1. (a) Enrollment by the Health and Human Services Commission (HHSC). HHSC or its designee will conduct enrollment and disenrollment activities. HHSC may not contract with a participating managed care organization (MCO) to serve as the administrator for enrollment or disenrollment activities in any area of the state.
2. (b) Procedures for enrollment. HHSC will establish procedures for enrollment into participating MCOs and with primary care providers (PCPs), including enrollment periods and time limits within which enrollment must occur. Beneficiaries will have 15 calendar days from the date notification is mailed to choose an MCO. If the beneficiary does not choose an MCO within this time period, HHSC will default the beneficiary into an MCO.
3. (c) Default assignment. Beneficiaries who fail to select an MCO or PCP during the period established by HHSC will have an MCO or PCP selected for them by HHSC or its designee using criteria determined by HHSC.

4. (d) Default assignment methodology. When possible, the default assignment methodology will take into consideration the beneficiary's history with a PCP or main dental home provider. If this is not possible, HHSC will equitably distribute beneficiaries among qualified MCOs. HHSC will establish an automated default methodology that includes, to the maximum extent possible, the following criteria:

   1. (1) PCP assignment.

      1. (A) A beneficiary who does not select a PCP and health care MCO will be assigned a PCP and health care MCO through the default process established by HHSC.
      2. (B) A beneficiary who selects a health care MCO but not a PCP will be assigned to the selected health care MCO and the beneficiary will be assigned to a PCP through the default process.
      3. (C) A beneficiary who selects a PCP but not a health care MCO will be assigned to the PCP chosen by the member, subject to PCP restrictions on client age, gender, and capacity, and the beneficiary will be assigned to a health care MCO through a default process that is established by HHSC.
      4. (D) Each beneficiary who has not selected a PCP may be defaulted to the PCP with whom there is the most recent Medicaid managed care encounter history. The number of encounters between the beneficiary and the PCP may also be considered.
      5. (E) If there is no Medicaid managed care encounter history, each beneficiary may be defaulted to the PCP with whom there is the most recent traditional Medicaid claims history. The number of prior encounters between the beneficiary and the PCP may also be considered.
      6. (F) If a member does not have history with a PCP, the beneficiary may be defaulted to a PCP on the basis of geographic proximity to the PCP.
      7. (G) HHSC 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).
      8. (H) PCP restrictions on member age, gender, and capacity will be considered as limitations to default assignments to PCPs.

   2. (2) MCO assignment.

      1. (A) HHSC will develop a methodology for assignment of defaults to each health care MCO and dental MCO participating in the same Medicaid managed care program and service area.
      2. (B) 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), capitation rates, market share, or other factors determined by HHSC.
      3. (C) A beneficiary who has not selected a PCP or MCO, and is defaulted to a PCP who is contracted with only one health care MCO will be assigned to that health care MCO.
      4. (D) HHSC will automatically re-enroll a beneficiary in the same MCO if there is a loss of Medicaid eligibility of six months or less.
   3. (3) Use of manual default processes. Members who cannot be assigned to a PCP, health care MCO, or dental MCO on the basis of an automated default process may be assigned through a manual default process determined by HHSC.
   4. (4) Beneficiaries with special medical needs may be defaulted on the basis of a manual default methodology if such beneficiaries can be identified and if the automated default process cannot be administered for such beneficiaries.
   5. (5) Treatment of family members. Family members will be defaulted to the same PCP, health care MCO, and dental MCO to the maximum extent possible within the limitation of the MCO's capacity and PCP restrictions on member age and gender.
5. (e) Modified default process. HHSC has the option to implement a modified default process of member enrollment, when contracting with a new MCO or when implementing managed care in a new service area.

6. (f) Disenrollment.

   1. (1) Disenrollment at a member's request.

      1. (A) Members will be informed of disenrollment opportunities no less than annually.
      2. (B) Except as provided in subsection (c) of this section, during the first 90 days of enrollment in an MCO, a member may request to move to another MCO for any reason. After 90 days with an MCO, a member may move one additional time for any reason. If a member shows good cause, he or she also may move to another MCO at any time.
      3. (C) Members of a health care MCO who are in a hospital, residential substance use disorder treatment, or residential detoxification for substance use disorder treatment cannot move to another health care MCO until discharged.
      4. (D) Disenrollment will take place no later than the first day of the second month after the month in which the member has requested a change.

   2. (2) Disenrollment at an MCO's request.

      1. (A) An MCO may submit a request to HHSC that a member be disenrolled without the member's consent in the following limited circumstances:

         1. (i) the member misuses or loans his or her MCO membership card to another person to obtain services;
         2. (ii) the member is disruptive, unruly, threatening or uncooperative to the extent that the member's membership seriously impairs the MCO's or a provider's ability to provide services to the member or to obtain new members, and member's behavior is not caused by a physical or behavioral health condition; or
         3. (iii) the member steadfastly refuses to comply with managed care restrictions (such as repeatedly using the emergency room in combination with a refusal to allow treatment for the underlying medical condition).
      2. (B) An MCO must take reasonable measures to correct a member's behavior prior to requesting disenrollment. Reasonable measures may include providing education and counseling regarding the offensive acts or behaviors.
      3. (C) HHSC will review all requests for disenrollment. HHSC will grant a request if it determines that all reasonable measures taken by the MCO have failed to correct the member's behavior. If HHSC grants a request, it will notify the member of the disenrollment decision and the availability of HHSC's fair hearings process for an appeal of the disenrollment.

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; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283.