Involuntary Disenrollment. The Department will involuntarily disenroll Participants from CHC when it determines the Participant is no longer eligible for CHC. The CHC-MCO may not request disenrollment of a Participant for any reason. The CHC-MCO must aid the disenrolled Participant in transitioning to other resources to provide for continuity of care.
Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved by the SAA2. The review process includes reviewing documentation from the PACE organization and from the State case to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with the participant and/or his/her authorized representative to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or make satisfactory arrangements to pay the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves out of the PACE service area or is out of the service area for more than 30 consecutive days and the move or extended absence was not facilitated or approved by the PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization is not renewed. • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization loses the contracts and/or licenses which enable it to offer health care services.
Involuntary Disenrollment a. With proper written documentation, the following are acceptable reasons for which the Health Plan shall submit Involuntary Disenrollment requests to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency:
Involuntary Disenrollment. Disenrollments under Sections 2.3.7.4 or 2.3.7.4.9 of this Contract
Involuntary Disenrollment. LIFE wants to keep you as a participant and will work with you to resolve any issues. If LIFE is no longer able to provide appropriate care, LIFE can terminate your participation by giving you at least 30 days’ notice in writing. All involuntary disenrollments must be approved by Division of Medical Assistance. Your involuntary disenrollment will be effective on the first day of the next month that begins 30 days after the day LIFE sends you notice of the disenrollment. LIFE can request to disenroll you if: • You move out of the LIFE service area or are out of the service area for more than 30 days, unless LIFE agrees to a longer absence due to extenuating circumstances. • The LIFE agreement with the Centers for Medicare & Medicaid Services and the Division of Medical Assistance is not renewed or is terminated. • You or your caregiver behave in a disruptive, unruly, abusive or uncooperative way so that the Interdisciplinary Team is unable to safely provide services to you or other participants. • LIFE is unable to offer health care services due to loss of state licenses or contracts with providers. • You fail to pay or make satisfactory arrangements to pay any required premium or any applicable spend down obligations due to the LIFE organization, any applicable Medicaid spend down liability, or any amount due under the post-eligibility treatment of income process after 30-day grace period. • It is determined that you are no longer eligible for nursing home care by state requirements by the North Carolina Medicaid Program Long Term Care Services Assessment tool, and are not deemed eligible. If you are going to be disenrolled due to failure to pay the Monthly Fee, you can remain enrolled simply by paying the Monthly Fee. You must make this payment before the effective date of your disenrollment. Once again, please note that involuntary disenrollment requires approval from the Division of Medical Assistance. The effective date of termination of benefits is midnight of the last day of the month. You are required to use LIFE’s services and pay any premiums due until termination becomes effective. LIFE will continue to provide all necessary services until your disenrollment is effective. LIFE will provide you with information on the consequences of subsequent enrollment in other optional Medicare or Medicaid programs following disenrollment form PACE PLEASE NOTE: Medicare beneficiaries may not enroll or disenroll through Social Security Administration.
Involuntary Disenrollment a. With proper written documentation, the Managed Care Plan may submit involuntary disenrollment requests to the Agency or its enrollment broker in a manner prescribed by the Agency.
Involuntary Disenrollment. CHA PACE will make reasonable efforts to avoid involuntary disenrollment. If CHA PACE is no longer able to provide appropriate care, CHA PACE may terminate your benefits through written notification to you if: • You move out of the CHA PACE service area or are out of the service area for more than 30 consecutive days. • You engage in disruptive or threatening behavior. • You knowingly do not comply with your plan of care so that it jeopardizes your health or safety or the safety of others. • You knowingly do not comply with medical advice and repeatedly fail to keep appointments. • You knowingly refuse services and/or are unwilling to meet conditions of participation. • You fail to pay or make satisfactory arrangements to pay any amount you agreed to pay at enrollment due CHA PACE after the 30-day grace period. • You are no longer determined to meet MassHealth’s nursing facility level of care requirements and are deemed ineligible by its screening agent. • CHA PACE loses the contracts and/or licenses enabling it to offer healthcare. • CMS and/or MassHealth do not renew or terminate the program agreement with CHA PACE.
Involuntary Disenrollment a. With proper written documentation, the following are acceptable reasons for which the PSN shall submit Involuntary Disenrollment requests to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency:
Involuntary Disenrollment. Fallon Health Xxxxxxxx-XXXX can initiate disenrollment for the following reasons: You fail to pay or fail to make satisfactory arrangements to pay any amount you owe Fallon Health Xxxxxxxx-XXXX after the 30-day grace period. You move out of the Fallon Health Xxxxxxxx-XXXX service area or you are out of the service area for more than 30 consecutive days unless Fallon Health Xxxxxxxx-XXXX agrees to a longer absence due to extenuating circumstances. You are a person whose behavior is jeopardizing your health or safety or that of others or you are a person with decision-making capacity who consistently does not comply with his/her individual plan of care or the terms of the enrollment agreement. You have a family member or caregiver whose behavior is jeopardizing your health or safety or not meeting the terms of the enrollment agreement. During annual recertification, it is determined you no longer are nursing home eligible and no longer require community based services. You provide false information or otherwise engage in fraudulent conduct. You are homeless living in the streets or in a shelter and the Program is unable to provide services. Fallon Health Xxxxxxxx-XXXX loses the contract and/or licenses enabling it to offer health care, or Fallon Health Xxxxxxxx-XXXX loses its contracts with necessary outside providers, or Fallon Health Xxxxxxxx-XXXX ceases operations. Fallon Health Xxxxxxxx-XXXX has a contract with the Centers for Medicare & Medicaid Services (CMS) and the New York State Medicaid Agency which is subject to renewal on a periodic basis, and failure of Fallon Health Xxxxxxxx-XXXX to renew the contract will result in termination of enrollment in the program. If you are eligible for Medicare and/or Medicaid at disenrollment, you may go back to other Medicare and/or Medicaid providers in the community. Fallon Health Xxxxxxxx-XXXX will make every effort to work with you to resolve any issues that could potentially lead to involuntary disenrollment. If you are a Medicare participant and the New York Medicaid Choice approves your involuntary disenrollment, you can request an external review through Medicare. If you are disenrolled, Fallon Health Xxxxxxxx-XXXX will work with you to make referrals to appropriate medical providers in your community, and we will make medical records available in a timely manner. We will work with Medicare and/or Medicaid to help you transition to an appropriate managed long term care program.
Involuntary Disenrollment. Serenity Care PACE will do everything possible to avoid involuntary disenrollment. We will provide you with reasonable notice before we take any action to disenroll you from our PACE program. Serenity Care PACE can terminate your benefits through written notification to you if: • You move out of Serenity Care PACE 's service area for more than 30 consecutive days without prior approval; • There is repeated non-compliance with your treatment plan, and all efforts have been exhausted to resolve the issues; • There is a breakdown in your relationship with the doctor or IDT and patient relationship; • Payments due to Serenity Care PACE are not made after the 30-day grace period (see Monthly Payments section; you must pay or work out a payment plan); • You are no longer eligible for a nursing facility level of care; • You no longer meet the State Medicaid Nursing Facility level of care requirement; • Your behavior jeopardizes your health or safety; • Your behavior jeopardizes the health or safety of others; • Serenity Care PACE closes because its PACE program agreement was not renewed or was cancelled by the State of Massachusetts and the federal government’s Center for Medicare and Medicaid Services; or • The PACE program loses its state license or Serenity Care PACE is unable to offer healthcare services because it loses its contracts with outside providers.
