Common use of Unacceptable Reasons for Disenrollment from an MCO Clause in Contracts

Unacceptable Reasons for Disenrollment from an MCO. ‌ 2.5.3.1 Adverse changes in the enrollee’s health; 2.5.3.2 Pre-existing medical or behavioral health conditions; 2.5.3.3 High cost medical or behavioral health bills; 2.5.3.4 Failure or refusal to pay applicable TennCare cost sharing responsibilities, except when this results in loss of eligibility for TennCare; 2.5.3.5 Enrollee’s utilization of medical or behavioral health services; 2.5.3.6 Enrollee’s diminished mental capacity; or 2.5.3.7 Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO seriously impairs the entity’s ability to furnish services to either this particular enrollee or other enrollees).