|(a) Enrollment by HHSC. HHSC will conduct enrollment
and disenrollment activities. Except as provided in subsection (d)(2)
and (5) of this section, regarding dental home assignments, HHSC may
not contract with a participating MCO to serve as the administrator
for enrollment or disenrollment activities in any area of the state.
(b) Procedures for enrollment. HHSC will establish
procedures for enrollment into participating MCOs, primary care providers
(PCPs), and dental homes, including enrollment periods and time limits
within which enrollment must occur. Beneficiaries will have at least
15 calendar days from the date notification is mailed to choose an
MCO, PCP, and dental home.
(c) Default assignment. Beneficiaries who fail to select
an MCO, PCP, or dental home within the timeframe specified in subsection
(b) of this section will have an MCO, PCP, or dental home selected
for them by HHSC using the default assignment methodology described
in subsection (d) of this section.
(d) Default assignment methodology. HHSC's default
assignment methodology will include the following criteria, to the
maximum extent possible:
(1) Automated PCP assignment. If a beneficiary has
not selected a PCP, HHSC or its administrative services contractor
will assign one using an automated algorithm that considers:
(A) the beneficiary's established history with a PCP,
as demonstrated by Medicaid claims or encounter history with the provider
in the preceding year, if available;
(B) the geographic proximity of the beneficiary's home
address to the PCP;
(C) whether the provider serves as a PCP to other members
of the beneficiary's household;
(D) limitations on default assignment, such as PCP
restrictions on age, gender, and capacity; and
(E) other criteria determined by HHSC.
(2) Automated dental home assignment. If a beneficiary
has not selected a dental home, the dental MCO will assign one using
an automated algorithm that considers:
(A) the beneficiary's established history with a dental
home, as demonstrated by Medicaid claims or encounter history with
the provider in the preceding year, if available;
(B) the geographic proximity of the beneficiary's home
address to the dental home;
(C) whether the provider serves as the dental home
to other members of the beneficiary's household;
(D) limitations on default assignment, such as dental
home restrictions on age and capacity; and
(E) other criteria approved by HHSC.
(3) Automated MCO assignment. If a beneficiary has
not selected a health care MCO or dental MCO, HHSC or its administrative
services contractor will assign one using an automated algorithm that
considers the beneficiary's history with a PCP or dental home when
possible. If this is not possible, HHSC or its administrative services
contractor will equitably distribute beneficiaries among qualified
MCOs, using an automated algorithm that considers one or more of the
(A) whether other members of the beneficiary's household
are enrolled in the MCO;
(B) MCO performance;
(C) the greatest variance between the percentage of
elective and default enrollments (with the percentage of default enrollments
subtracted from the percentage of elective enrollments);
(D) capitation rates;
(E) market share; and
(F) other criteria determined by HHSC.
(4) Automatic re-enrollment. Notwithstanding subsection
(d) of this section, HHSC will automatically re-enroll a beneficiary
in the same MCO if there is a loss of Medicaid eligibility of six
months or less.
(5) Use of manual default processes. A beneficiary
who cannot be assigned to a PCP, dental home, health care MCO, or
dental MCO on the basis of an automated default process may be assigned
through a manual default process determined by HHSC. Beneficiaries
with special medical needs may be defaulted on the basis of a manual
default methodology if such beneficiaries can be identified and if
the automated default process cannot be administered for such beneficiaries.
(e) Modified default enrollment process. HHSC has the
option to implement a modified default enrollment process for MCOs
when contracting with a new MCO or implementing managed care in a
new service area, or when it has placed an MCO on full or partial
(f) Request to change dental home or PCP. There is
no limit on the number of times a member can request to change his
or her dental home or PCP. A member can request a change in writing
or by calling the MCO's toll-free member hotline.
(g) Disenrollment from Medicaid managed care.
(1) Disenrollment at a member's request.
(A) Members will be informed of disenrollment opportunities
no less than annually.
(B) Members who are enrolled in a managed care program
on a voluntary basis may request disenrollment from the managed care
model and transfer to fee-for-service Medicaid at any time for any
(C) Members who are enrolled in a managed care program
on a mandatory basis may request, in writing to HHSC, disenrollment
from the managed care model and transfer to fee-for-service Medicaid.
HHSC considers disenrollment from the managed care model only if medical
documentation establishes that the MCO cannot provide the needed services.
An authorized HHSC representative reviews all disenrollment requests
and processes approved requests for disenrollment from an MCO.
(D) Disenrollment will take place no later than the
first day of the second month after the month in which the member
has requested a change.
(2) Disenrollment at an MCO's request.
(A) An MCO may submit a request to HHSC that a member
be disenrolled without the member's consent in the following limited
(i) the member misuses or loans his or her MCO membership
card to another person to obtain services;
(ii) the member's behavior is disruptive or uncooperative
to the extent that the member's continued enrollment in the MCO seriously
impairs the MCO's or a provider's ability to provide services to either
the member or other members, and the member's behavior is not related
to a developmental, intellectual, or physical disability, or behavioral
health condition; or
(iii) the member steadfastly refuses to comply with
managed care restrictions (such as repeatedly using the emergency
room in combination with a refusal to allow treatment for the underlying
(B) An MCO must take reasonable measures to correct
a member's behavior prior to requesting disenrollment. Reasonable
measures may include providing education and counseling regarding
the offensive acts or behaviors.
(C) An MCO cannot request a disenrollment based on
adverse change in the member's health status or utilization of medically
(D) HHSC will review all requests for disenrollment.
HHSC will grant a request if it determines that all reasonable measures
taken by the MCO have failed to correct the member's behavior.
(E) If HHSC grants a request, it will notify the member
of the disenrollment decision and the availability of HHSC's fair
hearings process for an appeal of the disenrollment.
(h) MCO Transfer. A beneficiary may request transfer
to another MCO in the service area through the enrollment broker at
any time for any reason.
|Source Note: The provisions of this §353.403 adopted to be effective December 18, 1996, 21 TexReg 11822; amended to be effective October 6, 1997, 22 TexReg 9673; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective July 8, 2012, 37 TexReg 4851; amended to be effective September 1, 2014, 39 TexReg 5873