Common use of Disenrollment Clause in Contracts

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS. (1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization. (2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR 455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_web (3) A Member may be Disenrolled from Contractor as follows: (a) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 for the following reasons: (i) Without cause: (A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days of the Member’s Enrollment; or (B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; or (C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or (D) Members who are eligible for both Medicare and Medicaid and Members who are AI/AN beneficiaries may change plans or disenroll to fee-for-service at any time; or (E) Upon Automatic Re-enrollment (e.g., a recipient who is automatically re-enrolled after being disenrolled, solely because he or she loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (F) Whenever the Member’s eligibility is re-determined by XXX.

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR §438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR §438.56(c)(2)(i) is expressly waived by CMS. (1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (“DRG”) applicable to the hospitalization. (2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR §455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_web (3) A Member may be Disenrolled from Contractor as follows: (a) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 for the following reasons: (i) Without cause: (A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days of the Member’s Enrollment; or (B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send sends the member notice of the Enrollment, whichever is later; or (C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or (D) Members who are eligible for both Medicare and Medicaid and Members who are American Indian/Alaska Native (“AI/AN AN”) beneficiaries may change plans or disenroll Disenroll to fee-for-service at any time; or (E) Upon Automatic Re-enrollment Enrollment (e.g., a recipient Recipient who is automatically re-enrolled after being disenrolledDisenrolled, solely because he or she such Recipient loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (F) Whenever the Member’s eligibility is re-determined by XXX.

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS.‌ (1) a. An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization. (2) b. If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR § 455.13 by one of the following methods: : (1) Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_webor (32) Via on-line portal at xxxxx://xxx.xxxxxx.xxx/oha/FOD/PIAU/Pages/Report-Fraud.aspx. c. A Member may be Disenrolled from Contractor as follows: (a1) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 3810 for the following reasons: (ia) Without cause: (A) i. OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 thirty (30) days of the Member’s Enrollment; or (B) ii. Newly eligible Members may change plans, if another plan is available, within 12 months ninety (90) days of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; or (C) iii. A Member may request Disenrollment at least once every 12 months after initial Enrollmentduring “OHP eligibility renewal,” as such term is defined in OAR 410-141-3805, which is typically twelve (12) months; or (D) iv. Members who are eligible for both Medicare and Medicaid and Members who are AIAmerican Indian/AN Alaska Native beneficiaries may change plans or disenroll Disenroll to feeFee-for-service Service at any time; or (E) v. Upon Automatic Re-enrollment Enrollment (e.g., a recipient Recipient who is automatically re-enrolled re- Enrolled after being disenrolledDisenrolled, solely because he or she such Recipient loses Medicaid eligibility for a period of 2 two (2) months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (F) vi. Whenever the Member’s eligibility is re-determined by XXXOHA.

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS. (1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization. (2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR 455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_webonline (3) A Member may be Disenrolled from Contractor as follows: (a) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 for the following reasons: (i) Without cause: (A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days of the Member’s Enrollment; or (B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; or (C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or (D) Members who are eligible for both Medicare and Medicaid and Members who are AI/AN beneficiaries may change plans or disenroll to fee-for-service at any time; or (E) Upon Automatic Re-enrollment (e.g., a recipient who is automatically re-enrolled after being disenrolled, solely because he or she loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (F) Whenever the Member’s eligibility is re-determined by XXX.

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS. (1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Hospital hospital services until discharge or until the Member’s PCP determines that care in the Hospital hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization. (2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraudfraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR 455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_web (3) A Member may be Disenrolled from Contractor as follows: (a) If requested orally or in writing by the Member or the Member Member’s Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 3000 and 410-141-3080(1)(b), OHP Disenrollment from PHPs, for the following reasons: (i) Without cause: (A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days After six months of the Member’s Enrollment; or (B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; or (C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or (D) Members who are eligible for both Medicare and Medicaid and Members who are AI/AN beneficiaries may change plans or disenroll to fee-for-service at any time; or (E) Upon Automatic Re-enrollment automatic reenrollment (e.g., a recipient who is automatically re-enrolled after being disenrolled, solely because he or she loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (FC) Whenever the Member’s eligibility is re-determined by XXXOHA. (ii) With cause: (A) During the 90 days following the date of the Member’s initial Enrollment with the Contractor, or the date OHA sends the Member notice of the Enrollment, whichever is later; (B) The Member has Disenrolled from a Medicare Advantage plan; (C) The Member receiving Medicare requests Disenrollment from Contractor which is the corresponding Medicare Advantage plan; (D) The Contractor does not, because of moral or religious objections, cover the service the Member seeks; (E) The Member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time, not all related services are available within the Contractor’s network, and the Member’s PCP or another Provider determines that receiving the services separately would subject the Member to unnecessary risk; or (F) For other reasons, including but not limited to, poor quality of care, lack of access to services covered under this Contract, or lack of access to Participating Providers experienced in dealing with the Member’s health care needs. Examples of sufficient cause include but are not limited to: (I) The Member moves out of the Service Area; (II) It would be detrimental to the Member’s health to continue Enrollment; (III) The Member is a AI/AN; or

Disenrollment. The requirements and limitations governing Disenrollments contained in 42 CFR 438.56 and OAR 410-141-3080, Disenrollment Requirements, apply to Contractor regardless of whether Enrollment is mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived by CMS. (1) An individual is no longer a Member for purposes of this Contract as of the effective date of the individual’s Disenrollment from Contractor. As of that date, Contractor is no longer required to provide services to such individual by the terms of this Contract, unless the Member is hospitalized at the time of Disenrollment. In such an event, Contractor is responsible for inpatient Hospital services until discharge or until the Member’s PCP determines that care in the Hospital is no longer Medically Appropriate. OHA will assume responsibility for other services not included in the Diagnosis Related Group (DRG) applicable to the hospitalization. (2) If Disenrollment occurs due to an illegal act which includes Member or Provider Medicaid Fraud, Contractor shall report to OHA Office of Payment Accuracy and Recovery, consistent with 42 CFR 455.13 by one of the following methods: Fraud hotline 1-888-FRAUD01 (0-000-000-0000); or Report fraud online at xxxxx://xxxx.xxxxx.xx.xx/cf1/OPR_Fraud_Ref/index.cfm?act=evt.subm_web (3) A Member may be Disenrolled from Contractor as follows: (a) If requested orally or in writing by the Member or the Member Representative, OHA may Disenroll the Member in accordance with OAR 410-141-3080 for the following reasons: (i) Without cause: (A) OHP Clients auto-enrolled or manual-enrolled in error may change plans, if another plan is available, within 30 days of the Member’s Enrollment; or (B) Newly eligible Members may change plans, if another plan is available, within 12 months of their initial plan Enrollment or the date OHA send the member notice of the Enrollment, whichever is later; orthe (C) A Member may request Disenrollment at least once every 12 months after initial Enrollment; or (D) Members who are eligible for both Medicare and Medicaid and Members who are AI/AN beneficiaries may change plans or disenroll to fee-for-service at any time; or (E) Upon Automatic Re-enrollment (e.g., a recipient who is automatically re-enrolled after being disenrolled, solely because he or she loses Medicaid eligibility for a period of 2 months or less), if the temporary loss of Medicaid eligibility has caused the Member to miss the annual Disenrollment opportunity; or (F) Whenever the Member’s eligibility is re-determined by XXX.