Common use of Disenrollment Clause in Contracts

Disenrollment. An Enrollee must be disenrolled from the Plan if the Beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writing. The effective date of any approved disenrollment will 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. An Enrollee must 12.1 ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the Plan if end of the Beneficiaryoverseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: a. No longer resides 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the State of Mississippi;enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. b. Is deceased;12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. c. No longer qualifies for medical assistance under one 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the Medicaid eligibility categories in end of the targeted populationoverseas tour when the ADSM departs to a new area of assignment. The Contractor must notify TOP contractor shall provide continuing coverage until (1) the Division within three enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the first 61st calendar day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the end date of the Enrollee’s initial enrollmentoverseas tour from TOP Prime or TOP TPR. Until December 31, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks2017, the Enrollee needs related services disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to be performed at the same timeTRICARE Standard. Effective January 1, not all related services are available within the network2018, the Enrollee’s primary care provider ADFMs disenrolled from TOP Prime 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 TOP TPR 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.only eligible for space available care at military treatment facilities.‌

Disenrollment. An Enrollee must 12.1 ADFMs shall be disenrolled from the Plan if the BeneficiaryTOP Prime/TOP Prime Remote when: a. No longer resides 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the State of Mississippi;enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. b. Is deceased;12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. c. No longer qualifies for medical assistance under one 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the Medicaid eligibility categories in end of the targeted populationoverseas tour when the ADSM departs to a new area of assignment. The Contractor must notify TOP contractor shall provide continuing coverage until (1) the Division within three enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollmentwhen enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day. Disenrollment shall be effective The TOP contractor will automatically disenroll the beneficiary on the first 61st calendar day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the end date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writingoverseas tour. The effective date of any approved disenrollment ADFM TOP Prime/TPR beneficiary 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.revert to TRICARE Standard.‌

Disenrollment. An Enrollee must 12.1 ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, or • The enrollee loses TRICARE eligibility in DEERS. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: • The enrollee transfers enrollment to a new TRICARE region, or • The enrollee loses TRICARE eligibility in DEERS. 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the Plan enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if the Beneficiary:they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one 12.5 TOP Prime/TOP Prime Remote ADFMs must either transfer enrollment or disenroll within 60 calendar days of the Medicaid eligibility categories in end of the targeted populationoverseas tour when the ADSM departs to a new area of assignment. The Contractor must notify TOP contractor shall provide continuing coverage until (1) the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on enrollment has been transferred to the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health statusnew location, or because of (2) the Enrollee’s utilization of medical services, diminished mental capacity, enrollee disenrolls. If the TOP Prime/TOP Prime Remote ADFM enrollee has not disenrolled or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in transferred their coverage to the CCO seriously impairs new region by the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks61st day, the Enrollee needs related services TOP contractor shall disenroll them from TOP Prime/TOP Prime Remote and enroll the ADFM to be performed at the same timeTRICARE Select. Until December 31, not all related services are available within the network2017, the Enrollee’s primary care provider disenrolled ADFM TOP Prime or another provider determines receiving the services separately would subject Enrollee TOP TPR beneficiary will revert 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 DivisionTRICARE Standard.

Disenrollment. An Enrollee must 12.1 ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote when: • The enrollee loses TRICARE eligibility in DEERS, or • The enrollee has not requested enrollment transfer/disenrollment within 60 calendar days following 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 end of the Medicaid overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: • The enrollee loses TRICARE eligibility categories in DEERS, or • The enrollee has not requested enrollment transfer/disenrollment within 60 calendar days following the targeted populationend of the overseas tour. 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The Contractor must notify TOP contractor shall provide continuing coverage until (1) the Division within three enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollmentwhen enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day. Disenrollment shall be effective The TOP contractor will automatically disenroll the beneficiary on the first 61st calendar day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the end date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writingoverseas tour. The effective date of any approved disenrollment ADFM TOP Prime/TPR beneficiary 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.revert to TRICARE Standard.‌