Common use of Disenrollment Initiated by Contractor Clause in Contracts

Disenrollment Initiated by Contractor. (A) The Contractor may not terminate an Enrollee’s enrollment because of an adverse change in the Enrollee’s health or because of the Enrollee’s utilization of Covered Services. (B) The Contractor may initiate disenrollment of any Enrollee for one or more of the following reasons: (1) For reasons specifically identified in the Contractor’s approved Enrollee handbook; (2) When the Enrollee ceases to be eligible for medical assistance under the State’s Title XXI State Plan and as finally determined by the Department; (3) Upon expiration of the Contractor’s Contract with the Department; (4) Confinement of an Enrollee in an institution when confinement is not a Covered Service under this contract; (5) Violation of enrollment requirements developed by the Contractor and approved by the Department but only after the Contractor and/or the Enrollee has exhausted the Contractor’s applicable internal Grievance procedure; or (6) When the Contractor has determined that the Enrollee has other valid health insurance coverage. (C) To initiate disenrollment of an Enrollee’s participation in the Contractor’s Dental Plan, the Contractor shall provide the Department with documentation justifying the proposed disenrollment. (1) The Department shall approve or deny the disenrollment request by email or in writing within thirty days of receipt of the request. Failure by the Department to deny a disenrollment request within thirty days shall constitute an approval of the Contractor’s disenrollment request. (2) If the Department approves the Contractor’s disenrollment request, the Contractor shall give the Enrollee thirty days written notice of the proposed disenrollment, and shall notify the Enrollee of his or her right to file a

Disenrollment Initiated by Contractor. (A) The Contractor may not terminate an Enrollee’s enrollment because of an adverse change in the Enrollee’s health or because of the Enrollee’s utilization of Covered Services. (B) The Contractor may initiate disenrollment of any Enrollee for one or more of the following reasons: (1) For reasons specifically identified in the Contractor’s approved Enrollee handbook; (2) When the Enrollee ceases to be eligible for medical assistance under the State’s Title XXI State Plan and as finally determined by the Department; (3) Upon expiration of the Contractor’s Contract with the Department; (4) Confinement of an Enrollee in an institution when confinement is not a Covered Service under this contract; (5) Violation of enrollment requirements developed by the Contractor and approved by the Department but only after the Contractor and/or the Enrollee has exhausted the Contractor’s applicable internal Grievance procedure; or (6) When the Contractor has determined that the Enrollee has other valid health insurance coverage. (C) To initiate disenrollment of an Enrollee’s participation in the Contractor’s Dental Health Plan, the Contractor shall provide the Department with documentation justifying the proposed disenrollment. (1) The Department shall approve or deny the disenrollment request by email or in writing within thirty days of receipt of the request. Failure by the Department to deny a disenrollment request within thirty days shall constitute an approval of the Contractor’s disenrollment request. (2) If the Department approves the Contractor’s disenrollment request, the Contractor shall give the Enrollee thirty days written notice of the proposed disenrollment, and shall notify the Enrollee of his or her right to file a