Disenrollment Due to Loss of Eligibility Sample Clauses

Disenrollment Due to Loss of Eligibility. In addition to the reasons outlined in the PACE Agreement, Appendix G, and 42
Sample 1Sample 2Sample 3
AutoNDA by SimpleDocs
Disenrollment Due to Loss of Eligibility. In addition to the reasons outlined in the PACE Agreement, Appendix G, and 42 C.F.R. § 460.164, Members admitted to an IMD when the service is authorized by the PACE IDT should not be disenrolled. Members may make choices below, that result in the loss of eligibility. When a member makes one of the following choices, the PACE organization will complete the change routing form and send it to the income maintenance agency and the resource center. The income maintenance agency will end the waiver eligibility and the resource center will process the disenrollment: Chooses a primary care provider who is not in the PACE organization provider network, or Chooses to enroll in any other Medicare or Medicaid prepayment plan or optional benefit, including hospice benefit. When the PO provides information to the income maintenance agency or another agency that may result in the member being disenrolled, the PO will also inform the resource center. The income maintenance agency will determine whether the person is ineligible. If the member is found ineligible for Medicaid, the disenrollment will occur automatically in ForwardHealth interChange. The PO must offer the member an opportunity to pay the PACE premium to remain in the PACE program. The member may elect to enroll in the PACE program with a premium or disenroll from the PACE program following the determination of Medicaid ineligibility.
Sample 1Sample 2Sample 3
Disenrollment Due to Loss of Eligibility. For those Members who are disenrolled because they are no longer eligible for CHIP, CONTRACTOR will receive from the Administrative Services Contractor notice informing CONTRACTOR that the Members' coverage will end on a particular date. Disenrollment due to loss of eligibility includes, but is not limited to: "Aging-out" when a child turns nineteen; Failure to re-enroll at the conclusion of the 12-month eligibility period; Change in health insurance status, such as a child enrolling in an employer-sponsored health plan; Failure to meet monthly cost-sharing obligation; Death of a child; The child permanently moves out of the state; and Data match with the Medicaid system indicates dual enrollment in Medicaid and CHIP. If a child is disenrolled from CHIP, the child loses his or her CHIP eligibility and must re-apply for a determination of CHIP eligibility in the future. Regardless of the reason for retroactive disenrollment, recoupment of premium payments by HHSC shall be in accordance with section 10.05. Under no circumstances may HHSC recoup premiums paid for a period greater than two (2) months.
Sample 1Sample 2
Disenrollment Due to Loss of Eligibility. For those Members who are disenrolled because they are no longer eligible for CHIP, CONTRACTOR will receive from the Administrative Services Contractor notice informing CONTRACTOR that the Members' coverage will end on a particular date. Disenrollment due to loss of eligibility includes, but is not limited to:
Sample 1
Disenrollment Due to Loss of Eligibility. “For those Members who are disenrolled because they are no longer eligible for CHIP, CONTRACTOR will receive from the Administrative Services Contractor notice informing CONTRACTOR that the Members’ coverage will end on a particular date. Disenrollment due to loss of eligibility includes, but is not limited to: • “Aging-out” when a child turns nineteen; • Failure to re-enroll at the conclusion of the 6-month term of coverage; • Change in health insurance status, such as a child enrolling in an employer-sponsored health plan; • Failure to meet monthly cost-sharing obligation; • Death of a child; • The child permanently moves out of the state; and • Data match with the Medicaid system indicates dual enrollment in Medicaid and CHIP. In most cases, if a child is disenrolled from CHIP, the child loses his or her CHIP eligibility and will have to re-apply for a determination of CHIP eligibility. Children not subject to re-application include, but are not necessarily limited to: Children who meet reinstatement requirements after disenrollment due to failure to meet cost-share obligation; and, Children who successfully re-enroll in the first month after disenrollment due to failure to re-enroll by the conclusion of their 6-month term of coverage. Regardless of the reason for retroactive disenrollment, recoupment of premium payments by HHSC shall be in accordance with section 10.05. Under no circumstances may HHSC recoup premiums paid for a period greater than two (2) months.”
Sample 1

Related to Disenrollment Due to Loss of Eligibility

  • Determination of Eligibility The Plan Administrator shall determine the eligibility of each Employee for participation in the Plan based upon information provided by the Employer. Such determination shall be conclusive and binding on all individuals except as otherwise provided herein or by operation of law.

  • 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 needs.

  • Employment Eligibility Verification As required by IC § 22-5-1.7, the Contractor swears or affirms under the penalties of perjury that the Contractor does not knowingly employ an unauthorized alien. The Contractor further agrees that: A. The Contractor shall enroll in and verify the work eligibility status of all his/her/its newly hired employees through the E-Verify program as defined in IC § 22-5-1.7-3. The Contractor is not required to participate should the E-Verify program cease to exist. Additionally, the Contractor is not required to participate if the Contractor is self-employed and does not employ any employees. B. The Contractor shall not knowingly employ or contract with an unauthorized alien. The Contractor shall not retain an employee or contract with a person that the Contractor subsequently learns is an unauthorized alien. C. The Contractor shall require his/her/its subcontractors, who perform work under this Contract, to certify to the Contractor that the subcontractor does not knowingly employ or contract with an unauthorized alien and that the subcontractor has enrolled and is participating in the E-Verify program. The Contractor agrees to maintain this certification throughout the duration of the term of a contract with a subcontractor. The State may terminate for default if the Contractor fails to cure a breach of this provision no later than thirty (30) days after being notified by the State.

  • Student Eligibility The LEA and POSTSECONDARY INSTITUTION shall qualify and advise candidates for dual credit from the pool of eligible high school students. A candidate for dual credit is eligible for consideration for fall, spring, and summer semesters if he or she: a. is enrolled during the fall and spring in a LEA in one-half or more of the minimum course requirements approved by PED for public school students under its jurisdiction or by being in physical attendance at a bureau of Indian education-funded high school at least three documented contact hours per day pursuant to 25 CFR 39.211(c); b. obtains permission from the LEA representative (in consultation with the student’s individualized education program team, as needed), the student’s parent or guardian if the student is under 18 years old, and POSTSECONDARY INSTITUTION representative prior to enrolling in a dual credit course; and c. meets POSTSECONDARY INSTITUTION requirements to enroll as a dual credit student.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!