Common use of Disenrollments Clause in Contracts

Disenrollments. The final per member per month capitation payment made by CMS and EOHHS to the Contractor for each Enrollee will be for the month in which the disenrollment was submitted, the Enrollee loses eligibility, or the Enrollee dies (see Section 2.3.B). Enrollee Contribution to Care Amounts If, in the financial eligibility process conducted by EOHHS, an Enrollee residing in a nursing facility is determined to owe a monthly Enrollee-paid amount, such amounts are the Enrollee’s contribution to care. At the time of enrollment, and as adjusted thereafter, EOHHS will advise the Contractor of the amount of the Enrollee’s contribution to care. When an Enrollee contribution to care is established, MassHealth will subtract that amount from the monthly capitation payment for that Enrollee. The Contractor is responsible for collecting this amount from the Enrollee subject to the Enrollee rights provisions of the Contractor’s Evidence of Coverage (see Appendix C). Modifications to Capitation Rates CMS and EOHHS will jointly notify the Contractor in advance and in writing of any proposed changes to the Capitation Rates, and the Contractor shall accept such changes as payment in full as described in Section 4.7. Rates will be updated using a similar process for each calendar year. Subject to Section 4.3.C.2, changes to the Medicare and MassHealth baselines outside of the annual Medicare Advantage and Part D rate announcements will be made only if and when CMS and EOHHS jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes or discrepancies in Federal law and/or State policy compared to assumptions about Federal law and/or state law or policy used in the development of baseline estimates; and changes in coding intensity.

Disenrollments. The final per member per month capitation payment made by CMS and EOHHS to the Contractor for each Enrollee will be for the month in which the disenrollment was submitted, the Enrollee loses eligibility, or the Enrollee dies (see Section 2.3.B). Enrollee Contribution to Care Amounts If, in the financial eligibility process conducted by EOHHS, an Enrollee residing in a nursing facility is determined to owe a monthly Enrollee-paid amount, such amounts are the Enrollee’s contribution to care. At the time of enrollment, and as adjusted thereafter, EOHHS will advise the Contractor of the amount of the Enrollee’s contribution to care. When an Enrollee contribution to care is established, MassHealth will subtract that amount from the monthly capitation payment for that Enrollee. The Contractor is responsible for collecting this amount from the Enrollee subject to the Enrollee rights provisions of the Contractor’s Evidence of Coverage (see Appendix C). Modifications to Capitation Rates CMS and EOHHS will jointly notify the Contractor in advance and in writing of any proposed changes to the Capitation Rates, and the Contractor shall accept such changes as payment in full as described in Section 4.7. Rates will be updated using a similar process for each calendar year. Subject to Section 4.3.C.2, changes to the Medicare and MassHealth baselines outside of the annual Medicare Advantage and Part D rate announcements will be made only if and when CMS and EOHHS jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes or discrepancies in Federal law and/or State policy compared to assumptions about Federal law and/or state law or policy used in the development of baseline estimates; and changes in coding intensity. Modifications to Rate Year 2015 MassHealth rates that are published after October 1, 2015 only apply if the Contractor participates in the Demonstration through December 31, 2016.