New Enrollees. Each MCO Enrollee with no FFS claim experience or managed care encounters in the assessment period will be assigned a risk score equal to the average risk score for the MCO’s Enrollees in the same rate cell.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if, (1) the Enrollee has a life-
New Enrollees. Participating Provider shall provide no less than 30 days’ prior written notice of Participating Provider’s decision to no longer accept new Enrollees. In no event shall any current patient of Participating Provider who becomes an Enrollee be considered a new Enrollee for purposes of this Section 2.3.
New Enrollees. At the time of eligibility determination, individuals who are mandated to participate must receive information about managed care plan choices in their area. They must be informed of their options in selecting an authorized managed care plan. Individuals must be provided the opportunity to meet or speak with a choice counselor to obtain additional information in making a choice. New enrollees will be required to select a plan within 30 days of eligibility determination. If the individual does not select a plan within the 30-day period, the state may auto-assign the individual into a capitated managed care plan or a FFS PSN in the Reform Counties or the MMA program when implemented. Once individuals have made their choice, they will be able to contact the state or the state’s designated choice counselor to register their plan selection. Once the plan selection is registered and takes effect, the plan must communicate to the enrollee, in accordance with 42 CFR 438.10, the benefits covered under the plan, including dental benefits, and how to access those benefits.
New Enrollees. The State will utilize diagnoses from fee-for-service and encounter data to determine new enrollee risk scores. The first quarter risk scores will be calculated by the STATE based on fee-for-service data and/or encounter data. Risk scores in subsequent quarters will be calculated by the STATE based on fee-for-service data and/or encounter data submitted by any MCO in which a given recipient was enrolled during the assessment period pursuant to section 4.4.4 of this contract as available from both sources. If an Enrollee has no fee-for-service or encounter claim experience, the Enrollee will be assigned the MCO risk score plan average.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the contractor shall permit the Enrollee to continue an on going course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if, (1) the Enrollee has a life-threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall Section 15 (EQUALITY OF ACCESS AND TREATMENT October 1, 1999 15-2 include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to:
i) accept reimbursement from the Contractor at rates established by the Contractor as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and
ii) adhere to the Contractor's quality assurance requirements and agrees to provide to the Contractor necessary medical information related to such care; and
iii) otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining preauthorization in a treatment plan approved by the Contractor. In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.
New Enrollees. DVHA shall be responsible for educating individuals at the time of their enrollment into the Global Commitment to Health Demonstration. Education activities may be conducted via mail, by telephone and/or through face-to-face meetings. DVHA may employ the services of an enrollment broker to assist in outreach and education activities. DVHA shall provide information and assist enrollees in understanding all facets pertinent to their enrollment, including the following: • What services are covered and how to access them; • Restrictions on freedom-of-choice; • Cost sharing; • Role and responsibilities of the primary care provider (PCP); • Importance of selecting and building a relationship with a PCP; • Information about how to access a list of PCPs in geographic proximity to the enrollee and the availability of a complete network roster; • Enrollee rights, including appeal and Fair Hearing rights, confidentiality rights, availability of the Health Care Advocate, and other beneficiary supports available under 42 CFR 438.71; • Enrollee responsibilities, including making, keeping, canceling appointments with PCPs and specialists, necessity of obtaining prior authorization (PA) for certain services and proper utilization of the emergency room (ER); and • Enrollees in the Choices for Care Program will also be educated about systems to prevent, detect and report, investigate and remediate abuse, neglect and exploitation.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provide during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if, (1) the Enrollee has a life SECTION 15 (EQUALITY OF ACCESS AND TREATMENT) OCTOBER 1, 2004 15-2 threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to:
New Enrollees. New Enrollees to the GHP will have one (1) opportunity to select a MCO during the Medicaid eligibility process with the Puerto Rico Medicaid Program. If the New Enrollee does not select a MCO, the Puerto Rico Medicaid Program will select a MCO on behalf of the New Enrollee. New Enrollees shall be permitted to select a different MCO once without cause, regardless of how the initial selection of MCO was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Effective Date of Enrollment.
New Enrollees. New Enrollees to the GHP will have one (1) opportunity to select a MCO during the Medicaid eligibility process with the Puerto Rico Medicaid Program. If the New Enrollee does not select a MCO, the Puerto Rico Medicaid Program will select a MCO on behalf of the New Enrollee. New Enrollees shall be permitted to select a different MCO once without cause, regardless of how the initial selection of MCO was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Effective Date of Enrollment. If a New Enrollee’s Open Enrollment Period in Section 5.3.1 coincides with the Annual Open Enrollment Period, the Open Enrollment Period in Section 5.3.1 controls. The Xxxxxx Care Population and Domestic Violence Population will be Auto- Enrolled in one MCO and are not eligible to enroll into another MCO. When an Enrollee ceases to be part of the Domestic Violence or Xxxxxx Care Populations but continues to be an Eligible Person, it will be considered a for cause reason for which the Enrollee may select a new MCO.. When an Enrollee ceases to be eligible for the Platino Program but continues to be eligible for the GHP, it is a for cause reason for which the Enrollee may select a new MCO. If the Enrollee does not make a change in MCO during the Open Enrollment Period, the Enrollee will remain enrolled with his/her current MCO. Disenrollment occurs only when ASES or the Medicaid Program determines that an Enrollee is no longer eligible for the GHP; or when Disenrollment is requested by the MCO or Enrollee or his or her Authorized Representative for cause, and approved by ASES or the Enrollment Counselor in accordance with the guidelines set forth in this Contract. The Xxxxxx Care Population and Domestic Violence Populations are not eligible to disenroll from their Auto- Enrolled GHP Plan. Disenrollment will be processed by ASES, and ASES will issue notification to the MCO. The Enrollment Counselor may accept disenrollment requests from the Enrollee or his or her Authorized Representative at any time orally or in writing. The Enrollment Counselor may approve disenrollment requests made outside of Open Enrollment provided that (1) the Enrollee or Authorized Representative has stated an appropriate cause to disenroll, and (2) the Enrollment Counselor ensures that the Enrollee’s disenrollment happens within the required timeframes as specified by 42 C.F.R. 438.3(q); 42 C.F.R. 438.56(c); (d)(3)(ii); and (e)(1)-(2). If the Enrollee or Authorized Representat...
