Common use of Contractor Initiated Disenrollment Clause in Contracts

Contractor Initiated Disenrollment. a) The Contractor must notify the LDSS and initiate an Enrollee's Disenrollment from the Contractor's Medicaid Advantage Product in the following cases: i) A change in residence makes the Enrollee ineligible to be a member of the plan; ii) The Enrollee disenrolls from the Contractor's Medicare Advantage Product as defined in this Agreement; iii) The Enrollee dies; iv) The Enrollee's status changes such that he/she is no longer eligible to participate in Medicaid Advantage as described in Section 5 of this Agreement. b) The Contractor may initiate an Enrollee's disenrollment from the Contractor's Medicaid Advantage Product in the following cases: i) The Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee. ii) The Enrollee provides fraudulent information on an enrollment form or the Enrollee permits abuse of an enrollment card in the Medicaid Advantage Program except when the Enrollee is no longer eligible for Medicaid and is in his/her Guaranteed Eligibility period. iii) Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued enrollment in the Contractor's plan seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees).

Contractor Initiated Disenrollment. a) 1. The Contractor must notify the LDSS DHS and initiate an Enrollee's ’s Disenrollment from the Contractor's Medicaid Advantage ’s D-SNP Product in the following cases: i) a. A change in residence outside of the contractor’s service area that makes the Enrollee ineligible to be a member of the plan; ii) b. The Enrollee disenrolls from the Contractor's ’s Medicare Advantage Product as defined in this Agreementcontract; iii) c. The Enrollee dies; iv) d. The Enrollee's ’s status changes such that he/she is no longer eligible to participate in Medicaid Advantage D-SNP as described in Section 5 Article 5.1 of this Agreementcontract. b) 2. The Contractor may initiate an Enrollee's ’s disenrollment from the Contractor's Medicaid Advantage ’s D- SNP Product in the following cases: i) a. The Enrollee engages in conduct or behavior that seriously impairs the Contractor's ’s ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee. ii) b. The Enrollee provides fraudulent information on an enrollment form or the Enrollee permits abuse of an enrollment card in the Medicaid Advantage Program except when the Enrollee is no longer eligible for Medicaid and is in his/her Guaranteed Eligibility periodD-SNP Program. iii) c. Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment because of an adverse change in the Enrollee's ’s health status, or because of the Enrollee's ’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's ’s special needs (except where continued enrollment in the Contractor's ’s plan seriously impairs the Contractor's ’s ability to furnish services to either the Enrollee or other Enrollees). 3. The Contractor must make a reasonable effort to identify for the Enrollee, both verbally and in writing, those actions of the Enrollee that have interfered with the effective provision of covered services as well as explain what actions or procedures are acceptable. 4. The Contractor shall give prior verbal and written notice to the Enrollee, with a copy to the DHS, of its intent to request disenrollment. 5. The Contractor shall keep the DHS informed of decisions related to all complaints filed by an Enrollee as a result of, or subsequent to, the notice of intent to disenroll. 6. The contractor will not consider an Enrollee disenrolled without confirmation from the DHS. Once an Enrollee has been disenrolled at the Contractor's request, he/she will not be re-enrolled with the Contractor's plan unless the Contractor first agrees to such re-enrollment.