1 Tex. Admin. Code § 353.403 – Enrollment

(a) For the purposes of this section, a managed care organization (MCO) includes a primary care case management (PCCM) provider network.
(b) The department shall determine which Medicaid eligible clients residing in a STAR Program service area will be mandatory or voluntary members and which Medicaid eligible clients may be excluded from participation in managed care.
(c) The department shall conduct enrollment and disenrollment activities or contract with another agency or contractor to assume administration of these functions. The department may not contract with a participating managed care organization to serve as the administrator for enrollment or disenrollment activities in any area of the state.
(d) The department shall establish procedures for enrollment into participating MCOs and primary care providers (PCP), including enrollment periods and time limits within which enrollment must occur. Members who are mandatory members must select an MCO or PCP within the time period allowed by the department or be defaulted to an MCO or PCP.
(e) Mandatory members who fail to select an MCO or PCP during the period established by the department will have an MCO or PCP selected for them by the department or its contractor using criteria determined by the department. The department shall establish a detailed default methodology that incorporates the following requirements.
1. (1) A member who does not select a PCP and MCO will be assigned a PCP and MCO through the default process established by the department. A member who selects an MCO but not a PCP, will be assigned to the selected MCO and the member will be assigned to a PCP through the default process. A member who selects a PCP but not an MCO will be assigned to the PCP chosen by the member, subject to PCP restrictions on client age, gender, and capacity, and the member will be assigned to an MCO through a manual default process that is established by the department based on the provisions of paragraph (6) of this subsection.
2. (2) Each member, who has not selected a PCP, will be defaulted to the PCP with whom there is the most recent Medicaid managed care encounter history. The number of encounters between the member and the PCP may also be considered.
3. (3) If there is no Medicaid managed care encounter history, each member will be defaulted to the PCP with whom there is the most recent traditional Medicaid claims history. The number of prior encounters between the member and the PCP may also be considered.
4. (4) If a member does not have history with a PCP, the member will be defaulted to a PCP on the basis of geographical proximity to the PCP.
5. (5) The department may identify other criteria to be used along with the criteria based on geographical proximity such as, but not limited to, capacity of the PCP, PCP performance, and greatest variance between the percentage of elective and default enrollments (with the percentage of default enrollments subtracted from the percentage of elective enrollments).
6. (6) The department shall develop a methodology for assignment of defaults to each MCO in the service area. Such methodology may be based on MCO performance, the greatest variance between the percentage of elective and default enrollments (with the percentage of default enrollments subtracted from the percentage of elective enrollments), or other factors determined by the department.
7. (7) Members who cannot be assigned to a PCP and MCO on the basis of an automated default process may be assigned through a manual default process determined by the department.
8. (8) Members with special medical needs may be defaulted on the basis of a manual default methodology if such members can be identified and if the automated default process cannot be administered for such members.
9. (9) A member who is defaulted to a PCP who is contracted with only one MCO shall be assigned to that MCO.
10. (10) PCP restrictions on client age, gender, and capacity shall be considered as limitations to default assignments to PCPs.
11. (11) Family members shall be defaulted to the same PCP and MCO to the maximum extent possible within the limitation of PCP restrictions on client age, gender, and capacity by MCO as well as geographical proximity considerations.
12. (12) The detailed default methodology developed by the department shall be fully applicable to each MCO in the Medicaid managed care program by service area. However, the number of defaults assigned to the state administered PCCM network shall be restricted as follows:
  1. (A) If a member is defaulted to a PCP who is contracted only with PCCM program, the member will be defaulted to the PCCM program;
  2. (B) If a member is defaulted to a PCP who is contracted with the PCCM program and an HMO, the member will be defaulted to the HMO;
  3. (C) If a member is defaulted to a PCP who is contracted with the PCCM program and two or more HMOs, the member will be defaulted to one of the HMOs on the basis of paragraph (6) of this subsection;
  4. (D) A member will be defaulted to the PCCM program if a PCCM provider is the only PCP within reasonable geographical proximity to the member as defined by the department.
(f) A member may request to change MCOs at any time and for any reason, regardless of whether the MCO was selected by the member or assigned by the department. Disenrollment will take place no later than the first day of the second month after the month in which the member has requested termination. MCOs must inform members of disenrollment procedures at the time of enrollment. MCOs must notify members in appropriate communication formats.
(g) The department shall establish limits for the number of members each PCP may accept to ensure members have reasonable access to the provider. The department shall develop criteria to allow exceptions to this limit on a case-by-case basis, provided the exceptions do not adversely affect member access.
(h) The department may not enroll any Medicaid eligible recipient who is excluded from participation by federal rule or regulation.
(i) Recipients who are located more than 30 miles from the nearest PCP in an MCO cannot be enrolled in the MCO unless an exception is made by the department.
(j) Medicaid recipients and Medicare beneficiaries must constitute less than 75% of the total enrollment of an MCO, unless the MCO has received a waiver for this requirement under 42 Code of Federal Regulations §434.26.

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.