Involuntary Disenrollment Requests Clause Samples
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:
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.
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).
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).
Involuntary Disenrollment Requests. (See Attachment II, Exhibit 3)
a. With proper written documentation, the following are acceptable reasons for which the Health Plan may submit involuntary disenrollment requests to the Agency or its agent:
(1) Fraudulent use of the enrollee ID card. In such cases the Health 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 Health Plan seriously impairs the organization's ability to furnish services to either the enrollee or other enrollees.
(a) This section does not apply to enrollees with mental health diagnoses if the enrollee’s behavior is attributable to the mental illness.
(b) An involuntary disenrollment request related to enrollee behavior must include documentation that the Health 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; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract
(iii) Offered assistance through case management that would enable the enrollee to comply;
(iv) Determined that the enrollee’s behavior is not related to the enrollee’s medical or behavioral condition.
(3) Falsification of prescriptions by an enrollee. In such cases the Health Plan shall report the event to MPI.
b. The Health Plan shall promptly submit such disenrollment requests to BMHC. 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.
c. All requests will be reviewed on a case-by-case basis and subject to the sole discretion of the Agency. Any request not approved is final and not subject to Health Plan dispute or appeal.
d. The Health 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 Item C., Disenrollment, sub-item 4.a.(2)(b) above);
(7) Attempt to exercise rights under the Health Pl...
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.
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.
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.
Involuntary Disenrollment Requests. The following are also reasons for which the Health Plan shall submit involuntary disenrollment requests to the Agency’s choice counselor/enrollment broker. 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. Aging out of the Health Plan at age 21;
b. No longer being clinically eligible to participate in the Health Plan as determined pursuant to the clinical screening requirements specified above; and