Introduction
During the enrollment period, care already prescribed must be continued until a new plan of care has been established. These models give the MCO an incentive to insure that members are evaluated as soon as possible by their new provider.
NHeLP Model
The health plan shall honor plans of care, prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances and any other ongoing care initiated prior to enrollment with the plan until the enrollee is evaluated by her/his PCP and a new plan of care is established. The record will clearly indicate the reason for any changes in the plan of care. If a service is terminated or reduced, the health plan shall provide written notice to the recipient, including notice of the member's right to continued services pending a final decision.
New Jersey
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES, DEPARTMENT OF HUMAN SERVICES, CONTRACT BETWEEN STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES AND [ ], HMO CONTRACTOR
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10.16 The contractor shall, for new enrollees, honor plans of care, prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other ongoing services initiated prior to enrollment with the contractor until the enrollee is evaluated by his/her primary care physician and a new plan of care is established with the contractor. The contractor shall use its best efforts to outreach and accommodate the new enrollees. However, if after documented reasonable outreach, i.e., mailers, certified mail, contact with the County Welfare Agency (CWA) to confirm addresses and/or to request CWA assistance in locating the enrollee, the enrollee fails to respond within 15 days of certified mail, the contractor may cease paying for the pre-existing service until the enrollee contacts the contractor for re-evaluation.
Florida
FLORIDA, PREPAID HEALTH PLAN, MEDICAID MODEL CONTRACT DRAFT (July 1996).
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(6) The Plan shall honor any written prior authorization of on-going covered services (from regular fee-for-service Medicaid) for a period of 10 days after the effective date of enrollment or until the plan's primary care physician assigned to that member reviews the member's treatment plan, whichever comes first. The Plan shall be responsible for payment to the existing treating provider at a prior negotiated rate or lesser of the provider's usual and customary rate or the established Medicaid fee-for-service rate for such services until the Plan is able to evaluate the need for on-going services.
