Enrollment

Enrollment is mandatory in most Medicaid managed long-term services and supports (LTSS) programs. If, under mandatory enrollment, a consumer does not affirmatively choose a particular managed care organization (MCO), the state will choose an MCO for him or her, based upon specified factors. Under federal regulations, a consumer can change from one MCO to another within the first 90 days and annually thereafter.

Florida allows for MCO enrollment while a consumer’s financial eligibility for Medicaid still is being determined. If the consumer is ultimately found ineligible for Medicaid, he or she must repay the MCO for services provided.

Default Enrollments

  • When consumer does not make affirmative choice, consumer is assigned to MCO based on residence and whether MCO has contract with consumer’s physician and/or long-term care facility: Arizona a
  • When consumer does not make affirmative choice, consumers in long-term care facilities are assigned to MCO based on whether MCO has contract with consumer’s physician and facility: Hawaii b
  • When consumer does not make affirmative choice, consumer is assigned to MCO based on previous relationship with provider of long-term services: Florida c

Ability to Change from One MCO to Another

  • Consistent with federal law (42 C.F.R. § 438.56), consumer can change MCO during first 90 days, thereafter annually and for good cause: Florida d, Hawaii e, New Mexico f
  • State must give consumer at least 60-day notice of open enrollment period: Florida g

Retroactive Coverage

  • MCO must provide retroactive coverage of up to three months under Medicaid’s retroactive coverage rules, including paying for fee-for-service claims even if claims are late under MCO’s filing policies: Kansas h

Medicaid Pending

  • Consumer may receive HCBS through MCO while Medicaid eligibility is being determined; if found ineligible, consumer liable to MCO for cost of services: Florida i
  1. Ariz. Contract, p. 17.  (back)
  2. Haw. RFP, pp. 50-51.  (back)
  3. Fla. Contract, Atch. II, Exh. 3, p. 9.  (back)
  4. Fla. Contract, Atch. II, p. 36.  (back)
  5. Haw. RFP, pp. 53-54.  (back)
  6. N.M. Contract, pp. 20-21.  (back)
  7. Fla. Contract, Atch. II, p. 36.  (back)
  8. Kan. RFP, p. 95.  (back)
  9. Fla. Contract, Atch. II, Exh. 3, p. 8.  (back)

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