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 Enrollee's contact with the Choice Counselor/Enrollment Broker or Medicaid Options. f. The Health Plan may submit an Involuntary Disenrollment request to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency, after providing to the Enrollee at least one (1) verbal warning and at least one (1) written warning of the full implications of his or her failure of actions: (1) For an Enrollee who continues not to comply with a recommended plan of health care. Such requests must be submitted at least sixty (60) Calendar Days prior to the requested effective date. (2) For an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative to the extent that his or her Enrollment in the Health 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 mental health diagnoses if the Enrollee’s behavior is attributable to the mental illness. g. The Agency may approve such requests provided that the Health Plan documents that attempts were made to educate the Enrollee regarding his/her rights and responsibilities, assistance which would enable the Enrollee to comply was offered through Case Management, and it has been determined that the Enrollee’s behavior is not related to the Enrollee’s medical or behavioral condition. 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 dispute or appeal. h. 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 C.4.f.2 above); (7) Attempt to exercise rights under the Health Plan's Grievance System; or (8) Request of one (1) PCP to have an Enrollee assigned to a different Provider out of the Health Plan.
Appears in 1 contract
Samples: Health Care Services Contract (Wellcare Health Plans, Inc.)
Involuntary Disenrollment. a. With proper written documentation, the following are acceptable reasons for which the Health Plan PSN shall submit Involuntary Iinvoluntary 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 PSN 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 PSN 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 PlanPSN’s receipt of the reason for Involuntary involuntary Disenrollment. The Health Plan PSN shall ensure that Involuntary involuntary Disenrollment documents are maintained in an identifiable Enrollee record.
c. If the Health Plan PSN submitted the Disenrollment request for one of the above reasons, the Health Plan PSN shall verify that the information is accurate.
d. If the Health Plan PSN 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 PSN 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 PSN shall be responsible for the provision of services to that Enrollee.
e. On a monthly basis, the Health Plan PSN shall review its ongoing Enrollment report (FLMR 8200-8200- R0004) to ensure that all Enrollees are residing in the same county in which they were enrolledEnrolled. PSN’s authorized Service Area. The Health Plan PSN shall update the records for all Enrollees who have moved from one county to another, but are still residing in the Health PlanPSN’s Service Area, and provide the Enrollee with a new Provider Directory for that county. For Enrollees with out-of-county countyService Area addresses on the Enrollment report, the Health Plan PSN 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-Non- Reform County, respectively, to choose another Health PSNHealth Plan, or other managed care option available in the Enrollee’s new countycountyService Area, and that the Enrollee will be Disenrolled as a result of the Enrollee's contact with the Choice Counselor/Enrollment Broker or Medicaid Options.
f. The Health Plan PSN may submit an Involuntary involuntary Disenrollment request requests to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency, after providing to the Enrollee at least one (1) verbal warning and at least one (1) written warning Agent for assigned Enrollees that meet both of the full implications of his or her failure of actionsfollowing requirements:
(1) For an The PSN was unable to contact the Enrollee who continues not to comply with a recommended plan by mail, phone, or personal visit within the first three (3) months of health care. Such requests must be submitted at least sixty (60) Calendar Days prior to the requested effective date.Enrollment; and
(2) For an The Enrollee whose behavior is disruptivedid not use PSN services within the first three (3) months of Enrollment. Such Disenrollments shall be submitted in accordance with Section XII, unrulyReporting Requirements, abusive or uncooperative of this Contract. The PSN shall maintain documentation of its inability to the extent that his or her Enrollment in the Health Plan seriously impairs the organization's ability to furnish services to either contact the Enrollee or other Enrollees. This Section does not apply to Enrollees with mental health diagnoses if the Enrollee’s behavior is attributable to the mental illness.
g. The Agency may approve such requests provided and that the Health Plan documents that attempts were made to educate the Enrollee regarding his/her rights and responsibilities, assistance which would enable the Enrollee to comply was offered through Case Management, and it has been determined that the Enrollee’s behavior is not related no record of providing services to the Enrollee’s medical , or behavioral condition. 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 dispute or appeal.
h. The Health Plan shall not request Disenrollment of an Enrollee due to:
(1) Health diagnosis;
(2) Adverse changes another family unit member, 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 C.4.f.2 above);
(7) Attempt to exercise rights under the Health Plan's Grievance System; or
(8) Request of one (1) PCP to have an Enrollee assigned to a different Provider out of the Health Planfile.
Appears in 1 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 Enrollee's ’s contact with the Choice Counselor/Enrollment Broker or Medicaid Options.
f. The Health Plan may submit an Involuntary Disenrollment request to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency, after providing to the Enrollee at least one (1) verbal warning and at least one (1) written warning of the full implications of his or her failure of actions:
(1) For an Enrollee who continues not to comply with a recommended plan of health care. Such requests must be submitted at least sixty (60) Calendar Days prior to the requested effective date.
(2) For an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative to the extent that his or her Enrollment in the Health Plan seriously impairs the organization's ’s ability to furnish services to either the Enrollee or other Enrollees. This Section does not apply to Enrollees with mental health diagnoses if the Enrollee’s behavior is attributable to the mental illness.
g. The Agency may approve such requests provided that the Health Plan documents that attempts were made to educate the Enrollee regarding his/her rights and responsibilities, assistance which would enable the Enrollee to comply was offered through Case Management, and it has been determined that the Enrollee’s behavior is not related to the Enrollee’s medical or behavioral condition. 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 dispute or appeal.
h. 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 C.4.f.2 above);
(7) Attempt to exercise rights under the Health Plan's ’s Grievance System; or
(8) Request of one (1) PCP to have an Enrollee assigned to a different Provider out of the Health Plan.
A. Enrollee Services
1. General Provisions
a. The Health Plan shall have written policies and procedures for the provision of Enrollee Services, as specified in this Contract. Such policies and procedures shall be submitted to the Agency for approval.
b. The Health Plan shall ensure that Enrollees are aware of their rights and responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or urgent medical situation, how to request a Grievance, Appeal or Medicaid Fair Hearing, how to report suspected Fraud and Abuse, procedures for obtaining required Behavioral Health Services, including any additional Health Plan phone numbers to be used for obtaining services, and all other requirements and Benefits of the Health Plan.
c. The Health Plan shall have the capability to answer Enrollee inquiries via written materials, telephone, electronic transmission, and face-to-face communication.
d. Mailing envelopes for Enrollee materials shall contain a request for address correction. For Enrollees whose Enrollee Materials are returned to the Health Plan as undeliverable, the Health Plan shall use and maintain in a file a record of all of the following methods to contact the Enrollee:
(1) Telephone contact at the telephone number obtained from the local telephone directory, directory assistance, city directory, or other directory;
(2) Telephone contact with DCF and Families Economic Self-Sufficiency Services Office staff to determine if they have updated address information and telephone number; and
(3) Routine checks (at least once a month for the first three (3) months of Enrollment) on services or claims authorized or denied by the Health Plan to determine if the Enrollee has received services, and to locate updated address and telephone number information.
e. New Enrollee materials are not required for a former Enrollee who was disenrolled because of the loss of Medicaid eligibility and who regains his/her eligibility within sixty (60) days and is automatically reinstated as a Health Plan Enrollee. In addition, unless requested by the Enrollee, new Enrollee materials are not required for a former Enrollee subject to Open Enrollment who was disenrolled because of the loss of Medicaid eligibility, who regains his/her eligibility within sixty (60) days of his/her managed care enrollment, and is reinstated as a Health Plan Enrollee. notation of the effective date of the reinstatement on the most recent application or conspicuously in the Enrollee’s administrative file. Enrollees, who were previously enrolled in a Health Plan, lose and regain eligibility after sixty (60) days, will be treated as new Enrollees.
f. The Health Plan shall notify, in writing, each person who is to be reinstated, of the effective date of the reinstatement and the assigned Primary Care Provider. The notifications shall distinguish between Enrollees subject to Open Enrollment and Enrollees not subject to Open Enrollment and shall include information regarding change procedures for Cause, or general Health Plan change procedures through the Agency’s toll-free Choice Counselor/Enrollment Broker telephone number, as appropriate. The notification shall also instruct the Enrollee to contact the Health Plan if a new Enrollee card and/or a new Enrollee handbook are needed. The Health Plan shall provide such notice to each affected Enrollee by the first (1st) Calendar Day of the month following the Health Plan’s receipt of the notice of reinstatement.
Appears in 1 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-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 Enrollee's contact with the Choice Counselor/Enrollment Broker or Medicaid Options.
f. The Health Plan may submit an Involuntary Disenrollment request to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency, after providing to the Enrollee at least one (1) verbal warning and at least one (1) written warning of the full implications of his or her failure of actions:
(1) For an Enrollee who continues not to comply with a recommended plan of health care. Such requests must be submitted at least sixty (60) Calendar Days prior to the requested effective date.
(2) For an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative to the extent that his or her Enrollment in the Health 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 mental health diagnoses if the Enrollee’s behavior is attributable to the mental illness.
g. The Agency may approve such requests provided that the Health Plan documents that attempts were made to educate the Enrollee regarding his/her rights and responsibilities, assistance which would enable the Enrollee to comply was offered through Case Management, and it has been determined that the Enrollee’s behavior is not related to the Enrollee’s medical or behavioral condition. 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 dispute or appeal.
h. 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 C.4.f.2 above);
(7) Attempt to exercise rights under the Health Plan's Grievance System; or
(8) Request of one (1) PCP to have an Enrollee assigned to a different Provider out of the Health Plan.
Appears in 1 contract
Samples: Health Care Services Agreement
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 Enrollee's contact with the Choice Counselor/Enrollment Broker or Medicaid Options.
f. The Health Plan may submit an Involuntary Disenrollment request to the Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency, after providing to the Enrollee at least one (1) verbal warning and at least one (1) written warning of the full implications of his or her failure of actions:
(1) For an Enrollee who continues not to comply with a recommended plan of health care. Such requests must be submitted at least sixty (60) Calendar Days prior to the requested effective date.
(2) For an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative to the extent that his or her Enrollment in the Health 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 mental health diagnoses if the Enrollee’s behavior is attributable to the mental illness.
g. The Agency may approve such requests provided that the Health Plan documents that attempts were made to educate the Enrollee regarding his/her rights and responsibilities, assistance which would enable the Enrollee to comply was offered through Case Management, and it has been determined that the Enrollee’s behavior is not related to the Enrollee’s medical or behavioral condition. 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 dispute or appeal.
h. 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 C.4.f.2 above);
(7) Attempt to exercise rights under the Health Plan's Grievance System; or
(8) Request of one (1) PCP to have an Enrollee assigned to a different Provider out of the Health Plan.
A. Enrollee Services
Appears in 1 contract
Samples: Health Care Services Contract (Wellcare Health Plans, Inc.)
