Section 22-B5509. ENROLLMENT AND DISENROLLMENT PROCEDURES

 

5509.1 Enrollment by Medicaid recipients shall be voluntary and without regard to any of the following:

 

(a)Health status or need or services;

 

(b)Physical or mental condition or handicap;

 

(c)Age;

 

(d)Sex;

 

(e)National origin;

 

(f)Race;

 

(g)Creed;

 

(h)Marital status; or

 

(i)Sexual orientation.

 

5509.2 A QO shall request Department approval for enrollment of each eligible applicant identified, which approval shall be granted.

 

5509.3 Each QO shall include in its enrollment activities an orientation program to inform recipients of available programs and facilities if eligibility conditions are met.

 

5509.4 If the Department approves the enrollment by the fifteenth (15th) of a month, the recipients enrollment shall be effective on the first day of the following month.

 

5509.5 If the Department approves the enrollment after the fifteenth (15th) of the month, the recipients enrollment shall be effective on the first day of the second month after the month in which the Department approves the enrollment.

 

5509.6 Except as provided in §§ 5509.9 and 5509.10, a Medicaid enrollee may voluntarily disenroll from any QO without cause.

 

5509.7 To disenroll, a Medicaid enrollee shall complete a disenrollment form and submit it to the QO, prior to the Department’s monthly deadline for receipt of disenrollment requests.

 

5509.8 The disenrollment shall be effective not later than the first day of the second month after the month in which the recipient requests termination.

 

5509.9 If the QO’s contract with the Department permits, during months two (2) through six (6) of membership, a Medicaid enrollee may only disenroll with good cause after exhausting the grievance process.

 

5509.10 Contracts permitting the QO to restrict Medicaid disenrollment can be signed only with QOs that meet the requirements of §§1903(m)(2)(F) or (G) of the Social Security Act.

 

5509.11 A QO shall be able to disenroll members who are disruptive or abusive or whose use of services is fraudulent or deceptive.

 

5509.12 A QO shall submit a written request to the Department, for written approval of each proposed involuntary disenrollment.

 

5509.13 An involuntary disenrollment shall be effective not later than the first day of the second month following the approval of the action by the Department.

 

5509.14 No enrollee shall be disenrolled solely because of an adverse change in health status.

 

5509.15 Each enrollee covered under this program whose enrollment is subsequently terminated due to loss of Medicaid eligibility shall have the opportunity to convert to a non-group enrollment contract consistent with conversion privileges offered to members of other groups enrolled in the QO.

 

 

source

Final Rulemaking published at 34 DCR 1550, 1561 (March 6, 1987).