Common use of Member Enrollment and Contractor Selection Clause in Contracts

Member Enrollment and Contractor Selection. Hoosier Care Connect applicants shall have the opportunity to select an MCE at the time of Medicaid application. The State’s Enrollment Broker will provide information and assistance with MCE selection to applicants. Members that lose Medicaid eligibility in the Hoosier Care Connect program for a period of two (2) months or less shall be automatically reenrolled with the Contractor in accordance with 42 CFR 438.56(g). Members who do not select an MCE at the time of application, and Supplemental Security Income (SSI) recipients who are not required to submit a Medicaid application, shall receive information from the State or its designee describing the process to select an MCE. Individuals who do not select a Contractor within sixty (60) calendar days of the enrollment mailing will be auto-assigned to a Contractor in accordance with an auto-enrollment algorithm to be designed by the State. The State reserves the right to revise the timing and strategies employed to facilitate member selection. Additional information on the auto- assignment process can be found in Contract Exhibit 4 Responsibilities of the State. Members will have the opportunity to change their MCE at the following intervals: ▪ Within ninety (90) days of starting coverage ▪ Once per calendar year for any reason ▪ At any time using the just cause process (defined below) ▪ 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; ▪ Significant language or cultural barriers; ▪ Corrective action levied against the Contractor by the office; ▪ Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; ▪ A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; ▪ Lack of access to medically necessary services covered under the Contractor’s contract with the State; ▪ A service is not covered by the Contractor for moral or religious objections, as described in Section 7.3.2; ▪ Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; ▪ The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE. The enrollee would have to change their residential, institutional, or employment supports provider based on that provider's change in status from an in-network to an out-of-network provider and, as a result, would experience a disruption in their residence or employment; or ▪ Other circumstances determined by the office or its designee to constitute poor quality of health care coverage.

Member Enrollment and Contractor Selection. Hoosier Care Connect applicants shall have the opportunity to select an MCE at the time of Medicaid application. The State’s Enrollment Broker will provide information and assistance with MCE selection to applicants. Members that lose Medicaid eligibility in the Hoosier Care Connect program for a period of two (2) months or less shall be automatically reenrolled with the Contractor in accordance with 42 CFR 438.56(g). Members who do not select an MCE at the time of application, and Supplemental Security Income (SSI) recipients who are not required to submit a Medicaid application, shall receive information from the State or its designee describing the process to select an MCE. Individuals who do not select a Contractor within sixty (60) calendar days of the enrollment mailing will be auto-assigned to a Contractor in accordance with an auto-auto- enrollment algorithm to be designed by the State. The State reserves the right to revise the timing and strategies employed to facilitate member selection. Additional information on the auto- auto-assignment process can be found in Contract Exhibit 4 4.B Responsibilities of the State. Members will have the opportunity to change their MCE at the following intervals: ▪ • Within ninety (90) days of starting coverage ▪ Once per calendar year for any reason ▪ • At least once every 12 months thereafter • At any time using the just cause process (defined below) ▪ • 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; ▪ Significant language or cultural barriers; ▪ Corrective action levied against the Contractor by the office; ▪ Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; ▪ A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; ▪ Lack of access to medically necessary services covered under the Contractor’s contract with the State; ▪ A service is not covered by the Contractor for moral or religious objections, as described in Section 7.3.2; ▪ Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; ▪ The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; EXHIBIT 1. The enrollee would have to change their residential, institutional, or employment supports provider based on that provider's change in status from an in-network to an out-of-network provider and, as a result, would experience a disruption in their residence or employment; or ▪ Other circumstances determined by the office or its designee to constitute poor quality of health care coverage.E SCOPE OF WORK