441—73.3(249A) Enrollment.
	73.3(1) Enrollment area. The coverage area for enrollment shall be statewide.
	73.3(2) Members subject to enrollment. All hawki program and Iowa Health and Wellness Plan members shall be subject to mandatory enrollment in a managed care organization. All Medicaid members, with the exception of the following, shall be subject to mandatory enrollment in a managed care organization:
	a. 	Members who are medically needy as defined at 441—subrule 75.1(35).
	b. 	Individuals eligible only for emergency medical services because the individuals do not meet citizenship or alienage requirements, pursuant to 441—subrule 75.11(4).
	c. 	Persons who are currently presumptively eligible as defined in 441—subrules 75.1(30), 75.1(40), and 75.1(44).
	d. 	Persons eligible for the program of all-inclusive care for the elderly (PACE) who voluntarily elect PACE coverage as defined in 441—subrule 88.24(1).
	e. 	Persons enrolled in the health insurance premium payment program (HIPP) pursuant to rule 441—75.21(249A).
	f. 	Persons eligible only for the Medicare savings program as defined in rules 441—75.1(249A) and 441—76.1(249A).
	g. 	American Indian and Alaska Native populations who are exempt from mandatory enrollment pursuant to 42 CFR 438.50(d)(2) but who may enroll voluntarily.
	73.3(3) Enrollment process. The department shall notify members who must be enrolled in a managed care organization of enrollment and the effective date of enrollment. The department will implement an enrollment process in accordance with federal funding requirements, including 42 CFR 438 as amended to May 6, 2016.
	a. 	General. Members may receive managed care organization choice counseling from the enrollment broker. The enrollment broker will provide information about individual managed care organization benefit structures, services and network providers, as well as information about other Medicaid programs as requested by the Medicaid member to assist the member in making an informed selection.
	b. 	 Passive assignment.  Effective no earlier than the first day of the month of the member’s application to Medicaid, the member shall be assigned to a managed care organization using the department’s passive enrollment process and offered the opportunity to choose from the available managed care organizations within a time frame specified in the passive assignment letter.
	c. 	Request to change enrollment. An enrollee may, within 90 days of initial enrollment, request to change enrollment from one managed care organization and enroll in another managed care organization. The request may be made on a form designated by the department, in writing, or by telephone call to the enrollment broker’s toll-free member telephone line. Enrollment changes are effective no later than the first day of the second month beginning after the date on which the enrollment broker receives the enrollee’s written or verbal request.
	d. 	Ongoing enrollment. Enrollees shall remain enrolled with the chosen managed care organization for a total of 12 months.
	e. 	Enrollment cycle. Prior to the end of the enrollee’s annual enrollment period, the enrollee shall be notified of the option to maintain enrollment with the current managed care organization or to enroll with a different managed care organization.
	73.3(4) Benefit reimbursement prior to enrollment.
	a. 	Prior to the effective date of managed care enrollment, except as provided in paragraph 73.3(4)“b,” the Medicaid program shall reimburse providers for covered program benefits pursuant to 441—Chapters 74 to 91, as applicable for eligible members.
	b. 	The managed care organization shall be responsible for covering newly retroactive Medicaid eligibility periods prior to the effective date of enrollment for babies born to Medicaid-enrolled women who are retroactively eligible to the month of birth.
[ARC 2358C, IAB 1/6/16, effective 1/1/16; ARC 4429C, IAB 5/8/19, effective 7/1/19]