Common use of Disenrollment Clause in Contracts

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.

Disenrollment. 2.3.2.1. The Contractor shall: : 2.3.2.1.1. 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 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 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; ; 2.3.2.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; ; 2.3.2.1.3. 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; ; 2.3.2.1.4. Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; ; 2.3.2.1.5. 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: : 2.3.2.1.5.1. 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.

Disenrollment. 2.3.2.1. The Contractor shall: : 2.3.2.1.1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s Contractor‘s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related 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 fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s 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; ; 2.3.2.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; ; 2.3.2.1.3. 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; ; 2.3.2.1.4. Not interfere with the Enrollee’s Enrollee‘s right to disenroll through threat, intimidation, pressure, or otherwise; ; 2.3.2.1.5. Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s Enrollee‘s health status or because of the Enrollee’s 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: : 2.3.2.1.5.1. The Enrollee’s Enrollee‘s continued enrollment seriously impairs the Contractor’s Contractor‘s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee’s 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.

Disenrollment. The Contractor shallshall process an Enrollee disenrollment under the following conditions, and shall report quarterly the reason for which disenrollment occurred A. Disenrollment of an MCE Enrollee is mandatory when: 1) In accordance with Medicaid law and policy; such reasons include: Have a mechanism Enrollee has been determined to be unable to provide documentation of citizenship; Enrollee does not provide or no longer meets program eligibility requirements; Enrollee exceeds income limits allowed for receiving timely information about all disenrollments the program; Enrollee voluntarily disenrolls from the Contractor’s One Care Plan, including program; Enrollee is institutionalized in an Institutions for Mental Diseases (IMD); Enrollee attains the age of 65; Enrollee is no longer living; or 2) If Enrollee no longer resides in the county participating in the MCE program. B. Disenrollment of an HCCI Enrollee is mandatory when: 1) Enrollee has been determined to be unable to provide documentation of citizenship; 2) Enrollee does not provide or no longer meets program eligibility requirements 3) Enrollee exceeds income limits allowed for the program; 4) Enrollee voluntarily disenrolls from the program 5) Enrollee no longer resides in the county participating in the HCCI program; 6) Enrollee becomes incarcerated or is institutionalized in an IMD; 7) Enrollee attains the age of 65; 8) Enrollees no longer living; or 9) Enrollee obtains other health coverage. C. Enrollee may voluntarily disenroll without cause at any time by submitting an oral or written request for disenrollment to the LIHP. D. Disenrollment shall become effective promptly upon receipt by Contractor of all documentation necessary to process the disenrollment. The effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related transactions will an approved disenrollment must be performed by no later than 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 first day of the second month will be effective on following the disenrollment request. On the first calendar day after enrollment ceases, Contractor is relieved of the following month; Be responsible for ceasing the provision of all obligations to provide 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.

Disenrollment. The Contractor shall: Have a mechanism PM shall provide primary care and management of other health care needs to all enrollees until disenrollment pursuant to the following provisions: A. Requests for receiving timely information about all disenrollments from disenrollment by an enrollee or the ContractorPM shall be processed by the department or the enrollment broker. B. An enrollee or an enrollee’s One Care Planrepresentative may request disenrollment by submitting an oral or written request to the department or the enrollment broker: 1. Without cause, including at the effective following times: a. During the 90 days following the date of disenrollmentthe enrollee’s initial enrollment with PM, 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 date of notice of the enrollment, whichever is later. b. At least once every 12 months thereafter. c. Upon automatic reenrollment under section IV D 3 of this agreement, if the temporary loss of Medicaid eligibility has caused the member to miss the annual disenrollment opportunity. d. When the Department imposes the intermediate sanction of granting enrollees the right to terminate enrollment without cause. 2. 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 for 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 causes: a. The enrollee moves out of the Service Area PM's service area. b. The PM does not, because of moral or religious objections, provide the service the enrollee seeks. c. Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the enrollee's health care needs. C. The department shall give all enrollees and enrollee’s representatives written notice of disenrollment rights at least 60 days before the start of each enrollment period. The department shall also give written or oral notice of disenrollment rights to any enrollee or representative upon receipt of any complaint from the enrollee or representative. The PM shall refer any and all requests for whom residence disenrollment from an enrollee or representative to the department or the enrollment broker. D. The department or enrollment broker will approve or disapprove a request for disenrollment by an enrollee or representative based on the following: 1. Reasons cited in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with request. 2. Any information provided by PM at the EnrolleeDepartment or enrollment broker’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request. 3. Any of the reasons specified in V B 2. E. The PM may request the disenrollment of any Enrollee due an enrollee as follows: 1. Requests for disenrollment by the PM must be submitted to an adverse change the department or enrollment broker in writing and must specify one or more of the Enrollee’s health status or following reasons for disenrollment: a. Failure to develop a provider/patient relationship b. the enrollee has moved out of the PM's service area; c. the PM does not, because of moral or religious objections, provide 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 service the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for enrollee seeks; or d. the following reason: The Enrollee’s continued enrollment of the enrollee seriously impairs the ContractorPM’s ability to furnish services to either this Enrollee the enrollee or other Enrolleesenrollees. 2. Requests for disenrollment by the PM must include a written assurance that the disenrollment is being requested for the reason or reasons stated and not for any other reason. 3. The PM will not request disenrollment based on the member’s health status or need for health care services, provided the Enrollee’s behavior is determined to be unrelated to because of an adverse change in the Enrolleeenrollee's health status, or because of the Enrolleeenrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsneeds (except when his or her continued enrollment seriously impairs the PM’s ability to furnish services to either the enrollee or other enrollees). 4. The PM will not request disenrollment solely on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, mental or physical disability, political belief or veteran status. F. The effective date of an approved disenrollment shall be no later than the first day of the second month following the month in which the enrollee or PM files the request. If the department or enrollment broker fails to make the determination within this timeframe, the disenrollment is considered approved. G. An enrollee who requested disenrollment and is dissatisfied with a department or enrollment broker determination that there is not good cause for disenrollment may appeal to the department pursuant to 441 Iowa Administrative Code chapter 7.

Disenrollment. ‌ The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen 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 sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if 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 participant exhibits uncooperative or disruptive behavior resulting that results from his or his/her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, needs with the following exception: a) Due to the Contract Management Team (CMT) to disenroll an Enrolleeparticipant’s uncooperative or disruptive behavior, for cause, for the following reason: The Enrolleeparticipant’s continued enrollment in the IRIS program seriously impairs the ContractorICA’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 verify health status, or because and safety of the Enrollee's utilization of medical services, diminished mental capacity, participant or uncooperative or disruptive behavior resulting from his or her special needsothers.

Disenrollment. A Member must be disenrolled from the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident. For the purposes of determining eligibility for MississippiCAN, PRTFs and ICF/IIDs shall not be considered a long term care facility; 5. Xxxxxxx enrolled in a waiver program; 6. Becomes eligible for Medicare coverage; or 7. Is diagnosed with hemophilia. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the calendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination by the first day of the second month following monththe month in which the enrollee requests disenrollment or the Contractor refers the request to the Division, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; Be responsible poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for ceasing Disenrollment must be directed to the provision of Covered Services to an Enrollee upon the Division either orally or in writing. The effective date of disenrollment; Notify EOHHS of any individual who is approved Disenrollment will be no longer eligible to remain enrolled in later than the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out first (1st) day of the Service Area second (2nd) month following the month in which the Member or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere Contractor files the request 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 needsDivision.

Disenrollment. The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planplan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related 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 plan or the Demonstration at any time and enroll in another One Care Planplan, 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 fee-for-service and a prescription drug plan Plan and to receive Medicaid services in accordance with the Commonwealth’s State state plan and any waiver programs. Disenrollments received by MassHealth or the Contractorits 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 ICO 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 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. Discretionary Involuntary Disenrollment: 42 C.F.R. § 422.74 and Sections 40.3 and 40.4 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to One Care Plans on discretionary involuntary disenrollment. This Contract, the regulation, and other guidance provide procedural and substantive requirements the Contractor must follow prior to being approved to involuntarily disenroll an Enrollee. If all of the procedural requirements are met to the satisfaction of EOHHS and CMS, EOHHS and CMS will decide whether to approve or deny each request for involuntary disenrollment based on an assessment of the particular facts associated with each request. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS’ evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall, in all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt.

Disenrollment. The Contractor shall: : 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planplan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related 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 plan or the Demonstration at any time and enroll in another One Care Planplan, 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 fee-for-service and a prescription drug plan Plan and to receive Medicaid services in accordance with the Commonwealth’s State state plan and any waiver programs. Disenrollments received by MassHealth or the Contractorits 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; ; 2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; ; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan ICO 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 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; . 4. 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. 5. EOHHS and CMS through the CMT will determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be granted based on the criteria in Section 2.3.B.4 above. EOHHS and CMS will develop a process to evaluate disenrollment requests for Enrollees whose continued enrollment seriously impairs the Contractor’s ability to furnish services to this Enrollee or other Enrollees. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS' evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall: a. In all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt; b. Provide a quarterly report to the CMT of all Enrollees who have not participated in either the Comprehensive Assessment or the care planning process or both, and whether this is because the Contractor could not locate or engage the Enrollee, because the Enrollee declined, or for another reason; 6. Transfer Enrollee record information promptly to the new provider upon written request signed by the disenrolled Enrollee; 7. If the Enrollee transfers to a plan offered by another One Care contractor, with the Enrollee’s written consent, in accordance with applicable laws and regulations, promptly transfer current Minimum Data Set-Home Care (MDS-HC) assessment information to the new One Care contractor; and 8. Notify EOHHS if the Contractor becomes aware that an Enrollee has comprehensive insurance other than Medicare or Medicaid.

Disenrollment. At the time of eligibility redetermination, the Member will be disenrolled from CHIP and the Contractor if the Member: 1. No longer qualifies for CHIP under the eligibility categories in the eligible population; or 2. Becomes eligible for Medicaid coverage; 3. Becomes institutionalized in a public institution or enrolled in a waiver program; or 4. Becomes eligible for Medicare coverage. At any time, the Member must be disenrolled from CHIP and the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is identified as pregnant and verified by the Division; 3. Is determined to have Creditable Coverage by the Division; 4. Is deceased; or 5. Becomes a Custodial Nursing Home resident. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the following month; Be responsible calendar month for ceasing which the provision Disenrollment appears on the Member Listing Report. The Contractor must notify the Division of Covered Services Members identified with a diagnosis related to an Enrollee upon the effective date pregnancy within seven (7) calendar days of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidanceidentification through a report, in order a format and manner to be specified by the Division. If the Member is determined to be eligible for EOHHS Medicaid, the Division will transmit a termination of eligibility date 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 Contractor, along with the Enrollee’s right to disenroll through threatcode indicating the reason for termination, intimidation, pressure, or otherwise; Not via the eligibility/enrollment update. Coverage will continue until such time as the Contractor receives a termination code from the Division. The Contractor may not request the disenrollment of any Enrollee due to a Member because of 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 EnrolleeMember's health status, or because of the Enrollee's Members’ utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his the Member’s special needs except when the Member’s continued enrollment in the Contractor impairs the Contractor's ability to furnish services to either this particular Member or her special other Member(s). The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor and Enrollment into another Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs; or 6. When the Division imposes intermediate sanctions, as defined by 42 U.S.C. § 1396u-2; on the Contractor and allows Members to disenroll without cause. In this event, Contractor shall be responsible for Member notification of ability to disenroll without cause. Member requests for Disenrollment must be directed to the Division in writing. The effective date of any approved Disenrollment will be no later than the first (1st) day of the second (2nd) month following the month in which the Member or the Contractor files the request with the Division. If the Division fails to make a disenrollment determination within the specified time frames, the disenrollment will be considered approved.

Disenrollment. ‌ The Contractor shall: : 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planplan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related 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 plan or the Demonstration at any time and enroll in another One Care Planplan, 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 fee-for-service and a prescription drug plan Plan and to receive Medicaid services in accordance with the Commonwealth’s State state plan and any waiver programs. Disenrollments received by MassHealth or the Contractorits 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; ; 2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; ; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan ICO 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 plan Service Area cannot be confirmed for more than six (6) consecutive months; ; 4. Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; ; 5. 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: : a. 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.

Disenrollment. 1. The Contractor shall: Have a mechanism for receiving timely : a. On each business day, obtain from EOHHS, via the HIPAA 834 Enrollment File, and process information about pertaining to all disenrollments from Enrollee disenrollments, including the Effective Date of Disenrollment and disenrollment reason code; b. No later than 30 days prior to the Enrollee’s MassHealth redetermination date, and at the Contractor’s One Care Plandiscretion, including contact the effective date of disenrollment, from CMS Enrollee 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 provide assistance (if they meet applicable eligibility requirements); or may elect required) to receive complete and return to MassHealth the redetermination form; c. At a minimum, continue to provide ACO Covered Services, and all other services required under this Contract, to Enrollees 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 11:59 p.m. on the first calendar day Effective Date of the following month; Be responsible Disenrollment, as specified by EOHHS; d. Demonstrate a satisfactorily low voluntary Enrollee disenrollment rate, as determined by EOHHS, as compared with other MassHealth Accountable Care Partnership Plans and MassHealth-contracted MCOs for ceasing the provision of Covered Services to an Enrollees in comparable Rating Categories; 2. The Contractor’s Request for 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 canDisenrollment a. The Contractor shall not 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 because of: 1) an adverse change in the Enrollee’s health status or because of status; 2) the Enrollee’s utilization of treatment plan, medical services, including but not limited to the Enrollee making treatment decisions with which a provider or the Contractor disagrees (such as declining treatment or diagnostic testing); 3) missed appointments by the Enrollee; 4) the Enrollee’s diminished mental capacity, or or 5) the Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to needs (except when the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment with the Contractor seriously impairs the Contractor’s ability to furnish services to either this the particular Enrollee or other Enrollees). b. As further specified by EOHHS and in accordance with 130 CMR 508.003(D), provided the Enrollee’s behavior is determined Contractor may submit a written request to be unrelated EOHHS to disenroll an adverse change Enrollee as follows: 1) The Contractor shall submit the written request in a form and format specified by EOHHS and accompanied by supporting documentation specified by EOHHS; 2) The Contractor shall follow all policies and procedures specified by EOHHS relating to such request, including but not limited to the Enrollee's health statusfollowing: a) The Contractor shall take all serious and reasonable efforts specified by EOHHS prior to making the request. Such efforts include, but are not limited to: (i) attempting to provide Medically Necessary ACO Covered Services to the particular Enrollee through at least three PCPs or because of other relevant Network Providers that: (a) Meet the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.access requirements specified in Section

Disenrollment. ‌ At the time of eligibility redetermination, the Member will be disenrolled from CHIP and the Contractor if the Member: 1. No longer qualifies for CHIP under the eligibility categories in the eligible population; or 2. Becomes eligible for Medicaid coverage; 3. Becomes institutionalized in a public institution or enrolled in a waiver program; or 4. Becomes eligible for Medicare coverage. At any time, the Member must be disenrolled from CHIP and the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is identified as pregnant and verified by the Division; 3. Is determined to have Creditable Coverage by the Division; 4. Is deceased; or 5. Becomes a Custodial Nursing Home resident. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the following month; Be responsible calendar month for ceasing which the provision Disenrollment appears on the Member Listing Report. The Contractor must notify the Division of Covered Services Members identified with a diagnosis related to an Enrollee upon the effective date pregnancy within seven (7) calendar days of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidanceidentification through a report, in order a format and manner to be specified by the Division. If the Member is determined to be eligible for EOHHS Medicaid, the Division will transmit a termination of eligibility date 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 Contractor, along with the Enrollee’s right to disenroll through threatcode indicating the reason for termination, intimidation, pressure, or otherwise; Not via the eligibility/enrollment update. Coverage will continue until such time as the Contractor receives a termination code from the Division. The Contractor may not request the disenrollment of any Enrollee due to a Member because of 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 EnrolleeMember's health status, or because of the Enrollee's Members’ utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his the Member’s special needs except when the Member’s continued enrollment in the Contractor impairs the Contractor's ability to furnish services to either this particular Member or her special other Member(s). The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor and Enrollment into another Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs; or 6. When the Division imposes intermediate sanctions, as defined by 42 U.S.C. § 1396u-2; on the Contractor and allows Members to disenroll without cause. In this event, Contractor shall be responsible for Member notification of ability to disenroll without cause. Member requests for Disenrollment must be directed to the Division in writing. The effective date of any approved Disenrollment will be no later than the first (1st) day of the second (2nd) month following the month in which the Member or the Contractor files the request with the Division. If the Division fails to make a disenrollment determination within the specified time frames, the disenrollment will be considered approved.

Disenrollment. An Enrollee may initiate disenrollment from the Contractor’s program for any reason and at any time. An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor shallContractor: Have Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planprogram, including the effective date of disenrollment, from CMS and MassHealth EOHHS 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 and approved by the last calendar business day of the month will be effective on the first calendar day of the following month; Be Must 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 May request that an Enrollee remains be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining 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 or If approved in advance by EOHHS, when the EnrolleeContractor’s right ability to disenroll through threat, intimidation, pressure, furnish services to the Enrollee or otherwiseto other Enrollees is seriously impaired; Not and May not request that an Enrollee be involuntarily disenrolled for any of the disenrollment of any Enrollee due to an following reasons: An adverse change in the Enrollee’s health status or because of the status; The Enrollee’s utilization of treatment plan, medical services, ; The Enrollee’s diminished mental capacity, ; or The Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to (except when 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 the Enrollee or other Enrollees); and Must transfer Enrollee record information to the new Provider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment for Enrollees for any amount of time without 30 calendar days advance notice and the approval of EOHHS. Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with the federal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or medications. Be developed by the PCP or PCT under the direction of the Enrollee (and/or the Enrollee’s behavior is determined representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be unrelated at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to an adverse change prepare for and fully participate in the Enrollee's care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/her health status, or because including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is not limited to: A summary of the Enrollee's utilization ’s health history; A prioritized list of medical servicesconcerns, diminished mental capacitygoals, and strengths; The plan for addressing concerns or uncooperative goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or disruptive behavior resulting from otherwise convey approval of his or her special ICP when it is developed and at the time of subsequent modifications to it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Accepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the ASAP and the ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the Contractor’s Service Area, the Contractor may: Contract with all of the ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the Contractor; Coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services; Monitoring the provision and outcomes of community long-term care and support services, according to the enrollee's service plan, and making periodic adjustments to the enrollee's service plan as deemed appropriate by the primary care team; Tracking enrollee transfer from one setting to another; and Scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee's care plan. Other care management related activities as may be determined and contracted for by the Contractor.

Disenrollment. The Contractor shall: Have a mechanism PM shall provide primary care and management of other health care needs to all enrollees until disenrollment pursuant to the following provisions. A. Requests for receiving timely information about all disenrollments from disenrollment by an enrollee or the ContractorPM shall be processed by the Department or the enrollment broker. B. An enrollee or an enrollee’s One Care Planrepresentative may request disenrollment by submitting an oral or written request to the Department or the enrollment broker: 1. Without cause, including at the effective following times: a. During the 90 days following the date of disenrollmentthe enrollee’s initial enrollment with PM, 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 date of notice of the enrollment, whichever is later. b. At least once every 12 months thereafter. c. Upon automatic reenrollment under section IV D 3 of this agreement, if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. d. When the Department imposes the intermediate sanction of granting enrollees the right to terminate enrollment without cause. 2. 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 for 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 causes: a. The enrollee moves out of the Service Area PM's service area. b. The PM does not, because of moral or religious objections, provide the service the enrollee seeks. c. Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the enrollee's health care needs. C. The Department shall give all enrollees and enrollees representatives written notice of disenrollment rights at least 60 days before the start of each enrollment period. The Department shall also give written or oral notice of disenrollment rights to any enrollee or representative upon receipt of any complaint from the enrollee or representative. The PM shall refer any and all requests for whom residence disenrollment from an enrollee or representative to the Department or the enrollment broker. D. The Department or enrollment broker will approve or disapprove a request for disenrollment by an enrollee or representative based on the following: Reasons cited in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with request. Any Information provided by PM at the EnrolleeDepartment or enrollment broker’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request. Any of the reasons specified in V B 2. E. The PM may request the disenrollment of any Enrollee due an enrollee as follows: Requests for disenrollment by the PM must be submitted to an adverse change the Department or enrollment broker in writing and must specify one or more of the Enrollee’s health status or following reasons for disenrollment: failure to develop a provider/patient relationship; the enrollee has moved out of the PM's service area; the PM does not, because of moral or religious objections, provide the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, service the enrollee seeks; 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 of the enrollee seriously impairs the ContractorPM’s ability to furnish services to either this Enrollee the enrollee or other Enrolleesenrollees. Requests for disenrollment by the PM must include a written assurance that the disenrollment is being requested for the reason or reasons stated and not for any other reason. The PM will not request disenrollment based on the recipient's health status or need for health care services, provided the Enrollee’s behavior is determined to be unrelated to because of an adverse change in the Enrolleeenrollee's health status, or because of the Enrolleeenrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsneeds (except when his or her continued enrollment seriously impairs the PM’s ability to furnish services to either the enrollee or other enrollees). The PM will not request disenrollment solely on the basis of age, race, creed, color, sex, physical or mental disability, health status, national origin, religion, or political affiliation. F. The effective date of an approved disenrollment shall be no later than the first day of the second month following the month in which the enrollee or PM files the request. If the Department or enrollment broker fails to make the determination within this timeframe, the disenrollment is considered approved. G. An enrollee who requested disenrollment and is dissatisfied with a Department or enrollment broker determination that there is not good cause for disenrollment may appeal to the Department pursuant to 441 Iowa Admin. Code ch. 7.

Disenrollment. The Contractor shall: Have In certain circumstances, a mechanism Member may be disenrolled on either a voluntary or involuntary basis. Group and Health Plan will work cooperatively to ensure that Member disenrollments are handled in accordance with the CMS Enrollment and Disenrollment Guidance. At a minimum, disenrollments will be conducted in accordance with one of the following procedures: a. For voluntary disenrollments other than described in (c) below and for receiving timely information about all involuntary disenrollments from other than those described in (b) below, Health Plan will process the Contractor’s One Care disenrollment under the individual disenrollment requirements specified in the CMS Enrollment and Disenrollment Guidance. b. For involuntary disenrollments that occur when the Group determines that a Member is no longer eligible to participate in the Group MA Plan, Group shall follow the below process, as applicable. Group and Health Plan also agree: i. Group will (including in cases where Health Plan or Group terminates this Agreement): (1) Provide a prospective notice to the affected Member(s): alerting them of the termination event and describing other health plan or health insurance options that may be available through Group. This notice must be received by the member no less than twenty-one (21) days prior to the effective date of disenrollment. (2) Provide a prospective notice of the termination event to Health Plan. This notice must be sent one hundred twenty (120) days prior to the effective date of disenrollment; and (3) Provide Health Plan with all information necessary for Health Plan to submit a complete disenrollment request transaction to CMS. c. Health Plan may accept a voluntary disenrollment request directly from Group without receiving an election form from each employee or retiree. Group agrees that in order to use this process: i. Group must submit to Health Plan information that accurately reflects Group’s record of the disenrollment made by each Member. Health Plan must maintain its record of information received from Group for ten (10) years or through the date of the completion of any CMS audit, whichever is later. ii. Group and Health Plan’s electronic disenrollment transactions must, at a minimum, comply with CMS electronic security policies. iii. Health Plan’s receipt date for the disenrollment request will be the date Group’s record of a Member’s disenrollment choice is received by Health Plan. The effective date of disenrollment cannot be prior to receipt date. iv. Group’s record of the request to disenroll must exist in a format that can be easily, accurately and quickly reproduced for later reference by each individual member, Health Plan and/or CMS, as necessary. Group shall include that record when Group sends its next weekly file to Health Plan. Health Plan shall maintain Group’s record of the request to disenroll for at least ten (10) years after the effective date of the individual’s disenrollment or through the date of the completion of any CMS audit, whichever is later. d. Group agrees to retain, for a period of ten (10) years from 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 provide to an Enrollee Health Plan 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, documents evidencing Group’s adherence 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 requirements set forth in 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 needsArticle VII.

Disenrollment. ‌ A Member must be disenrolled from the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident or a resident of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). For the purposes of determining eligibility for MississippiCAN, PRTFs shall not be considered a long term care facility; 5. Becomes institutionalized in a facility that is not a Psychiatric Residential Treatment Facility (PRTF); 6. Becomes enrolled in a waiver program; 7. Becomes eligible for Medicare coverage; or 8. Is diagnosed with hemophilia. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the following monthcalendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination within the specified timeframes, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; Be responsible poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for ceasing Disenrollment must be directed to the provision of Covered Services to an Enrollee upon the Division either orally or in writing. The effective date of disenrollment; Notify EOHHS of any individual who is approved Disenrollment will be no longer eligible to remain enrolled in later than the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out first (1st) day of the Service Area second (2nd) month following the month in which the Member or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere Contractor files the request 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 needsDivision.

Disenrollment. An Enrollee may initiate disenrollment from the Contractor’s program for any reason and at any time. An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor shallContractor: Have Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planprogram, including the effective date of disenrollment, from CMS and MassHealth EOHHS 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 and approved by the last calendar business day of the month will be effective on the first calendar day of the following month; Be Must 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 May request that an Enrollee remains be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining 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 or If approved in advance by EOHHS, when the EnrolleeContractor’s right ability to disenroll through threat, intimidation, pressure, furnish services to the Enrollee or otherwiseto other Enrollees is seriously impaired; Not and May not request that an Enrollee be involuntarily disenrolled for any of the disenrollment of any Enrollee due to an following reasons: An adverse change in the Enrollee’s health status or because of the status; The Enrollee’s utilization of treatment plan, medical services, ; The Enrollee’s diminished mental capacity, ; or The Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to (except when 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 the Enrollee or other Enrollees); and Must transfer Enrollee record information to the new Provider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment for Enrollees for any amount of time without 30 calendar days advance notice and the approval of EOHHS. Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with the federal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or medications. Be developed by the PCP or PCT under the direction of the Enrollee (and/or the Enrollee’s behavior representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to prepare for and fully participate in the care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/her health status, including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is determined not limited to: A summary of the Enrollee’s health history; A prioritized list of concerns, goals, and strengths; The plan for addressing concerns or goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or otherwise convey approval of his or her ICP when it is developed and at the time of subsequent modifications to be unrelated it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an adverse Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Accepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the ASAP and the ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the Contractor’s Service Area, the Contractor may: Contract with all of the ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Other care management related activities as may be determined and contracted for by the Contractor. If there is only one ASAP operating in the Contractor’s service area and the Contractor identifies any of the following deficiencies in the performance of the ASAP with which it has contracted, the Contractor must follow the procedure in Section 2.4.A.5.e. The ASAP does not meet its responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor; The ASAP does not satisfy clinical or administrative performance standards, based on a performance review evaluation by the Contractor and subsequent failure by the ASAP to correct documented deficiencies; or The ASAP meets its basic responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor, but is substantially less qualified than other ASAPs. The Contractor and an ASAP may enter into any appropriate reimbursement relationship for GSSC services, such as fee-for-service reimbursement, capitation, or partial capitation. If the Contractor is unable to execute or maintain a contract with any of the ASAPs operating in its Service Area due to lack of agreement on reimbursement-related issues, the Contractor must collaborate with EOHHS and EOEA to explore all reasonable options for reconciling financial differences, before terminating or failing to initiate a contract. If the Contractor fails to execute a contract with an ASAP operating in its service area, or determines that it must terminate a contract with an ASAP, and that is the only ASAP operating in its service area, the Contractor must follow the procedure in Section 2.4.A.5.e. The Contractor will cooperate with EOHHS and the Executive Office of Elder Affairs to ensure any claims submitted by the ASAPs are accepted and processed through a standardized system. The Contractor must ensure GSSC services are not duplicated by other care management functions delivered by the Contractor, Providers or other subcontractors and that care management is only counted once for each member in the Medicaid-only MLR calculation, as that term is defined in Section 2.13.Q.1. If the Contractor has identified any of the deficiencies set forth in Section 2.4.A.5.c; is unable to execute a contract with an ASAP; or determines that it must terminate a GSSC contract with an ASAP, and that is the only ASAP that operates in the Contractor’s Service Area; the Contractor must notify EOHHS in writing, within five business days of the triggering event, with detailed specific findings of fact that indicate the deficiencies. If EOHHS finds that the Contractor’s reasons are not substantiated with sufficient findings, EOHHS will develop a corrective action plan for the Contractor that ensures continuation of GSSC services and specifies the actions the Contractor will take. Nothing in this Section 2.4.A.5 precludes the Contractor from entering into a subcontracting relationship with any ASAP for functions beyond those required by M.G.L. c. 118E § 9D, including, but not limited to: Providing community-based services, such as homemaker, chore, and respite services; Performing initial and on-going assessments; and Conducting risk-assessment and care-planning activities regarding non-medical service needs of Enrollees without Complex Care Needs. Integration and Coordination of Services The Contractor must ensure effective linkages of clinical and management information systems among all Providers in the Provider Network, including clinical Subcontractors (that is, acute, specialty, behavioral health, and long term care Providers). The Contractor must ensure that the PCP or the PCT integrates and coordinates services including, but not limited to: An IPC, as described in Section 2.4.A.2 of this Contract; Written protocols for generating or receiving referrals and for recording and tracking the results of referrals; Written protocols for providing or arranging for second opinions, whether in or out of the Provider Network; Written protocols for sharing clinical and IPC information, including management of medications; Written protocols for determining conditions and circumstances under which specialty services will be provided appropriately and without undue delay to Enrollees who do not have established Complex Care Needs; Written protocols for obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers in the Provider Network, and with CMS and EOHHS for quality management and program evaluation purposes; Coordinating the services the Contractor furnishes to the Enrollee between settings of care, including appropriate discharge planning for short- and long-term hospital and institutional stay; and Coordinating services provided by the Contractor with the services: The Contractor shall ensure that each Enrollee receives the contact information for the person or entity primarily responsible for coordinating the Enrollee’s care and services, whether that is the PCP or his or her designee on the PCT. Coordinating Access for Emergency Conditions and Urgent Care Services The Contractor must ensure linkages among the PCP, the PCT, and any appropriate acute, long term care, or behavioral health Providers to keep all parties informed about utilization of services for Emergency Conditions and Urgent Care. The Contractor may not require advance approval for the following services: Any services for Emergency Conditions; Emergency behavioral health care; Urgent Care sought out of the Service Area; Urgent Care under unusual and extraordinary circumstances provided in the Service Area when the contracted medical Provider is unavailable or inaccessible; Direct-access women’s services; and Out-of-area renal dialysis services. Centralized Enrollee Record (CER) To coordinate care, the Contractor must maintain a single, centralized, comprehensive record that documents the Enrollee's health medical, functional, and social status. The Contractor must make appropriate and timely entries describing the care provided, or because diagnoses determined, medications prescribed, and treatment plans developed. The organization and documentation included in the CER must meet all applicable professional requirements. The CER must contain the following: Enrollee identifying information; Documentation of each service provided, including the date of service, the name of both the authorizing Provider and the servicing Provider (if different), and how they may be contacted; Multidisciplinary assessments, using the assessment tool designated by EOHHS, including diagnoses, prognoses, reassessments, plans of care, and treatment and progress notes, signed and dated by the appropriate Provider; Laboratory and radiology reports; Reconciled medication list; Prescribed medications, including dosages and any known drug contraindications; Reports about the involvement of community agencies that are not part of the Provider Network, including any services provided; Documentation of contacts with family members and persons giving informal support, if any; Physician orders; Disenrollment agreement, if applicable; Enrollee's utilization ’s individual advance directives and health care proxy, recorded and maintained in a prominent place; Plan for Emergency Conditions and Urgent Care, including identifying information about any emergency contact persons; and Allergies and special dietary needs Documentation of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsInitial and Ongoing Assessments; including verification that an Enrollee has received services for which Providers have billed the Contractor and in accordance with Section 2.4.A.11.b.iv.

Disenrollment. The Contractor shall: Have ICO shall have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plandisenrollments, including the effective date of disenrollment, from CMS and MassHealth systemsMDHHS or its authorized agent. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendorCMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. 423.100, Enrollees can elect to disenroll from the One Care Plan ICO or the Demonstration at any time and enroll in another One Care PlanICO, a Medicare Advantage MA-PD plan, PACE, or Senior Care Options PACE (if they meet applicable eligibility requirementseligible and the program has capacity); or may elect to receive services through Medicare fee‑for‑service FFS and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan FFS and any waiver programsprograms (if eligible). Disenrollments CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by MassHealth or the ContractorCMS, or by CMS MDHHS or its contractor authorized agent, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month; Be . The ICO shall be responsible for ceasing the provision of Covered Services to an Enrollee Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who . The ICO shall notify MDHHS if it has information that shows that an Enrollee is no longer eligible to remain enrolled in the One Care ICO per Medicare-Medicaid Plan per CMS enrollment guidanceEnrollment and Disenrollment Guidance, in order for EOHHS MDHHS to disenroll the individualEnrollee. This includes where an Enrollee Enrollee remains out of the Service Area or for whom residence in the One Care Plan ICO’s Service Area cannot be confirmed for more than six (6) consecutive months; Not . This includes where an Enrollee remains out of the Service Area, confirmed by the Enrollee or authorized representative. MDHHS will investigate and make an Enrollment decision as appropriate. Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area for more than 6 consecutive months confirmed by the Enrollee or authorized representative. It is allowable for an Enrollee residing in the Service Area to be admitted to a Nursing Facility outside the Service Area for a service that cannot be obtained in the service area (and placement is not based on the family or social situation of the Enrollee). This placement is allowable for up to six months, unless the local MDHHS updates the Enrollee address to outside of the Service Area sooner, in which case the Enrollee cannot stay enrolled in the ICO. If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. When requesting disenrollment due to out of Service Area, the ICO must be able to provide upon request, verifiable information that an Enrollee has moved out of the Service Area, verified by the Enrollee or an authorized representative. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of the ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. MDHHS will automatically disenroll the Enrollee for the next available month. Until the Enrollee is disenrolled from the ICO, the ICO will receive a Capitation Payment for the Enrollee. The ICO is responsible for all Medically Necessary Services for the Enrollee until they are disenrolled. The ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of an Enrollee who resides out of the Service Area of the ICO before the effective date of Enrollment will be considered an "enrollment error". The ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the date of Enrollment. When CMS or MDHHS is made aware that an Enrollee is incarcerated in a county jail, Michigan Department of Corrections facility, or Federal penal institution. Termination of coverage shall take effect on the first of the month of the month following the State’s confirmation of a current incarceration if the start date is not known, or the first of the month following the start date of incarceration if the start date is known. The termination or expiration of this Contract terminates coverage for all Enrollees with the ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the last day of the month following the month the Disenrollment is processed. The ICO may 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.Discretionary Involuntary Disenrollments:

Disenrollment. The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen 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 sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if 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 participant exhibits uncooperative or disruptive behavior resulting that results from his or his/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 needs with 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.exception:

Disenrollment. The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen 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 sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if 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 participant exhibits uncooperative or disruptive behavior resulting that results from his or his/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 needs with 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.exception:

Disenrollment. A Member must be disenrolled from the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident. For the purposes of determining eligibility for MississippiCAN, PRTFs and ICF/IIDs shall not be considered a long term care facility; 5. Becomes enrolled in a waiver program; 6. Becomes eligible for Medicare coverage; or 7. Is diagnosed with hemophilia. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the calendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination by the first day of the second month following monththe month in which the enrollee requests disenrollment or the Contractor refers the request to the Division, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; Be responsible poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for ceasing Disenrollment must be directed to the provision of Covered Services to an Enrollee upon the Division either orally or in writing. The effective date of disenrollment; Notify EOHHS of any individual who is approved Disenrollment will be no longer eligible to remain enrolled in later than the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out first (1st) day of the Service Area second (2nd) month following the month in which the Member or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere Contractor files the request 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 needsDivision.

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 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 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.

Disenrollment. The Contractor shall: Have a mechanism HMO must direct all members with disenrollment requests to the Enrollment Specialist for receiving timely information about all disenrollments from assistance. Disenrollment requests will be processed as soon as possible and will be effective the Contractor’s One Care Planfirst day of the next month of the request, including unless otherwise specified. The HMO will not be liable for services, as of the effective date of the disenrollment, from CMS . There are two types of disenrollment: Voluntary and MassHealth systemssystem-based. 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 Voluntary Disenrollment a. A member may voluntarily disenroll from an HMO for any reason when the One Care Plan or member is not in the Demonstration at any time and enroll lock-in another One Care Planperiod. Voluntary disenrollment requests must come from the member, a Medicare Advantage plan, PACEthe member’s family, 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 legal guardian. Voluntary disenrollment shall be effective no later than 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 first day of the second month following the month in which the member requests disenrollment. b. A member may only disenroll from an HMO when in their lock-in period for the following reasons: Upon automatic reenrollment under 42 CFR § 438.56(c) the temporary loss of BadgerCare Plus and/or Medicaid SSI enrollment has caused the member to miss the annual enrollment period. If an HMO does not, because of moral or religious objections, cover the service the member seeks. The HMO must notify the Department, at the time of certification, of any services that they would not provide due to moral or religious objections. If the member needs related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk. The SSI HMO fails to complete the assessment and care plan during the first 90 days of enrollment, and is able to demonstrate a good faith process to complete the assessment, the voluntary disenrollment period will be extended an additional 30 days. Other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member’s care needs. System Based Disenrollments System based disenrollments happen automatically in the system as a result of changes to the member’s eligibility. If an HMO believes a member should have had a system-based disenrollment but has not, the HMO may request disenrollment through the Department’s HMO Enrollment Specialists. a. Loss of BadgerCare Plus and/or Medicaid SSI Eligibility The member shall be disenrolled when a member loses BadgerCare Plus or Medicaid SSI eligibility. The date of disenrollment shall be the date of BadgerCare Plus or Medicaid SSI eligibility termination. No recoupments will be made to the capitation payment to reflect a mid-month disenrollment, but any capitation payment(s) made for months subsequent to the disenrollment month will be effective on the first calendar day recouped. b. Out-of-Service Area Disenrollment The member shall be disenrolled when a member moves to a location that is outside of the following month; Be responsible for ceasing HMO’s service area but within the provision state of Covered Services to an Enrollee upon the effective Wisconsin. The 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 disenrollment shall be the individual. This includes where an Enrollee remains out end of the Service Area or for whom residence month in which 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 needsmove occurred.

Disenrollment. ‌ A Member must be disenrolled from the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident or a resident of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). For the purposes of determining eligibility for MississippiCAN, PRTFs shall not be considered a long term care facility; 5. Becomes institutionalized in a facility that is not a Psychiatric Residential Treatment Facility (PRTF); 6. Xxxxxxx enrolled in a waiver program; 7. Becomes eligible for Medicare coverage; or 8. Is diagnosed with hemophilia. The Contractor shall: Have may request Disenrollment of 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 Member at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month reasons listed herein. The Contractor must notify the Division within three (3) calendar days of receipt of the Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first calendar (1st) day of the following monthcalendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination within the specified timeframes, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; Be responsible poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for ceasing Disenrollment must be directed to the provision of Covered Services to an Enrollee upon the Division either orally or in writing. The effective date of disenrollment; Notify EOHHS of any individual who is approved Disenrollment will be no longer eligible to remain enrolled in later than the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out first (1st) day of the Service Area second (2nd) month following the month in which the Member or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere Contractor files the request 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 needsDivision.

Disenrollment. The Contractor shall: : 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planplan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related 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 plan or the Demonstration at any time and enroll in another One Care Planplan, 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 fee-for-service and a prescription drug plan Plan and to receive Medicaid services in accordance with the Commonwealth’s State state plan and any waiver programs. Disenrollments received by MassHealth or the Contractorits 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; ; 2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; ; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan ICO 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 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; . 4. 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. 5. EOHHS and CMS through the CMT will determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be granted based on the criteria in Section 2.3.B.4 above. EOHHS and CMS will develop a process to evaluate disenrollment requests for Enrollees whose continued enrollment seriously impairs the Contractor’s ability to furnish services to this Enrollee or other Enrollees. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS' evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall: a. In all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt; b. Provide a quarterly report to the CMT of all Enrollees who have not participated in either the Comprehensive Assessment or the care planning process or both, and whether this is because the Contractor could not locate or engage the Enrollee, because the Enrollee declined, or for another reason; 6. Transfer Enrollee record information promptly to the new provider upon written request signed by the disenrolled Enrollee; 7. If the Enrollee transfers to a plan offered by another One Care contractor, with the Enrollee’s written consent, in accordance with applicable laws and regulations, promptly transfer current Minimum Data Set-Home Care (MDS-HC) assessment information to the new One Care contractor; and 8. Notify EOHHS if the Contractor becomes aware that an Enrollee has comprehensive insurance other than Medicare or Medicaid.

Disenrollment. The Contractor shall: Have Agency shall be responsible for processing disenrollments. The PDHP’s responsibility is to ensure that disenrollees who wish to file a mechanism grievance are afforded the opportunity to do so, unless the proposed disenrollment is 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 one of the following reasons: disenrollment due to moving out of the service area; disenrollment due to loss of Medicaid eligibility; and disenrollment due to death. The following are unacceptable reasons for the PDHP, on its own initiative, to request disenrollment of a member: pre-existing dental condition, changes in health status, periodically missed appointments, or utilization of services. With proper written documentation, the PDHP shall promptly submit disenrollment requests to the Agency for members who have died. The PDHP shall ensure that disenrollment documents are maintained in an identifiable member record. The PDHP must report fraudulent use of the beneficiary ID card to DCF. a. If the PDHP discovers that an ineligible beneficiary has been enrolled, then it must notify the beneficiary in writing that the beneficiary shall be disenrolled the next contract month; Be . Until the beneficiary is disenrolled, the PDHP shall be responsible for ceasing the provision of Covered Services services to an Enrollee upon that beneficiary. b. On a monthly basis, the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible PDHP shall review its enrollment report to remain enrolled ensure that all members are residing in the One Care Plan per CMS PDHP's authorized service area. For beneficiaries with out-of-service-area addresses on the enrollment guidancereport, the PDHP shall notify the beneficiary in order for EOHHS to disenroll either by telephone or in writing that the individual. This includes where an Enrollee remains out beneficiary will be disenrolled and inform the beneficiary of the Service Area requirement to update their address on file at DCF or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six Social Security Administration (6) consecutive months; Not interfere with the Enrollee’s right SSA). c. The PDHP shall assign a different dentist to disenroll through threata member whose behavior is disruptive, intimidationunruly, 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 capacityabusive, or uncooperative or disruptive behavior resulting from to the extent that his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to membership in the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment PDHP seriously impairs the Contractor’s organization's ability to furnish services to either this Enrollee the member or other Enrollees, provided members. The PDHP must maintain documentation of at least one oral and at least one written warning to the Enrollee’s behavior is determined to be unrelated to an adverse change in member regarding the Enrollee's health status, or because implications of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsactions. A written explanation of the reason for changing the primary care dentist must be given to the member. d. The PDHP shall provide disenrollment data via an Agency-approved transmission medium. Documentation must contain the following minimum information: name, address, telephone number, reason for disenrollment with brief explanation, date, and signature by PDHP staff. e. The PDHP shall keep a daily written log or electronic documentation of all oral and written enrollment change requests and the disposition of such requests. The log shall include the following: the date the request was received by the PDHP; the date of the letter advising them of the enrollment change procedure; and the reason that the member is requesting an enrollment change.

Disenrollment. An Enrollee must be dis-enrolled 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 shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plan, including the effective date may request disenrollment 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 an enrollee at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, based upon one 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 more of the month will reasons listed herein. The Contractor must notify the Division within three (3) days of their request that an Enrollee be dis-enrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first calendar day of the following month; Be responsible calendar month for ceasing which the provision of Covered Services to disenrollment appears on the Enrollee Listing Report. The Contractor shall not dis-enroll an Enrollee upon the effective date because 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 ’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his Enrollee’s special needs (except when Enrollee’s continued enrollment in the Contractor seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or her special 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 who is eligible for voluntary enrollment 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. A mandatory enrolled eligible may request one change between Contractors within the first ninety (90) days following the first date of enrollment into the health plan. Any Enrollee may request disenrollment from the Contractor for cause if the Contractor 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 be no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

Disenrollment. 2.3.5.1. The Contractor shall: : 2.3.5.1.1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care PlanMMP, including the effective date of disenrollment, from CMS and MassHealth systemsDMAS or its authorized agent. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56DMAS or its authorized agent. Enrollees can elect to disenroll from the One Care Plan MMP or the Demonstration at any time and enroll in another One Care PlanMMP, 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 fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s Virginia Medicaid State plan Plan and any waiver programsprograms (if eligible). Disenrollments received by MassHealth DMAS or the Contractorits authorized agent, or by CMS or its contractor contractor, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month; . 2.3.5.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; . 2.3.5.1.3. Notify EOHHS DMAS or its authorized agent of any individual who is no longer eligible to remain enrolled in the One Care Plan MMP per CMS enrollment Enrollment guidance, in order for EOHHS DMAS or its authorized agent to disenroll the individualEnrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan MMP Service Area cannot be confirmed for more than six (6) consecutive months; . 2.3.5.1.4. Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; ; 2.3.5.1.5. Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status status, unless they enter a hospice program, 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) CMT to disenroll an Enrollee, for cause, for the following reason: : 2.3.5.1.5.1. The Enrollee’s continued enrollment 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. 2.3.5.1.6. DMAS and CMS through the CMT will determine when and if the Contractor’s request to terminate the Enrollment of an Enrollee will be granted based on the criteria in Section

Disenrollment. 5.3.1 Disenrollment occurs only when ASES or the Medicaid Program determines that an Enrollee is no longer eligible for the GHP; or when Disenrollment is requested by the Contractor or Enrollee, and approved by ASES, as provided in Sections 5.3.4 and 5.3.5. The Xxxxxx Care Population and Domestic Violence Populations are not eligible to disenroll from their Auto-Enrolled GHP Plan. 5.3.2 Disenrollment will be effectuated by ASES, and ASES will issue notification to the Contractor. Such notice shall be delivered via file transfer to the Contractor on a Daily Basis simultaneously with Information on Potential Enrollees within five (5) Calendar Days of making a final determination on Disenrollment. Disenrollment decisions are the responsibility of ASES; however, notice to Enrollees of Disenrollment shall be issued by the Contractor. The Contractor shallshall issue such notice in person or via surface mail to the Enrollee within five (5) Business Days of a final Disenrollment decision, as provided in Sections 5.3.4 and 5.3.5. Each notice of Disenrollment shall include information concerning: Have a mechanism The Effective Date of Disenrollment; The reason for receiving timely information about all disenrollments from the ContractorDisenrollment; The Enrollee’s One Care PlanAppeal rights, including the effective date availability of disenrollmentthe Grievance and Appeal System and of ASES’s Administrative Law Hearing process, from CMS and MassHealth systems. All enrollments and disenrollment‑related transactions will be performed as provided by Act 72 of September 7, 1993; The right to re-enroll in the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll GHP upon receiving a Recertification from the One Care Plan Puerto Rico Medicaid Program, if applicable; and Disenrollment shall occur according to the timeframes in Section 5.3.3 (the “Effective Date of Disenrollment”). 5.3.3 The Effective Date of Disenrollment is as follows: Except as otherwise provided in this Section 5.3, Disenrollment will take effect as of the Effective Date of Disenrollment specified in ASES’s notice to the Contractor that an Enrollee is no longer eligible. If ASES notifies the Contractor of Disenrollment on 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 before the last calendar working day of the month in which eligibility ends, the Disenrollment will be effective on the first calendar day of the following month; Be responsible for ceasing . When Disenrollment is effected at 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 Contractor’s 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 threatrequest, intimidationas provided in Sections 5.3.4 and 5.3.5 of this Contract, pressure, or otherwise; Not request Disenrollment shall take effect no later than the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because first day of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, second month following the month that the Contractor or uncooperative or disruptive behavior resulting from his or her special needsEnrollee requested the Disenrollment. The Contractor, however, may submit If XXXX fails to make 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 decision on the Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee’s behavior request before this date, the Disenrollment will be deemed granted. If the Enrollee requests reconsideration of a Disenrollment through the Contractor’s Grievance and Appeal System, as provided in Article 14, the Grievance and Appeal System process shall be completed in time to permit the Disenrollment (if approved) to take effect in accordance with this timeframe. If what would otherwise be the Effective Date of Disenrollment under this Section 5.3.3 falls: When the Enrollee is determined to an inpatient at a hospital, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the Enrollee is discharged from the hospital, or the last day of the month following the month in which Disenrollment would otherwise be unrelated to an adverse change effective, whichever occurs earlier; During a month in which a Medicaid, CHIP or Commonwealth Enrollee is pregnant, or on the date the pregnancy ends, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the 60-day post-partum period ends; When the Enrollee is in the Enrollee's health statusprocess of appealing a Disenrollment though either the Grievance and Appeal System, ASES’s Administrative Law Hearing process, or because the Puerto Rico Medicaid Department’s dedicated hearing process on Disenrollments, as applicable, then ASES shall postpone the Effective Date of Disenrollment until a decision is rendered after the hearing; or During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the Enrollee's utilization of medical servicesfollowing month. For the public employees and pensioners who are Other Eligible Persons referred to in Section 1.3.1.2.2, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsDisenrollment shall occur according to the timeframes set forth in a Normative Letter issued by ASES annually.

Disenrollment. The Contractor shall: Have a mechanism Coverage of benefits shall end, and service fees shall be paid until the date the enrollee is no longer qualified for receiving timely information about all disenrollments from the Contractor’s One Care Planbenefits under Medicaid or Law No. 72, including the effective date of disenrollment, from CMS and MassHealth systemswhichever applies to that enrollee. All enrollments and disenrollment‑related transactions Disenrollment will be performed effected exclusively by a notification issued by the EOHHS customer service vendorADMINISTRATION. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from In 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 event of disenrollment on the last calendar day of the month of coverage while the enrollee is under inpatient status at a hospital, and the individual continues such inpatient status during the month following the enrollee’s disenrollment, the ADMINISTRATION will cover the payment of the services for that following month. However, if the enrollee remains hospitalized in subsequent months, the conversion clause of Section 2.7 of this Contract will be triggered automatically. The enrollee ceases to be eligible as of the disenrollment date specified in THE ADMINISTRATION’ report to the TPA. If the ADMINISTRATION notifies the TPA that the enrollee ceased to be eligible on or before the last working day of the month in which eligibility ceases, the disenrollment will be effective on the first calendar day of the following month; Be responsible for ceasing . Disenrollment will be effected exclusively by a notification issued and delivered by the provision ADMINISTRATION to enrollee. If following disenrollment, an enrollee’s contract is reinstated and the enrollee is re-enrolled on the same month of Covered Services to an Enrollee upon disenrollment, the effective contract will be reinstated as of the 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 individualre-enrollment. 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 The TPA/HCO has a limited right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of a enrollee from HCO services without the enrollee’s/enrollee’s consent. The ADMINISTRATION must approve any TPA/HCO disenrollment request of a enrollee for cause. Disenrollment of a enrollee/enrollee may be permitted under the following circumstances: a) Enrollee due misuses or loans his/her membership card to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plananother person to obtain services. b) Enrollee is disruptive, medical servicesunruly, diminished mental capacity, threatening 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 Enrolleeextent that enrollee’s continued enrollment membership seriously impairs the ContractorTPA’s or provider’s ability to furnish provide services to either this Enrollee enrollees or other Enrolleesto obtain new enrollees, provided the Enrolleeand enrollee’s behavior is determined not caused by a physical or mental health condition. The TPA/HCO must undertake reasonable measures to be unrelated allow a enrollee to an adverse change improve his/her behavior prior to requesting disenrollment and must notify, in writing, said enrollee of its intent to disenroll. Reasonable measures may include, without limitation, providing education and counseling regarding the Enrollee's health status, offensive acts or because behavior. TPA/HCO must notify the enrollee in writing of its decision to disenroll after reasonable measures have failed to remedy the problem. Said written notification shall include information pertaining to the availability of the Enrollee's utilization Complaints and Grievances System set forth hereunder and the ADMINISTRATION’s fair hearing process, as provided by Law 72 of medical servicesSeptember 7, diminished mental capacity1993, or uncooperative or disruptive behavior resulting from his or her special needsas amended.

Disenrollment. The Contractor shall: Have ICO shall have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plandisenrollments, including the effective date of disenrollment, from CMS and MassHealth systemsMDHHS or its authorized agent. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendorCMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. 423.100, Enrollees can elect to disenroll from the One Care Plan ICO or the Demonstration at any time and enroll in another One Care PlanICO, a Medicare Advantage MA-PD plan, PACE, or Senior Care Options PACE (if they meet applicable eligibility requirementseligible and the program has capacity); or may elect to receive services through Medicare fee‑for‑service FFS and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan FFS and any waiver programsprograms (if eligible). Disenrollments CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by MassHealth or the ContractorCMS, or by CMS MDHHS or its contractor authorized agent, either orally or in writing, 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 . The ICO shall notify MDHHS of any individual who is no longer eligible to remain enrolled in the One Care ICO per Medicare-Medicaid Plan per CMS enrollment guidanceEnrollment and Disenrollment Guidance, in order for EOHHS MDHHS to disenroll the individualEnrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan ICO’s Service Area cannot be confirmed for more than six (6) consecutive months; Not . Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area or for whom residence in the ICO Service Area cannot be confirmed for more than six (6) consecutive months. When an Enrollee no longer resides in the Service Area (except for an Enrollee living in the Service Area who is admitted to a Nursing Facility outside the Service Area for up to six months and placement is not based on the family or social situation of the Enrollee). If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date. When requesting disenrollment, the ICO must submit verifiable information that an Enrollee has moved out of the Service Area. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of the ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date. MDHHS will automatically disenroll the Enrollee for the next available month. Until the Enrollee is disenrolled from the ICO, the ICO will receive a Capitation Payment for the Enrollee. The ICO is responsible for all Medically Necessary Services for the Enrollee until they are disenrolled. The ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of an Enrollee who resides out of the Service Area of the ICO before the effective date of Enrollment will be considered an "enrollment error". The ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the date of Enrollment. The termination or expiration of this Contract terminates coverage for all Enrollees with the ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the last day of the month following the month the Disenrollment is processed. The ICO may 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 Discretionary Involuntary Disenrollments: 42 C.F.R. § 422.74 and Section 40.3 of the Enrollee’s utilization of treatment planMedicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to ICOs on discretionary Involuntary Disenrollment. This Contract and the Medicare-Medicaid Plan Enrollment and Disenrollment guidance provide procedural and substantive requirements the ICO, medical servicesMDHHS, 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, and CMS must follow prior to the Contract Management Team (CMT) to disenroll involuntarily disenrolling an Enrollee. If all of the procedural requirements are met, MDHHS and CMS will decide whether to approve or deny each request for cause, Involuntary Disenrollment based on an assessment of whether the particular facts associated with each request satisfy the substantive evidentiary requirements. Bases for Discretionary Involuntary Disenrollment Disruptive conduct: When the following reason: The Enrollee’s continued enrollment Enrollee engages in conduct or behavior that seriously impairs the ContractorICO’s ability to furnish services Covered Items and Services to either this Enrollee or other Enrollees, Enrollees and provided the Enrollee’s behavior is determined ICO made and documented reasonable efforts to be unrelated to an adverse change in resolve the problems presented by 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.