441—88.2 (249A) Participation.
	 88.2(1) Contracts with HMOs. The department shall enter into contracts for the scope of services specified in 441—Chapter 78, or a part thereof, with an HMO licensed under the provisions of commerce department rules 191—Chapter 40.
	  a.   	 The department must determine that the HMO meets the following additional requirements:
	 (1) 	 It shall make the services it provides to its Medicaid enrollees at least as accessible to them (in terms of timeliness, duration and scope) as those services are accessible to nonenrolled Medicaid recipients in the area served by the HMO.
	 (2) 	 It shall provide satisfaction to the department against the risk of insolvency and assure that Medicaid recipients shall not be responsible for its debts if it does become insolvent. Compliance shall exist with commerce department rules regarding deposit requirements at 191—40.12(514B) and reporting requirements at 191—40.14(514B).
	 (3) 	 For any contract executed or extended to be in effect on or after July 1, 2002, an HMO must have accreditation by the National Committee on Quality Assurance (NCQA) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
	  b.   	 The contract shall meet the following minimum requirements. The contract shall:
	 (1) 	 Be in writing.
	 (2) 	 Be renewable by mutual consent for a period of up to three years.
	 (3) 	 List the services covered.
	 (4) 	 Describe information access and disclosure.
	 (5) 	 List conditions for nonrenewal, termination, suspension, and modification.
	 (6) 	 Specify the method and rate of reimbursement.
	 (7) 	 Provide for disclosure of ownership and subcontractor relationship.
	 (8) 	 Be made with the licensee by the department.
	 (9) 	 Specify the enrollment area which shall be at least a county and effective July 1, 1998, a region of two or more contiguous counties.
	  c.   	 Any protests to the award of contracts shall be in writing and submitted to the director of the department. Prior to termination or suspension of a contract, the department shall send a notice to cure to the HMO, specifying the number of days the HMO has to correct the problems. Failure to correct the problems in the time given shall then result in termination or suspension. The HMO may appeal the decision of the department in writing to the director of the department or to the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services, if the appeal documents state violations of federal law or regulation.
	 88.2(2) Method of selection of HMO. In those counties served by a single HMO, the department shall attempt to negotiate a contract. In those counties served by two or more HMOs, the department shall initiate communication and attempt to negotiate as many contracts as are cost-effective and administratively feasible. The department reserves the right to contract with more than one HMO serving any enrollment area.
	  a.   	 Request for proposal. Rescinded IAB 11/10/93, effective 11/1/93.
	  b.   	 Minimum contract requirements. Rescinded IAB 11/10/93, effective 11/1/93.
	 88.2(3) Termination of contract. The department and an HMO may by mutual consent terminate a contract by either party giving 60 days’ written notice to the other party. The department may terminate or suspend a contract if the contract is determined by the department to be inconsistent with the overall goals and objectives of the Medicaid program. The determination shall be based on factors including, but not limited to, the following:
	  a.   	 The HMO’s delivery system does not ensure Medicaid recipients adequate access to medical services.
	  b.   	 The HMO’s delivery system does not ensure the availability of all services covered under the contract.
	  c.   	 There are not proper assurances of financial solvency on the part of the HMO.
	  d.   	 There is not substantial compliance with all provisions of the contract.
	  e.   	 The HMO has discriminated against persons eligible to be covered under the contract on the basis of age, race, sex, religion, national origin, creed, color, physical or mental disability, political belief, health status, or the need for health services.
	 88.2(4) Recipients eligible to enroll. Any Medicaid-eligible recipient is eligible to enroll in a contracting HMO except for the following:
	  a.   	 Recipients who are medically needy as defined at 441—subrule 75.1(35).
	  b.   	 Recipients over the age of 65 and under the age of 21 in psychiatric institutions as defined at 441—Chapter 85.
	  c.   	 Recipients who are supplemental security income-related case members.
	  d.   	 Rescinded IAB 10/3/01, effective 12/1/01.
	  e.   	 Recipients whose eligibility is in the process of automatic redetermination as defined at rule 441—76.11(249A).
	  f.   	 Recipients who are foster care and subsidized adoption-related case members.
	  g.   	 Recipients who are Medicare beneficiaries.
	  h.   	 Recipients who are pregnant women and who are deemed to be presumptively eligible as defined at 441—subrule 75.1(30).
	  i.   	 Recipients who are Native American Indians or Alaskan natives.
	  j.   	 Recipients who are receiving services from a Title V provider.