Common use of Termination by STATE Clause in Contracts

Termination by STATE. An Enrollee’s coverage in the MCO may be terminated by the STATE for one of the following reasons: Required termination includes: The Enrollee becomes ineligible for Medical Assistance; The Enrollee’s basis of eligibility changes and no longer meets enrollment criteria in section 3.1.1; The Enrollee moves out of the MCO’s Service Area and the MMIS county of residence is updated per eligibility policy; For MSHO, the Enrollee becomes ineligible for Medicare Part A or Part B; The Enrollee’s MA Plan application is rejected by CMS or cancelled by the‌ Beneficiary before the effective date. For MSHO enrollment, the Beneficiary will be re-enrolled in MSC+ retroactively, and the capitation will be re-processed; For MSHO, for non-payment of Medical Spenddown if the Enrollee does not pay the Medical Spenddown in full for three (3) months directly to the State as described in section 3.1.1(G)(1)(c). The Enrollee will not be allowed to re-enroll in MSHO after termination for non-payment unless all past due Medical Spenddowns are paid in full and the Enrollee no longer has a Medical Spenddown at the time of application; The Enrollee changes MCOs without cause pursuant to 42 CFR §438.56(c) within ninety (90) days following the Enrollee’s initial enrollment with the MCO. For counties where the MCO is the only choice, the Enrollee cannot disenroll, but may change Primary Care Providers pursuant to section 3.1.2(M). The enrollee may change MCOs pursuant to 42 CFR § 438.56 and Minnesota Rules, Part 9500.1453 because of problems with access, service delivery, or other good cause; For MSC+, pursuant to Minnesota Rules, Part 9500.1453, subpart 5, the Enrollee elects to change MCOs once during the first year of initial enrollment in the MCO or during the first sixty (60) days after a change in enrollment from an MCO that is no longer participating; The Enrollee elects to change MCOs due to substantial travel time or Local Agency error, pursuant to Minnesota Rules, Part 9500.1453, subparts 7 and 8; The Enrollee elects to change MCOs during an annual open enrollment period, pursuant to Minnesota Rules, Part 9500.1453, subpart 5; or the Enrollee misses the opportunity to change during the annual health-plan selection period due to disenrollment; or for MSHO, monthly, pursuant to section 3.1.2(G); and The Enrollee elects to change MCOs within one hundred twenty (120) days following notice of a Material Modification of the MCO’s Provider network under section 3.6.14(A); Incarceration

Termination by STATE. An Enrollee’s coverage in the MCO may be terminated by the STATE for one of the following reasons: reasons:‌ Required termination includes: The Enrollee becomes ineligible for Medical Assistance; The Enrollee’s basis of eligibility changes and no longer meets enrollment criteria in section 3.1.1; The Enrollee moves out of the MCO’s Service Area and the MMIS county of residence is updated per eligibility policy; For MSHO, the Enrollee becomes ineligible for Medicare Part A or Part B; The Enrollee’s MA Plan application is rejected by CMS or cancelled by the‌ Beneficiary before the effective date. For MSHO enrollment, the Beneficiary will be re-enrolled in MSC+ retroactively, and the capitation will be re-processed; For MSHO, for non-payment of Medical Spenddown if the Enrollee does not pay the Medical Spenddown in full for three (3) months directly to the State as described in section 3.1.1(G)(1)(c). The Enrollee will not be allowed to re-enroll in MSHO after termination for non-payment unless all past due Medical Spenddowns are paid in full and the Enrollee no longer has a Medical Spenddown at the time of application; The Enrollee changes MCOs without cause pursuant to 42 CFR §438.56(c) within ninety (90) days following the Enrollee’s initial enrollment with the MCO. For counties where the MCO is the only choice, the Enrollee cannot disenroll, but may change Primary Care Providers pursuant to section 3.1.2(M). The enrollee may change MCOs pursuant to 42 CFR § 438.56 and Minnesota Rules, Part 9500.1453 because of problems with access, service delivery, or other good cause; For MSC+, pursuant to Minnesota Rules, Part 9500.1453, subpart 5, the Enrollee elects to change MCOs once during the first year of initial enrollment in the MCO or during the first sixty (60) days after a change in enrollment from an MCO that is no longer participating; The Enrollee elects to change MCOs due to substantial travel time or Local Agency error, pursuant to Minnesota Rules, Part 9500.1453, subparts 7 and 8; The Enrollee elects to change MCOs during an annual open enrollment period, pursuant to Minnesota Rules, Part 9500.1453, subpart 5; or the Enrollee misses the opportunity to change during the annual health-plan selection period due to disenrollment; or for MSHO, monthly, pursuant to section 3.1.2(G); and The Enrollee elects to change MCOs within one hundred twenty (120) days following notice of a Material Modification of the MCO’s Provider network under section 3.6.14(A); Incarceration