37.86.5005    HEALTH MAINTENANCE ORGANIZATIONS: ENROLLMENT

(1) Recipient enrollment with an HMO contracting with the department is voluntary, except as noted below.

(a) Individuals 21 years of age or older receiving medicaid or medically needy assistance as participants of the FAIM project, and who are not pregnant, are required to enroll in an HMO if one is available in the enrollment area and has not reached its maximum enrollment. If the HMOs in the enrollment area are at maximum enrollment, the individual must participate in the passport to health program as required in ARM 37.86.5101, et seq.

(2) An eligible recipient may request enrollment with a particular HMO.

(3) An eligible recipient may only enroll with an HMO contracting with the department to provide HMO services in the locality of the recipient's residence.

(4) An eligible recipient who is hospitalized, other than a newborn recipient, may enroll initially with an HMO contracting with the department only after the recipient's discharge from the hospital.

(5) Enrollment is requested either by completing a form designated by the administrative contractor for managed care or by a written or verbal request to the administrative contractor for managed care.

(a) The form must be available through the county office, the HMO office, the administrative contractor for managed care, or other locations designated by the department.

(b) An HMO or any entity responsible for making the form available, receiving a form or a request, must forward the form or request in writing to the administrative contractor for managed care within 3 working days.

(6) An HMO must accept without restriction eligible recipients in the order in which they are received for enrollment by the administrative contractor for managed care until the HMO's maximum enrollment under the contract is reached.

(7) The effective date of enrollment for an eligible recipient must be no later than the first day of the second month subsequent to the date on which the administrative contractor for managed care receives the designated managed health care choice form or written or verbal request. The effective date must be earlier than the second subsequent month if enrollment can be processed before the last 4 working days of the month.

(8) An HMO may issue an appropriate identification card to an enrollee. A medicaid card is issued to enrollees by the department.

(9) Enrollment with an HMO is indicated by the appearance of the HMO's name and 24-hour telephone number on the medicaid card.

(10) An enrollee must obtain covered services as defined in ARM 37.86.5007 through the HMO.

(11) An enrollee may obtain noncovered services as defined in ARM 37.86.5007 in the usual manner.

History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-113, 53-6-116 and 53-6-117, MCA; NEW, 1995 MAR p. 1974, Eff. 9/29/95; AMD, 1996 MAR p. 284, Eff. 1/26/96; AMD, 1997 MAR p. 503, Eff. 3/11/97; AMD, 1997 MAR p. 1210, Eff. 7/8/97; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 866, Eff. 3/31/00.