Common use of SCDHHS Initiated Member Disenrollment Clause in Contracts

SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of Medicaid eligibility or loss of Medicaid MHN Program eligibility; • Death of a Member; • Member is placed out of home (i.e. Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric Residential Treatment Facility (PRTF); • Member’s intentional submission of fraudulent information; • Becomes an inmate (see Appendix A – Definition of Terms and Acronyms) of a Public Institution; • Member moves out of state or MHN service area or plan does not operate in the new service area; • Member becomes institutionalized in a Long Term Care Facility/Nursing Home for more than thirty (30) days; • Member elects Home and Community Based Waiver Programs, with the exception of the Medically Complex Children’s Program; • Loss of Contractor's Participation; • Member enrolls in another Medicaid managed care plan; or, Member’s behavior is disruptive, unruly, abusive, or uncooperative and impairs the MHN’s ability to furnish services to the member or other enrolled members. The Contractor shall immediately notify SCDHHS when it obtains knowledge of any Medicaid MHN Program member whose enrollment should be terminated. See the MHN Policy and Procedure Guide. In an effort to minimize the number of disenrollments due to loss of Medicaid eligibility, SCDHHS or its designee will provide the Contractor with a monthly listing of Medicaid MHN Program members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain Medicaid eligibility.

SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of Medicaid eligibility or loss of Medicaid MHN Program program eligibility; • Death of a Member; • Member is placed out Intentional Submission of home (i.e. Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric Residential Treatment Facility (PRTF); • Member’s intentional submission of fraudulent informationFraudulent Information; • Becomes an inmate (see Appendix A – Definition of Terms and Acronyms) of a Public Institution; • Member moves Moves out of state or MHN service area or plan does not operate in the new service areaState; • Member becomes Becomes institutionalized in a Long Term Care Facility/Nursing Home for more than thirty (30) days; • Member elects Home and Community Based Waiver Programs, with the exception of Enters the Medically Complex Fragile Children’s Program; • Loss of Contractor's Participation; or • Member enrolls Enrollment in another Medicaid managed care plan; or, Member’s behavior is disruptive, unruly, abusive, or uncooperative and impairs the MHN’s ability to furnish services to the member or other enrolled members. plan The Contractor shall immediately notify SCDHHS when it obtains knowledge of any Medicaid MHN Program program member whose enrollment should be terminatedterminated prior to SCDHHS' knowledge. See the MHN Policy and Procedure Guide. The Contractor shall have the right to contact MHN members who have been disenrolled when the reason for disenrollment is "ineligible for Medicaid". This means that Medicaid eligibility has been terminated. These members will be identified on the member listing file with a special indicator. The Contractor may contact the member upon receipt of the monthly member listing file to assist the member in taking any possible actions to continue or regain eligibility. If the member regains Medicaid eligibility, within 60 days of the disenrollment date, the member will be automatically re-enrolled with the Contractor. If eligibility is regained after 60 days of the disenrollment date, the member will need to contact SCDHHS to initiate re-enrollment. Automatic re-enrollment will only occur in cases where the Medicaid MHN Program Member has not submitted a written request to disenroll from the Contractor's plan. In an effort to minimize the number of disenrollments due to loss of Medicaid eligibility, SCDHHS DHHS or its designee will provide the Contractor with a monthly listing of Medicaid MHN Program program members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain Medicaid eligibility.

SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of Medicaid eligibility or loss of Medicaid MHN Program MCO program eligibility; • Death of a Member; • Member is placed out Member’s Iintentional Ssubmission of home (i.e. Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric Residential Treatment Facility (PRTF)Ffraudulent Iinformation; • Member’s intentional submission of fraudulent information; • Becomes Member Bbcomes an inmate (see Appendix A – Definition of Terms and AcronymsTerms) of a Public Institution; • Member moves Mmoves out of state or MHN service area or plan does not operate in the new service areaSstate; • Member Eelects Hhospice; • Member becomes Medicare Eligibleility; Eligible; • Member Bbecomes institutionalized in a Long Term Care Facility/Nursing Home for more than thirty (30) days; • Member elects Eelects Home and Community Based Waiver Programs, with the exception of ; • Enters the Medically Complex Fragile Children’s Program; • Loss of Contractor's Participation; • Member Bbecomes age 65 or older; • Member Enrollment enrolls in another MCO through third party coverage; or • Enrollment in another Medicaid managed care plan; or, Member’s behavior is disruptive, unruly, abusive, or uncooperative and impairs the MHN’s ability to furnish services to the member or other enrolled members. plan The Contractor shall immediately notify SCDHHS when it obtains knowledge of any Medicaid MHN Program MCO program member whose enrollment should be terminatedterminated prior to SCDHHS' knowledge. See the MHN MCO Policy and Procedure Guide. The Contractor shall have the right to contact MCO members who have been disenrolled when the reason for disenrollment is "ineligible for Medicaid". This means that Medicaid eligibility has been terminated. These members will be identified on the member listing file with a special indicator. The Contractor may contact the member upon receipt of the monthly member listing file to assist the member in taking any possible actions to continue or regain eligibility. If the member regains Medicaid eligibility, within 60 days of the disenrollment date, the member will be automatically re- enrolled with the Contractor. If eligibility is regained after 60 days of the disenrollment date, the member will need to contact SCDHHS to initiate re-enrollment. Automatic re-enrollment will only occur in cases where the Medicaid MCO Program Member has not submitted a written request to disenroll from the Contractor's plan. In an effort to minimize the number of disenrollments due to loss of Medicaid eligibility, SCDHHS or its designee will provide the Contractor with a monthly listing of Medicaid MHN Program MCO program members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain Medicaid eligibility.

SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of Medicaid eligibility or loss of Medicaid MHN Program program eligibility; • Death of a Member; • Member is placed out Intentional Submission of home (i.e. Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric Residential Treatment Facility (PRTF); • Member’s intentional submission of fraudulent informationFraudulent Information; • Becomes an inmate (see Appendix A – Definition of Terms and Acronyms) of a Public Institution; • Member moves Moves out of state or MHN service area or plan does not operate in the new service areaState; • Member becomes Becomes institutionalized in a Long Term Care Facility/Nursing Home for more than thirty (30) days; • Member elects Home and Community Based Waiver Programs, with the exception of Enters the Medically Complex Fragile Children’s Program; • Loss of Contractor's Participation; or • Member enrolls Enrollment in another Medicaid managed care plan; or, Member’s behavior is disruptive, unruly, abusive, or uncooperative and impairs the MHN’s ability to furnish services to the member or other enrolled members. The Contractor shall immediately notify SCDHHS when it obtains knowledge of any Medicaid MHN Program program member whose enrollment should be terminatedterminated prior to SCDHHS' knowledge. See the MHN Policy and Procedure Guide. The Contractor shall have the right to contact MHN members who have been disenrolled when the reason for disenrollment is "ineligible for Medicaid". This means that Medicaid eligibility has been terminated. These members will be identified on the member listing file with a special indicator. The Contractor may contact the member upon receipt of the monthly member listing file to assist the member in taking any possible actions to continue or regain eligibility. If the member regains Medicaid eligibility, within 60 days of the disenrollment date, the member will be automatically re-enrolled with the Contractor. If eligibility is regained after 60 days of the disenrollment date, the member will need to contact SCDHHS to initiate re-enrollment. Automatic re-enrollment will only occur in cases where the Medicaid MHN Program Member has not submitted a written request to disenroll from the Contractor's plan. In an effort to minimize the number of disenrollments due to loss of Medicaid eligibility, SCDHHS DHHS or its designee will provide the Contractor with a monthly listing of Medicaid MHN Program program members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain Medicaid eligibility.