Common use of Default Enrollment Process Clause in Contracts

Default Enrollment Process. a. On behalf of Members who receive full medical assistance benefits, and who become newly Medicare eligible either by age or disability, and such Medicare eligibility results in full benefit Dual Eligible Beneficiary status for such Members, Health Plan shall perform the default enrollment process as provided by 42 CFR §§ 422.66 & 422.68. b. Through this Agreement, and in conformance with 42 CFR § 422.66(c)(2)(i)(B) and 42 CFR § 422.107, SDOH approves Health Plan’s implementation of the default enrollment process for its D-SNP subject to CMS’ prior approval as per the requirements of 42 CFR §§ 422.66(c)(2)(i)(E), (F), & (G) inclusive; 42 CFR § 422.66(c)(2)(ii); and other CMS- published regulatory guidance as applicable. c. Health Plan shall be responsible for timely obtaining initial default enrollment process approval from CMS. Health Plan shall coordinate with SDOH regarding those activities necessary to obtain such CMS prior approval. Health Plan shall forward to SDOH a copy of CMS’ default enrollment process prior approval notification or correspondence to Health Plan within 10 calendar days of receipt. d. Health Plan shall be responsible for coordination and continuity of care to ensure that, for each Member enrolled in Health Plan’s D-SNP through the default enrollment process (and who is thus also enrolled in a managed care organization operated by the Health Plan), Health Plan shall be responsible for continuing to provide covered services authorized by the Member’s managed care organization, without regard to whether such services are being provided by participating or non-participating providers for at least sixty (60) days, which shall be extended as necessary to ensure continuity of care pending the provider’s contracting with the Health Plan’s D-SNP plan or the Member’s transition to a participating provider and any needed actions to mitigate potential negative consequences related to transition of providers. e. Health Plan shall be responsible for coordinating those activities necessary to renew any existing default enrollment process approval(s) with CMS, as per the requirements of 42 CFR § 422.66(c)(2)(ii), so that any such subsequent CMS approval(s)/renewal(s) of an existing approved default enrollment process shall be effective no later than 120 calendar days prior to the expiration of the existing CMS approval requested to be renewed. Health Plan shall coordinate with SDOH regarding those activities necessary to obtain such CMS renewal approval(s) of an existing default enrollment process. Health Plan shall forward to SDOH copies of its default enrollment process renewal notification and materials, and CMS’ renewal approval(s) notification or correspondence, within 10 calendar days of receipt. f. Health Plan shall maintain a minimum 3.0 overall plan star rating as assigned by CMS to implement the default enrollment process. g. Through implementation of the default enrollment process, SDOH shall provide Health Plan with information necessary to prospectively identify those members eligible for default enrollment.

Default Enrollment Process. a. On behalf of Members who receive full medical assistance benefits, and who become newly Medicare eligible either by age or disability, and such Medicare eligibility results in full benefit Dual Eligible Beneficiary status for such Members, Health Plan shall perform the default enrollment process as provided by 42 CFR §§ 422.66 & 422.68. b. Through this Agreement, and in conformance with 42 CFR § 422.66(c)(2)(i)(B) and 42 CFR § 422.107, SDOH approves Health Plan’s implementation of the default enrollment process for its D-SNP subject to CMS’ prior approval as per the requirements of 42 CFR §§ 422.66(c)(2)(i)(E), (F), & (G) inclusive; 42 CFR § 422.66(c)(2)(ii); and other CMS- CMS-published regulatory guidance as applicable. c. Health Plan shall be responsible for timely obtaining initial default enrollment process approval from CMS. Health Plan shall coordinate with SDOH regarding those activities necessary to obtain such CMS prior approval. Health Plan shall forward to SDOH a copy of CMS’ default enrollment process prior approval notification or correspondence to Health Plan within 10 calendar days of receipt. d. Health Plan shall be responsible for coordination and continuity of care to ensure that, for each Member enrolled in Health Plan’s D-SNP through the default enrollment process (and who is thus also enrolled in a managed care organization operated by the Health Plan), Health Plan shall be responsible for continuing to provide covered services authorized by the Member’s managed care organization, without regard to whether such services are being provided by participating or non-participating providers for at least sixty (60) days, which shall be extended as necessary to ensure continuity of care pending the provider’s contracting with the Health Plan’s D-SNP plan or the Member’s transition to a participating provider and any needed actions to mitigate potential negative consequences related to transition of providers. e. Health Plan shall be responsible for coordinating those activities necessary to renew any existing default enrollment process approval(s) with CMS, as per the requirements of 42 CFR § 422.66(c)(2)(ii), so that any such subsequent CMS approval(s)/renewal(s) of an existing approved default enrollment process shall be effective no later than 120 calendar days prior to the expiration of the existing CMS approval requested to be renewed. Health Plan shall coordinate with SDOH regarding those activities necessary to obtain such CMS renewal approval(s) of an existing default enrollment process. Health Plan shall forward to SDOH copies of its default enrollment process renewal notification and materials, and CMS’ renewal approval(s) notification or correspondence, within 10 calendar days of receipt. f. Health Plan shall maintain a minimum 3.0 overall plan star rating as assigned by CMS to implement the default enrollment process. g. Through implementation of the default enrollment process, SDOH shall provide Health Plan with information necessary to prospectively identify those members eligible for default enrollment.