Persons Eligible for Enrollment Sample Clauses

Persons Eligible for Enrollment. To be eligible to enroll in the MississippiCAN program (“Plan”) established pursuant to this Contract, a person must be a Beneficiary of Mississippi Medicaid (Beneficiary). In addition, a Beneficiary must be a resident of the State of Mississippi and be a targeted, high cost beneficiary. Targeted, high cost Medicaid beneficiaries are defined as those individuals in a category of eligibility that has been determined by claims where beneficiaries in categories of eligibility with an above average per member per month cost and more than 1,200 member months, excluding those persons in an institution, dual eligibles and waiver members. For the purposes of this program, targeted, high cost beneficiaries include: a. Medicaid beneficiaries eligible for Supplemental Security Income; b. Medicaid beneficiaries eligible for Disabled Child at Home; c. Medicaid beneficiaries eligible for Working Disabled; d. Medicaid beneficiaries eligible for Xxxxxx Care; and e. Medicaid beneficiaries eligible for Breast/Cervical Group.
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Persons Eligible for Enrollment. To be eligible to enroll in the MCO PIHP established pursuant to this Contract, a person shall be a recipient in the North Carolina Medical Assistance (Medicaid) Program in one of the aid categories listed below, and with county of residence for Medicaid eligibility purposes of MCO County. a. Individuals covered under Section 1931 of the Social Security Act (1931 Group, TANF/AFDC);
Persons Eligible for Enrollment. To be eligible to enroll in the MississippiCAN program (“Plan”) established pursuant to this Contract, a person must be a Beneficiary of Mississippi Medicaid (Beneficiary). In addition, a Beneficiary must be a resident of the State of Mississippi, as identified below: a. Pregnant Women; b. Children under the age of one year; c. Targeted, high cost Medicaid beneficiaries is defined as those individuals in a category of eligibility that has been determined by claims where beneficiaries in categories of eligibility with an above average per member per month cost and more than 1,200 member months, excluding those persons in an institution, dual eligibles and waiver members; d. Medicaid beneficiaries eligible for Disabled Child at Home; e. Medicaid beneficiaries eligible for Working Disabled; f. Medicaid beneficiaries eligible for Xxxxxx Care g. Medicaid beneficiaries eligible for Breast/Cervical Group.
Persons Eligible for Enrollment. To be eligible to enroll in the MississippiCAN program (“Plan”) established pursuant to this Contract, a person must be a Beneficiary of Mississippi Medicaid (Beneficiary). In addition, a Beneficiary must be a resident of the State of Mississippi and be a targeted, high cost beneficiary. For the purposes of this program, targeted, high cost beneficiaries include: a. Medicaid beneficiaries eligible for 001 Supplemental Security Income, ages 0 to 65; b. Medicaid beneficiaries eligible for 019-Disabled Child at Home, ages 0 to 19; c. Medicaid beneficiaries eligible for 025 Working Disabled, ages 19 to 65; d. Medicaid beneficiaries eligible for 026 and 003 Xxxxxx Care, ages 0 to 19; e. Medicaid beneficiaries eligible for 27 Breast/Cervical Group, ages 19 to 65; f. Medicaid beneficiaries eligible for 088 Pregnant women and Infants, ages 0 to 1 and 8 to 65; g. Medicaid beneficiaries eligible for 085 Family and Children/TANF, ages 0 to 1 and 19 to 65; and h. Medicaid beneficiaries eligible for 087 and 091 Children, ages 0 to 1.
Persons Eligible for Enrollment. To be eligible to enroll in the LME established pursuant to this Contract, a person shall be a recipient in the North Carolina Medical Assistance (Medicaid) Program in one of the aid categories listed below, and with county of residence for Medicaid eligibility purposes of Counties. a. Individuals covered under Section 1931 of the Social Security Act (1931 Group, TANF/AFDC);
Persons Eligible for Enrollment. To be enrolled with a Contractor, the individual shall be a resident of the Contractor Region, and shall be eligible to receive Medicaid assistance under one of the aid categories defined below: Eligible Member Categories A. Temporary Assistance to Needy Families (TANF); B. Children and family related; C. Aged, blind, and disabled Medicaid only; D. Pass through; E. Poverty level pregnant women and children, including presumptive eligibility; F. Aged, blind, and disabled receiving State Supplementation;
Persons Eligible for Enrollment. To be enrolled with a Contractor, the individual shall be a resident of the Contractor Region, and shall be eligible to receive Medicaid assistance under one of the aid categories defined below: Eligible Member Categories* A. Temporary Assistance to Needy Families (TANF); B. Children and family related; C. Aged, blind, and disabled Medicaid only; D. Pass through; X. Xxxxxxx level pregnant women and children, including presumptive eligibility; X. Xxxx, blind, and disabled receiving State Supplementation; G. Aged, blind, and disabled receiving Supplemental Security Income (SSI); or H. Under the age of twenty-one (21) years and in an inpatient psychiatric facility. *The populations identified in 42 CFR 438.50(d) will be included in the eligible member categories. These eligibles may be voluntarily enrolled prior to the Department receiving approval of the waiver. Members eligible to enroll with the Contractor will be enrolled beginning with the first day of the application month with the exception of (1) newborns who are enrolled beginning with their date of birth and (2) unemployed parent program Members who are enrolled beginning with the date the definition of unemployment in accordance with 45 CFR 233.100 is met. The Contractor shall also be responsible for providing coverage to individuals who are retro-actively determined eligible for Medicaid. Retro- active Medicaid coverage is defined as a period of time up to three (3) months prior to the application month. For SSI Members, Medicaid coverage may also include previous months or years in situations where an individual appealed a SSI denial, and were subsequently approved as of the original application date. Any expansion of eligibility categories referenced above, which changes eligible recipients to be provided service under this Contract after its Execution Date, shall require that the parties negotiate an Amendment under Section 39.16 herein.
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Related to Persons Eligible for Enrollment

  • 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.

  • SALARY DETERMINATION FOR EMPLOYEES IN ADULT EDUCATION [Not applicable in School District No. 62 (Sooke)]

  • Eligibility and Enrollment 2.3.1 The State of Georgia has the sole authority for determining eligibility for the Medicaid program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its Agent will determine eligibility for PeachCare for Kids™ and will collect applicable premiums. DCH or its agent will continue responsibility for the electronic eligibility verification system (EVS). 2.3.2 DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all Members who are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a monthly notice of all Enrollments to the CMO plan. 2.3.3 If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the following algorithm: · If an immediate family member(s) of the Member is already enrolled in one CMO plan, the Member will be Auto-Assigned to that plan; · If there are no immediate family members already enrolled and the Member has a Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to the CMO plan where the Provider is contracted; · If the Member does not have a Historical Provider Relationship with a Provider in any CMO plan, or the Provider contracts with all plans, the Member will be Auto-Assigned based on an algorithm determined by DCH that may include quality, cost, or other measures. 2.3.4 Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first (1st) Calendar Day of the month following the Member selection or Auto-Assignment, for those Members assigned on or between the first (1st) and twenty-fourth (24th) Calendar Day of the month. For those Members assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the second (2nd) month after assignment. 2.3.5 In the future, at a date to be determined by DCH, DCH or its Agent may include quality measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to those plans that have higher scores based on quality, cost, or other measures to be defined by DCH. This factor will be applied after determining that there are no Historical Provider Relationships. 2.3.6 In any Service Region, DCH may, at its discretion, set a threshold percentage for the enrollment of members in a single plan and change this threshold percentage at its discretion. Members will not be Auto-Assigned to a CMO plan that exceeds this threshold unless a family member is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Service Region. When DCH changes the threshold percentage in any Service Region, DCH will provide the CMOs in the Service Region with a minimum of fourteen (14) days advance notice in writing. 2.3.7 DCH or its Agent will have five (5) Business Days to notify Members and the CMO plan of the Auto-Assignment. Notice to the Member will be made in writing and sent via surface mail. Notice to the CMO plan will be made via file transfer. 2.3.8 DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment functions. 2.3.9 Conditioned on continued eligibility, all Members will be enrolled in a CMO plan for a period of twelve (12) consecutive months. This consecutive Enrollment period will commence on the first (1st) day of Enrollment or upon the date the notice is sent, whichever is later. If a Member disenrolls from one CMO plan and enrolls in a different CMO plan, consecutive Enrollment period will begin on the effective date of Enrollment in the second (2nd) CMO plan. 2.3.10 DCH or its Agent will automatically enroll a Member into the CMO plan in which he or she was most recently enrolled if the Member has a temporary loss of eligibility, defined as less than sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will continue as though there has been no break in eligibility, keeping the original twelve (12) month period. 2.3.11 DCH or its Agent will notify Members at least once every twelve (12) months, and at least sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends (the annual Enrollment opportunity), that they have the opportunity to switch CMO plans. Members who do not make a choice will be deemed to have chosen to remain with their current CMO plan. 2.3.12 In the event a temporary loss of eligibility has caused the Member to miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan in which he or she was enrolled prior to the loss of eligibility. The member will receive a new 60-calendar day notification period beginning the first day of the next month. 2.3.13 In accordance with current operations, the State will issue a Medicaid number to a newborn upon notification from the hospital, or other authorized Medicaid provider. 2.3.14 Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant mother. This packet shall include information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her newborn to choose a different CMO plan. 2.3.15 DCH may, at its sole discretion, elect to modify this threshold and/or use quality based auto-assignments for reasons it deems necessary and proper.

  • Maintaining Eligibility for Employer Contribution The employer's contribution continues as long as the employee remains on the payroll in an insurance eligible position. Employees who complete their regular school year assignment shall receive coverage through August 31.

  • File Management and Record Retention relating to CRF Eligible Persons or Households Grantee must maintain a separate file for every applicant, Eligible Person, or Household, regardless of whether the request was approved or denied. a. Contents of File: Each file must contain sufficient and legible documentation. Documents must be secured within the file and must be organized systematically.

  • 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.

  • Eligibility for Employer Contribution This section describes eligibility for an Employer Contribution toward the cost of coverage.

  • 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.

  • Distributions on Account of Separation from Service If and to the extent required to comply with Section 409A, no payment or benefit required to be paid under this Agreement on account of termination of the Executive’s employment shall be made unless and until the Executive incurs a “separation from service” within the meaning of Section 409A.

  • Performance and Salary Review Company will periodically review Executive’s performance on no less than an annual basis. Adjustments to salary or other compensation, if any, will be made by Company in its sole and absolute discretion.

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