Common use of Required Involuntary Disenrollments Clause in Contracts

Required Involuntary Disenrollments. Texas and CMS shall terminate an Enrollee’s Enrollment in the STAR+PLUS MMP upon the occurrence of any of the conditions enumerated in Section 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s residence outside the Service Area or alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this Section, the CMT shall not be responsible for processing disenrollments under this Section. Further, nothing in this Section alters the obligations of the Parties for administering disenrollment transactions described elsewhere in this Contract. 288 2.3.5.6.1. If the STAR+PLUS MMP becomes aware of any conditions enumerated in Section 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Section that would prompt termination of coverage, the STAR+PLUS MMP shall notify the HHSC Administrative Services Contractor of any individual who is no longer eligible to remain enrolled in the Demonstration per CMS Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, in order for them to disenroll the Enrollee. 289 2.3.5.6.2. The STAR+PLUS MMP shall notify HHSC when an Enrollee has private or Third Part Health Insurance coverage with the STAR+PLUS MMP or any other carrier: 289 2.3.5.6.2.1. Within fifteen (15) Business Days when an Enrollee is verified as having Third Party Health Insurance with the STAR+PLUS MMP, as defined herein. 289 2.3.5.6.2.2. Within fifteen (15) Business Days of the date when the STAR+PLUS MMP becomes aware that an Enrollee has any health care insurance coverage with any other insurance carrier. The STAR+PLUS MMP is not responsible for the determination of Third-Party Health Insurance. 289 2.3.5.6.3. Any Enrollee with Third Party Health Insurance will be disenrolled from the STAR+PLUS MMP. 289 2.3.5.6.4. The Enrollment of any Enrollee under this Contract shall be terminated if the Enrollee becomes ineligible for Enrollment due to a change in eligibility status. When an Enrollee’s Enrollment is terminated for eligibility, the termination shall be effective: 289 2.3.5.6.4.1. The first day of the month following the month in which the eligibility is lost or person determined to be out of the Service Area. 289 2.3.5.6.5. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. 289 2.3.5.6.6. When an Enrollee remains out of the Service Area or for whom residence in the Service Area cannot be confirmed for more than six (6) consecutive months. 290

Required Involuntary Disenrollments. Texas and CMS shall terminate an Enrollee’s Enrollment in the STAR+PLUS MMP upon the occurrence of any of the conditions enumerated in Section 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s residence outside the Service Area or alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this Section, the CMT shall not be responsible for processing disenrollments under this Section. Further, nothing in this Section alters the obligations of the Parties for administering disenrollment transactions described elsewhere in this Contract. 288. 2.3.5.6.1. If the STAR+PLUS MMP becomes aware of any conditions enumerated in Section 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Section that would prompt termination of coverage, the STAR+PLUS MMP shall notify the HHSC Administrative Services Contractor of any individual who is no longer eligible to remain enrolled in the Demonstration per CMS Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, in order for them to disenroll the Enrollee. 289. 2.3.5.6.2. The STAR+PLUS MMP shall notify HHSC when an Enrollee has private or Third Part Health Insurance coverage with the STAR+PLUS MMP or any other carrier: 289: 2.3.5.6.2.1. Within fifteen (15) Business Days when an Enrollee is verified as having Third Party Health Insurance with the STAR+PLUS MMP, as defined herein. 289. 2.3.5.6.2.2. Within fifteen (15) Business Days of the date when the STAR+PLUS MMP becomes aware that an Enrollee has any health care insurance coverage with any other insurance carrier. The STAR+PLUS MMP is not responsible for the determination of Third-Party Health Insurance. 289. 2.3.5.6.3. Any Enrollee with Third Party Health Insurance will be disenrolled from the STAR+PLUS MMP. 289. 2.3.5.6.4. The Enrollment of any Enrollee under this Contract shall be terminated if the Enrollee becomes ineligible for Enrollment due to a change in eligibility status. When an Enrollee’s Enrollment is terminated for eligibility, the termination shall be effective: 289: 2.3.5.6.4.1. The first day of the month following the month in which the eligibility is lost or person determined to be out of the Service Area. 289. 2.3.5.6.5. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. 289. 2.3.5.6.6. When an Enrollee remains out of the Service Area or for whom residence in the Service Area cannot be confirmed for more than six (6) consecutive months. 290.

Required Involuntary Disenrollments. Texas and CMS shall terminate an Enrollee’s Enrollment in the STAR+PLUS MMP upon the occurrence of any of the conditions enumerated in Section 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Sectionsection. Except for the CMT’s role in reviewing documentation related to an Enrollee’s residence outside the Service Area or alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this Sectionsection, the CMT shall not be responsible for processing disenrollments Disenrollments under this Sectionsection. Further, nothing in this Section section alters the obligations of the Parties parties for administering disenrollment Disenrollment transactions described elsewhere in this Contract. 288. 2.3.5.6.12.3.5.7.1. If the STAR+PLUS MMP becomes aware of any conditions enumerated in Section Sections 40.2 of the most current Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this Section that would prompt termination of coverage, the STAR+PLUS MMP shall notify the HHSC Administrative Services Contractor of any individual who is no longer eligible to remain enrolled in the Demonstration per CMS Medicare-Medicaid Plan Enrollment and Disenrollment Guidanceguidance, in order for them the HHSC Administrative Services Contractor to disenroll the Enrollee. 289. 2.3.5.6.22.3.5.7.2. The STAR+PLUS MMP shall notify HHSC when an Enrollee has private or Third Part Party Health Insurance coverage with the STAR+PLUS MMP or any other carrier: 289: 2.3.5.6.2.12.3.5.7.2.1. Within fifteen (15) Business Days business days when an Enrollee is verified as having Third Party Health Insurance with the STAR+PLUS MMP, as defined herein. 289. 2.3.5.6.2.22.3.5.7.2.2. Within fifteen (15) Business Days business days of the date when the STAR+PLUS MMP becomes aware that an Enrollee has any health care insurance coverage with any other insurance carrier. The STAR+PLUS MMP is not responsible for the determination of Third-Third Party Health Insurance. 289. 2.3.5.6.32.3.5.7.3. Any Enrollee with Third Party Health Insurance will be disenrolled from the STAR+PLUS MMP. 289 2.3.5.6.4. The Enrollment of any Enrollee under this Contract shall be terminated if the Enrollee becomes ineligible for Enrollment due to a change in eligibility status. When an Enrollee’s Enrollment is terminated for eligibility, the termination shall be effective: 289 2.3.5.6.4.1. The first day of the month following the month in which the eligibility is lost or person determined to be out of the Service Area. 289 2.3.5.6.5. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. 289 2.3.5.6.6. When an Enrollee remains out of the Service Area or for whom residence in the Service Area cannot be confirmed for more than six (6) consecutive months. 290.