New Mexico Register / Volume XXIX,
Issue 8 / April 24, 2018
TITLE 8 SOCIAL SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 7 ENROLLMENT
AND DISENROLLMENT
8.308.7.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.308.7.1 NMAC - Rp, 8.308.7.1
NMAC, 5/1/2018]
8.308.7.2 SCOPE: This rule applies to the general public.
[8.308.7.1 NMAC - Rp,
8.308.7.2 NMAC, 5/1/2018]
8.308.7.3 STATUTORY AUTHORITY: The New Mexico medicaid
program and other health care programs are administered pursuant to regulations
promulgated by the federal department of health and human services under Title
XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA 1978.
[8.308.7.3 NMAC - Rp,
8.308.7.3 NMAC, 5/1/2018]
8.308.7.4 DURATION: Permanent.
[8.308.7.4 NMAC - Rp,
8.308.7.4 NMAC, 5/1/2018]
8.308.7.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.7.5 NMAC - Rp,
8.308.7.5 NMAC, 5/1/2018]
8.308.7.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
programs (MAP).
[8.308.7.6 NMAC - Rp,
8.308.7.6 NMAC, 5/1/2018]
8.308.7.7 DEFINITIONS: [RESERVED].
8.308.7.8 [RESERVED]
[8.308.7.8 NMAC - Rp,
8.308.7.8 NMAC, 5/1/2018]
8.308.7.9 MANAGED CARE ENROLLMENT
A. General: A medical assistance division (MAD) eligible
recipient is required to enroll in a HSD managed care organization (MCO) unless
he or she is:
(1) a native American and elects enrollment in MAD’s fee-for-service
(FFS); or
(2) is in an excluded population. See 8.200.400 NMAC and
8.308.6 NMAC. Enrollment in a MCO
may be the result of the eligible recipient’s selection of a particular MCO or assignment
by HSD. The MCO shall accept as a member
an eligible recipient in accordance with 42 CFR. 434.25 and shall not
discriminate against, or use any policy or practice that has the effect of
discrimination against the potential or enrolled member on the basis of health
status, the need for health care services, or race, color, national origin,
ancestry, spousal affiliation, sexual orientation or gender identity. HSD reserves the right to limit enrollment in
a specific MCO.
B. Newly eligible recipients: An individual who applies for a MAP category
of eligibility and has an approved eligibility effective date of January 1,
2014, or later, and who is required to enroll in a MCO, must select a MCO at
the time of his or her application for a MAP category of eligibility. An eligible recipient who fails to select a
MCO at such time will be assigned to a MCO.
See Subsection C of this Section.
Members may choose a different MCO during the first three months of
their enrollment.
C. Auto assignment: HSD will auto-assign an eligible recipient to
a MCO in specific circumstances, including but not limited to: a) the eligible
recipient is not exempt from managed care and does not select a MCO at the time
of his or her application for MAD eligibility; b) the eligible recipient cannot
be enrolled in the requested MCO pursuant to the terms of this rule (e.g., the
MCO is subject to and has reached its enrollment limit). HSD may modify the auto-assignment algorithm,
at its discretion, when it determines it is in the best interest of the
program, including but not limited to, sanctions imposed on the MCO,
consideration of quality measures, cost or utilization management performance
criteria.
The
HSD auto-assignment process will consider the following:
(1) if the eligible
recipient was previously enrolled with a MCO and lost his or her eligibility
for a period of six months or less, he or she will be re-enrolled with that
MCO;
(2) if the eligible recipient has a family member enrolled in a
specific MCO, he or she will be enrolled with that MCO;
(3) if the eligible recipient is a newborn, he or she will be
assigned to the mother’s MCO; see Subsection A of 8.308.6.10 NMAC; or
(4) if none of the above applies, the eligible recipient will be
assigned using the default logic that assigns an eligible recipient to a MCO.
D. Effective date for a newly eligible
recipient’s enrollment in managed care:
In most instances, the effective date of enrollment with a MCO will be
the same as the effective date of eligibility approval. In instances of an award of retroactive MAD
eligibility, the effective date of managed care enrollment of the eligible
recipient may not exceed a two year retroactive span.
E. Eligible recipient member lock-in: A member’s enrollment with a MCO is for a
12-month lock-in period. During the
first three months after his or her initial or annual MCO enrollment, either by
the member’s choice or by auto-assignment, he or she shall have one option to
change MCOs for any reason, except as described below.
(1) If
the member does not choose a different MCO during his or her first three months,
the member will remain with this MCO for the full 12-month lock-in period
before being able to switch MCOs.
(2) If
during the member’s first three months of enrollment in the initially or
annually-selected or a HSD assigned MCO, and chooses a different MCO, he or she
is subject to a new 12-month lock-in period and will remain with the newly
selected MCO until the lock-in period ends.
After that time, the member may switch to another MCO.
(3) At
the conclusion of the 12-month lock-in period, the member shall have the option
to select a new MCO, if desired. The
member shall be notified of the option to switch MCOs 60 days prior to the
expiration date of the member’s lock-in period, the deadline by when to choose
a new MCO.
(4) If
a member loses his or her MAD eligibility for a period of six months or less,
he or she will be automatically re-enrolled with the former MCO. If the member misses what would have been his
or her annual switch MCO enrollment period, he or she may select another MCO
within three months of reinstated MAD eligibility.
F. Open MCO enrollment period: Open enrollment periods are when a member can
change his or her MCO without having to wait until the end of the 12 month
lock-in period, and may be initiated at HSD’s discretion in order to support
program needs.
G. Mass transfers from another MCO: A MCO shall accept any member transferring
from another MCO as authorized by HSD.
The transfer of membership may occur at any time during the year.
H. Change of enrollment initiated by a member:
(1) A
member may select another MCO during his or her annual renewal of eligibility,
or re-certification period.
(2) A
member may request to be switched to another MCO for cause, even during a
lock-in period. The member must submit a
written request to HSD. Examples of
“cause” include, but are not limited to:
(a) the MCO does not, because of moral or religious objections,
cover the service the member seeks;
(b) the
member requires related services (for example a cesarean section and a tubal
ligation) to be performed at the same time, not all of the related services are
available within the network, and his or her PCP or another provider determines
that receiving the services separately would subject the member to unnecessary
risk; and
(c) poor quality of care, lack of access to covered benefits, or
lack of access to providers experienced in dealing with the member's health
care needs.
(3) No
later than the first calendar day of the second month following the month in
which the request is filed by the member, HSD must respond. If HSD does not respond,
the request of the member is deemed approved. If the member is dissatisfied with HSD’s determination,
he or she may request a HSD administrative hearing; see 8.352.2 NMAC for
detailed description.
[8.308.7.9 NMAC - Rp,
8.308.7.9 NMAC, 5/1/2018]
8.308.7.10 DISENROLLMENT
A. Member disenrollment initiated by a MCO: The MCO shall not, under any circumstances, disenroll a member.
The MCO shall not request disenrollment because of a change in the
member’s health status, because of the his or her
utilization of medical or behavioral health services, his or her diminished
mental capacity, or uncooperative or disruptive behavior resulting from his or
her special needs.
B. Other HSD member disenrollment: A member may be disenrolled
from a MCO or may lose his or her MAD eligibility if:
(1) he or she moves out of the state of New Mexico;
(2) he or she no longer qualifies for a MAP category of
eligibility;
(3) he or she requests disenrollment for cause, including but
not limited to the unavailability of a specific care requirement that none of
the contracted MCOs are able to deliver and disenrollment is approved by HSD;
(4) a member makes a request for disenrollment which is denied
by HSD, but the denial is overturned in the member’s HSD administrative hearing
final decision; or
(5) HSD
imposes a sanction on the MCO that warranted disenrollment.
C. Effective
date of disenrollment: All HSD-approved
disenrollment requests are effective on the first calendar day of the month
following the month of the request for disenrollment, unless otherwise
indicated by HSD. In all instances, the
effective date shall be indicated on the termination record sent by HSD to the
MCO.
[8.308.7.10 NMAC - Rp,
8.308.7.10 NMAC, 5/1/2018]
8.308.7.11 MASS TRANSFER PROCESS: The mass transfer process is initiated when
HSD determines that the transfer of MCO members from one MCO to another is in
the best interests of the program.
A. Triggering a mass transfer: The mass transfer process may be triggered by
two situations:
(1) a
maintenance change, such as changes in the
MCO identification number or the MCO changes its name or other changes
that is not relevant to the member and services will continue with that MCO;
and
(2) a significant change in a MCO’s contracting status,
including but not limited to, the loss of licensure, substandard care, fiscal
insolvency or significant loss in network providers; in such instances, a
notice is sent to the member informing him or her of the transfer and the
opportunity to select a different MCO.
B. Effective date of mass transfer: The change in enrollment initiated by the mass
transfer begins with the first day of the month following HSD’s identification
of the need to transfer MCO members.
[8.308.7.11 NMAC - Rp,
8.308.7.11 NMAC, 5/1/2018]
8.308.7.12 MEMBER IDENTIFICATION CARD
A. Each
member shall receive an identification card (ID) that provides his or her MCO
membership information within 20 calendar days of notification of enrollment
with the MCO.
B. The
MCO shall re-issue a member ID card within 10 calendar days of notice if the
member reports a lost card or if information on the card needs to be changed.
C. The
MCO shall ensure a member understands that the ID card:
(1) is intended to be used only by the member;
(2) the sharing the member’s ID card constitutes fraud; and
(3) the process of how to report sharing of a member’s ID card.
[8.308.7.12 NMAC - Rp,
8.308.7.12 NMAC, 5/1/2018]
8.308.7.13 MEDICAID MARKETING GUIDELINES: HSD shall review and approve the content,
comprehension level, and language(s) of all marketing materials directed at a
member before use by a MCO. The MCO
shall comply with all federal regulations regarding medicare-advantage
and medicaid marketing. See 42 CFR. Parts 422, 438.
[8.308.7.13 NMAC - Rp,
8.308.7.13 NMAC, 5/1/2018]
HISTORY OF
8.308.7 NMAC: [RESERVED]
History of Repealed Material:
8.308.7 NMAC - Managed Care Program,
Enrollment and Disenrollment, filed 12/17/2013 Repealed effective 5/1/2018.