Common use of Involuntary Disenrollment Requests Clause in Contracts

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. 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 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 PIHP HMO 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 This might include, but is not limited to: a. Just Cause The PIHP 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 PIHP HMO cannot provide the member with appropriate medically necessary contract services for reasons beyond its control. The PIHP 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 PIHP HMO seriously impairs the entity’s ability to furnish services to either this particular member or other members) (42 CFR 438.56).