is approval of an enrollee’s request to disenroll, the agency is not required to make a determination in the case.

(b)

The agency must make a determination and take final action on a recipient’s request so that disenrollment occurs no later than the first day of the second month after the month the request was made. If the agency fails to act within the specified timeframe, the recipient’s request to disenroll is deemed to be approved as of the date agency action was required. Recipients who disagree with the agency’s finding that good cause does not exist for disenrollment shall be advised of their right to pursue a Medicaid fair hearing to dispute the agency’s finding.

(c)

Medicaid recipients enrolled in a managed care plan after the 90-day period shall remain in the plan for the remainder of the 12-month period. After 12 months, the recipient may select another plan. However, nothing shall prevent a Medicaid recipient from changing providers within the plan during that period.

(d)

On the first day of the month after receiving notice from a recipient that the recipient has moved to another region, the agency shall automatically disenroll the recipient from the managed care plan the recipient is currently enrolled in and treat the recipient as if the recipient is a new Medicaid enrollee. At that time, the recipient may choose another plan pursuant to the enrollment process established in this section.

(e)

The agency must monitor plan disenrollment throughout the contract term to identify any discriminatory practices.

History.

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s. 10, ch. 2011-134.