441—73.4(249A) Disenrollment process.
	73.4(1) Enrollee-requested disenrollment. An enrollee may request disenrollment with a managed care organization as follows:
	a. 	During the first 90 days following the date of the enrollee’s initial enrollment with the managed care organization, the enrollee may request disenrollment, for any reason, in writing or by a telephone call to the enrollment broker’s toll-free member telephone line.
	b. 	After the 90 days following the date of the enrollee’s enrollment with the managed care organization, when an enrollee is requesting disenrollment due to good cause, the enrollee member shall first make a verbal or written filing of the issue through the managed care organization’s grievance system. If the member does not experience resolution, the managed care organization shall direct the member to the enrollment broker. The enrolled member may request disenrollment in writing or by a telephone call to the enrollment broker’s toll-free member telephone line and must request a good-cause change for enrollment. Good-cause changes include the following:
	(1)	The managed care organization does not, because of moral or religious objections, cover the service the member seeks.
	(2)	The member needs related services to be performed at the same time; not all related services are available within the network; and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.
	(3)	Other reasons, including but not limited to poor quality of care, lack of access to services covered under the contract, lack of access to providers experienced in dealing with the member’s health care needs, or eligibility and choice to participate in a program not available in managed care (for example, PACE).
	c. 	The final decision for disenrollment shall be determined by the department.
	73.4(2) Disenrollment by department. Disenrollment will occur when:
	a. 	The contract between the department and the managed care organization is terminated.
	b. 	The enrollee becomes ineligible for Medicaid, the hawki program or the Iowa Health and Wellness Plan. If the enrollee becomes ineligible and is later reinstated to these programs, enrollment in the managed care organization will also be reinstated.
	c. 	The enrollee transfers to an eligibility group excluded from managed care organization enrollment. See definition of “enrollee” in rule 441—73.1(249A).
	d. 	The department has determined that participation in the HIPP program as described in rule 441—75.21(249A) is more cost-effective than enrollment in managed health care.
	e. 	Death of the enrollee.
	f. 	The enrollee has changed residence to another state.
	73.4(3) Managed care organization-requested disenrollment. A managed care organization shall not disenroll an enrollee or encourage an enrollee to disenroll for any reason, including the enrollee’s health care needs or change in health care status or because of the enrollee’s utilization of medical services, diminished capacity, or uncooperative or disruptive behavior resulting from the enrollee’s special needs (except when the enrollee’s continued enrollment seriously impairs the managed care organization’s ability to furnish services to either this particular enrollee or other enrollees). In instances where the exception applies, the managed care organization shall provide evidence to the department that continued enrollment of an enrollee seriously impairs the managed care organization’s ability to furnish services to either this particular enrollee or other enrollees. The managed care organization shall have methods by which the department is assured that disenrollment is not requested for another reason.
	73.4(4) Disenrollment effective date. The effective date of a department-approved disenrollment shall be no later than the first day of the second calendar month beginning after the month in which: (1) the enrollee requests disenrollment pursuant to subrule 73.4(1); (2) the department notifies the enrollee and managed care organization of disenrollment pursuant to subrule 73.4(2); or (3) the managed care organization requests disenrollment pursuant to subrule 73.4(3). The enrollee shall remain enrolled in the managed care organization and the managed care organization will be responsible for services covered under the contract until the effective date of disenrollment unless the enrollee is in an inpatient setting at the time of disenrollment. If the enrollee is in an inpatient setting at the time of disenrollment, the managed care organization shall be responsible for the inpatient services for 60 days or until the enrollee is discharged.
[ARC 2358C, IAB 1/6/16, effective 1/1/16]