TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.995 MANDATORY ENROLLMENT


 

Section 140.995  Mandatory Enrollment

 

a)         Effective on the dates set forth in subsection (e) of this Section, individuals enrolled in programs administered by the Department under Article V of the Public Aid Code, the Children's Health Insurance Program Act, the Covering ALL KIDS Health Insurance Act, or the Veterans' Health Insurance Program Act and not excluded in Section 140.992(b) who are not enrolled in a Managed Care Organization must enroll with a PCP.

 

b)                     HFS shall send a notice to each individual for whom enrollment in the PCCM program is mandatory, notifying the individual of the need to enroll with a Primary Care Provider and explaining the options for doing so, and, where available, the options for enrolling with a PCP within a Managed Care Organization (MCO).  If the individual has not chosen a PCP within 30 days after the date of the first notice, the Department shall send a second notice to the individual instructing him or her to choose a PCP and informing the individual that the Department will assign him or her to a PCP in the PCCM program if he or she does not choose one. 

 

c)         Individuals who have not chosen a PCP within 60 days after the date of their first notice shall be assigned by HFS to a PCP in the PCCM program in their service area.  The algorithm used in the default enrollment process shall be in compliance with 42 CFR 438.50.  The individuals will be mailed a notice to inform them of their assigned PCP. Assignment to a PCP shall be effective no sooner than 60 days after the date that the first notice is mailed by the Department.

 

d)         An individual and the PCP with whom that individual is enrolled will receive notice of the enrollment.  Enrollment information will be available the day following the enrollment through internet-based and electronic eligibility verification systems.

 

e)         Mandatory enrollment shall be phased in effective with the dates set forth in this subsection.

 

1)         The Department will send notices to individuals living in Cook, DuPage, Grundy, Kane, Kankakee, Kendall, Lake, McHenry, and Will counties beginning no sooner than February 2007.

 

2)         The Department will send notices to individuals living in Boone, Bureau, Carroll, DeKalb, Fulton, Henderson, Henry, JoDaviess, Knox, LaSalle, Lee, Marshall, Mercer, Ogle, Peoria, Putnam, Rock Island, Stark, Stephenson, Tazewell, Warren, Whiteside, Winnebago, and Woodford counties beginning no sooner than March 2007.

 

3)         The Department will send notices to individuals living in the remainder of the State beginning no sooner than April 2007.

 

f)         Individuals may change PCPs within the PCCM program once per calendar month.  Changes shall be effective no later than the fourth day after the request for change is registered with the Department or its agent.  In counties where managed care organizations operate, an individual enrolled in the PCCM program may disenroll from the PCCM program and enroll in a managed care organization, and an individual enrolled in a managed care organization may disenroll from the managed care organization and enroll in the PCCM program.  Such enrollments shall be effective no later than the first day of the second month following the month in which the enrollee files the request. 

 

g)         Individuals living in a service area where there is no PCP available with capacity for an enrollment are excluded from mandatory enrollment requirements.

 

h)         PCPs may request that an individual assigned to them be disenrolled from them in accordance with 42 CFR 438.56.

 

i)          If an individual enrolled in the PCCM program loses Medical Assistance eligibility and his or her Medical Assistance eligibility is reinstated within 60 days, that individual will be assigned to the PCP to whom assigned when Medical Assistance eligibility terminated.

 

j)          If a PCP in the PCCM Program is terminated or otherwise becomes unavailable, an individual in the PCCM Program who is enrolled with that PCP may access any Medicaid enrolled provider until that member is enrolled in a new PCP.

 

(Source:  Added at 31 Ill. Reg. 6930, effective April 29, 2007)