441—88.46 (249A) Enrollment and changes in enrollment.
	 88.46(1) Mandatory enrollment. Participation in managed health care, if available, is required for covered eligibles as specified in subrule 88.42(1) who reside in a mandatory project county. The department shall require, whenever administratively feasible, that all eligible recipients enroll with a managed care entity. Administrative feasibility is determined by whether a freedom-of-choice waiver or state plan amendment has been approved by the Centers for Medicare and Medicaid Services and whether the managed care entities demonstrate sufficient access to and quality of services.
	 88.46(2) Enrollment procedures. In mandatory enrollment counties, recipients shall be required to choose their managed health care provider. When no choice is made by the recipient, the recipient will be assigned to a contracting health maintenance organization (HMO) serving the recipient’s county of residence when an HMO is available or to a MediPASS patient manager on a rotating basis to ensure an equitable distribution between the HMO and MediPASS programs based on the number of managed health care options (MediPASS and HMOs) available in the county. In the event there is no contracting HMO serving the recipient’s county of residence in a mandatory enrollment county, the recipient shall be assigned to a MediPASS patient manager.
Within the MediPASS option, recipients shall be assigned according to age appropriateness. Whenever possible, family units shall be assigned to the same provider that an enrolled family member has selected, if that provider is appropriate according to age parameters. MediPass patient managers shall not be assigned more recipients than their self-imposed maximum or the maximum described in subrule 88.46(5), whichever is lower.
Recipients who are assigned a managed care entity as described in this subrule shall have at least ten days in which to request enrollment in a different available entity. The change is subject to provisions in subrule 88.46(4) dealing with the effective date.
	  a.   	 Timely notice. Recipients shall be sent timely notice of the managed health care assignment. The recipient shall have a minimum of ten days in which a change to the assigned managed care entity can be made. The notice shall include the name of the managed care entity to whom the recipient shall be assigned if the recipient does not make a different selection by the date specified in the notice. If the covered eligible does not make a selection before the due date, the recipient shall be enrolled with the managed care entity listed on the notice.
	  b.   	 Enrollment. Enrollment in managed health care shall be discussed during the face-to-face interview with all applicants for Medicaid under covered categories of assistance in mandatory or voluntary enrollment areas. The applicant shall be shown an informational videotape and encouraged to make a selection of a managed care entity. Applicants in mandatory enrollment areas shall be informed that should the applicant become eligible for a managed health care selection, one shall be assigned. Covered eligibles who are not enrolled shall be sent a notice of their managed health care assignment when the recipient:
	 (1) 	 Attains initial eligibility for a covered category of service in a mandatory project county.
	 (2) 	 Changes from an excluded category of assistance to a covered category of assistance in a mandatory project county.
	 (3) 	 Is receiving a covered category of assistance and moves from a county where no managed health care is available or voluntary project county to a mandatory project county.
	 (4) 	 Reattains eligibility.
	 (5) 	 Has a new member of the household receiving a covered category of assistance.
If the covered eligible in a mandatory project county does not make another selection before the due date specified in the notice, the covered eligible shall be enrolled with the managed health care provider listed on the notice.
	  c.   	 Selection of a managed health care provider. A list of managed health care providers participating in managed care entities serving the county shall be available to recipients for use in selecting a provider. If the recipient wishes to request an exception to the list of available managed health care providers as described in subrule 88.44(3), the managed health care review committee shall make a determination on the exception request. While the determination is being made, the recipient’s enrollment shall be placed in a pending status.
	  d.   	 Rescinded IAB 5/7/97, effective 7/1/97.
	  e.   	 Request to change enrollment. An enrolled recipient may, within 90 days from timely notice, request to change enrollment from one managed health care provider to another or one managed care entity to another. The request shall be made on a choice form designated by the department, in writing, or by telephone call to the toll-free recipient managed health care telephone line maintained by the department. Changes are subject to the provisions of subrule 88.46(3) dealing with effective date.
	  f.   	 Managed care entity extended-participation program (EPP). After the initial 90 days from timely notice, recipients will remain enrolled with the chosen provider for the following six months, with three exceptions:
	 (1) 	 A request for disenrollment by recipient for good cause pursuant to paragraph 88.4(3)“a.”
	 (2) 	 A request for disenrollment by provider for good cause pursuant to paragraph 88.4(3)“b.”
	 (3) 	 Availability of a new, previously unavailable, managed care entity. In this instance recipients will be allowed to select that entity for the remainder of the current EPP period.
	  g.   	 Enrollment cycle. Prior to the end of any extended-participation program (EPP) period, recipients will be notified of their ability to enroll with a different managed care option. A change in enrollment or failure to change enrollment will begin a new EPP enrollment period at the end of the current EPP.
	 88.46(3) Voluntary enrollment procedures. Voluntary enrollment procedures shall be the same guidelines as mandatory enrollment procedures except:
	  a.   	 Recipients shall not be informed at the face-to-face interview that enrollment is required.
	  b.   	 Notice to recipient shall not include assignment language.
	  c.   	 Recipients shall not be assigned if no selection is made voluntarily.
	  d.   	 A managed health care provider must be available for enrollment.
	 88.46(4) Effective date. Enrollment or changes in enrollment shall always be effective on the first day of a month. The effective date of enrollment shall be no later than the first day of the second month subsequent to the date the department or its designee receives a choice as specified in subrules 88.46(1) and 88.46(2) or the deadline given a recipient to indicate the recipient’s managed health care choice, whichever is applicable. The effective date shall be earlier where computer cutoff allows.
	 88.46(5) Identification card. The department shall issue Form 470-1911, Medical Assistance Eligibility Card, to all enrolled recipients.
Providers of medical services shall access the department’s eligibility verification system (ELVS) via telephone or access the department’s secure Web site at the time of service in order to establish that the patient is Medicaid-eligible and whether the services being provided require the authorization of the patient manager.
	 88.46(6) Enrollment limits.
	  a.   	 Unless one or more of the following special situations exist, enrollment shall be limited to 1500 enrollees per full-time patient manager with an additional 300 enrollees allowed for each full-time nurse practitioner or physician’s assistant employed by the MediPASS provider or clinic:
	 (1) 	 The provider treats a disproportionate share of Medicaid patients in the provider’s current practice.
	 (2) 	 A special group practice arrangement exists with a demonstrated ability to manage a large number of enrollees.
	 (3) 	 Other exceptional situations may be considered as special demonstration projects on a case-by-case basis.
	  b.   	 Patient managers wishing to receive consideration for one of these special situations must make a request for consideration in writing to the department and provide sufficient documentation that they fit one or more of the special situations.
	  c.   	 Providers or clinics may set a lower self-imposed maximum number of enrollees at the time they sign the initial contract and may revise that number by notifying the department or its designee in writing.
	 (1) 	 If the patient manager decreases the patient manager’s own maximum to a number below which the patient manager currently has enrolled, the patient manager must continue to serve those recipients until normal disenrollments put the provider below the provider’s new maximum.
	 (2) 	 No minimum number of enrollees shall be required.
	 88.46(7) Reinstatement of patient management status. When an enrolled recipient loses Medicaid eligibility and is subsequently reinstated before the effective date of cancellation, the enrollment in patient management will also be reinstated.