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 n...
Disenrollment. Adverse Benefit Determination taken by the Division, or its Agent, to remove a Member's name from the monthly Member Listing report following the Division's receipt and approval of a request for Disenrollment or a determination that the Member is no longer eligible for Enrollment in the Contractor.
Disenrollment. An Enrollee must be disenrolled from the Plan if the Beneficiary:
a. No longer resides in the State of Mississippi;
b. Is deceased;
c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of 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 Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writing. The effective date of any approved disenrollment will b...
Disenrollment. If a woman becomes pregnant while enrolled in the Demonstration, she may be determined eligible for Medicaid under the State plan. The State must not submit claims under the Demonstration for any woman who is found to be eligible under the Medicaid State plan. In addition, women who receive a sterilization procedure and complete all necessary follow-up procedures will be disenrolled from the Demonstration.
Disenrollment. If an Enrolled Employee elects coverage under any other plan which is offered by, through, or in connection with Employer Group in lieu of Benefits under this Agreement, then Benefits for such Enrolled Employee and his or her enrolled Dependents terminate automatically on the last day for which the Premiums received by Plan cover that Enrolled Employee and his or her Dependents. Employer Group and the Enrolled Employee agree to notify Plan immediately when the Enrolled Employee elects other coverage.
Disenrollment. A. The Contractor must use the disenrollment letters in Appendix X.
X. The Contractor shall assist individuals who disenroll by making appropriate referrals for continuity of care and providing medical records to new providers.
C. The Contractor shall notify all Providers that were delivering services to an individual who disenrolls that the Provider will not be paid for services rendered after the effective date of disenrollment or, for Participants between twenty-one (21) and sixty-four (64) years of age who are admitted to an IMD, that the Provider will not be paid for services rendered after the date of admission to the IMD.
D. The Contractor shall not terminate enrollment for any reason except as provided in this Section.
Disenrollment. The removal of a Member from participation in the Contractor’s plan, but not necessarily from the Medicaid or PeachCare for Kids® program. Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts may include written correspondence that outlines contracted negotiations between the parties, including rate and contract terms disclosure, as well as documented verbal conversations, to include date and time and parties involved. Durable Medical Equipment (DME): Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title XIX mandated program that covers screening and Diagnostic Services to determine physical and mental deficiencies in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered. P4HB Participants are not eligible to participate in the EPSDT Program.
Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS.
(1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization.
(2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR 455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_web
(3) A Member may be Disenrolled from Contractor as follows:
(a) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 for the following reasons:
(i) Without cause:
(A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days of the Member’s Enrollment; or
(B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; or
(C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or
(D) Members who are eligible for both Medicare and Medicaid and Members who are AI/AN beneficiaries may change plans or disenroll to fee-for-service at any time; or
(E) Upon Automatic Re-enrollment (e.g., a recipient who is automatically re-enrolled after being disenrolled, solely because he or she loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opp...
Disenrollment. For Family Care, the MCO shall comply with the following requirements and use Department issued forms related to disenrollment. For Partnership and PACE, the MCO shall comply with the following requirements and use Department issued and CMS approved forms related to disenrollments.
Disenrollment. Participants may request to be disenrolled from the FIDA Plan or from the FIDA Demonstration altogether at any time for any reason, orally or in writing. A Disenrollment request may be made by the Participant to the Enrollment Broker or 1-800-MEDICARE.
