Common use of LDSS Responsibilities Clause in Contracts

LDSS Responsibilities. i) The LDSS is responsible for accepting requests for Disenrollment directly from Enrollees and may not require Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS and the Enrollment Broker must utilize the State-approved Disenrollment forms. ii) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves an urgent medical need, a complaint of non­consensual Enrollment or, in local districts where homeless individuals are exempt, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iii) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (lst) day of the following month if the request is made before the fifteenth (15th) day of the month. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. iv) The LDSS is responsible for disenrolling Enrollees automatically upon death or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death or loss of eligibility occurs or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their Disenrollment request is denied. Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms, of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH. or its agent that the Enrollment was not consensual; or G) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 4.9 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with a notice of his or her right to request a fair hearing. viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee is determined to have been non-consensually enrolled in a MCO; he or she enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC program; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage from an MCO and is enrolled in either the MMC or FHPlus product of the same MCO; or he or she has died - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. x) The SDOH may recover premiums paid for Medicaid or FHPlus Enrollees whose eligibility for those programs was based on false information, when such false information was provided as a result of intentional actions or failures to act on the part of an employee of the Contractor; and the Contractor shall have no right of recourse against the Enrollee or a providers of service for the cost of services provided to the Enrollee for the period covered by such premiums. xi) The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment prior to the action. The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims within thirty (30) business days of notification from the LDSS for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. Failure by the LDSS to notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment. xii) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI re1ated category First Day of the month of birth of the month of onset of disability, whichever is later. B) Death of Enrollee First day of the month after death C) Incarceration First day of the month of incarceration (note- Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, or is in receipt of waivered services through the Long Term Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. First day of the month of entry or first day of the month of classification of the stay as permanent subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment orautoassignment into a MMC product occurred whilemeeting institutional criteria in (D) above Effective Date of Enrollment in the Contractor's Plan

LDSS Responsibilities. i) The LDSS is responsible for accepting requests for Disenrollment directly from Enrollees and may not require Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS and the Enrollment Broker must utilize the State-approved Disenrollment forms. ii) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves an urgent medical need, a complaint of non­consensual Enrollment or, in local districts where homeless individuals are exempt, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iii) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (lst1st) day of the following month if the request is made before the fifteenth (15th) day of the month. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. iv) The LDSS is responsible for disenrolling Enrollees automatically upon death or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death or loss of eligibility occurs or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their Disenrollment request is denied. Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms, terms of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in2(b)(xiin 2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH. , or its agent that the Enrollment was not consensual; or GX) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 4.9 49 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with a notice of his or her right to request a fair hearing. viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee is determined to have been non-consensually enrolled in a MCO; he or she enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC program; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage from an MCO and is enrolled in either the MMC or FHPlus product of the same MCO; or he or she has died - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. x) The SDOH may recover premiums paid for Medicaid or FHPlus Enrollees whose eligibility for those programs was based on false information, when such false information was provided as a result of intentional actions or failures to act on the part of an employee of the Contractor; and the Contractor shall have no right of recourse against the Enrollee or a providers provider of service for the cost of services provided to the Enrollee for the period covered by such premiums. xi) The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment prior to the action. The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims within thirty (30) business days of notification from the LDSS for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. Failure by the LDSS to notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment. xii) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI re1ated related category First Day of the month of birth of or the month of onset of disability, whichever is later. B) Death of Enrollee First day of the month after death C) Incarceration First day of the month of incarceration (note- note-Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, or is in receipt of waivered services through the Long Term Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. First day of the month of entry or first day of the month of classification of the stay as permanent subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment orautoassignment or autoassignment into a MMC product occurred whilemeeting while meeting institutional criteria in (D) above Effective Date of Enrollment in the Contractor's Plan

LDSS Responsibilities. i) The LDSS is responsible for accepting requests for Disenrollment directly from Enrollees and may not require Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS and the Enrollment Broker must utilize the State-approved Disenrollment forms. ii) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves an urgent medical need, a complaint of non­consensual non-consensual Enrollment or, in local districts where homeless individuals are exempt, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iii) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (lst1st) day of the following month if the request is made before BEFORE the fifteenth (15th) day of the month. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. iv) The LDSS is responsible for disenrolling Enrollees automatically upon death or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death or loss of eligibility occurs or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their Disenrollment request is denied. denied Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms, of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH. or its agent that the Enrollment was not consensual; or G) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 4.9 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with a notice of his or her right to request a fair hearing. viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee is determined to have been non-consensually enrolled in a MCO; he or she enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC program; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage from an MCO and is enrolled in either the MMC or FHPlus product of the same MCO; or he or she has died - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. x) The SDOH may recover premiums paid for Medicaid or FHPlus Enrollees whose eligibility for those programs was based on false information, when such false information was provided as a result of intentional actions or failures to act on the part of an employee of the Contractor; and the Contractor shall have no right of recourse against the Enrollee or a providers of service for the cost of services provided to the Enrollee for the period covered by such premiums. xi) The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment prior to the action. The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims within thirty (30) business days of notification from the LDSS for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus product whether or not the Contractor has made payments to providers. Failure by the LDSS to notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment. xii) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI re1ated category First Day of the month of birth of the month of onset of disability, whichever is later. B) Death of Enrollee First day of the month after death C) Incarceration First day of the month of incarceration (note- Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, or is in receipt of waivered services through the Long Term Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. First day of the month of entry or first day of the month of classification of the stay as permanent subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment orautoassignment into a MMC product occurred whilemeeting institutional criteria in (D) above Effective Date of Enrollment in the Contractor's Plan

LDSS Responsibilities. i) The LDSS is responsible Enrollees may request to disenroll from the Contractor's Medicaid Advantage Product at any time for accepting any reason. Disenrollment requests for Disenrollment directly from Enrollees and may not require be made by Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate EnrollmentLDSS, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS , or the Contractor. ii) Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize the State-approved Disenrollment forms. iiiii) The LDSS will accept requests for Disenrollment directly from the Enrollee or from the Contractor. iv) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite is responsible for expediting the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves concurrent Disenrollment from the Contractor's Medicare Advantage Product, an urgent medical need, a complaint of non­consensual Enrollment enrollment or, in local districts where homeless individuals are exemptNew York City, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care Medicaid Advantage based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iiiv) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (lst1st) day of the following month if to the request is made before the fifteenth (15th) day of the monthextent possible. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. ivvi) The LDSS is responsible for disenrolling Enrollees automatically upon death death, Disenrollment from the Contractor's Medicare Advantage Product, or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death death, Effective Date of Disenrollment from the Contractor's Medicare Advantage Product, or loss of eligibility occurs occurs, or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their Disenrollment request is denied. Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms, of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH. or its agent that the Enrollment was not consensual; or G) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 4.9 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC managed care eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteriano longer be eligbile for Medicaid Advantage Enrollment. The LDSS will provide the MMC Enrollee is responsibile for providing Enrollees with a notice of his or her their right to request a fair hearing.. Medicaid Advantage Contract APPENDIX H State January 1, 2008 H-9 viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee individual is determined deemed to have been non-consensually enrolled in a MCO; he the Contractor's Medicaid Advantage Product, is enrolled when ineligible for Enrollment, or she when an Enrollee enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC programineligible; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage retroactively disenrolled from an MCO and is enrolled in either the MMC Contractor's Medicare Advantage Product, or FHPlus product of the same MCO; or he or she has died dies - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus Medicaid Advantage premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus Medicaid Advantage product whether or not the Contractor has made payments to providers. xix) The SDOH may recover premiums paid for Medicaid or FHPlus Advantage Enrollees whose eligibility for those programs this program was based on false information, when such false information was provided as a result of intentional actions or failures to act on the part of an employee of the Contractor; and the Contractor shall have no right of recourse against the Enrollee or a providers provider of service services for the cost of services provided to the Enrollee for the period covered by such premiums. xix) The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment disenrollment prior to the action. : The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims within thirty (30) business days of notification from the LDSS for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus Medicaid Advantage premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus Medicaid Advantage product whether or not the Contractor has made payments to providers. Failure by the LDSS to notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment.. APPENDIX H State January 1, 2008 H-10 xiixi) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI re1ated category First Day of the month of birth of the month of onset of disability, whichever is later. B) : ·Death of Enrollee ·First day of the month after death C) death ·Incarceration ·First day of the month of incarceration (note- note-Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care . ·Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, ineligible for enrollment in Medicaid Advantage or is in receipt of waivered services through the Long Term Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. ·First day of the month of entry or first day of the month of classification of the stay as permanent permanent, subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment orautoassignment into a MMC product occurred whilemeeting institutional criteria in (D) above ). ·Individual enrolled while ineligible for enrollment ·Effective Date of Enrollment in the Contractor's Plan. ·Non-consensual Enrollment ·Retroactive to the first day of the month of Enrollment ·Enrollee moved outside of the District/County of Fiscal Responsibility ·First day of the month after the update of the system with the new address* ·Urgent medical need ·First day of the next month after determination except where medical need requires an earlier Disenrollment ·Homeless Enrollees in Medicaid Advantage residing in the shelter system in NYC ·Retroactive to the first day of the month of the request ·An Enrollee with more than one Client Identification Number (CIN) is enrolled in the Contractor's Medicaid Advantage Product under more than one of the CINs. ·First day of the month the duplicate Enrollment began. APPENDIX H State January 1, 2008 H-11 xii) The LDSS is responsible for informing Enrollees of their right to disenroll at any time for any reason. xiii) The LDSS will render a decision within five (5) days of the receipt of a fully documented request for Disenrollment. xiv) To the extent possible, the LDSS is responsible for processing an expedited disenrollment within two (2) business days of its determination that an expedited Disenrollment is warranted. xv) The LDSS is responsible for sending the following notices to Enrollees regarding their Disenrollment status. Where practicable, the process will allow for timely notification to Enrollees unless there is "good cause" to disenroll more expeditiously.

LDSS Responsibilities. i) The LDSS is responsible Enrollees may request to disenroll from the Contractor's Medicaid Advantage Product at any time for accepting any reason. Disenrollment requests for Disenrollment directly from Enrollees and may not require be made by Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate EnrollmentLDSS, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS , or the Contractor. ii) Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize the State-approved Disenrollment forms. iiiii) The LDSS will accept requests for Disenrollment directly from the Enrollee or from the Contractor. iv) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite is responsible for expediting the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves concurrent Disenrollment from the Contractor's Medicare Advantage Product, an urgent medical need, a complaint of non­consensual Enrollment enrollment or, in local districts where homeless individuals are exemptNew York City, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care Medicaid Advantage based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iiiv) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (lst1st) day of the following month if to the request is made before the fifteenth (15th) day of the monthextent possible. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. ivvi) The LDSS is responsible for disenrolling Enrollees automatically upon death death, Disenrollment from the Contractor's Medicare Advantage Product, or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death death, Effective Date of Disenrollment from the Contractor's Medicare Advantage Product, or loss of eligibility occurs occurs, or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their Disenrollment request is denied. Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to furnish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms, of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH. or its agent that the Enrollment was not consensual; or G) The Enrollee, the Contractor and the LDSS agree that a change of MCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 4.9 of the PHL and the Enrollee requests Enrollment in an MCO that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC managed care eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteriano longer be eligible for Medicaid Advantage Enrollment. The LDSS will provide the MMC Enrollee is responsible for providing Enrollees with a notice of his or her their right to request a fair hearing. viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee individual is determined deemed to have been non-consensually enrolled in a MCO; he the Contractor's Medicaid Advantage Product, is enrolled when ineligible for Enrollment, or she when an Enrollee enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC programineligible; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage retroactively disenrolled from an MCO and is enrolled in either the MMC Contractor's Medicare Advantage Product, or FHPlus product of the same MCO; or he or she has died dies - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus Medicaid Advantage premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus Medicaid Advantage product whether or not the Contractor has made payments to providers. xix) The SDOH may recover premiums paid for Medicaid or FHPlus Advantage Enrollees whose eligibility for those programs this program was based on false information, when such false information was provided as a result of intentional actions or failures to act on the part of an employee of the Contractor; and the Contractor shall have no right of recourse against the Enrollee or a providers provider of service services for the cost of services provided to the Enrollee for the period covered by such premiums. xix) The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment disenrollment prior to the action. The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims within thirty (30) business days of notification from the LDSS for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. Notwithstanding the foregoing, the SDOH always has the right to recover duplicate MMC or FHPlus Medicaid Advantage premiums paid for persons enrolled under more than one Client Identification Number (CIN) in the Contractor's MMC or FHPlus Medicaid Advantage product whether or not the notthe Contractor has made payments to providers. Failure by the LDSS to notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement or for the State Attorney General to bring legal action to recover any overpayment. xiixi) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI re1ated category First Day of the month of birth of the month of onset of disability, whichever is later. B) : ● Death of Enrollee ● First day of the month after death C) death ● Incarceration ● First day of the month of incarceration (note- note-Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care . ● Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, ineligible for enrollment in Medicaid Advantage or is in receipt of waivered services through the Long Term Tenn Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. ● First day of the month of entry or first day of the month of classification of the stay as permanent permanent, subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment orautoassignment into a MMC product occurred whilemeeting institutional criteria in (D) above ). - ● Individual enrolled while ineligible for enrollment ● Effective Date of Enrollment in the Contractor's Plan. ● Non-consensual Enrollment ● Retroactive to the first day of the month of Enrollment ● Enrollee moved outside of the District/County of Fiscal Responsibility ● First day of the month after the update of the system with the new address* ● Urgent medical need ● First day of the next month after determination except where medical need requires an earlier Disenrollment ● Homeless Enrollees in Medicaid Advantage residing in the shelter system in NYC ● Retroactive to the first day of the month of the request ● An Enrollee with more than one Client Identification Number (CIN) is enrolled in the Contractor's Medicaid Advantage Product under more than one of the CINs. ● First day of the month the duplicate Enrollment began. xii) The LDSS is responsible for informing Enrollees of their right to disenroll at any time for any reason. xiii) The LDSS will render a decision within five (5) days of the receipt of a fully documented request for Disenrollment. xiv) To the extent possible, the LDSS is responsible for processing an expedited disenrollment within two (2) business days of its determination that an expedited Disenrollment is warranted. xv) The LDSS is responsible for sending the following notices to Enrollees regarding their Disenrollment status. Where practicable, the process will allow for timely notification to Enrollees unless there is "good cause" to disenroll more expeditiously.