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. Disenrollments under Sections 2.3.7.4 or 2.3.7.4.9 of this Contract
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:
(1) Enrollee has moved out of the Service Area;
(2) Enrollee death;
(3) Determination that the Enrollee is ineligible for Enrollment based on the criteria specified in this Contract in Section III.A.3, Excluded Populations; and
(4) Fraudulent use of the Enrollee ID card.
b. The Health Plan shall promptly submit such Disenrollment requests to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency. In no event shall the Health Plan submit the Disenrollment request at such a date as would cause the Disenrollment to be effective later than forty-five (45) Calendar Days after the Health Plan’s receipt of the reason for Involuntary Disenrollment. The Health Plan shall ensure that Involuntary Disenrollment documents are maintained in an identifiable Enrollee record.
c. If the Health Plan submitted the Disenrollment request for one of the above reasons, the Health Plan shall verify that the information is accurate.
d. If the Health Plan discovers that an ineligible Enrollee has been enrolled, then it shall request Disenrollment of the Enrollee and shall notify the Enrollee in writing that the Health Plan is requesting Disenrollment and the Enrollee will be disenrolled in the next Contract month, or earlier if necessary. Until the Enrollee is Disenrolled, the Health Plan shall be responsible for the provision of services to that Enrollee.
e. On a monthly basis, the Health Plan shall review its ongoing Enrollment report (FLMR 8200-R0004) to ensure that all Enrollees are residing in the same county in which they were enrolled. The Health Plan shall update the records for all Enrollees who have moved from one county to another, but are still residing in the Health Plan’s Service Area, and provide the Enrollee with a new Provider Directory for that county. For Enrollees with out-of-county addresses on the Enrollment report, the Health Plan shall notify the Enrollee in writing that the Enrollee should contact the Choice Counselor/Enrollment Broker or Medicaid Options, depending on whether the Enrollee moves into a Reform or Non-Reform County, respectively, to choose another Health Plan, or other managed care option available in the Enrollee’s new county, and that the Enrollee will be Disenrolled as a result of the ...
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. 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
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.
b. The following are acceptable reasons for which the Managed Care Plan may submit involuntary disenrollment request:
(1) Fraudulent use of the enrollee identification (ID) card. In such cases the Managed Care Plan shall notify MPI of the event.
(2) Falsification of prescriptions by an enrollee. In such cases the Managed Care Plan shall notify MPI of the event.
(3) The enrollee’s behavior is disruptive, unruly, abusive or uncooperative to the extent that enrollment in the Managed Care Plan seriously impairs the organization’s ability to furnish services to either the enrollee or other enrollees.
(a) This provision does not apply to enrollees with medical or mental health diagnoses if the enrollee’s behavior is attributable to the diagnoses.
(b) An involuntary disenrollment request related to enrollee behavior must include documentation that the Managed Care Plan:
(i) Provided the enrollee at least one (1) oral warning and at least one
(1) written warning of the full implications of the enrollee’s actions;
(ii) Attempted to educate the enrollee regarding rights and responsibilities;
(iii) Offered assistance through care coordination/case management that would enable the enrollee to comply; and
(iv) Determined that the enrollee’s behavior is not related to the enrollee’s medical or mental health condition.
c. The Managed Care Plan shall not request disenrollment of an enrollee due to:
(1) Health diagnosis;
(2) Adverse changes in an enrollee’s health status;
(3) Utilization of medical services;
(4) Diminished mental capacity;
(5) Pre-existing medical condition;
(6) Uncooperative or disruptive behavior resulting from the enrollee’s special needs (with the exception of Section III.C.5.b.(3)(b));
(7) Attempt to exercise rights under the Managed Care Plan’s grievance and appeal system; or
(8) Request of a provider to have an enrollee assigned to a different provider out of the Managed Care Plan.
d. The Managed Care Plan shall promptly submit such disenrollment requests to the Agency. In no event shall the Managed Care Plan submit a disenrollment request at such a date as would cause the disenrollment to be effective later than forty-five (45) days after the Managed Care Plan’s receipt of the reason for involuntary disenrollment. The Managed Care Plan shall ensure that involuntary dis...
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:
(1) Enrollee has moved out of the Service Area;
(2) Enrollee death;
(3) Determination that the Enrollee is ineligible for Enrollment based on the criteria specified in this Contract in Section III.A.3, Excluded Populations, and
(4) Fraudulent use of the Enrollee ID card.
b. The Health Plan shall promptly submit such Disenrollment requests to the Agency. In no event shall the Health Plan submit the Disenrollment request at such a date as would cause the Disenrollment to be effective later than forty-five (45) Calendar Days after the Health Plan’s receipt of the reason for involuntary Disenrollment. The Health Plan shall ensure that involuntary Disenrollment documents are maintained in an identifiable Enrollee record.
c. If the Health Plan submitted the Disenrollment request for one of the above reasons, the Health Plan shall verify that the information is accurate.
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. In the event a Member no longer meets Group’s eligibility requirements for participation in the Plan, Group and/or Member shall provide written notice to United of such Member’s disenrollment from the Plan or Group shall provide notice via the monthly Group Eligibility List submission, if applicable. Such notice, regardless of medium, shall include the reason for disenrollment. Group shall notify United thirty (30) calendar days prior to the proposed effective date of disenrollment. Disenrollment generally cannot be effective prior to the date Group submits the disenrollment notice. In the case of a Member who no longer meets Group’s eligibility requirements for participation in the Plan or in the case of termination of this Agreement in accordance with Section 6, Group will issue prospective notice to Member of the termination a minimum of twenty-one (21) calendar days prior to the effective date of said termination. Such notice must advise Member of other insurance options that may be available through Group. Group will also advise such Member that the disenrollment action means the Member will not have coverage. If the Plan provides coverage for prescription drugs, the Notice must include information about the potential for late-enrollment penalties that may apply in the future. The effective date of disenrollment always falls on the last calendar day of a month. In the case of a Member no longer meeting Group’s eligibility requirements, Group will send United notice of a Member’s termination from the Plan by the first calendar day of the month for an effective date of the last calendar day of that month. All notifications received after the first calendar day of the month will result in a termination effective date of the last calendar day of the following month. Group agrees to pay any applicable Plan Beneficiary Premium through the last calendar day of the month in which Member is enrolled.
