1. A. The MCO shall abide by all enrollment and disenrollment policy and procedures as outlined in the contract developed by the department.

2. B. The department will contract with an enrollment broker who will be responsible for the enrollment and disenrollment process for MCO enrollees. The enrollment broker shall be:

   1. 1. the primary contact for Medicaid beneficiaries regarding the MCO enrollment and disenrollment process, and shall assist the beneficiary with MCO enrollment;
   2. 2. the only authorized entity, other than the department, to assist a Medicaid beneficiary in the selection of an MCO; and
   3. 3. responsible for notifying all MCO members of their enrollment and disenrollment rights and responsibilities within the timeframe specified in the contract.

3. C. Enrollment Period. The enrollment of an MCO member shall be based on a calendar year, contingent upon his/her continued Medicaid eligibility. A member shall remain enrolled in the MCO until:

   1. 1. the member submits a request to transfer to another MCO. The member may request to transfer to another MCO without cause up to two times per calendar year. After transferring a second time, the member will remain in that MCO until the end of the calendar year unless the member submits a for cause disenrollment request that is approved; or
   2. 2. the member becomes ineligible for Medicaid and/or the MCO program.

4. D. Special Enrollment Provisions for Mandatory, Opt-In Population Only

   1. 1. Mandatory, opt-in populations may request participation in Healthy Louisiana for physical health services at any time. The effective date of enrollment shall be no later than the first day of the second month following the calendar month the request for enrollment is received. Retroactive begin dates are not allowed.
   2. 2. The enrollment broker will ensure that all mandatory, opt-in populations are notified at the time of enrollment of their ability to disenroll for physical health at any time. The effective date will be the first day of a month, and no later than the first day of the second month following the calendar month the request for disenrollment is received.
   3. 3. Following an opt-in for physical health and selection of an MCO and subsequent 90-day choice period, these members may transfer to another MCO up to two times for the remainder of the calendar year. If the member transfers a second time, the member will be locked in that MCO until the beginning of the next calendar year unless they elect to disenroll from physical health, or the member submits a for cause disenrollment request that is approved.

5. E. Enrollment of Newborns. Newborns of Medicaid eligible mothers, who are enrolled at the time of the newborn's birth, will be automatically enrolled with the mother’s MCO.

   1. 1. If there is an administrative delay in enrolling the newborn and costs are incurred during that period, the member shall be held harmless for those costs and the MCO shall pay for those services.

   2. 2. The MCO and its providers shall be required to:

      1. a. report the birth of a newborn within 48 hours by requesting a Medicaid identification (ID) number through the department’s online system for requesting Medicaid ID numbers; and
      2. b. complete and submit any other Medicaid enrollment form required by the department.

6. F. Selection of an MCO

   1. 1. As part of the eligibility determination process, Medicaid and LaCHIP applicants, for whom the department determines eligibility, shall receive information and assistance with making informed choices about participating MCOs from the enrollment broker. These individuals will be afforded the opportunity to indicate the MCO of their choice on their Medicaid application or in a subsequent contact with the department prior to determination of Medicaid eligibility.

   2. 2. All new beneficiaries who have made a proactive selection of an MCO shall have that MCO choice transmitted to the enrollment broker immediately upon determination of Medicaid or LaCHIP eligibility. The member will be assigned to the MCO of their choosing unless the MCO is otherwise restricted by the department.

      1. a. Beneficiaries who fail to choose an MCO shall be automatically assigned to an MCO by the enrollment broker, and the MCO shall be responsible to assign the member to a primary care provider (PCP) if a PCP is not selected at the time of enrollment into the MCO.
      2. b. For mandatory populations for all covered services as well as mandatory, specialized behavioral health populations, the auto-assignment will automatically enroll members using a hierarchy that takes into account family/household member enrollment, or a round robin method that maximizes preservation of existing provider-enrollee relationships.
   3. 3. All new beneficiaries shall be immediately, automatically assigned to an MCO by the enrollment broker if they did not select an MCO during the eligibility determination process.
   4. 4. All new beneficiaries will be given 90 days to change MCOs if they so choose.

   5. 5. The following provisions will be applicable for recipients who are mandatory participants.

      1. a. If there are two or more MCOs in a department designated service area in which the recipient resides, they shall select one.
      2. b. Enrollees may request to transfer out of the MCO for cause and the effective date of enrollment into the new plan shall be no later than the first day of the second month following the calendar month that the request for disenrollment is filed.

7. H. Automatic Assignment Process

   1. 1. The following participants shall be automatically assigned to an MCO by the enrollment broker in accordance with the department’s algorithm/formula and the provisions of §3105.D:

      1. a. mandatory MCO participants;
      2. b. pregnant women with Medicaid eligibility limited to prenatal care, delivery and post-partum services; and
      3. c. other beneficiaries as determined by the department..

   2. 2. MCO automatic assignments shall take into consideration factors including, but not limited to:

      1. a. assigning members of family units to the same MCO;
      2. b. existing provider-enrollee relationships;
      3. c. previous MCO-enrollee relationship;
      4. d. MCO capacity; and
      5. e. MCO performance outcome indicators.
   3. 3. MCO assignment methodology shall be available to enrollees upon request to the enrollment broker.

8. I. Selection or Automatic Assignment of a Primary Care Provider for Mandatory Populations for All Covered Services

   1. 1. The MCO is responsible to develop a PCP automatic assignment methodology in accordance with the department’s requirements for the assignment of a PCP to an enrollee who:

      1. a. does not make a PCP selection after being offered a reasonable opportunity by the MCO to select a PCP;
      2. b. selects a PCP within the MCO that has reached their maximum physician/patient ratio; or
      3. c. selects a PCP within the MCO that has restrictions/limitations (e.g. pediatric only practice).
   2. 2. The PCP automatically assigned to the member shall be located within geographic access standards, as specified in the contract, of the member's home and/or who best meets the needs of the member. Members for whom an MCO is the secondary payor will not be assigned to a PCP by the MCO, unless the member requests that the MCO do so.
   3. 3. If the enrollee does not select an MCO and is automatically assigned to a PCP by the MCO, the MCO shall allow the enrollee to change PCP, at least once, during the first 90 days from the date of assignment to the PCP.
   4. 4. If a member requests to change his/her PCP for cause at any time during the enrollment period, the MCO must agree to grant the request.
9. J. Enrollment Period
10. 1. Members have 90 days from the initial date of enrollment into an MCO in which they may change the MCO for any reason. Beginning on the ninety-first day, the member will be able to change his/her MCO for any reason up to two times for the remainder of the calendar year. If the member transfers two times, he/she will remain in his/her MCO until the end of the calendar year, unless disenrolled under one of the conditions described in this Section, with the exception of the mandatory, opt-in populations, who may disenroll from Healthy Louisiana for physical health and return to legacy Medicaid at any time. Beginning January first of the following calendar year, the member will again be able to change MCOs up to two times per calendar year.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:1574 (June 2011), amended LR 40:310 (February 2014), LR 40:1097 (June 2014), LR 41:929 (May 2015), LR 41:2364 (November 2015), amended by the Department of Health, Bureau of Health Services Financing, LR 42:755 (May 2016), LR 52:226 (February 2026).