N.J. Admin. Code § 10:74-7.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:74-7.1 - Disenrollment

(a) Disenrollment shall occur:

1. Upon death or whenever the enrollee is no longer Medicaid/NJ FamilyCare eligible, unless otherwise specified in the contract;

2. Except for the aged, blind, or disabled populations, whenever the enrollee moves outside of the MCO's enrollment area boundaries. The contractor shall remain responsible for the enrollee's care until the individual or the family/case has been disenrolled from the plan. Moving from the MCO's enrollment area does not negate a plan's responsibility to provide Medicaid/NJ FamilyCare benefits. If a plan is aware that a beneficiary who is not aged, blind, or disabled is residing outside its enrollment area, the contractor shall ask DMAHS to disenroll the beneficiary due to the change of residence;

3. Whenever the enrollee is admitted to a Residential Treatment Center;

4. Whenever the contract between the Department and the contractor is terminated;

5. Whenever granted through the formal grievance, in accordance with N.J.A.C. 10:74-11.1;

6. Whenever a Medicaid/NJ FamilyCare enrollee who was determined eligible under NJ FamilyCare-Children's Program attains the age of 19 years;

7. Whenever a Medicaid/NJ FamilyCare enrollee becomes ineligible due to other health insurance coverage; or

8. Whenever a Medicaid/NJ FamilyCare-Plans B, C, or D participant loses program eligibility in accordance with N.J.A.C. 10:79-7.1.

(b) A Medicaid/NJ FamilyCare-Plan A enrollee may elect to disenroll from the contractor's plan at any time during the first 90 days of an initial period of enrollment in an MCO and once every 12 months after the initial period of managed care enrollment without the need to state a cause.

(c) After the first 90-day period and for the remainder of the enrollment period, a Medicaid/NJ FamilyCare enrollee may elect to disenroll, with cause, at any time. Good cause shall be determined on a case-by-case basis, upon notification to the HBC. Good cause reasons may include, but are not limited to, failure of the contractor to provide services to the enrollee, failure of the contractor to respond to an enrollee's grievance, enrollee is qualified for an enrollment exemption, or enrollee has more convenient access to a PCP/APN in another MCO. Such information shall be made available to the enrollee by the contractor MCO and/or the health benefits coordinator.

1. Medicaid/NJ FamilyCare enrollees subject to mandatory enrollment shall transfer to another participating MCO upon disenrollment from a contractor's plan.

(d) Until such time as the enrollee's termination of coverage becomes effective, the contractor shall remain liable for all contracted services. If an enrollee is hospitalized at the time of disenrollment or termination, the contractor shall be liable for all inpatient hospital charges through the date of discharge (if those charges are for a contracted service).

(e) Beneficiaries receiving services in or admitted to a long-term psychiatric hospital or facility, or an ICF/IID shall be disenrolled from the managed care entity on the date of admission to the facility.

N.J. Admin. Code § 10:74-7.1

Amended by 51 N.J.R. 1359(a), effective 8/19/2019