38.4 HMO Enrollment

Most BadgerCare Plus members who are eligible for BadgerCare Plus and reside in a BadgerCare Plus HMO service area must enroll in an HMO.

Members may choose their own HMO or work with the HMO Enrollment Specialist to choose the best one for their needs. They may choose at any time during the enrollment process. All eligible members of the member’s family must choose the same HMO. However, individuals within a family may be eligible for an exemption from enrollment.

This is the enrollment process:

Members residing in an HMO service area receive an HMO enrollment packet. The packet has an enrollment form, a list of available HMOs, instructions on how to choose an HMO and how to find out if a provider is affiliated with an HMO.

If the member lives in an area covered by two or more HMOs, enrollment is mandatory. In areas with only one available HMO, enrollment is voluntary and the process stops here.

If the member lives in a mandatory area and does not choose and HMO, he or she will be assigned an HMO. A letter explaining the assignment will be sent to him or her. He or she will receive another enrollment form and have an opportunity to change the assigned HMO.

He or she will then receive a notice confirming enrollment in the assigned or chosen HMO for the following month. The member has up to three months to change HMOs, once enrolled. This is the open enrollment period. After the initial three months, the member is locked into the HMO and cannot change for nine months. If your member has questions about HMO enrollment, he or she should contact the Enrollment Specialist at 1-800-291-2002.

Exemptions: A member may qualify for an exemption from HMO enrollment if he or she meets certain criteria, such as a chronic illness, high-risk third trimester pregnancy, or continuity of care concerns, etc.

If the member believes he or she has a valid reason for exemption, he or she should call the HMO Enrollment Specialist at 1-800-291-2002. The number is also in the enrollment materials he or she receives.

38.4.1 Change of Circumstances

Members who lose BadgerCare Plus eligibility, but become eligible again may be automatically re-enrolled in their previous HMO.

If the member’s eligibility is re-established after a Restrictive Re-enrollment Period ( RRP ), he or she will be automatically re-enrolled in the previous HMO, unless the HMO is no longer accepting reassignments.

After six months, or if the HMO is no longer accepting reassignments or has exceeded its enrollment level, he or she will receive an enrollment packet, and the enrollment process will start over.

38.4.2 Disenrollment

Members are automatically disenrolled from the HMO program if:

Their medical status code changes to a BadgerCare Plus subprogram that does not require enrollment in an HMO.

They become eligible for Medicare.

They lose eligibility.

They move out of the HMO’s service area.

Members can be disenrolled by the HMO’s request in the following situations:

They become inmates of a public institution.
They need an experimental transplant.

Note: HMO disenrollment is not automatic in these situations.

Members who move out of the HMO service area receive a new packet showing the HMO(s) available in the new area and the enrollment process begins again. If no HMO covers the member’s new area, he or she remains fee-for-service.

38.4.3 Fiscal Agent Ombuds

Members with questions about their rights as HMO members may call 1-800-760-0001 or write:

HMO Ombudsman

P.O. Box 6470

Madison, WI 53791-9823

This page last updated in Release Number: 13-02

Release Date: 10/25/13

Effective Date: 10/01/13