Auto Assignment. 4.2.4.1 Selected Centennial Care 2.0 MCOs that did not participate in the delivery of Covered Services under the Centennial Care program between January 1, 2014 and December 31, 2018 will receive the highest percentage of auto-assignment until a membership threshold of at least fifteen percent (15%) of the total managed care enrollment as of the last day of the month is achieved. If any Centennial Care CONTRACTOR falls below a membership threshold of fifteen percent (15%) of the total managed care enrollment it will receive the highest percentage of auto-assignment until the threshold is maintained for a period of at least one year.
4.2.4.2 Once HSD determines that the established enrollment threshold is reached per Section 4.2.4.1, the Centennial Care 2.0 CONTRACTOR(s) with the highest scoring cost proposal in the bidding process will receive the highest percentage of the auto-assignment, subject to the considerations in 4.2.4.
Auto Assignment. 4.2.5.1 HCA will auto-assign a Recipient to a Turquoise Care MCO in specified circumstances, including but not limited to: (i) the Recipient does not select an MCO at the time of eligibility or (ii) the Recipient cannot be enrolled in the requested MCO pursuant to the terms of this Agreement (e.g., the CONTRACTOR is subject to and has reached its enrollment limit).
4.2.5.2 Auto-assignment during the initial open enrollment period for Turquoise Care will be determined by HCA. However, during initial enrollment:
4.2.5.2.1 Turquoise Care MCO enrollment will be driven by Recipient and Member choice.
4.2.5.2.2 Centennial Care 2.0 Members who do not select a Turquoise Care MCO and whose current Centennial Care 2.0 is awarded a contract to become a Turquoise Care MCO will remain enrolled in their current MCO. Centennial Care 2.0 Members who do not select a Turquoise Care MCO and whose current Centennial Care 2.0 MCO is not awarded a contract to become a Turquoise Care MCO will be auto-assigned during initial enrollment as determined by HCA.
4.2.5.2.3 Members currently enrolled in a Centennial Care 2.0 MCO awarded a contract for Turquoise Care will remain in their current plan, unless they elect a different Turquoise Care MCO through open enrollment.
4.2.5.2.4 The upper enrollment limit established by HCA pursuant to 4.2.8 of this Section will not prevent or limit enrollment in any Turquoise Care MCO based upon Recipient/Member choice.
4.2.5.3 Following the initial open enrollment period for Turquoise Care, the auto- assignment process will consider the following:
4.2.5.3.1 If a Recipient was previously enrolled with a Turquoise Care MCO and loses eligibility for a period of three (3) months or less, the Recipient will be re- enrolled with that Turquoise Care MCO;
4.2.5.3.2 If the Recipient has family Members in a Turquoise Care MCO, the Recipient will be enrolled in that Turquoise Care MCO;
4.2.5.3.3 If the Recipient is a newborn, the Recipient will be assigned to their mother’s Turquoise Care MCO; and
4.2.5.3.4 If none of the above applies, the Recipient will be assigned using an auto- assignment algorithm default logic that considers nationally-recognized quality standards or other auto-assignment algorithm methodologies that reward MCOs that demonstrate superior performance on one (1) or more key dimensions of performance as determined by HCA. HCA will notify the CONTRACTOR at least twelve (12) months in advance of changes to the quality metrics impacting the ...
Auto Assignment. An Eligible Person whose enrollment in a MCO is mandatory and who fails to select a MCO within sixty (60) days of receipt of notice of mandatory enrollment may be assigned by the LDSS to the Contractor's plan pursuant to NYS Social Services Law Section 364-j and in accordance with Appendix H. SECTION 6 (ENROLLMENT) October 1, 2004 6-1
Auto Assignment. 2.4.4.6.1 TENNCARE will auto assign an enrollee to an MCO, in specified circumstances, including but not limited to, the enrollee does not request enrollment in a specified MCO, cannot be enrolled in the requested MCO, or is an adult eligible as a result of receiving SSI benefits.
2.4.4.6.2 The current auto assignment process does not apply to children eligible for TennCare as a result of being eligible for SSI or children in the state’s custody.
2.4.4.6.3 There are four different levels to the current auto assignment process:
2.4.4.6.3.1 If the enrollee was previously enrolled with an MCO and lost TennCare eligibility for a period of two (2) months or less, the enrollee will be re-enrolled with that MCO.
2.4.4.6.3.2 If the enrollee has family members in an MCO (other than TennCare Select), the enrollee will be enrolled in that MCO.
2.4.4.6.3.3 If the enrollee is a newborn, the enrollee will be assigned to his/her mother’s MCO.
2.4.4.6.3.4 If none of the above applies, the enrollee will be assigned using default logic that randomly assigns enrollees to MCOs (other than TennCare Select).
2.4.4.6.4 TENNCARE may modify the auto assignment algorithm to change or add criteria including but not limited to quality measures or cost or utilization management performance.
2.4.4.6.5 During implementation of this Contract there may be a one-time exception to the auto assignment process described above. If an incumbent MCO (defined herein as an MCO other than TennCare Select that had a contract with the Bureau of TennCare immediately preceding the start date of operations under this Contract) will provide covered services as of the start date of operations under this Contract in the same Grand Region as the previous contract, current TennCare enrollees who are known to be members of the incumbent MCO may be assigned by TENNCARE to remain with the incumbent MCO with enrollment effective the start date of operations. Current TennCare enrollees who are not known to be members of an incumbent MCO will be assigned by TENNCARE to an MCO in accordance with the process described in Section A.2.
Auto Assignment. 2.4.4.2.1 TENNCARE will auto assign an enrollee to an MCO, in specified circumstances, including but not limited to, the enrollee does not request enrollment in a specified MCO, cannot be enrolled in the requested MCO, or is an adult eligible as a result of receiving SSI benefits.
2.4.4.2.2 The current auto assignment process does not apply to children eligible for TennCare as a result of being eligible for SSI or children in State custody.
2.4.4.2.3 There are four different levels to the current auto assignment process:
2.4.4.2.3.1 If the enrollee was previously enrolled with an MCO and lost TennCare eligibility for a period of two (2) months or less, the enrollee will be re-enrolled with that MCO.
2.4.4.2.3.2 If the enrollee has family members in an MCO (other than TennCare Select), the enrollee will be enrolled in that MCO.
2.4.4.2.3.3 If the enrollee is a newborn, the enrollee will be assigned to his/her mother’s MCO.
2.4.4.2.3.4 If none of the above applies, the enrollee will be assigned using default logic that randomly assigns enrollees to MCOs (other than TennCare Select).
2.4.4.2.4 TENNCARE may modify the auto assignment algorithm to change or add criteria including but not limited to quality measures or cost or utilization management performance.
Auto Assignment. Eligible individuals that fail to select a plan will be assigned to an MCOP at the discretion of ODM.
Auto Assignment. The process used by the Division to randomly select a qualified vendor 10 to provide services to a member.
Auto Assignment. The assignment of an Enrollee to a PMG and a PCP, normally at the time the person is Auto-Enrolled in the GHP Program. Auto-Enrollment: The Enrollment of a Potential Enrollee in an MCO by ASES without any action by the Potential Enrollee. Blocked Call: A call that cannot be connected immediately because no circuit is available at the time the call arrives or because the telephone system is programmed to block calls from entering the queue when the queue is backed up beyond a defined threshold. Business Continuity and Disaster Recovery (“BC-DR”) Plan: A documented plan (process) to restore vital and critical Information/health care technology systems in the event of business interruption due to human, technical, or natural causes. The plan focuses mainly on technology systems, encompassing critical hardware, operating and application software, and tertiary elements required to support the operating environment. It must support the process requirement to restore vital business Data inside the defined business requirement, including an emergency mode operation plan as necessary. Business Days: Traditional workdays, including Monday, Tuesday, Wednesday, Thursday, and Friday. Puerto Rico Holidays, as defined in the Law for Compliance with the Fiscal Plan, Act No. 26 of April 29, 2017, or any other law enacted during the duration of this Contract regarding this subject, are excluded. Business Hours: 8:00 a.m. to 6:00 p.m. local Puerto Rico time on Business Days. Calendar Days: All seven (7) days of the week. Call Center: A telephone service facility equipped to handle a large number of inbound and outbound calls and perform all the functions described in this Contract via telephone. Centers for Medicare & Medicaid Services (“CMS”): The agency within the US Department of Health and Human Services with responsibility for the Medicare, Medicaid, and the Children’s Health Insurance Programs (“CHIP”). Children’s Health Insurance Program (“CHIP”): Puerto Rico’s Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.
Auto Assignment. 1. If a member/responsible person fails to select a Qualified Vendor from the vendors who respond “yes” to the vendor call, the Division will auto assign a Qualified Vendor to the member.
a. Qualified Vendors that respond “yes” to the vendor call in Focus will be included in the auto assignment process as necessary.
b. Qualified Vendors should not respond “yes” to vendor calls if they do not have qualified staff available to provide the identified service(s).
2. The Division will notify Qualified Vendors within one day of selection if they have been auto assigned.
3. The auto-assigned Qualified Vendor shall contact the member/responsible person within one day of being notified of the auto assignment.
Auto Assignment. 4.2.4.1 Selected Centennial Care 2.0 MCOs that did not participate in the delivery of Covered Services under the Centennial Care program between January 1, 2014 and December 31, 2018 will receive the highest percentage of auto-assignment until a membership threshold of at least 10% of the total managed care enrollment as of January 1, 2019 is achieved. .
4.2.4.2 Once HSD determines that the established enrollment threshold is reached per Section 4.2.4.1, the Centennial Care 2.0 CONTRACTOR(s) with the highest scoring cost proposal in the bidding process will receive the highest percentage of the auto-assignment, subject to the considerations in 4.2.44. For a minimum of one (1) Contract year period. HSD reserves the right to modify the auto- assignment methodology at its discretion.
4.2.4.3 HSD will auto assign a Recipient to a MCO in specified circumstances, including but not limited to (i) the Recipient does not select a MCO at the time of eligibility or (ii) the Recipient cannot be enrolled in the requested MCO pursuant to the terms of this Agreement (e.g., the CONTRACTOR is subject to and has reached its enrollment limit).
4.2.4.4 The auto assignment process will consider the following:
4.2.4.4.1 If the Recipient was previously enrolled with a MCO and lost eligibility for a period of six (6) months or less, the Recipient will be re-enrolled with that MCO;
4.2.4.4.2 If the Recipient has family members in a MCO, the Recipient will be enrolled in that MCO;
4.2.4.4.3 If the Recipient is a newborn, the Recipient will be assigned to his or her mother’s MCO; and
4.2.4.4.4 If none of the above applies, the Recipient will be assigned using default logic that randomly assigns Recipients to MCOs.
4.2.4.5 HSD may modify the auto assignment algorithm to incorporate criteria including but not limited to quality measures, cost or Utilization Management performance.
