Common use of Member Enrollment & Disenrollment Clause in Contracts

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 availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process.

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 availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) HMO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Upon implementation of the Comprehensive Healthcare Program for Xxxxxx Care, STAR and CHIP Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled effective the date of conservatorship.

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. To enroll in an HMOMCO, the Member’s 's permanent residence must be located within the HMO’s MCO's Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s 's consent. HHSC must approve any HMO MCO 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 's MCO membership card to another person to obtain services. (2) Member is disruptive, unruly, threatening or uncooperative to the extent that Member’s 's membership seriously impairs HMO’s MCO's or Provider’s 's ability to provide services to Member or to obtain new Members, and Member’s '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 MCO to treat the underlying medical condition). (4) HMO For STAR+PLUS MCOs, under limited conditions, the MCO may request disenrollment of members who are totally dependent on a ventilator or who have been diagnosed with End Stage Renal Disease. MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

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 availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process.

Member Enrollment & Disenrollment. (a) The HHSC or the HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. The HHSC Administrative Services Contractor will use HHSC’s default assignment methodologies, as described in 1 Tex. Admin. Code § 353.403 and § 370.303, to enroll individuals who do not select an MCO or PCP. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO request for disenrollment of a Member for cause. MCO must take reasonable documented measures to correct Member behavior prior to requesting disenrollment. Reasonable documented measures may include providing education and counseling regarding the offensive acts or behaviors. HHSC may permit disenrollment of a Member under the following circumstances: (1) Member misuses or loans Member’s HMO MCO membership card to another person to obtain services. (2) Member Member's behavior is disruptive, unruly, threatening disruptive or uncooperative to the extent that Member’s membership continued enrollment in the MCO seriously impairs HMOMCO’s or Provider’s ability to provide services to either the Member or to obtain new other Members, and Member’s behavior is not caused by related to a developmental, intellectual, or physical disability 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 MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

Member Enrollment & Disenrollment. (a) The HHSC or the HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. The HHSC Administrative Services Contractor will use HHSC’s default assignment methodologies, as described in 1 Tex. Admin. Code § 353.403 and § 370.303, to enroll individuals who do not select an MCO or PCP. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO request for disenrollment of a Member for cause. MCO 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. HHSC may permit disenrollment of a Member under the following circumstances: (1) Member misuses or loans Member’s HMO MCO 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 HMOMCO’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 MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

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 availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) HMO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Upon implementation of the Comprehensive Healthcare Program for Xxxxxx Care, STAR and CHIP Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled effective the date of conservatorship.

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO 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 MCO 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 HMOMCO’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 MCO to treat the underlying medical condition). (4) HMO MCO 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 HMOsMCOs, under limited conditions, the HMO MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. To enroll in an HMOMCO, the Member’s 's permanent residence must be located within the HMO’s MCO's Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s 's consent. HHSC must approve any HMO MCO request for disenrollment of a Member for cause. MCO 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. HHSC may permit disenrollment of a Member under the following circumstances: (1) Member misuses or loans Member’s HMO 's MCO membership card to another person to obtain services. (2) Member is disruptive, unruly, threatening or uncooperative to the extent that Member’s 's membership seriously impairs HMO’s MCO's or Provider’s 's ability to provide services to Member or to obtain new Members, and Member’s '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 MCO 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 '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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s 's Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member's health status or utilization of services that are Medically Necessary for treatment of a member's condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

Member Enrollment & Disenrollment. (a) The HHSC or the HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. The HHSC Administrative Services Contractor will use HHSC’s default assignment methodologies, as described in 1 Tex. Admin. Code § 353.403 and § 370.303, to enroll individuals who do not select an MCO or PCP. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO request for disenrollment of a Member for cause. MCO 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. HHSC may permit disenrollment of a Member under the following circumstances: (1) Member misuses or loans Member’s HMO MCO 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 HMOMCO’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 MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process.

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 HMO must notify the Member of HHSCHMO’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 HMO must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) HMO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition.

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO 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 MCO 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 HMOMCO’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 MCO to treat the underlying medical condition). (4) HMO MCO 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 HMOsMCOs, under limited conditions, the HMO MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process. (h) MCO cannot request a disenrollment based on adverse change in the member’s health status or utilization of services that are Medically Necessary for treatment of a member’s condition. (i) Members taken into conservatorship by the Department of Family and Protective Services (DFPS) will be disenrolled from the MCO effective the date of conservatorship, and enrolled in the STAR Health Program unless otherwise determined by DFPS.

Member Enrollment & Disenrollment. (a) The HHSC Administrative Services Contractor will enroll and disenroll eligible individuals in the HMO MCO Program. To enroll in an HMOMCO, the Member’s permanent residence must be located within the HMOMCO’s Service Area. The HMO MCO is not allowed to induce or accept disenrollment from a Member. The HMO MCO must refer the Member to the HHSC Administrative Services Contractor. (b) HHSC makes no guarantees or representations to the HMO MCO regarding the number of eligible Members who will ultimately be enrolled into the HMO MCO 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 ProgramMCO. The MCO has no ownership interest in its Member base, and therefore cannot sell or transfer this base to another entity. (c) The HHSC Administrative Services Contractor will electronically transmit to the HMO MCO new Member information and change information applicable to active Members. (d) As described in the following Sections, depending on the HMO MCO Program, special conditions may also apply to enrollment and span of coverage for the HMOMCO. (e) A Medicaid HMO MCO has a limited right to request a Member be disenrolled from HMO MCO without the Member’s consent. HHSC must approve any HMO MCO 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 MCO 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 HMOMCO’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 MCO to treat the underlying medical condition). (4) HMO MCO 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 HMOsMCOs, under limited conditions, the HMO MCO 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 HMOMCO, HHSC must notify the Member of the availability of the Complaint procedure and, for Medicaid Members, HHSC’s Fair Hearing process.