Common use of Cause for Disenrollment Clause in Contracts

Cause for Disenrollment. a. An Enrollee may request Disenrollment from the Health Plan for Cause at any time. Such request shall be submitted to the Agency or its Agent. The following reasons constitute Cause for Disenrollment from the Health Plan: (1) The Enrollee moves out of the county, or the Enrollee’s address is incorrect and the Enrollee does not live in the county; (2) The Provider is no longer with the Health Plan; (3) The Enrollee is excluded from enrollment; (4) A substantiated marketing violation occurred; (5) The Enrollee is prevented from participating in the development of his/her treatment plan; (6) The Enrollee has an active relationship with a provider who is not on the Health Plan's network, but is in the network of another health plan; (7) The Enrollee is enrolled in the wrong Health Plan as determined by the Agency; (8) The Health Plan no longer participates in the county; (9) The State has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3); (10) The Enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, the Enrollee's PCP has determined that receiving the services separately would subject the Enrollee to unnecessary risk; (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee seeks; (12) The Enrollee missed his/her Open Enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less; or (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers experienced in dealing with the Enrollee’s health care needs; or fraudulent Enrollment.

Cause for Disenrollment. a. An Enrollee A mandatory enrollee may request Disenrollment disenrollment from the Health Plan for Cause cause at any time. Such request shall be submitted to the Agency or its Agentagent. The following reasons constitute Cause cause for Disenrollment disenrollment from the Health Plan: (1) The Enrollee enrollee moves out of the county, or the Enrolleeenrollee’s address is incorrect and the Enrollee enrollee does not live in a county where the county;Health Plan is authorized to provide services. (2) The Provider provider is no longer with the Health Plan;. (3) The Enrollee enrollee is excluded from enrollment;. (4) A substantiated marketing or community outreach violation has occurred;. (5) The Enrollee enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee enrollee has an active relationship with a provider who is not on the Health Plan's network’s panel, but is in on the network panel of another health plan;. (7) The Enrollee enrollee is enrolled in the wrong Health Plan health plan as determined by the Agency;. (8) The Health Plan no longer participates in the county;. WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (9) The State state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3);. (10) The Enrollee enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, or the Enrollee's enrollee’s PCP has determined that receiving the services separately would subject the Enrollee enrollee to unnecessary risk;. (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee enrollee seeks;. (12) The Enrollee enrollee missed his/her Open Enrollment open enrollment due to a temporary loss of eligibility, defined as sixty (60) calendar days or less; orless for non-Reform populations and one-hundred eighty (180) calendar days or less for Reform populations. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers providers experienced in dealing with the Enrolleeenrollee’s health care needs; or fraudulent Enrollmentenrollment. b. Voluntary enrollees may disenroll from the Health Plan at any time.

Cause for Disenrollment. a. An Enrollee may request Disenrollment from the Health Plan for Cause at any time. Such request shall be submitted to the Agency or its Agent. The following reasons constitute Cause for Disenrollment from the Health Plan: (1) The Enrollee moves out of the county, or the Enrollee’s address is incorrect and the Enrollee does not live in the county; (2) The Provider is no longer with the Health Plan; (3) The Enrollee is excluded from enrollment; (4) A substantiated marketing violation occurred; (5) The Enrollee is prevented from participating in the development of his/her treatment plan; (6) The Enrollee has an active relationship with a provider who is not on the Health Plan's ’s network, but is in the network of another health plan; (7) The Enrollee is enrolled in the wrong Health Plan as determined by the Agency; (8) The Health Plan no longer participates in the county; (9) The State has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3); (10) The Enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, the Enrollee's ’s PCP has determined that receiving the services separately would subject the Enrollee to unnecessary risk; (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee seeks; (12) The Enrollee missed his/her Open Enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less; or (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers experienced in dealing with the Enrollee’s health care needs; or fraudulent Enrollment.

Cause for Disenrollment. a. An A Mandatory Enrollee may request Disenrollment from the Health Plan PSN for Cause at any time. Such request shall be submitted to the Agency or its Agent. The following reasons constitute Cause for Disenrollment from the Health PlanPSN: (1) The Enrollee moves out of the countycounty Service Area, or the Enrollee’s his/her address is incorrect and the Enrollee does not live in the county;. (2) The Provider is no longer with the Health Plan;PSN. (3) The Enrollee is excluded from enrollment;. (4) A substantiated marketing violation occurred;. (5) The Enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee has an active relationship with a provider who is not on the Health PlanPSN's networkpanel, but is in on the network panel of another health plan;Health Plan. (7) The Enrollee is enrolled in the wrong Health Plan as determined by the Agency;Agencydue to an error. (8) The Health Plan PSN no longer participates in the county;. (9) The State has imposed intermediate sanctions upon the Health PlanPSN, as specified in 42 CFR 438.702(a)(3);. (10) The Enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan PSN network; or, the Enrollee's PCP has determined that receiving the services separately would subject the Enrollee to unnecessary risk;. (11) The Health Plan PSN does not, because of moral or religious objections, cover the service the Enrollee seeks;. (12) The Enrollee missed his/her Open Enrollment due to a temporary loss of eligibility, defined as sixty (60) 180 days or less; or. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers experienced in dealing with the Enrollee’s health care needs; or fraudulent Enrollment. b. Voluntary Enrollees may disenroll from the PSN at any time.

Cause for Disenrollment. a. An Enrollee A mandatory enrollee may request Disenrollment disenrollment from the Health Plan for Cause cause at any time. Such request shall be submitted to the Agency or its Agentagent. The following reasons constitute Cause cause for Disenrollment disenrollment from the Health Plan: (1) The Enrollee enrollee moves out of the county, or the Enrolleeenrollee’s address is incorrect and the Enrollee enrollee does not live in a county where the county;Health Plan is authorized to provide services. (2) The Provider provider is no longer with the Health Plan;. (3) The Enrollee enrollee is excluded from enrollment;. (4) A substantiated marketing or community outreach violation has occurred;. (5) The Enrollee enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee enrollee has an active relationship with a provider who is not on the Health Plan's network’s panel, but is in on the network panel of another health plan;. (7) The Enrollee enrollee is enrolled in the wrong Health Plan health plan as determined by the Agency;. (8) The Health Plan no longer participates in the county;. (9) The State state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3);. AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract (10) The Enrollee enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, . or the Enrollee's enrollee’s PCP has determined that receiving the services separately would subject the Enrollee enrollee to unnecessary risk;. (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee enrollee seeks;. (12) The Enrollee enrollee missed his/her Open Enrollment open enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less; orless for non-Reform populations and one-hundred and eighty (180) days or less for Reform populations. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers providers experienced in dealing with the Enrolleeenrollee’s health care needs; or fraudulent Enrollmentenrollment. b. Voluntary enrollees may disenroll from the Health Plan at any time.

Cause for Disenrollment. a. An A Mandatory Enrollee may request Disenrollment from the Health Plan PSN for Cause at any time. Such request shall be submitted to the Agency or its Agent. The following reasons constitute Cause for Disenrollment from the Health PlanPSN: (1) The Enrollee moves out of the countycounty , or the Enrollee’s Enrollee‘s address is incorrect and the Enrollee does not live in the county;. (2) The Provider is no longer with the Health Plan;PSN. (3) The Enrollee is excluded from enrollment;. (4) A substantiated marketing violation occurred;. (5) The Enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee has an active relationship with a provider who is not on the Health PlanPSN's networkpanel, but is in on the network panel of another health plan;Health Plan. (7) The Enrollee is enrolled in the wrong Health Plan as determined by the Agency;. (8) The Health Plan PSN no longer participates in the county;. (9) The State has imposed intermediate sanctions upon the Health PlanPSN, as specified in 42 CFR 438.702(a)(3);. (10) The Enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan PSN network; or, the Enrollee's PCP has determined that receiving the services separately would subject the Enrollee to unnecessary risk;. (11) The Health Plan PSN does not, because of moral or religious objections, cover the service the Enrollee seeks;. (12) The Enrollee missed his/her Open Enrollment due to a temporary loss of eligibility, defined as sixty (60) 180 days or less; or. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers experienced in dealing with the Enrollee’s Enrollee‘s health care needs; or fraudulent Enrollment. b. Voluntary Enrollees may disenroll from the PSN at any time.

Cause for Disenrollment. a. An Enrollee A mandatory enrollee may request Disenrollment disenrollment from the Health Plan for Cause cause at any time. Such request shall be submitted to the Agency or its Agentagent. The following reasons constitute Cause cause for Disenrollment disenrollment from the Health Plan: (1) The Enrollee enrollee moves out of the county, or the Enrolleeenrollee’s address is incorrect and the Enrollee enrollee does not live in a county where the county;Health Plan is authorized to provide services. (2) The Provider provider is no longer with the Health Plan;. (3) The Enrollee enrollee is excluded from enrollment;. (4) A substantiated marketing or community outreach violation has occurred;. (5) The Enrollee enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee enrollee has an active relationship with a provider who is not on the Health Plan's network’s panel, but is in on the network panel of another health plan;. (7) The Enrollee enrollee is enrolled in the wrong Health Plan health plan as determined by the Agency;. (8) The Health Plan no longer participates in the county;. (9) The State state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3);. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract (10) The Enrollee enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, . or the Enrollee's enrollee’s PCP has determined that receiving the services separately would subject the Enrollee enrollee to unnecessary risk;. (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee enrollee seeks;. (12) The Enrollee enrollee missed his/her Open Enrollment open enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less; orless for non-Reform populations and one-hundred and eighty (180) days or less for Reform populations. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers providers experienced in dealing with the Enrolleeenrollee’s health care needs; or fraudulent Enrollmentenrollment. b. Voluntary enrollees may disenroll from the Health Plan at any time.

Cause for Disenrollment. a. An Enrollee A mandatory enrollee may request Disenrollment disenrollment from the Health Plan for Cause cause at any time. Such request shall be submitted to the Agency or its Agentagent. The following reasons constitute Cause cause for Disenrollment disenrollment from the Health Plan: (1) The Enrollee enrollee moves out of the county, or the Enrolleeenrollee’s address is incorrect and the Enrollee enrollee does not live in a county where the county;Health Plan is authorized to provide services. (2) The Provider provider is no longer with the Health Plan;. (3) The Enrollee enrollee is excluded from enrollment;. (4) A substantiated marketing or community outreach violation has occurred;. (5) The Enrollee enrollee is prevented from participating in the development of his/her treatment plan;. (6) The Enrollee enrollee has an active relationship with a provider who is not on the Health Plan's network’s panel, but is in on the network panel of another health plan;. (7) The Enrollee enrollee is enrolled in the wrong Health Plan health plan as determined by the Agency;. (8) The Health Plan no longer participates in the county;. (9) The State state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a)(3);. WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract (10) The Enrollee enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan network; or, . or the Enrollee's enrollee’s PCP has determined that receiving the services separately would subject the Enrollee enrollee to unnecessary risk;. (11) The Health Plan does not, because of moral or religious objections, cover the service the Enrollee enrollee seeks;. (12) The Enrollee enrollee missed his/her Open Enrollment open enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less; orless for non-Reform populations and one-hundred and eighty (180) days or less for Reform populations. (13) Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; lack of access to Providers providers experienced in dealing with the Enrolleeenrollee’s health care needs; or fraudulent Enrollmentenrollment. b. Voluntary enrollees may disenroll from the Health Plan at any time.