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 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 notify the Enrollment Specialist for disenrollment: 2) Medicaid SSI After a SSI member has been in a nursing home 90 days or longer and is expected to remain in the facility, the HMO must notify the HMO Enrollment Specialist to request disenrollment. In the event the member transfers from the nursing home to a hospital and back to the nursing home, the applicable 90 day period shall run continuously from the first admission to the nursing home and shall include any days in the hospital. The HMO must wait until 90 days have occurred before requesting an exemption, which will occur the first of the next month. The HMO is responsible for nursing home costs until the disenrollment is effective.

Involuntary Disenrollment Requests. The Department may approve an involuntary disenrollment with an effective date that will be (See Attachment II, Exhibit 3) a. With proper written documentation, the next available benefit month based on enrollment system logic, except following are acceptable reasons 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 Health Plan may 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 toAgency or its agent: a. Just Cause (1) Fraudulent use of the enrollee ID card. In such cases the Health Plan shall report the event to MPI. (2) The HMO may request and the Department will approve disenrollment requests for specific cases enrollee’s behavior is disruptive, unruly, abusive or persons where there is just cause. Just cause is defined as a situation where enrollment would be harmful uncooperative 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 extent that enrollment in the HMO Health Plan seriously impairs the entity’s organization's ability to furnish services to either this particular member the enrollee or other membersenrollees. (a) This section does not apply to enrollees with mental health diagnoses if the enrollee’s behavior is attributable to the mental illness. (42 CFR 438.56)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. Nursing Home For BadgerCare Plus 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 Medicaid SSI members 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 Plan's grievance system; (8) Request of one (1) PCP to have an enrollee assigned to a nursing home at different provider out of the time of HMO enrollmentHealth Plan. e. When the Health Plan requests an involuntary disenrollment, it shall notify the enrollee in writing that the Health Plan is requesting disenrollment, the memberreason for the request, and an explanation that the Health Plan is requesting that the enrollee be disenrolled in the next Contract month, or earlier if necessary. Until the enrollee is disenrolled, the nursing home, or the HMO may contact the HMO Enrollment Specialist for an exemption. The nursing home services would Health Plan shall 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 effectiveprovision of services to that enrollee. Automatic disenrollment does not occur for the following populations and HMOs must notify the Enrollment Specialist for disenrollment: 2) WellCare of Florida, Inc., Medicaid SSI After a SSI member has been in a nursing home 90 days or longer and is expected to remain in the facility, the HMO must notify the HMO Enrollment Specialist to request disenrollment. In the event the member transfers from the nursing home to a hospital and back to the nursing home, the applicable 90 day period shall run continuously from the first admission to the nursing home and shall include any days in the hospital. The HMO must wait until 90 days have occurred before requesting an exemption, which will occur the first of the next month. The HMO is responsible for nursing home costs until the disenrollment is effective.Non-Reform Contract