Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 of this Agreement, a Member has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled with the CONTRACTOR until the annual choice period described in Section 4.2.9.2 of this Agreement. 4.3.2.2 A Member may select another MCO during the Member’s annual choice period. 4.3.2.3 A Member may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment: 4.3.2.3.1 The Member moves out of the State of New Mexico; 4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks; 4.3.2.3.3 HSD has imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement; 4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period; 4.3.2.3.5 The Member needs related services (for example a cesarean Section and a tubal ligation) to be performed at the same time, the Related Services are not available within the network and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk; 4.3.2.3.6 A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer MCOs; or 4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing the Member's health care needs.
Appears in 14 contracts
Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 4.2.10 of this Agreement, a Member Member, other than a CISC Member, has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled with the CONTRACTOR until the annual choice period described in Section 4.2.9.2 4.2.10.2 of this Agreement.
4.3.2.2 A Member In accordance with Section 4.2.10.2 of this Agreement, a Member, other than a CISC Member, may select another MCO during the Member’s annual choice period.
4.3.2.3 A Member Member, including a CISC Member, may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD HCA for approval. HSD HCA must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD HCA does not respond, the request will be deemed approved. The Member will have access to HSDHCA’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment:
4.3.2.3.1 The Member moves out of the State of New Mexico;
4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;
4.3.2.3.3 HSD HCA has imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement;
4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period;
4.3.2.3.5 The Member needs related services (for example a cesarean Section section and a tubal ligation) to be performed at the same time, the Related Services related services are not available within the network and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk;
4.3.2.3.6 A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her her/their current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer MCOs; or
4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing the Member's health care needs.
Appears in 9 contracts
Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 4.2.10 of this Agreement, a Member Member, other than a CISC Member, has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled with the CONTRACTOR until the annual choice period described in Section 4.2.9.2 4.2.10.2 of this Agreement.
4.3.2.2 A Member In accordance with Section 4.2.10.2 of this Agreement, a Member, other than a CISC Member, may select another MCO during the Member’s annual choice period.
4.3.2.3 A Member Member, including a CISC Member, may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment:
4.3.2.3.1 The Member moves out of the State of New Mexico;
4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;
4.3.2.3.3 HSD has imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement;
4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period;
4.3.2.3.5 The Member needs related services (for example a cesarean Section section and a tubal ligation) to be performed at the same time, the Related Services related services are not available within the network and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk;
4.3.2.3.6 A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer MCOs; or
4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing the Member's health care needs.
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Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 of this Agreement, a A Member has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCOa twelve (12) month period. After exercising change rights, the Member shall remain enrolled with the CONTRACTOR until the annual choice his or her twelve (12) month period described in Section 4.2.9.2 of this Agreementexpires.
4.3.2.2 A Member may select another MCO during the Member’s annual choice period.
4.3.2.3 A Member may request to be disenrolled from the CONTRACTOR for cause at any time, even during a lock-in period (see Section 4.22 of this Agreement). The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment:
4.3.2.3.1 The Member moves out of the State of New Mexico;
4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;
4.3.2.3.3 If HSD has imposed imposes intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement;
4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual disenrollment opportunity during the annual choice period;
4.3.2.3.5 The Member needs related services (for example a cesarean Section section and a tubal ligation) to be performed at the same time, the Related Services not all related services are not available within the network network, and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk;
4.3.2.3.6 A Where a Member’s LTSS residential or employment supports Provider provider is leaving the CONTRACTORContractor’s network. A MCO, a Member may transfer switch MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s provider departure from the CONTRACTOR’s networkMCO. If the a requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departureDays, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider provider requirements, the CONTRACTOR Contractor must assist the Member in locating a new provider or the Member may transfer switch MCOs; or
4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers providers experienced in addressing dealing with the Member's health care needs.
4.3.3.1.1 The Members loses Medicaid eligibility; or
4.3.3.1.2 At any point in the Fair Hearing process when it is determined that such removal is in the best interest of the Member and/or HSD.
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Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 of this Agreement, a Member M e m b e r has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled enro lled with the CONTRACTOR until the annual choice cho ice period described in Section 4.2.9.2 of this Agreement.
4.3.2.2 A Member may select another MCO during the Member’s annual choice period.
4.3.2.3 A Member may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment:
4.3.2.3.1 The Member moves out of the State of New Mexico;
4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;
4.3.2.3.3 HSD has h a s imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement;
4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. CFR § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period;
4.3.2.3.5 The Member needs related services Related Services (for example a cesarean Section section and a tubal ligation) to be performed at the same time, the Related Services are not available within the network network, and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk;
4.3.2.3.6 A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer t r ans fer MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer t r a ns fe r MCOs; or
4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing a d d r e s s i n g the Member's health care needs.
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Member Disenrollment Initiated by Member. 4.3.2.1 In accordance with Section 4.2.9 of this Agreement, a Member M e m b e r has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled enro lled with the CONTRACTOR until the annual choice period described in Section 4.2.9.2 of this Agreement.
4.3.2.2 A Member may select another MCO during the Member’s annual choice period.
4.3.2.3 A Member may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment:
4.3.2.3.1 The Member moves out of the State of New Mexico;
4.3.2.3.2 The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;
4.3.2.3.3 HSD has h a s imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement;
4.3.2.3.4 If the Member is automatically re-enrolled under 42 C.F.R. CFR § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period;
4.3.2.3.5 The Member needs related services Related Services (for example a cesarean Section section and a tubal ligation) to be performed at the same time, the Related Services are not available within the network network, and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk;
4.3.2.3.6 A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer t r a ns fe r MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer t r a n s f e r MCOs; or
4.3.2.3.7 Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing a d d r e s s i n g the Member's health care needs.
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