Common use of Dates of Enrollment and Disenrollment Clause in Contracts

Dates of Enrollment and Disenrollment. The enrollment date for an otherwise eligible individual can be set for the first day of the month in which she or he achieves the age specified in Article XIX, MCO Specific Contract Terms, Section D, page 241, except for PACE, in which the individual must have achieved the age of 55 prior to enrollment. The MCO shall begin serving individuals as of the effective date of enrollment recorded in CARES. The MCO is responsible to monitor ForwardHealth interChange enrollment reports for discrepancies in persons the MCO considers enrolled. a. The Department will consider requests for correcting enrollment dates in the past if the MCO has submitted to the Department monthly enrollment discrepancy reports on a form approved by the Department. The purpose of these reports is to identify discrepancies between the MCO’s enrollment as documented in ForwardHealth interChange and the MCO’s internal enrollment records. Such reports shall demonstrate that the MCO has taken steps to resolve discrepancies with the local resource center and income maintenance agency. If there is a discrepancy between the enrollment in ForwardHealth interChange and the MCO’s internal enrollment records, the enrollment may be corrected as follows: i. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred less than three (3) calendar months in the past, the enrollment start date may be corrected by income maintenance if the MCO has documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. ii. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred more than three (3) calendar months in the past, the enrollment start date may be corrected by the Department contract coordinator if the: a) Discrepancy is identified on the MCO’s monthly enrollment discrepancy reports no more than the last day of the month three calendar months after the discrepancy first occurred; and b) MCO provides documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. b. A member-requested disenrollment shall be effective on the date indicated on the disenrollment form signed by the member or the member’s authorized representative. The effective date cannot be earlier than the date the individual last received services authorized by the MCO. c. An MCO-requested disenrollment shall be effective on the date approved by the Department as the disenrollment date, but no later than the first day of the second month following the month in which the MCO filed the request. In order to allow time for the member to appeal an MCO- requested disenrollment decision from the Department, the Department shall retain the disenrollment form for fourteen (14) calendar days after the MCO and member have been notified by the Department of the decision to approve the disenrollment before forwarding it to the Medicaid fiscal agent or income maintenance agency to process the disenrollment. If the member files an appeal of an MCO-requested disenrollment decision to the DHA fair hearing process within fourteen (14) calendar days, disenrollment shall be delayed until the appeal is resolved. d. If the member dies, the date of disenrollment shall be the date of death. e. Loss of eligibility resulting in disenrollment shall have the effective dates as identified in i. through v. below. i. If an MCO member is planning to or has moved out of the MCO service area, the date of disenrollment shall be the date the move occurs. ii. If an individual has been incarcerated, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of incarceration. iii. If a person who is at least 21 years old and less than 65 years old has been admitted to an IMD, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of admission to the IMD. iv. If an MCO member loses eligibility for a reason other than those identified in (i) through (iii) above, the last day of eligibility shall be set according to adverse action logic in CARES. The disenrollment date will be the date eligibility ends. The MCO shall continue to provide services to the member through the date of disenrollment.

Dates of Enrollment and Disenrollment. The enrollment date for an otherwise eligible individual can be set for the first day of the month in which she or he achieves the age specified in Article XIX, MCO Specific Contract Terms, Section D, page 241256, except for PACE, in which the individual must have achieved the age of 55 prior to enrollment. The MCO shall begin serving individuals as of the effective date of enrollment recorded in CARES. The MCO is responsible to monitor ForwardHealth interChange enrollment reports for discrepancies in persons the MCO considers enrolled. a. The Department will consider requests for correcting enrollment dates in the past if the MCO has submitted to the Department monthly enrollment discrepancy reports on a form approved by the Department. The purpose of these reports is to identify discrepancies between the MCO’s enrollment as documented in ForwardHealth interChange and the MCO’s internal enrollment records. Such reports shall demonstrate that the MCO has taken steps to resolve discrepancies with the local resource center and income maintenance agency. If there is a discrepancy between the enrollment in ForwardHealth interChange and the MCO’s internal enrollment records, the enrollment may be corrected as follows: i. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred less than three (3) calendar months in the past, the enrollment start date may be corrected by income maintenance if the MCO has documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. ii. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred more than three (3) calendar months in the past, the enrollment start date may be corrected by the Department contract coordinator if the: a) Discrepancy is identified on the MCO’s monthly enrollment discrepancy reports no more than the last day of the month three calendar months after the discrepancy first occurred; and b) MCO provides documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. b. A member-requested disenrollment shall be effective on the date indicated on the disenrollment form signed by the member or the member’s authorized representative. The effective date cannot be earlier than the date the individual last received services authorized by the MCO. c. An MCO-requested disenrollment shall be effective on the date approved by the Department as the disenrollment date, but no later than the first day of the second month following the month in which the MCO filed the request. In order to allow time for the member to appeal an MCO- requested disenrollment decision from the Department, the Department shall retain the disenrollment form for fourteen (14) calendar days after the MCO and member have been notified by the Department of the decision to approve the disenrollment before forwarding it to the Medicaid fiscal agent or income maintenance agency to process the disenrollment. If the member files an appeal of an MCO-requested disenrollment decision to the DHA fair hearing process within fourteen (14) calendar days, disenrollment shall be delayed until the appeal is resolved. d. If the member dies, the date of disenrollment shall be the date of death. e. Loss of eligibility resulting in disenrollment shall have the effective dates as identified in i. through v. below. i. If an MCO member is planning to or has moved out of the MCO service area, the date of disenrollment shall be the date the move occurs. ii. If an individual has been incarcerated, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of incarceration. iii. If a person who is at least 21 years old and less than 65 years old has been admitted to an IMD, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of admission to the IMD. iv. If an MCO member loses eligibility for a reason other than those identified in (i) through (iii) above, the last day of eligibility shall be set according to adverse action logic in CARES. The disenrollment date will be the date eligibility ends. The MCO shall continue to provide services to the member through the date of disenrollment.

Dates of Enrollment and Disenrollment. The enrollment date for an otherwise eligible individual can be set for the first day of the month in which she or he achieves the age specified in Article XIX, MCO Specific Contract Terms, Section D, page 241222, except for PACE, in which the individual must have achieved the age of 55 prior to enrollment. The MCO shall begin serving individuals as of the effective date of enrollment recorded in CARES. The MCO is responsible to monitor ForwardHealth interChange enrollment reports for discrepancies in persons the MCO considers enrolled. a. The Department will consider requests for correcting enrollment dates in the past if the MCO has submitted to the Department monthly enrollment discrepancy reports on a form approved by the Department. The purpose of these reports is to identify discrepancies between the MCO’s enrollment as documented in ForwardHealth interChange and the MCO’s internal enrollment records. Such reports shall demonstrate that the MCO has taken steps to resolve discrepancies with the local resource center and income maintenance agency. If there is a discrepancy between the enrollment in ForwardHealth interChange and the MCO’s internal enrollment records, the enrollment may be corrected as follows: i. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred less than three (3) calendar months in the past, the enrollment start date may be corrected by income maintenance if the MCO has documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. ii. If the discrepancy between ForwardHealth interChange and the MCO’s internal records first occurred more than three (3) calendar months in the past, the enrollment start date may be corrected by the Department contract coordinator if the: a) Discrepancy is identified on the MCO’s monthly enrollment discrepancy reports no more than the last day of the month three calendar months after the discrepancy first occurred; and b) MCO provides documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. b. A member-requested disenrollment shall be effective on the date indicated on the disenrollment form signed by the member or the member’s authorized representative. The effective date cannot be earlier than the date the individual last received services authorized by the MCO. c. An MCO-requested disenrollment shall be effective on the date approved by the Department as the disenrollment date, but no later than the first day of the second month following the month in which the MCO filed the request. In order to allow time for the member to appeal an MCO- requested disenrollment decision from the Department, the Department shall retain the disenrollment form for fourteen (14) calendar days after the MCO and member have been notified by the Department of the decision to approve the disenrollment before forwarding it to the Medicaid fiscal agent or income maintenance agency to process the disenrollment. If the member files an appeal of an MCO-requested disenrollment decision to the DHA fair hearing process within fourteen (14) calendar days, disenrollment shall be delayed until the appeal is resolved. d. If the member dies, the date of disenrollment shall be the date of death. e. Loss of eligibility resulting in disenrollment shall have the effective dates as identified in i. through v. below. i. If an MCO member is planning to or has moved out of the MCO service area, the date of disenrollment shall be the date the move occurs. ii. If an individual has been incarcerated, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of incarceration. iii. If a person who is at least 21 years old and less than 65 years old has been admitted to an IMD, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of admission to the IMD. iv. If an MCO member loses eligibility for a reason other than those identified in (i) through (iii) above, the last day of eligibility shall be set according to adverse action logic in CARES. The disenrollment date will be the date eligibility ends. The MCO shall continue to provide services to the member through the date of disenrollment.