BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 SECTION 5– ENROLLMENT & ELIGIBILITY INFORMATION ELIGIBILITY Group Health covers the following groups of Medicaid HMO Members and their corresponding group numbers: Group Health BadgerCare Plus Standard Plan (7100-7299) Group Health BadgerCare Plus Benchmark Plan (7300-7499) Group Health BadgerCare Plus Core Plan (7000-7001) Group Health Medicaid SSI (6000-6299 & 6500-6799) Compcare BadgerCare Plus Standard Plan (7600-7799) Compcare BadgerCare Plus Benchmark Plan (7800-7999) Compcare BadgerCare Plus Core Plan (7500-7501) Compcare Medicaid SSI (6300-6302) BadgerCare Plus Standard Plan covers families with income at or below 200% of the Federal Poverty Level (FPL). BadgerCare Plus Benchmark Plan covers families, self-employed parents, and Caretakers with income above 200% of the FPL. The Benchmark plan provides more limited services than the Standard Plan. BadgerCare Plus Core Plan provides childless adults with access to basic health services including primary and preventive care. Medicaid SSI Plan recipients receive benefits and coverage comparable to the BadgerCare Plus Standard Plan and are eligible for Medicaid due to their eligibility for SSI (Supplemental Security Income) for limited income and resources. Members may choose their own HMO or work with the HMO Enrollment Specialist to choose the best one for their needs. They may choose an HMO at any time during the enrollment process. All eligible members of the member’s family must choose the same HMO. However, individuals within a family may be eligible for an exemption from enrollment. Following is the enrollment process: 1. Members residing in an HMO service area receive an HMO enrollment packet. The packet has an enrollment form, a list of available HMOs, and instructions on how to choose an HMO and how to find out if a provider is affiliated with an HMO. 2. If the member does not choose an HMO within two weeks of receiving the enrollment packet, s/he receives a reminder card. Members in areas with only one available HMO do not have to enroll in an HMO, unless the zip code has been designated rural mandatory by DHS. 3. If the member has not chosen an HMO after four weeks, and resides in a mandatory enrollment zip code area, s/he will be assigned an HMO. A letter explaining the assignment will be sent to him/her. S/he will receive another enrollment form and have an opportunity to change the assigned HMO. [34]
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012 4. S/he will then receive a notice confirming enrollment in the assigned or chosen HMO for the following month. The member has up to three months to change HMOs, once enrolled. This is the open enrollment period. After the initial three months, the member is locked into the HMO and cannot change for nine months. If your member has questions about HMO enrollment, s/he should contact the Enrollment Specialist at 1-800-291-2002. The Member Services Department staff attempts to call all new members within one month of their enrollment. Staff presents an overview of the plan benefits and procedures and, if necessary, assists new members in selecting a primary care provider. Exemptions: A member may qualify for an exemption from HMO enrollment if s/he meets certain criteria, such as a chronic illness, high-risk third trimester pregnancy, or continuity of care concerns, etc. If the member believes s/he has a valid reason for exemption, s/he should call the HMO Enrollment Specialist at 1-800-291-2002. The number is also in the enrollment materials s/he receives. Change of Circumstances: Members who lose BadgerCare Plus and Medicaid SSI eligibility, but become eligible again, may be automatically re-enrolled in their previous HMO. If the member’s eligibility is re-established after a Restrictive Reenrollment Period (RRP), s/he will be automatically re-enrolled in the previous HMO, unless the HMO is no longer accepting reassignments. After six months, or if the HMO is no longer accepting reassignments or has exceeded its enrollment level, s/he will receive an enrollment packet, and the enrollment process will start over. [35]
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