Member Enrollment & Disenrollment Sample Clauses

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO Program. To enroll in an HMO, the Member’s permanent residence must be located within the HMO’s Service Area. The HMO is not allowed to induce or accept disenrollment from a Member. The HMO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO regarding the number of eligible Members who will ultimately be enrolled into the HMO or the length of time any such enrolling Members remain enrolled with the HMO beyond the minimum mandatory enrollment periods established for each HHSC HMO Program. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO Program, special conditions may also apply to enrollment and span of coverage for the HMO. (e) A Medicaid HMO has a limited right to request a Member be disenrolled from HMO without the Member’s consent. HHSC must approve any HMO request for disenrollment of a Member for cause. HHSC may permit disenrollment of a Member under the following circumstances: (1) Member misuses or loans Member’s HMO membership card to another person to obtain services. (2) Member is disruptive, unruly, threatening or uncooperative to the extent that Member’s membership seriously impairs HMO’s or Provider’s ability to provide services to Member or to obtain new Members, and Member’s behavior is not caused by a physical or behavioral health condition. (3) Member steadfastly refuses to comply with managed care restrictions (e.g., repeatedly using emergency room in combination with refusing to allow HMO to treat the underlying medical condition). (4) HMO must take reasonable measures to correct Member behavior prior to requesting disenrollment. Reasonable measures may include providing education and counseling regarding the offensive acts or behaviors. (5) For STAR+PLUS HMOs, under limited conditions, the HMO may request disenrollment of members who are totally dependent on a ventilator or who have been diagnosed with End Stage Renal Disease. (f) HHSC must notify the Member of HHSC’s decision to disenroll the Member if all reasonable measures have failed to remedy the problem. (g) If the Member disagrees with the decision to disenroll the Member from HMO, HHSC must notify the Member of the avail...
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Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO Program. To enroll in an HMO, the Member’s permanent residence must be located within the HMO’s Service Area. The HMO is not allowed to induce or accept disenrollment from a Member. The HMO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO regarding the number of eligible Members who will ultimately be enrolled into the HMO or the length of time any such enrolling Members remain enrolled with the HMO beyond the minimum mandatory enrollment periods established for each HHSC HMO Program. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO Program, special conditions may also apply to enrollment and span of coverage for the HMO. (e) A Medicaid HMO has a limited right to request a Member be disenrolled from HMO without the Member’s consent. HHSC must approve any HMO request for disenrollment of a Member for cause. HHSC may permit disenrollment of a Member under the following circumstances:
Sample 1
Member Enrollment & Disenrollment. The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the MCO Program. To enroll in an MCO, the Member’s permanent residence must be located within the MCO’s Service Area. The MCO is not allowed to induce or accept disenrollment from a Member. The MCO must refer the Member to the HHSC Administrative Services Contractor.
Sample 1

Related to Member Enrollment & Disenrollment

  • Disenrollment An Enrollee must be disenrolled from the Plan if the Beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writing. The effective date of any approved disenrollment will be no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

  • Enrollment The Competitive Supplier shall be responsible for enrolling all Eligible Consumers through EDI transactions submitted to the LDC for all enrollments of Eligible Consumers during the term of this Agreement.

  • Enrollment Process The Department may, at any time, revise the enrollment procedures. The Department will advise the Contractor of the anticipated changes in advance whenever possible. The Contractor shall have the opportunity to make comments and provide input on the changes. The Contractor will be bound by the changes in enrollment procedures.

  • Open Enrollment Period Open Enrollment is a period of time each year when you and your eligible dependents, if family coverage is offered, may enroll for healthcare coverage or make changes to your existing healthcare coverage. The effective date will be on the first day of your employer’s plan year. A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health coverage. You and your eligible dependents may enroll for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days of the following events: • you get married, the coverage effective is the first day of the month following your marriage. • you have a child born to the family, the coverage effective date is the date of birth. • you have a child placed for adoption with your family, the coverage effective date is the date of placement. Special note about enrolling your newborn child: You must notify your employer of the birth of a newborn child and pay the required premium within thirty -one (31) days of the date of birth. Otherwise, the newborn will not be covered beyond the thirty -one (31) day period. This plan does not cover services for a newborn child who remains hospitalized after thirty-one (31) days and has not been enrolled in this plan. If you are enrolled in an Individual Plan when your child is born, the coverage for thirty- one (31) days described above means your plan becomes a Family Plan for as long as your child is covered. Applicable Family Plan deductibles and maximum out-of-pocket expenses may apply. In addition, if you lose coverage from another plan, you may enroll or add your eligible dependents for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days following the date you lost coverage. Coverage will begin on the first day of the month following the date your coverage under the other plan ended. In order to be eligible, the loss of coverage must be the result of: • legal separation or divorce; • death of the covered policy holder; • termination of employment or reduction in the number of hours of employment; • the covered policy holder becomes entitled to Medicare; • loss of dependent child status under the plan; • employer contributions to such coverage are being terminated; • COBRA benefits are exhausted; or • your employer is undergoing Chapter 11 proceedings. You are also eligible for a Special Enrollment Period if you and/or your eligible dependent lose eligibility for Medicaid or a Children’s Health Insurance Program (CHIP), or if you and/or your eligible dependent become eligible for premium assistance for Medicaid or a (CHIP). In order to enroll, you must provide required information within sixty (60) days following the change in eligibility. Coverage will begin on the first day of the month following our receipt of your application. In addition, you may be eligible for a Special Enrollment Period if you provide required information within thirty (30) days of one of the following events: • you or your dependent lose minimum essential coverage (unless that loss of coverage is due to non-payment of premium or your voluntary termination of coverage); • you adequately demonstrate to us that another health plan substantially violated a material provision of its contract with you; • you make a permanent move to Rhode Island: or • your enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, or inaction by us or an agent of HSRI or the U.S. Department of Health and Human Services (HHS).

  • Enrollment Period Educational Support Professionals may elect to participate in the Career Transition Trust annually during a two (2) week enrollment period determined by the District, but that will occur no later than May 1st each year, provided they have met the eligibility requirements for participation in Subdivision. 2.

  • Open Enrollment KFHPWA will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible as described above during a limited period of time specified by the Group and KFHPWA.

  • Special Enrollment a. KFHPWA will allow special enrollment for persons: 1) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events: • Cessation of employer contributions. • Exhaustion of COBRA continuation coverage. • Loss of eligibility, except for loss of eligibility for cause. 2) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and who have had such other coverage exhausted because such person reached a lifetime maximum limit. KFHPWA or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage must be made within 31 days of the termination of previous coverage. b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents (other than for nonpayment or fraud) in the event one of the following occurs: 1) Divorce or Legal Separation. Application for coverage must be made within 60 days of the divorce/separation. 2) Cessation of Dependent status (reaches maximum age). Application for coverage must be made within 30 days of the cessation of Dependent status. 3) Death of an employee under whose coverage they were a Dependent. Application for coverage must be made within 30 days of the death of an employee. 4) Termination or reduction in the number of hours worked. Application for coverage must be made within 30 days of the termination or reduction in number of hours worked. 5) Leaving the service area of a former plan. Application for coverage must be made within 30 days of leaving the service area of a former plan. 6) Discontinuation of a former plan. Application for coverage must be made within 30 days of the discontinuation of a former plan. c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents in the event one of the following occurs: 1) Marriage. Application for coverage must be made within 31 days of the date of marriage. 2) Birth. Application for coverage for the Subscriber and Dependents other than the newborn child must be made within 60 days of the date of birth. 3) Adoption or placement for adoption. Application for coverage for the Subscriber and Dependents other than the adopted child must be made within 60 days of the adoption or placement for adoption. 4) Eligibility for premium assistance from Medicaid or a state Children’s Health Insurance Program (CHIP), provided such person is otherwise eligible for coverage under this EOC. The request for special enrollment must be made within 60 days of eligibility for such premium assistance. 5) Coverage under a Medicaid or CHIP plan is terminated as a result of loss of eligibility for such coverage. Application for coverage must be made within 60 days of the date of termination under Medicaid or CHIP. 6) Applicable federal or state law or regulation otherwise provides for special enrollment.

  • Deferral Election A Participant may elect to defer all or a specified percentage of the Compensation earned in a Plan Year by such Participant for serving as a member of the Board of any Participating Fund or as a member of any committee or subcommittee thereof. Reimbursement of expenses of attending meetings of the Board, committees of the Board or subcommittees of such committees may not be deferred. Such election shall be made by executing before the first day of such Plan Year such election notice as the Administrator may prescribe; provided, however, that upon first becoming eligible to participate in the Plan by reason of appointment to a Board, a Participant may file a Deferral Election not later than 30 days after the effective date of such appointment, which election shall apply to Compensation earned in the portion of the Plan Year commencing the day after such election is filed and ending on the last day of such Plan Year.

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Eligible Employee For purposes of the SIMPLE 401(k) Plan provisions, any Employee who is entitled to make Elective Deferrals under the terms of the SIMPLE 401(k) Plan.

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