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adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished capacity or uncooperative disruptive behavior resulting from the member’s special needs (except when their continued enrollment in the HMO seriously impairs the HMO’s ability to furnish services to the member or other members).

The member is residing in a nursing home for longer than 30 days – The member, the nursing home or the HMO may contact the HMO Enrollment Specialist to disenroll the member from the BadgerCare Plus HMO so that nursing home services can be billed fee-for-service. Once the member is no longer residing in the nursing home, the member may be eligible for HMO enrollment. 38.4.5 Enrollment Exemptions 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 the member’s 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 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 BadgerCare Plus 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.