20-04 Version of 21.6 HMO Enrollment

21.6.1 HMO Enrollment Introduction
21.6.2 Exemptions
21.6.3 Change of Circumstances
21.6.4 Disenrollment
21.6.5 HMO Ombudsmen

21.6.1 HMO Enrollment Introduction

Most Medicaid memberA recipient of Medicaid; formerly referred to as a "client."s who are eligible for BadgerCare Plus, MAPP, or SSI-related Medicaid and reside in a Medicaid 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 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 does not choose an HMO within two weeks of receiving the enrollment packet, he or she receives a reminder card. Members in areas with only one available HMO will stop here in the process. They do not have to enroll in an HMO.
If the member has not chosen an HMO after four weeks and lives in an area covered by two or more HMOs, 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.

21.6.2 Exemptions

A member may qualify for an exemption from HMO enrollment if they meet certain criteria, such as a chronic illness, high-risk third trimester pregnancy, or continuity of care concerns.

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 they receive.

21.6.3 Change of Circumstances

Members who lose Medicaid 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, if the HMO is no longer accepting reassignments, or if the HMO has exceeded its enrollment level, he or she will receive an enrollment packet, and the enrollment process will start over.

Note:

The policies in this section also apply to members whose Medicaid was suspended due to incarceration but have regained full Medicaid eligibility upon release from jail or prison.

21.6.4 Disenrollment

Members are automatically disenrolled from the HMO program if:

Their medical status code changes to a BadgerCare Plus or Medicaid subprogram that does not require enrollment in an HMO.
They enroll in an Adult LTC program.
They become eligible for Medicare.
They lose eligibility.
They move out of the HMO’s service area.
Their Medicaid is suspended due to incarceration in jail or prison.

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-serviceA method of payment for health services. The medical provider bills the Medicaid fiscal agent rather than an HMO for specific individual services..

21.6.5 HMO Ombudsmen

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

HMO Ombuds
P.O. Box 6470
Madison, WI 53791-9823

This page last updated in Release Number: 20-04
Release Date: 11/23/2020
Effective Date: 10/24/2020