Disenrollment Due to Loss of Eligibility Clause Samples

The "Disenrollment Due to Loss of Eligibility" clause defines the process by which a participant is removed from a program or plan when they no longer meet the required eligibility criteria. Typically, this clause outlines the specific events or changes in status—such as aging out, changes in employment, or loss of dependent status—that trigger disenrollment, and may specify notification procedures or effective dates for coverage termination. Its core function is to ensure that only qualified individuals remain enrolled, thereby maintaining compliance with program rules and preventing unauthorized access to benefits or services.
Disenrollment Due to Loss of Eligibility. In addition to the reasons outlined in the PACE Agreement, Appendix G, and 42
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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.
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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.
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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:
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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.”
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Related to Disenrollment Due to Loss of Eligibility

  • Loss of Eligibility If a Member no longer meets the eligibility requirements and is not enrolled for continuation coverage as described in Subsection G. below, coverage will terminate at the end of the month during which the loss of eligibility occurs, unless otherwise specified by the Group.

  • 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.

  • Compensatory Time Eligibility The Employer may grant compensatory time in lieu of cash payment for overtime to an overtime-eligible employee, upon agreement between the Employer and the employee. Compensatory time must be granted at the rate of one and one-half (1-1/2) hours of compensatory time for each hour of overtime worked.

  • Dependent Eligibility For all programs covered in this article, eligible dependents are an employee’s lawful spouse or domestic partner (as defined by Section 297 of the California Family Code), and unmarried children (natural, step, adopted, legal guardianship, and/or ▇▇▇▇▇▇) of the employee or domestic partner, who are qualified IRS dependents of the employee or domestic partner, up to twenty-three (23) years of age. Disabled dependents may be able to continue coverage beyond the limiting age if the disability occurred while the dependent was covered under a County-sponsored medical plan or prior to the dependent’s 19th birthday, and is certified by a licensed physician.

  • Verification of Employment Eligibility By executing this Agreement, Consultant verifies that it fully complies with all requirements and restrictions of state and federal law respecting the employment of undocumented aliens, including, but not limited to, the Immigration Reform and Control Act of 1986, as may be amended from time to time, and shall require all subconsultants and sub-subconsultants to comply with the same.