Involuntary Disenrollment Requests Sample Clauses

Involuntary Disenrollment Requests. The Reform Health Plan shall submit involuntary disenrollment requests for the following reasons to the Agency’s choice counselor/enrollment broker as specified in the Health Plan Report Guide. In no event shall the Health Plan submit a 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. a. No longer being clinically eligible to participate in the Health Plan pursuant to the clinical screening/eligibility requirements specified for the Health Plan.
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Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be the next available benefit month based on enrollment system logic, except for specific cases or persons where there is a situation where enrollment would be harmful to the interests of the member or in which the PIHP cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The PIHP must direct all members with involuntary disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling. For any request for involuntary disenrollment, the PIHP must submit a disenrollment request to the Department and include evidence attesting to cause which might include, but is not limited to: a. Just Cause The PIHP may request and the Department will approve disenrollment requests for specific cases or persons where there is just cause. Just cause is defined as a situation where enrollment would be harmful to the interests of the member or in which the PIHP cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The PIHP may not request just cause disenrollment because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the PIHP seriously impairs the entity’s ability to furnish services to either this particular member or other members) (42 CFR 438.56).
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Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be the next available benefit month based on enrollment system logic, except for specific cases or persons where there is a situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. For any request for involuntary disenrollment, the HMO must submit a disenrollment request to the Department and include evidence attesting to cause. The HMO must direct all members with involuntary disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling. This might include, but is not limited to: a. Just Cause The HMO may request and the Department will approve disenrollment requests for specific cases or persons where there is just cause. Just cause is defined as a situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The HMO may not request just cause disenrollment because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the HMO seriously impairs the entity’s ability to furnish services to either this particular member or other members) (42 CFR 438.56). b. Nursing Home For BadgerCare Plus and Medicaid SSI members in a nursing home at the time of HMO enrollment, the member, the nursing home, or the HMO may contact the HMO Enrollment Specialist for an exemption. The nursing home services would be billed to fee-for-service, and upon discharge, the exemption will end and the member may be eligible for HMO enrollment. 1) BadgerCare Plus (non-CLA) A BadgerCare Plus (non-CLA) member who has been in a nursing home for longer than 30 days will have their medical status code changed to an institutional code, which will automatically disenroll them from the HMO. The HMO does not need to report this population to the Enrollment Specialist as the disenrollment is automatic. The HMO is responsible for nursing home costs until the disenrollment is effective. Automatic disenrollment does not occur for the following populations and HMOs must ...
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Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be the next available benefit month based on enrollment system logic, except for specific cases or persons where there is a situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. For any request for involuntary disenrollment, the HMO must submit a disenrollment request to the Department and include evidence attesting to cause. This might include, but is not limited to: a. Just Cause The HMO may request and the Department will approve disenrollment requests for specific cases or persons where there is just cause. Just cause is defined as a situation where enrollment would be harmful to the interests of the member or in which the HMO cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The HMO may not request just cause disenrollment because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the HMO seriously impairs the entity’s ability to furnish services to either this particular member or other members) (42 CFR 438.56). b. Nursing Home BadgerCare Plus members in a nursing home for longer than 30 days will have their medical status code changed to an institutional code which will automatically disenroll them from an HMO. Automatic disenrollment does not occur for the following populations and HMOs must notify the Enrollment Specialist for disenrollment:
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Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be the next available benefit month based on enrollment system logic, except for specific cases or persons where there is a situation where enrollment would be harmful to the interests of the member or in which the PIHP cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. For any request for involuntary disenrollment, the PIHP must submit a disenrollment request to the Department and include evidence attesting to cause which might include, but is not limited to: a. Just Cause The PIHP may request and the Department will approve disenrollment requests for specific cases or persons where there is just cause. Just cause is defined as a situation where enrollment would be harmful to the interests of the member or in which the PIHP cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The PIHP may not request just cause disenrollment because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the PIHP seriously impairs the entity’s ability to furnish services to either this particular member or other members) (42 CFR 438.56).
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Involuntary Disenrollment Requests. The Reform Health Plan shall submit involuntary disenrollment requests for the following reasons to the Agency’s choice counselor/enrollment broker as specified in the Health Plan Report Guide. In no event shall the Health Plan submit a 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. a. Moved out of Reform Health Plan service area; b. Enrollee death; and c. Enrollee ineligible for Health Plan enrollment.
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Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be the next available benefit month based on enrollment system logic, except for specific cases or persons where there is a situation where enrollment would be harmful to the interests of the member or in which the PIHP cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The PIHP must direct all members with involuntary disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling. For any request for involuntary disenrollment, the PIHP must submit a disenrollment request to the Department and include evidence attesting to cause.
Sample 1
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Involuntary Disenrollment Requests a. With proper written documentation, the following are acceptable reasons for which the Managed Care Plan may submit involuntary disenrollment requests to the Agency or its agent: (1) Fraudulent use of the enrollee identification (ID) card. In such cases the Managed Care Plan shall report the event to MPI. (2) 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. This section does not apply to enrollees with medical or mental health diagnoses if the enrollee’s behavior is attributable to the diagnoses. 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.
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Related to Involuntary Disenrollment Requests

  • 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.

  • Enrollment Period Educational Support Professionals may elect to participate in the Career Transition Trust annually during a two (2) week enrollment period determined by the District, but that will occur no later than May 1st each year, provided they have met the eligibility requirements for participation in Subdivision. 2.

  • Open Enrollment Period Open Enrollment is a period of time each year when you and your eligible dependents, if family coverage is offered, may enroll for healthcare coverage or make changes to your existing healthcare coverage. The effective date will be on the first day of your employer’s plan year. A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health coverage. You and your eligible dependents may enroll for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days of the following events: • you get married, the coverage effective is the first day of the month following your marriage. • you have a child born to the family, the coverage effective date is the date of birth. • you have a child placed for adoption with your family, the coverage effective date is the date of placement. Special note about enrolling your newborn child: You must notify your employer of the birth of a newborn child and pay the required premium within thirty -one (31) days of the date of birth. Otherwise, the newborn will not be covered beyond the thirty -one (31) day period. This plan does not cover services for a newborn child who remains hospitalized after thirty-one (31) days and has not been enrolled in this plan. If you are enrolled in an Individual Plan when your child is born, the coverage for thirty- one (31) days described above means your plan becomes a Family Plan for as long as your child is covered. Applicable Family Plan deductibles and maximum out-of-pocket expenses may apply. In addition, if you lose coverage from another plan, you may enroll or add your eligible dependents for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days following the date you lost coverage. Coverage will begin on the first day of the month following the date your coverage under the other plan ended. In order to be eligible, the loss of coverage must be the result of: • legal separation or divorce; • death of the covered policy holder; • termination of employment or reduction in the number of hours of employment; • the covered policy holder becomes entitled to Medicare; • loss of dependent child status under the plan; • employer contributions to such coverage are being terminated; • COBRA benefits are exhausted; or • your employer is undergoing Chapter 11 proceedings. You are also eligible for a Special Enrollment Period if you and/or your eligible dependent lose eligibility for Medicaid or a Children’s Health Insurance Program (CHIP), or if you and/or your eligible dependent become eligible for premium assistance for Medicaid or a (CHIP). In order to enroll, you must provide required information within sixty (60) days following the change in eligibility. Coverage will begin on the first day of the month following our receipt of your application. In addition, you may be eligible for a Special Enrollment Period if you provide required information within thirty (30) days of one of the following events: • you or your dependent lose minimum essential coverage (unless that loss of coverage is due to non-payment of premium or your voluntary termination of coverage); • you adequately demonstrate to us that another health plan substantially violated a material provision of its contract with you; • you make a permanent move to Rhode Island: or • your enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, or inaction by us or an agent of HSRI or the U.S. Department of Health and Human Services (HHS).

  • Enrollment Process The Department may, at any time, revise the enrollment procedures. The Department will advise the Contractor of the anticipated changes in advance whenever possible. The Contractor shall have the opportunity to make comments and provide input on the changes. The Contractor will be bound by the changes in enrollment procedures.

  • Other Payroll Deductions Upon appropriate written authorization from the employee, the Board shall deduct from the salary of any employee and make appropriate remittance for annuities, credit union, savings bonds, insurance, or any other plans or programs approved by the parties.

  • Enrollment Requirements You must maintain with Blue Cross and Blue Shield a current and updated listing of covered employees. You will be responsible for all claims costs and expenses associated with failure to maintain an accurate and current listing with Blue Cross and Blue Shield, unless such claims costs and expenses are due to an error on Blue Cross and Blue Shield’s part. In order to maintain health care coverage with Blue Cross and Blue Shield, an employee must meet the written eligibility requirements (such as length of service, active employment and number of hours worked) you impose as long as they do not conflict with Blue Cross and Blue Shield’s eligibility requirements. An eligible employee as defined by Blue Cross and Blue Shield means: • A permanent full-time employee regularly working 30 hours or more each week at the employer’s usual place(s) of business and who is paid a salary or wage in accordance with state and federal wage requirements; or • A permanent part-time employee regularly working at least 20 hours but less than 30 hours each week at the employer’s usual place(s) of business and who is paid a salary or wage in accordance with state and federal wage requirements; or • A disabled permanent full-time or part-time employee who is actively working despite the disability (including one who is engaged in a trial work period) and a disabled employee who is not actively working but whom the employer treats as an employee; or • A former employee (or a former covered dependent of the employee of the group) who qualifies for continued group coverage under federal or state law, but only if the employer maintains Blue Cross and Blue Shield group coverage for permanent full-time employees as defined in (a) above; or • A retired employee of the employer. Newly hired employees who are eligible for group benefits can enroll in the benefits plan according to your eligibility requirements for coverage, provided that your requirements comply with Blue Cross and Blue Shield’s eligibility and enrollment requirements. The effective date of an eligible employee’s (or his or her dependent’s) membership in the benefits plan may be the Member’s initial eligibility date or your subsequent anniversary/renewal date, as long as: (a) Blue Cross and Blue Shield receives your written notice no later than 30 days after the Member’s enrollment notification period applicable to membership modifications (as described in the Subscriber Certificate for your benefits plan); and (b) you pay the applicable premium charges.

  • Deferral Election A Participant may elect to defer all or a specified percentage of the Compensation earned in a Plan Year by such Participant for serving as a member of the Board of any Participating Fund or as a member of any committee or subcommittee thereof. Reimbursement of expenses of attending meetings of the Board, committees of the Board or subcommittees of such committees may not be deferred. Such election shall be made by executing before the first day of such Plan Year such election notice as the Administrator may prescribe; provided, however, that upon first becoming eligible to participate in the Plan by reason of appointment to a Board, a Participant may file a Deferral Election not later than 30 days after the effective date of such appointment, which election shall apply to Compensation earned in the portion of the Plan Year commencing the day after such election is filed and ending on the last day of such Plan Year.

  • Election Period The period which begins on the first day of the Plan Year in which the Participant attains age thirty-five (35) and ends on the date of the Participant’s death. If a Participant separates from Service prior to the first day of the Plan Year in which age thirty-five (35) is attained, the Election Period shall begin on the date of separation, with respect to the account balance as of the date of separation.

  • Termination for Good Reason The Employee's employment may be terminated by the Employee for Good Reason. For purposes of this Agreement, "Good Reason" shall mean:

  • Termination of Service for Cause Upon a termination of the Participant’s Service by the Company for Cause the Option, including the Vested Portion, shall immediately terminate and be forfeited without consideration.

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