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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
7.1.6.1Change of Circumstances
Most MA clients who are eligible for Family MA and reside in a MA HMO service area must enroll in a HMO.
Clients may choose their own HMO or work with the HMO Enrollment Specialist to choose the best one for their needs. They may choose at any time during the enrollment process. All eligible members of the client’s family must choose the same HMO. However, individuals within a family may be eligible for exemption from enrollment.
This is the enrollment process:
Clients residing in a HMO service area receive a HMO enrollment packet. The packet has an enrollment form, a list of available HMOs, instructions on how to choose a HMO and how to find out if a provider is affiliated with a HMO.
If the client does not choose a HMO within two weeks of receiving the enrollment packet, s/he receives a reminder card. Clients in areas with only one available HMO will stop here in the process. They do not have to enroll in a HMO.
If the client has not chosen a HMO after four weeks, and lives in an area covered by two or more HMO’s, s/he will be assigned a HMO. A letter explaining the assignment will be sent to him/her. S/he will receive another enrollment form and have an opportunity to change the assigned HMO.
S/he will then receive a notice confirming enrollment in the assigned or chosen HMO for the following month. The client has up to three months to change HMOs, once enrolled. This is the open enrollment period. After the initial three months, the client is locked into the HMO and cannot change for nine months. If your client has questions about HMO enrollment, s/he should contact the Enrollment Specialist at 1-800-291-2002.
Exemptions: A client may qualify for an exemption from HMO enrollment if they meet certain criteria, such as a chronic illness, high-risk third trimester pregnancy, or continuity of care concerns, etc.
If the client believes s/he has a valid reason for exemption, s/he should call the HMO Enrollment Specialist at 1-800-291-2002. The number is also in the enrollment materials they receive.
Clients who lose MA eligibility, but become eligible again may be automatically re-enrolled in their previous HMO.
If the client’s eligibility is re-established after the six-month period, s/he will be automatically re-enrolled in the previous HMO, unless the HMO is no longer accepting reassignments.
After six months, or if the HMO is no longer accepting reassignments or has exceeded its enrollment level, s/he will receive an enrollment packet, and the enrollment process will start over.
Clients are automatically disenrolled from the HMO program if:
Their medical status code changes to a non-Family MA subprogram.
They become eligible for Medicare.
They lose eligibility.
They move out of the HMO’s service area.
Clients who move out of the HMO service area receive a new packet showing the HMO(s) available in the new area and the enrollment process begins again. If no HMO covers the client’s new area, s/he remains fee-for-service.
Clients with questions about their rights as HMO enrollees may call 1-800-760-0001 or write:
HMO Ombuds
P.O. Box 6470
Madison, WI 53791-9823
This page last updated in Release Number : 03-02
Release Date: 04/01/03
Effective Date: 04/01/03
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