Common use of Member Enrollment and Contractor Selection Clause in Contracts

Member Enrollment and Contractor Selection. Healthy Indiana Plan applicants have an opportunity to select an MCE on their application. MCEs are expected to conduct marketing and outreach efforts to raise awareness of both the program and their product. The Enrollment Broker is available to assist members in choosing an MCE. Applicants who do not select an MCE on their application will be auto- assigned to an MCE according to the State’s auto-assignment methodology. The State reserves the right to amend the auto-assignment logic and may incorporate HEDIS or other quality indicators into the auto-assignment logic at a future date. Default auto-assignment will not be available to any MCE who does not successfully complete readiness review. Members that lose Medicaid eligibility for the HIP program for a period of three (3) months or less shall be automatically reenrolled with the Contractor, 42 CFR 438.56(g). Members will have the opportunity to change their MCE at the following intervals: 1. Within ninety (90) days of starting coverage, 2. Once per calendar year for any reason 3. At any time using the just cause process (defined below) 4. During the Medicare open enrollment window (mid-October-mid December) to be effective the following calendar year. Any Medicaid member may change their MCE for Just Cause. The “for cause” reasons are described in 42 CFR 438.56(d)(2). Determination as to whether a member has met one of these reasons is solely the determination of the Enrollment Broker and FSSA. The reasons include, but not limited to, the following: ▪ Receiving poor quality of care; ▪ Failure to provide covered services; ▪ Failure of the Contractor to comply with established standards of medical care administration; ▪ Lack of access to providers experienced in dealing with the member’s health care needs;