Common use of ROSTER RECONCILIATION Clause in Contracts

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. a) All enrollments Enrollments are effective the first of the month. . b) SDOH Responsibilities: 1i) The SDOH maintains both the PCP subsystem enrollment Enrollment files and the WMS eligibility files, using data input entered by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2A) SDOH shall send each MCO the Contractor and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs the Contractor and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3B) SDOH shall send each MCO the Contractor and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments Enrollments were deleted from the file. Notification to the MCOs Contractor and LDSSs LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 4C) The SDOH shall also forward an error report as necessary to each MCO the Contractor and LDSS. 5D) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs the Contractor and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment Enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. . c) LDSS RESPONSIBILITIESResponsibilities: 1i) The LDSS must notify is responsible for notifying the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment Enrollment status. MCOs The Contractor and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2ii) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment Enrollment and WMS eligibility files, if appropriate. d) Contractor Responsibilities: i) The Contractor is at risk for providing Benefit Package services for those Enrollees listed on the 1st and 2nd Rosters for the month in which the 2nd Roster is generated. MCO RESPONSIBILITIES:Contractor is not at risk for providing services to Enrollees who appear on the monthly Disenrollment report. ii) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters, adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive Disenrollments, the Contractor is responsible for submitting an adjustment to void any previously paid premiums for the period of retroactive Disenrollment, where the Contractor was not at risk for the provision of Benefit Package services. Payment of subcapitation does not constitute "provision of Benefit Package services."

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH ResponsibilitiesRESPONSIBILITIES: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS.: 5) On the first (1st) weekend after the first (1st) day of the month ninth following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment ENROLLMENT for the THE current month. The THE SDOH will also include INCLUDE any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES: 1) The Contractor is at, risk for providing Benefit Package services for those Enrollees listed ON the 1st and 2nd rosters for the month in which the 2nd Roster is generated. Contractor is not at risk for providing services to Enrollees who appear on the monthly disenrollment report. 2) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H, page 7), adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive disenrollments, the Contractor is responsible for submitting an adjustment to void any previously paid premiums for the period of retroactive disenrollment, where the Contractor was not at risk for the provision of Benefit APPENDIX H OCTOBER 1, 2004 H-8 Package services. Payment of subcapitation does not constitute "provision of Benefit Package services."

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. file Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP PC ' subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES: 1) The Contractor is at risk for providing Benefit Package services for those Enrollees listed on the 1st and 2" rosters for the month in which the 2nd Roster is generated. Contractor is not at risk for providing services to Enrollees who appear on the monthly disenrollment report. 2) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H, page 7), adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive disenrollments, the Contractor is responsible for submitting an adjustment to void any previously pa 1 premiums for the period of retroactive disenrollment, where the Contractor was not at risk for the provision of Benefit APPENDIX H October 1, 2004 H-8 Package services. Payment of subcapitation does not constitute "provision of Benefit Package services."

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) . The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSSLDSSs. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2) . SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will LDSSs can be accomplished via paper transmission, magnetic media, or the HPNvia an electronic bulletin board. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) 4. On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS LDSSs a second Roster which contains any additional Enrollees that the an LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS LDSSs must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. .) MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to adjusting the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. a) All enrollments Enrollments are effective the first of the month. . b) SDOH Responsibilities: 1i) The SDOH maintains both the PCP subsystem enrollment Enrollment files and the WMS eligibility files, using data input entered by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7. 2A) SDOH shall send each MCO the Contractor and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs the Contractor and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3B) SDOH shall send each MCO the Contractor and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments Enrollments were deleted from the file. Notification to the MCOs Contractor and LDSSs LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 4C) The SDOH shall also forward an error report as necessary to each MCO the Contractor and LDSS. 5D) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs the Contractor and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment Enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-7 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that than remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES:

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-72004 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. file Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES: 1) The Contractor is at risk for providing Benefit Package services for those Enrollees listed on the 1st and 2nd rosters for the month in which the 2nd Roster is generated. Contractor is not at risk for providing services to Enrollees who appear on the monthly disenrollment report. 2) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H, page 7), adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive disenrollments, the Contractor is responsible for submitting an adjustment to void any previously paid premiums for the period of retroactive disenrollment, where the Contractor was not at risk for the provision of Benefit APPENDIX H October 1, 2004 Package services. Payment of subcapitation does not constitute "provision of Benefit Package services."

ROSTER RECONCILIATION. All enrollments are effective the first of the month. SDOH Responsibilities: 1) The SDOH maintains both the PCP subsystem enrollment files and the WMS eligibility files, using data input by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October OCTOBER 1, 2004 H-7 2) SDOH shall send each MCO and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3) SDOH shall send each MCO and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments were deleted from the file. Notification to the MCOs and LDSSs will be accomplished via paper transmission, magnetic media, or the HPN. 4) The SDOH shall also forward an error report as necessary to each MCO and LDSS. 5) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. LDSS RESPONSIBILITIES: 1) LDSS must notify the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment status. MCOs and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment and WMS eligibility files, if appropriate. MCO RESPONSIBILITIES: 1) The Contractor is at risk for providing Benefit Package services for those Enrollees listed on the 1st and 2nd rosters for the month in which the 2nd Roster is generated. Contractor is not at risk for providing services to Enrollees who appear on the monthly disenrollment report. 2) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H, page 7), adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive disenrollments, the Contractor is responsible for submitting an adjustment to void any previously paid premiums for the period of retroactive disenrollment, where the Contractor was not at risk for the provision of Benefit APPENDIX H OCTOBER 1, 2004 H-8 Package services. Payment of subcapitation does not constitute "provision of Benefit Package services."

ROSTER RECONCILIATION. a) All enrollments Enrollments are effective the first of the month. . b) SDOH Responsibilities: 1i) The SDOH maintains both the PCP subsystem enrollment Enrollment files and the WMS eligibility files, using data input entered by the LDSS. SDOH uses data contained in both these files to generate the Roster. APPENDIX H October 1, 2004 H-72005 2A) SDOH shall send each MCO the Contractor and LDSS monthly (according to a schedule established by SDOH), a complete list of all Enrollees for which the Contractor is expected to assume medical risk beginning on the 1st of the following month (First Monthly Roster). Notification to MCOs the Contractor and LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 3B) SDOH shall send each MCO the Contractor and LDSS monthly, at the time of the first monthly roster production, a Disenrollment Report listing those Enrollees from the previous month's roster who were disenrolled, transferred to another MCO, or whose enrollments Enrollments were deleted from the file. Notification to the MCOs Contractor and LDSSs LDSS will be accomplished via paper transmission, magnetic media, or the HPN. 4C) The SDOH shall also forward an error report as necessary to each MCO the Contractor and LDSS. 5D) On the first (1st) weekend after the first (1st) day of the month following the generation of the first (1st) Roster, SDOH shall send MCOs the Contractor and LDSS a second Roster which contains any additional Enrollees that the LDSS has added for enrollment Enrollment for the current month. The SDOH will also include any additions to the error report that have occurred since the initial error report was generated. . c) LDSS RESPONSIBILITIESResponsibilities: 1i) The LDSS must notify is responsible for notifying the Contractor electronically or in writing of changes in the First Roster and error report, no later than the end of the month. (Note: To the extent practicable the date specified must allow for timely notice to Enrollees regarding their enrollment Enrollment status. MCOs The Contractor and the LDSS may develop protocols for the purpose of resolving Roster discrepancies that remain unresolved beyond the end of the month. These protocols should be contained in Section G of this Appendix.) 2ii) Enrollment and eligibility issues are reconciled by the LDSS to the extent possible, through manual adjustments to the PCP subsystem enrollment Enrollment and WMS eligibility files, if appropriate. d) Contractor Responsibilities: i) The Contractor is at risk for providing Benefit Package services for those Enrollees listed on the 1st and 2nd Rosters for the month in which the 2nd Roster is generated. Contractor is not at risk for providing services to Enrollees who appear on the monthly Disenrollment report. ii) The Contractor must submit claims to the State's Fiscal Agent for all Eligible Persons that are on the 1st and 2nd Rosters, adjusted to add Eligible Persons enrolled by the LDSS after Roster production and to remove individuals APPENDIX H October 1, 2005 disenrolled by LDSS after Roster production (as notified to the Contractor). In the cases of retroactive Disenrollments, the Contractor is responsible for submitting an adjustment to void any previously paid premiums for the period of retroactive Disenrollment, where the Contractor was not at risk for the provision of Benefit Package services. Payment of subcapitation does not constitute "provision of Benefit Package services." 6 Disenrollment: a) DSS Responsibilities: i) The LDSS is responsible for accepting requests for Disenrollment directly from Enrollees and may not require Enrollees to approach the Contractor for a Disenrollment form. Where an LDSS is authorized to mandate Enrollment, all requests for Disenrollment must be directed to the LDSS or the Enrollment Broker. The LDSS and the Enrollment Broker must utilize the State-approved Disenrollment forms. ii) Enrollees may initiate a request for an expedited Disenrollment to the LDSS. The LDSS will expedite the Disenrollment process in those cases where an Enrollee's request for Disenrollment involves an urgent medical need, a complaint of non-consensual Enrollment or, in local districts where homeless individuals are exempt, homeless individuals in the shelter system. If approved, the LDSS will manually process the Disenrollment through the PCP Subsystem. MMC Enrollees who request to be disenrolled from managed care based on their documented HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited Disenrollment on the basis of urgent medical need. iii) The LDSS is responsible for processing routine Disenrollment requests to take effect on the first (1st) day of the following month if the request is made before the fifteenth (15th) day of the month. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second month after the month in which an Enrollee requests a Disenrollment. iv) The LDSS is responsible for disenrolling Enrollees automatically upon death or loss of Medicaid or FHPlus eligibility. All such Disenrollments will be effective at the end of the month in which the death or loss of eligibility occurs or at the end of the last month of Guaranteed Eligibility, where applicable. v) The LDSS is responsible for informing Enrollees of their right to change Contractors if there is more than one available including any applicable Lock-In restrictions. Enrollees subject to Lock-In may disenroll after the grace period for Good Cause as defined below. The LDSS is responsible for determining if the Enrollee has Good Cause and processing the Disenrollment request in accordance with the procedures outlined in this Appendix. The LDSS is responsible for providing Enrollees with notice of their right to request a fair hearing if their October 1, 2005 Disenrollment request is denied. Such notice must include the reason(s) for the denial. An Enrollee has Good Cause to disenroll if: A) The Contractor has failed to famish accessible and appropriate medical care services or supplies to which the Enrollee is entitled under the terms of the contract under which the Contractor has agreed to provide services. This includes, but is not limited to the failure to: I) provide primary care services; II) arrange for in-patient care, consultation with specialists, or laboratory and radiological services when reasonably necessary; III) arrange for consultation appointments; IV) coordinate and interpret any consultation findings with emphasis on continuity of medical care; V) arrange for services with qualified licensed or certified providers; VI) coordinate the Enrollee's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury; or B) The Contractor cannot make a Primary Care Provider available to the Enrollee within the time and distance standards prescribed by SDOH; or C) The Contractor fails to adhere to the standards prescribed by SDOH and such failure negatively and specifically impacts the Enrollee; or D) The Enrollee moves his/her residence out of the Contractor's service area or to a county where the Contractor does not offer the product the Enrollee is eligible for; or E) The Enrollee meets the criteria for an Exemption or Exclusion as set forth in 2(b)(xi) of this Appendix; or F) It is determined by the LDSS, the SDOH, or its agent that the Enrollment was not consensual; or G) The Enrollee, the Contractor and the LDSS agree that a change ofMCOs would be in the best interest of the Enrollee; or H) The Contractor is a primary care partial capitation provider that does not have a utilization review process in accordance with Title I of Article 49 of the PHL and the Enrollee requests Enrollment in an MCO RESPONSIBILITIES:that has such a utilization review process; or I) The Contractor has elected not to cover the Benefit Package service that an Enrollee seeks and the service is offered by one or more other MCOs in the Enrollee's county of fiscal responsibility; or J) The Enrollee's medical condition requires related services to be performed at the same time but all such related services cannot be arranged by the October 1, 2005 Contractor because the Contractor has elected not to cover one of the services the Enrollee seeks, and the Enrollee's Primary Care Provider or another provider determines that receiving the services separately would subject the Enrollee to unnecessary risk; or K) An FHPlus Enrollee is pregnant. vi) An Enrollee subject to Lock-In may initiate Disenrollment for Good Cause by filing an oral or written request with the LDSS. vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC eligibility or health status changes such that he/she is deemed by the LDSS to meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with a notice of his or her right to request a fair hearing. viii) In instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion, the LDSS must notify the MMC Enrollee of the approval or denial of exclusion/Disenrollment status, including fair hearing rights if Disenrollment is denied. ix) The LDSS is responsible for ensuring that retroactive Disenrollments are used only when absolutely necessary. Circumstances warranting a retroactive Disenrollment are rare and include when an Enrollee is determined to have been non-consensually enrolled in a MCO; he or she enters or resides in a residential institution under circumstances which render the individual Excluded from the MMC program; is incarcerated; is an SSI infant less than six (6) months of age; is simultaneously in receipt of comprehensive health care coverage from an MCO and is Enrolled in either the MMC or FHPlus product of the same MCO; it is determined that an Enrollee with more than one Client Identification Number (CIN) is enrolled in an MCO's MMC or FHPlus product under more than one of the CINs; or he or she has died - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period. Payment of subcapitation does not constitute "provision of Benefit Package services." The LDSS is responsible for notifying the Contractor of the retroactive Disenrollment prior to the action. The LDSS is responsible for finding out if the Contractor has made payments to providers on behalf of the Enrollee prior to Disenrollment. After this information is obtained, the LDSS and Contractor will agree on a retroactive Disenrollment or prospective Disenrollment date. In all cases of retroactive Disenrollment, including Disenrollments effective the first day of the current month, the LDSS is responsible for sending notice to the Contractor at the time of Disenrollment, of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided premium claims for any full months of retroactive Disenrollment where the Contractor was not at risk for the provision of Benefit Package services during the month. However, failure by the LDSS to so notify the Contractor does not affect the right of the SDOH to recover the premium payment as authorized by Section 3.6 of this Agreement. APPENDIX H October 1, 2005 x) Generally the effective dates of Disenrollment are prospective. Effective dates for other than routine Disenrollments are described below: Reason for Disenrollment Effective Date of Disenrollment A) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI related category First Day of the month of birth or the month of onset of disability, whichever is later B) Death ofEnrollee First day of the month after death C) Incarceration First day of the month of incarceration (note-Contractor is at risk for covered services only to the date of incarceration and is entitled to the capitation payment for the month of incarceration) D) Medicaid Managed Care Enrollee entered or stayed in a residential institution under circumstances which rendered the individual excluded from managed care, or is in receipt of waivered services through the Long Term Home Health Care Program (LTHHCP), including when an Enrollee is admitted to a hospital that 1) is certified by Medicare as a long-term care hospital and 2) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002. First day of the month of entry or first day of the month of classification of the stay as permanent subsequent to entry (note-Contractor is at risk for covered services only to the date of entry or classification of the stay as permanent subsequent to entry, and is entitled to the capitation payment for the month of entry or classification of the stay as permanent subsequent to entry) E) Individual's effective date of Enrollment or autoassignment into a MMC product occurred while meeting institutional criteria in (D) above Effective Date of Enrollment in the Contractor's Plan