Page 7
A. EOHHS, or its designee, is responsible for determining the eligibility of members in the IHCC groups in accordance with requirements established in the applicable sections of Federal and State laws, Rules and Regulations unless deemed eligible by virtue of receipt of SSI. In general, persons will be informed of their enrollment options at the time a determination of eligibility is made. B. IHCC group beneficiaries who are eligible on the basis of SSI income standard, do not require LTSS, and do not have third (3rd) party coverage are subject to mandatory enrollment in an RHP Medicaid managed care plan. EOHHS enters into contractual arrangements with the MCOs offering RHP plans that assure access to high quality Medicaid covered services and supports. EOHHS is also responsible for informing beneficiaries of their service delivery options and initiating enrollment in a participating RHP plan. 1.3.3 RHP Enrollees A. Enrollment in an RHP plan typically occurs no more than thirty (30) days from the date of the determination of eligibility unless excluded from enrollment. B. Excluded from RHP enrollment. Beneficiaries in the following categories are excluded from enrollment in an RHP plan and may be enrolled in an alternative Medicaid managed care arrangement: 1. Third-Party Coverage – SSI and EAD eligible beneficiaries who are enrolled in Medicare Parts A and/or B or have other third (3rd) party coverage are not subject to mandatory enrollment in an RHP plan. 2. Exempt Due to Age – SSI and EAD beneficiaries who are between the ages of nineteen (19) and twenty-one (21) are exempt from mandatory enrollment in RHP and receive all Medicaid health coverage on a fee-for- service basis. 3. Medically Needy Eligible, Non-LTSS – Beneficiaries who are determined eligible as medically needy due to excess income and resources are also exempt from enrollment in managed care. Medicaid health coverage for beneficiaries in this category is provided in accordance with the provisions of Subchapter 05 Part 2 of this Chapter. 4. The excluded populations receive all Medicaid covered services on a fee- for-service basis, unless they are otherwise eligible for another Medicaid delivery system. In addition, during the period while awaiting plan enrollment, beneficiaries eligible for RHP receive health coverage on a fee-for-service basis. 1.3.4 RHP Enrollment Process A. RHP-eligible beneficiaries have the choice of two (2) participating plans. EOHHS employs a formula, or algorithm, to assign prospective enrollees to a health plan.