Section 104.05. Preferred enrollment.

 

(1)   Contracts for services from group plans. The department may enter into contracts for MA services with health maintenance organizations (HMOs) or prepaid health plans (PHPs). Each contract shall include specific information about services to be provided by the group, the number and types of practitioners who will provide the services, the geographic service area covered by the group plan, the period of time in which recipients are enrolled, the procedures for recipient enrollment, additional services which may be available, and the cost of services for each enrollee.

(2)   Enrollment responsibility. MA recipients within the geographic area stipulated in a group plan service contract shall have the choice of enrolling for service membership under the following conditions:

(a) Minimum enrollment period. The department may enter into arrangements with HMOs or PHPs which establish minimum enrollment periods for MA recipients.

(b) Disenrollment period. In geographic areas where there is only one certified group plan provider, each recipient may be automatically enrolled in the group plan. A recipient may disenroll from the group plan, and the effective date of the disenrollment shall be no later than one month from the month in which the recipient disenrolls.

(3)   Control of services. Enrollees in an HMO or PHP shall obtain services paid for by MA from that organization's providers, except for referrals or emergencies. Recipients who obtain services in violation of this section shall pay for these services.

(4)   Identification of covered services. Services available to MA recipients shall be identified in the provider's contract with the department and shall be made known to all MA enrollees.

History: Cr. Register, February, 1986, No. 362 , eff. 3-1-86.