Member Disenrollment. The PH-MCO may not request Disenrollment of a Member 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 or disruptive behavior resulting from his or her Special Needs. The PH-MCO may not reassign or remove Members involuntarily from Network Providers who are willing and able to serve the Member.
Member Disenrollment. Disenrollments may be initiated by: (1) the Member, (2) the Department, or (3) the CONTRACTOR. A Member may be Disenrolled from the CONTRACTOR’s Health Plan only when authorized by the Department. The Department or its designee is responsible for any Disenrollment action to remove a Member from the CONTRACTOR’s Health Plan.
Member Disenrollment. In accordance with 42 CFR 438.3(d)(3), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of his or her health care needs or a change in health care status. A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. The Contractor must notify the DFR, in the manner prescribed by the State, within thirty (30) calendar days of the date it becomes aware of the death of one of its members, giving the member's full name, address, Social Security Number, member identification number and date of death. The Contractor will have no authority to pursue recovery against the estate of a deceased Medicaid member.
Member Disenrollment. A. CONTRACTOR Requests for Disenrollment Member disenrollment shall only be considered in rare circumstances. The CONTRACTOR may request that a particular member be disenrolled. Disenrollment requests shall be submitted in writing to HSD. The request and supporting documentation shall meet requirements specified by HSD. If the disenrollment request is granted the CONTRACTOR retains responsibility for the member's care until such time as the member is enrolled with a new CONTRACTOR. If a request for disenrollment is approved the member shall not be re-enrolled with the CONTRACTOR for a period of time to be determined by HSD. Conditions that may permit lock-out or disenrollment are:
i. The CONTRACTOR demonstrates that it has made a good faith effort to accommodate the member but such efforts have been unsuccessful;
ii. The conduct of the member is such that it is not feasible safe or prudent to provide medical care subject to the terms of the contract;
iii. The CONTRACTOR has offered to the member in writing the opportunity to utilize the grievance procedures;
iv. The CONTRACTOR shall not terminate enrollment because of an adverse change in the member's health. The CONTRACTOR shall provide adequate documentation that terminations are proper and not due to an adverse change in the member's health; and
v. The CONTRACTOR has received threats or attempts of intimidation from the member to the CONTRACTORS, providers or its own staff.
B. Member Initiated Disenrollment A Medicaid member who is required to participate in managed care may request to be disenrolled from the CONTRACTOR "for cause" at anytime, even during a lock-in period. This request shall be submitted in writing to HSD for review. HSD shall complete the review and furnish a written decision to the member and the CONTRACTOR in a timely manner. Members who voluntarily enroll may choose to disenroll at any time.
C. HSD Initiated Disenrollment HSD may initiate disenrollment in three circumstances:
i. If a member loses Medicaid eligibility;
ii. If the member is re-categorized into a Medicaid coverage category not included in the managed care initiative; or
iii. The CONTRACTOR'S enrollment maximum is reduced to below contract levels. After HSD becomes aware of, or is alerted to, the existence of one of the reasons listed above, HSD shall immediately notify the member or family and the CONTRACTOR and shall update the enrollment roster.
Member Disenrollment. Disenrollments may be initiated by: (1) the Member, (2) the Department, or (3) the CONTRACTOR. A Member may be Disenrolled from the CONTRACTOR’s Health Plan only when authorized by the Department. The Department or its designee is responsible for any Disenrollment action to remove a Member from the CONTRACTOR’s Health Plan.
3.11.1 Member Disenrollment Requests A Member may request Disenrollment from the CONTRACTOR’s Health Plan
(1) for cause at any time, or (2) without cause for the reasons listed in Section 3 of this contract.
3.11.1.1 All Member requests for Disenrollment must be referred to the Department or its designee.
3.11.1.2 Effective date of an approved Disenrollment request must be no later than the first day of the second month following the month in which the Medicaid MCO Member filed the request.
3.11.1.3 A Member’s request to Disenroll must be acted on by the Department no later than the first day of the second month following the month in which the Member filed the request. If not, the request shall be considered approved.
Member Disenrollment. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of his or her health care needs, adverse change in health care status, diminished mental capacity, or because of uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members). A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i) -
Member Disenrollment. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of his or her health care needs, adverse change in health care status, diminished mental capacity, or because of uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members). A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i) - (iii), members have the right to disenroll from the Contractor: • For cause, at any time. • Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. • Without cause at least once every twelve (12) months at the member’s annual redetermination date. • Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438, 42 CFR 438.56(b)-(d) and Section 1932(e)(2)(B)(ii) of the Social Security Act. • Without cause upon reenrollment if a temporary loss of enrollment has caused the enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2), members may request disenrollment if the: • Member moves out of the service area. • Contractor does not cover the service the enrollee seeks, because of moral or religious objections.
EXHIBIT 1. E SCOPE OF WORK
Member Disenrollment. The PH-MCO may not reassign or remove Members involuntarily from Network Providers who are willing and able to serve the Member.
Member Disenrollment. Upon Group’s notification to Coventry, Coverage for a Member will terminate on the last day of the month of an Employee termination or loss of eligibility.
Member Disenrollment. The PH-MCO may not request Disenrollment of a Member 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 or disruptive behavior resulting from his or her Special Needs. The PH-MCO may not reassign or remove Members involuntarily from Network Providers who are willing and able to serve the Member.
G. Member Services
1. General The PH-MCO’s Member services functions must be operational at a minimum during regular business hours (9:00 a.m. to 5:00 p.m., Monday through Friday) and one (1) evening per week (5:00 p.m. to 8:00 p.m.) or one (1) weekend per month to address non-emergency problems encountered by Members. The PH-MCO must have arrangements to receive, identify, and resolve in a timely manner Emergency Member Issues on a twenty-four (24) hour, seven (7) day-a-week basis. The PH-MCO’s Member services functions must include, but are not limited to, the following: Explaining the operation of the PH-MCO and assisting Members in the selection of a PCP. Assisting Members with making appointments and obtaining services, including interpreter services, as needed. Assisting with arranging transportation for Members through the MATP. See Section V.A.15., Transportation and Exhibit L, Medical Assistance Transportation Program. Receiving, identifying and resolving Emergency Member Issues. Under no circumstances will unlicensed Member services staff provide health-related advice to Members requesting clinical information. The PH-MCO must require that all such inquiries are addressed by clinical personnel acting within the scope of their licensure to practice a health-related profession. The PH-MCO must forward all calls received by the Member services area in which the caller requests the Special Needs Unit to the SNU. In the event the call is received beyond the hours of availability of the SNU, The PH-MCO’s SNU must allow the Member to leave a message. The SNU must return the call as soon as possible but no longer than two (2) business days from the receipt of the call.
