Page 295

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). 21.6.1 SSI HMO Enrollment 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: • Persons who are enrolled in a long-term care managed care organization (MCO) • Persons who live in a nursing home or medical facility • SSI Medicaid members who are under the age of 19 • Persons who are eligible for suspended benefits (see CHAPTER 13 INMATES) 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: • If eligibility was established prior to the 10th of the month, HMO enrollment will begin the 1st of the following month. • If eligibility was established on the 10th of the month or later, HMO enrollment will begin the 1st of the month following the next month. 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. 21.6.1.1 Voluntary HMO Enrollment 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: