Adjustments in Service Area or Enrollment Sample Clauses

Adjustments in Service Area or Enrollment a. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with a (1) If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA. (2) If Contractor cannot demonstrate sufficient Provider capacity, OHA may seek other avenues to provide services to Members. If OHA determines that some or all of the affected Members must be disenrolled from Contractor, the applicable provisions of this Section shall apply. b. If Contractor experiences a Material Change, or is engaged in the termination or loss of a Provider or group or affected by other factors which has significant impact on access in that Service Area and which may result in reducing or terminating Contractor’s Service Area or disenrolling a substantial number of Members from Contractor, Contractor shall provide OHA with a written notice and a plan for implementation (which may include an intent to transfer its Members in the Service Area to a Contractor designated by OHA) at least 90 days prior to the date of such action. Contractor shall remain responsible for providing all Covered Services through the end of the 90 day period, without limitation, for all Members for which the Contractor received a CCO Payment. (1) If Contractor must terminate a Provider or group due to circumstances that could compromise Member care, less than the required notice to OHA may be provided with the approval of OHA. (2) If a Provider or group terminates its Subcontract or employment with Contractor or Contractor is affected by other circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice, less than the required notice to OHA may be provided with the approval of OHA. (3) If Contractor provides OHA with the required 90 day notice but provides no Letter of Intent to transfer its Members to a designated Contractor within 30 days of the 90 day notice, Members in the affected Service Area will be disenrolled from Contractor and will be ...
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Adjustments in Service Area or Enrollment. The terms and conditions of Section 14, Exhibit B, Part 4 in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
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Adjustments in Service Area or Enrollment a. If Contractor is engaged in the termination or loss of a Provider or group or affected by other factors which have significant impact on access in that Service Area and which may result in transferring a substantial number of Members to other Providers employed or subcontracted with Contractor, Contractor shall provide OHA with a written plan for transferring the Members and an updated DSN Provider Report, Exhibit G, at least 90 days prior to the date of such action. b. If Contractor experiences a change which may result in the reduction or termination of any portion of Contractor’s Service Area or may result in the disenrollment of a substantial number c. OHA will not approve a transfer of Members if the Provider’s contract with the transferring Contractor is terminated for reasons related to quality of care, competency, Fraud or other reasons described in OAR 410-141-3080. d. OHA reserves the right to waive the required notice period in certain circumstances, including but not limited to: (1) i. If Contractor must terminate a Provider or group due to circumstances that could compromise Member care; (2) ii. If a Provider or group terminates its subcontract or employment with Contractor or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor cannot reasonably provide the required 90 day notice; or,
Sample 1
Adjustments in Service Area or Enrollment a. If RAE reasonably anticipates losing a substantial number of Members from its enrollment, or experiencing a reduction in its network or capacity due to: (i) the occurrence of a Material Change or other significant change; (ii) engaging in the termination or loss of Participating Providers; or (iii) decreased access in RAE’s Service Area, RAE shall notify TCMC at least 120 days, or as soon as reasonably practicable, prior to the date of such anticipated loss or reduction. b. In such an event, RAE shall cooperate with and assist TCMC to develop a written plan for removing or reassigning the Members, and to cooperate and assist in the preparation of any written reports required by the Core Contract or the OHA related to the removal or reassignment. x. XXX shall remain responsible for maintaining sufficient capacity and solvency, and providing Covered Care Services through such 120-day period, without limitation, for all Members for which RAE received Compensation. d. If RAE cannot demonstrative sufficient capacity to provide Covered Services to Members during such 120-day period, TCMC may seek other avenues to provide Covered Services to Members. Part 5 – Health Equity and Elimination Health Disparities
Sample 1

Related to Adjustments in Service Area or Enrollment

  • Disenrollment The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment seriously impairs the Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee’s behavior is determined to be unrelated to an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.

  • Enrollment The Competitive Supplier shall be responsible for enrolling all Eligible Consumers through EDI transactions submitted to the LDC for all enrollments of Eligible Consumers during the term of this Agreement.

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