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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
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 enrollment in an SSI HMO and does not cover enrollment in a BadgerCare Plus HMO or Long-Term Care Managed Care Organization (LTC MCO). |
SSI Medicaid and SSI-Related Medicaid are mandatory HMO enrollment programs, meaning most members are required to enroll in an HMO. However, the following persons cannot enroll in an HMO:
Certain persons may enroll in an HMO on a voluntary basis (see SECTION 21.6.1.1 VOLUNTARY HMO ENROLLMENT) or qualify for an exemption from HMO enrollment (see SECTION 21.6.5 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:
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 Medicaid-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 an 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 SSI 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 that could be enrolled in an HMO.
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 SSI HMO enrollment if they meet any of the following criteria:
Members can choose an HMO after they are found eligible for SSI Medicaid, SSI-Related Medicaid, or MAPP. Individuals who are applying for benefits online through ACCESS can indicate an HMO preference when they submit their application. Indicating a preference does not guarantee the individual 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 individual based on any previous enrollment in an SSI HMO or based on a round-robin HMO assignment.
Enrollment in an SSI HMO is on an individual basis, meaning household members could be in different HMOs from other members of the household or their spouse. If the member was previously enrolled in an SSI HMO in the last 12 months, the member will be assigned to their previous HMO.
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, an SSI HMO Program Guide (P-12770) 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:
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.)
The SSI Managed Care External Consumer Advocate also provides advocacy services for SSI Medicaid HMO members with a disability. Members can contact the SSI Managed Care External Consumer Advocate at 800-928-8778 from 8:30 a.m. to 5 p.m., Monday through Friday.
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. |
| Example 1 | Lorena applies and is found eligible for SSI-Related Medicaid on September 15 with a 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 remain eligible for Medicaid under the same category of eligibility) that they can change HMOs.
Voluntary members will be subject to the open enrollment and lock-in period if they choose to enroll in an HMO. During the open enrollment period, a voluntary member may choose to disenroll from the HMO without cause and choose fee-for-service (FFS).
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.
Automatic disenrollment occurs when there are changes to the member’s eligibility or enrollment status that affects their HMO enrollment and typically occurs automatically once eligibility has been updated. The table below includes a list of automatic disenrollments and date on which the disenrollment is effective.
| Reason for Disenrollment | Disenrollment Date |
| Loss of Medicaid 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 waiver program or LTC MCO enrollment starts |
| Becoming eligible for Medicare |
Depending on when notification of Medicare eligibility was received and the Medicare eligibility start date, if the notification is received:
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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:
Voluntary disenrollments are effective no later than the first day of the month following the month in which the disenrollment was requested.
If the SSI HMO fails to complete a required assessment and care plan during the first 90 days of enrollment and is able to demonstrate a good faith process to complete the assessment, the open enrollment period will be extended an additional 30 days.
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:
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 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 and/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 SSI HMO 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 individual who wants to see a nurse midwife/practitioner of their choosing who is not part of the HMO’s provider network. For a pregnant individual, 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 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 transplant that is considered experimental, such as liver, heart, lung, heart-lung, pancreas, pancreas-kidney, 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. |
This page last updated in Release Number: 23-03
Release Date: 08/14/2023
Effective Date: 08/14/2023
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 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-10030