State of Wisconsin Department of Health Services

Release 24-01 April 03, 2024

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38.4 HMO Enrollment

In Wisconsin, health maintenance organization (HMO) refers to managed care organizations that contract with health care providers and facilities to provide services for BadgerCare Plus and the Medicaid for Elderly, Blind or Disabled programs. 

The HMO Enrollment Specialist is an organization under contract with DHS to provide unbiased HMO enrollment counseling to BadgerCare Plus and SSI Medicaid members and outreach about enrollment choice options. The HMO Enrollment Specialist also assists members in making an HMO selection and responds to questions about enrollment.

Note	This section only addresses policies related to enrollment in a BadgerCare Plus HMO and does not cover enrollment in an SSI HMO or Long-Term Care Managed Care Organization (LTC MCO).

38.4.1 BadgerCare Plus HMO Enrollment

BadgerCare Plus is a mandatory HMO enrollment program, meaning most BadgerCare Plus members are required to enroll in an HMO. All eligible BadgerCare Plus members in the same household must enroll in the same HMO. However, the following persons cannot enroll in a BadgerCare Plus HMO:

• Members enrolled in a long-term care managed care organization (MCO)
• Members who live in a nursing home or medical facility
• Members eligible for both BadgerCare Plus and Medicare, often referred to as a dual eligible (see Section 38.7 Impact on Dual Eligible Individuals)
• Members who are eligible for suspended BadgerCare Plus (see Chapter 45 Inmates)

Certain members within a household may enroll in an HMO on a voluntary basis (see Section 38.4.1.1 Voluntary HMO Enrollment) or qualify for an exemption from HMO enrollment (see Section 38.4.5 Enrollment Exemptions).

HMO enrollment always begins the 1st of a month. The month in which enrollment begins depends on the time of the month when eligibility was established or when the member’s enrollment status changed:

• If eligibility was established prior to the 10th of the month, HMO enrollment will begin the 1st of the following month. 
• If eligibility was established on the 10th of the month or later, HMO enrollment will begin the 1st of the month following the next month. 

Until a member’s HMO enrollment has started, the member will receive their services on a fee-for-service basis, which means they can receive covered services from any BadgerCare Plus-certified provider.

If the member’s enrollment status changes during the month (for example, going from being exempt from HMO enrollment to no longer being exempt), the member will be enrolled in an HMO effective the 1st of the following month.

Retroactive enrollment (backdating HMO enrollment) may be allowed in some circumstances but may also require approval from the HMO. Members who would like to request backdated enrollment should contact the HMO Enrollment Specialist at 800-291-2002. The HMO Enrollment Specialist will review retroactive enrollment backdating requests and coordinate with the HMO if necessary.

The list of medical status codes under which a member is eligible for BadgerCare Plus HMO enrollment can be found on the ForwardHealth Enrollment Information page. This list does not differentiate between voluntary or mandatory HMO enrollment. It is only a compilation of all Medical Status codes under which a member could be enrolled in an HMO.

38.4.1.1 Voluntary HMO Enrollment

Voluntary HMO enrollment means a member is not required to enroll in an HMO but can choose to enroll in an HMO if they want to. Someone is considered voluntary for BadgerCare Plus HMO enrollment if they meet any of the following criteria: 

• The member is residing in a service area where there is only one HMO available.
• The member reports they are Native American, American Indian, an Alaskan Native, or a member of a federally recognized tribe, or has verified their tribal member status for eligibility purposes.

If anyone within the household meets the voluntary enrollment criteria listed above, everyone in the household who is enrolled in BadgerCare Plus is considered voluntary. 

38.4.2 HMO Selection and Assignment

Members can choose an HMO after they are found eligible for BadgerCare Plus. Applicants who are applying for benefits online through ACCESS can indicate an HMO preference when they submit their application. Indicating a preference does not guarantee they will be enrolled in the HMO they selected when they submitted the application, but the preference will be taken into account when assigning the member to an HMO after they become eligible for benefits. If the member did not indicate a preference when they submitted their application, an HMO will be assigned for the BadgerCare Plus household based on the primary applicant’s previous enrollment in a BadgerCare Plus, if applicable, or based on a round-robin HMO assignment.

If the member was previously enrolled in a BadgerCare Plus HMO in the last 12 months, they will be assigned to the previous HMO unless they are joining a household that is already enrolled in a BadgerCare Plus HMO. If the member is joining a household that is already enrolled in a BadgerCare Plus HMO, the member will be enrolled in the same HMO as the other members of the household effective the 1st of the next month.

For members who are required to enroll in an HMO, if the member never indicated a preference to begin with, they will be assigned to an HMO and will receive an HMO enrollment packet in the mail. The enrollment packet includes a cover letter with information on their assigned HMO and start date, a BadgerCare Plus HMO Program Guide (P-12020) with a list of available HMOs and their service areas, an enrollment form, and instructions on how to choose or change an HMO. 

Voluntary members will also receive an HMO enrollment packet but will not be assigned to an HMO. They will receive a cover letter explaining they are not required to enroll in an HMO but can choose one if they want to.

To select an HMO, check their current enrollment status, or make a change to their current enrollment, members can:

• Log in to their ACCESS account and navigate to the “Manage My HMO” tab
• Complete and return the HMO Enrollment Choice form by mail
• Call the HMO Enrollment Specialist by phone at 1-800-291-2002

Members with questions about their rights as HMO members or concerns about the care they receive from the HMO may contact the HMO Ombuds. The HMO Ombuds can assist members in researching and resolving grievances or conflicts about their care.

HMO Ombuds

P.O. Box 6470

Madison, WI 53791-9823

Phone: 1-800-760-0001 (Monday through Friday from 8 a.m. to 4:30 p.m.)

38.4.3 Open Enrollment and Lock-in Periods

Once a member has been assigned to an HMO, they will have a three-month open enrollment period beginning from their initial HMO enrollment date in which they can change HMOs freely. After the three-month open enrollment period, the member enters a lock-in period for nine months. During the lock-in period, they cannot change HMOs or disenroll from the HMO without a qualifying reason such as an exemption or a change to an enrollment status that does not require HMO enrollment. 

Note	The open enrollment and lock-in periods do not align with the 12-month eligibility certification period for BadgerCare Plus.

 

Example 1

Lynn applies and is found eligible for BadgerCare Plus on September 15 with a BadgerCare Plus certification period of September 1 through August 31. She is assigned to HMO A with an enrollment start date of November 1. Her open enrollment period is from November 1 through January 31. Her lock-in period is from February 1 through November 30.

If a member is regaining HMO enrollment after more than two months of not being enrolled, the member will be assigned to their previous HMO (if they were enrolled in this HMO in the last 12 months) but will get a new open enrollment and lock-in period.

After the lock-in period has ended, the member is able to change HMOs at any time and does not need a qualifying reason to change HMOs. However, when a new HMO is selected, it will restart the open enrollment and lock-in cycle again effective with the start date of enrollment in the new HMO. If the member does not change HMOs after the lock-in period has ended, they will be reminded once every year (if they continue to be eligible for BadgerCare Plus) that they can change HMOs.

38.4.4 HMO Disenrollment

Members may be disenrolled from the HMO for a variety of reasons. Some disenrollments are automatic, meaning the disenrollment occurs based on changes to the member’s eligibility or enrollment status. There are also voluntary disenrollments, which can be requested by the member, the member’s family, or a legal guardian, and involuntary disenrollments, which are requested by the HMO.

38.4.4.1 Automatic Disenrollment

Automatic disenrollment occurs when there are changes to the member’s eligibility or enrollment status that affect their HMO enrollment and typically occurs automatically once eligibility has been updated. The table below includes a list of automatic disenrollments and the date on which the disenrollment is effective. 

Reason for Disenrollment	Disenrollment Date
Loss of BadgerCare Plus eligibility	End of the month in which the loss/termination occurred, even if that is prior to when the loss of benefits is effective.
Date of Death Entered	Date of Death
Moving outside of the HMO’s service area	End of the month in which the move was reported
Incarceration or Institutionalization	End of the month in which the incarceration or institutionalization was reported
Enrollment in a Waiver program or Long-Term Care MCO	End of the month prior to the month when waiver program or LTC MCO enrollment occurs
Becoming eligible for Medicare	Depending on when notification of Medicare eligibility was received and the Medicare eligibility start date, if the notification is received: Prior to the Medicare eligibility begin date, the disenrollment date is the end of the month in which notification was received. After the Medicare eligibility begin date, the disenrollment date is the end of the month prior to the month of notification.

38.4.4.2 Voluntary Disenrollment

The member may voluntarily disenroll from the HMO for any reason as long as they are no longer in their lock-in period. 
If the member is still in the lock-in period, the member, the member’s family, or the legal guardian must request a voluntary disenrollment based on a qualifying reason.  

Qualifying reasons for voluntary disenrollments may include but are not limited to:

• A temporary loss of eligibility caused the member to miss their open enrollment period.
• The HMO does not cover the service the member seeks, due to moral or religious objections.
• The member needs related services (for example, a cesarean section and tubal ligation) to be performed at the same time and not all related services are within the provider network and the member’s primary care provider, or another provider determines the risk of receiving services separately would subject the member to unnecessary risk.
• Other reasons, including poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the member’s care needs

Voluntary disenrollments are effective no later than the first day of the month following the month in which the disenrollment was requested.

38.4.4.3 Involuntary Disenrollment

The Department of Health Services may approve involuntary disenrollments with an effective date of the following month, if approved with the exception of a just cause disenrollment, which may require additional review of the effective date of disenrollment based on the circumstances.

The HMO must submit a disenrollment request to the Department and include evidence attesting to the reason. The HMO must direct all members for whom an involuntary disenrollment request has been made to the HMO Enrollment Specialist for assistance and/or for choice counseling. 

Involuntary disenrollments may include but are not limited to:

• Just Cause – A situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with medically necessary services for reasons beyond the HMO’s control. An HMO cannot request just cause disenrollment because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished capacity or uncooperative disruptive behavior resulting from the member’s special needs (except when their continued enrollment in the HMO seriously impairs the HMO’s ability to furnish services to the member or other members).
• The member is residing in a nursing home for longer than 30 days – The member, the nursing home or the HMO may contact the HMO Enrollment Specialist to disenroll the member from the BadgerCare Plus HMO so that nursing home services can be billed fee-for-service. Once the member is no longer residing in the nursing home, the member may be eligible for HMO enrollment.

38.4.5 Enrollment Exemptions

Members with specific needs can disenroll or opt out of HMO enrollment and receive their health care under fee-for-service if they meet the rules for an enrollment exemption. Most exemption requests must come from the member, the member’s family, or the member’s legal guardian. They may need to be approved by either the HMO Enrollment Specialist, an HMO Ombuds, or state Nurse Consultant. Exemptions apply to individuals, not households.

Exemptions will generally be effective the first day of the next month after the month in which the exemption was requested, unless otherwise specified. Exemption requests will not be backdated unless an exception is granted by the Department. The duration of the exemption may vary depending on the type of exemption. Members should be directed to the HMO Enrollment Specialist for assistance in requesting an exemption or choice counseling.

Note	The state Nurse Consultant provides consultation and technical assistance on topics related to health needs and complex care. The Nurse Consultant may need to make decisions on enrollment exemptions related to complex health care needs.

Types of Enrollment Exemptions

Exemption	Description
Admission or Enrollment in the Birth to 3 Program (BadgerCare Plus only)	The head of the household or the county Birth to 3 Program may request an exemption on behalf of the child when the child is enrolled in the Birth to 3 Program. Birth to 3 Program providers are encouraged to work with the member’s HMO before requesting the enrollment exemption. This exemption can be backdated up to two months from the month the request is received.
Commercial Insurance or Commercial HMO Enrollment	The member is enrolled in a commercial insurance plan or commercial HMO that limits them to a restricted private network and does not align with the BadgerCare Plus provider network.
Continuity of Care	A one- to two-month continuity of care exemption may be granted when a member is newly enrolled or about to be enrolled in an HMO and has an upcoming appointment (within the next two months) with a provider with whom they have a previously established-relationship and that provider is not part of the HMO’s network.  If the member has more complex medical needs and requires an exemption longer than two months, the HMO Enrollment Specialist will refer the member to the State Nurse Consultant.  In addition, a longer continuity of care exemption can be granted for a pregnant member who wants to see a nurse midwife/practitioner of their choosing who is not part of a BadgerCare Plus HMO’s provider network. For a pregnant member, the exemption can be applied at any time starting from the month of request through two months after the estimated due date.
Distance	This exemption may be granted for a one-to-two-month period when a member has moved out of an HMO’s service area while their eligibility has not yet been updated to reflect the change in address AND the member needs immediate care in the area that is not covered by their current HMO.
HIPP Determination in progress or enrollment in the HIPP program	This exemption may be granted if the member is pending an eligibility determination for the HIPP program or is enrolled in the HIPP program, and the employer-sponsored insurance plan limits the member to a restricted provider network that does not align with the BadgerCare Plus HMO’s provider network.
Long Term Complex Care	The state Nursing Consultant may apply this exemption for up to 12 months for individuals who have complex needs and may need specialized care outside of a member’s HMO network.
Low Birth Weight	The state Nurse Consultant may apply this exemption to newborns with a low birth weight (birth weight less than 2,500 grams or 5 lbs. 8 oz.).
Native American, American Indian, Alaskan Native or member of a federally recognized Tribe	If the member attests they are a Native American, American Indian, Alaskan Native, or a member of a federally recognized tribe, they are not required to enroll in an HMO. The member can choose to remove this exemption at any time to enroll into an HMO.
Care4Kids Extension	This exemption applies to children in BadgerCare Plus who are still receiving services under the Care4Kids 12-month extension after being discharged from out-of-home care.  Care4Kids is a specialized managed care program for children in out-of-home care in Kenosha, Ozaukee, Milwaukee, Racine, Washington, and Waukesha counties.
Transplants	The member had a stem cell or bone marrow transplant. The member will be permanently exempted from HMO enrollment effective the first of the month in which the surgery is performed.  Transplant exemption requests may be made by the HMO and directed to the state Nurse Consultant.

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10171