1 Tex. Admin. Code § 353.403 – Enrollment

(a) For purposes of this section, Health Plan includes Primary Care Case Management (PCCM) and health maintenance organizations (HMO).
(b) The Commission will determine which Medicaid eligible clients residing in a Medicaid Managed Care service area will be mandatory or voluntary members and which Medicaid eligible clients may be excluded from participation in managed care.
(c) The Commission or its designee will conduct enrollment and disenrollment activities. The Commission 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 Commission will establish procedures for enrollment into participating Health Plans and with primary care providers (PCPs), including enrollment periods and time limits within which enrollment must occur. Members who are mandatory members must select a Health Plan and PCP within the time period allowed by the department or be defaulted to a Health Plan and PCP.
(e) Mandatory members who fail to select a Health Plan or PCP during the period established by the Commission will have a Health Plan or PCP selected for them by the Commission or its designee using criteria determined by the Commission. The Commission shall establish a detailed default methodology that incorporates the following requirements.
1. (1) A member who does not select a PCP and Health Plan will be assigned a PCP and Health Plan through the default process established by the Commission. A member who selects a Health Plan but not a PCP, will be assigned to the selected Health Plan and the member will be assigned to a PCP through the default process. A member who selects a PCP but not a Health Plan 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 a Health Plan through a manual default process that is established by the Commission.
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 geographic proximity to the PCP.
5. (5) The Commission may identify other criteria to be used along with the criteria based on geographic 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 Commission will develop a methodology for assignment of defaults to each Health Plan in the service area. Such methodology may be based on Health Plan 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 Commission.
7. (7) Members who cannot be assigned to a PCP and Health Plan on the basis of an automated default process may be assigned through a manual default process determined by the Commission.
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 Health Plan will be assigned to that Health Plan.
10. (10) PCP restrictions on Client age, gender, and capacity will be considered as limitations to default assignments to PCPs.
11. (11) Family members shall be defaulted to the same PCP and Health Plan to the maximum extent possible within the limitation of PCP restrictions on client age, gender, and capacity by Health Plan as well as geographic proximity.
12. (12) The detailed default methodology developed by the Commission will be fully applicable to each Health Plan in the Medicaid managed care program by service area. However, the number of defaults assigned to the state-administered PCCM network will be restricted as follows:
  1. (A) If a Member is defaulted to a PCP who is contracted only with the 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 Commission.
(f) A member may request to change Health Plan at any time and for any reason, regardless of whether the Health Plan was selected by the member or assigned by the Commission. Disenrollment will take place no later than the first day of the second month after the month in which the member has requested termination. Health Plans must inform members of disenrollment procedures at the time of enrollment. Health Plans must notify members in appropriate communication formats.
(g) The Commission shall establish limits for the number of members each PCP may accept to ensure members have reasonable access to the provider. The Commission 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) Recipients who are located more than 30 miles from the nearest PCP in a Health Plan cannot be enrolled in the Health Plan unless an exception is made by the Commission.
(i) The Commission has the option to implement a modified default process of member enrollment for a period not to exceed 6 months, when contracting with new Health Plan or when implementing managed care in a new service area.

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; amended to be effective August 10, 2005, 30 TexReg 4466.