Section 405IAC10-8-2. Changing insurers

   (a) A member shall remain enrolled with the same insurer during the member's benefit period. A member may change insurers upon request only in the following circumstances:

(1) Without cause before making the member's fast track prepayment or initial POWER account contribution or within sixty (60) days of being assigned to an insurer, whichever comes first.

(2) For cause at any time. A member under this subsection may request to change insurers at any time by submitting a grievance to the insurer and receiving the insurer's or the division's approval.

(3) Without cause, at renewal, if the member submits the request to change insurers to the enrollment broker at least forty-five (45) days prior to the end of the member's benefit period.

(4) At any time during the member's pregnancy, a member in the pregnant women Medicaid category may request to change insurers through the enrollment broker.

  (b) For purposes of subsection (a)(2), "for cause" includes any of the following:

(1) The causes for disenrollment set forth in 42 CFR 438.56(d)(2)(i) – (iii).

(2) Receiving poor quality care.

(3) Failure of the insurer to provide covered services.

(4) Failure of the insurer to comply with established standards of medical care administration.

(5) Lack of access to providers experienced in dealing with the member's health care needs.

(6) Significant language or cultural barriers.

(7) Corrective action levied against the insurer by the office.

(8) Limited access to a primary care clinic or other health services within reasonable proximity to a member's residence.

(9) A determination that another insurer's formulary is more consistent with a new member's existing health care needs.

(10) Other circumstances determined by the office to constitute poor quality of health care coverage.

  (c) A member who receives an unfavorable decision from the insurer under subsection (a)(2) may submit a request for reconsideration pursuant to the instructions in the insurer's notice of decision. A request for reconsideration shall be deemed approved if official action is not taken on the request by the first day of the second month following the month in which the individual submits the request. A member who files a grievance with the insurer and completes the reconsideration process shall be considered to have met the requirements of 405 IAC 10-5-2 for purposes of filing an appeal with the state. (Office of the Secretary of Family and Social Services; 405 IAC 10-8-2; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA)