Disenrollment Initiated by Contractor Clause Samples

Disenrollment Initiated by Contractor. The Contractor may not request disenrollment an Enrollee 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 his or her special needs (except when his or her continued enrollment in the Health Plan seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees).
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Disenrollment Initiated by Contractor. (A) The Contractor may not terminate an Enrollee’s enrollment because of an adverse change in the Enrollee’s health or because of the Enrollee’s utilization of Covered Services. (B) The Contractor may initiate disenrollment of any Enrollee for one or more of the following reasons: (1) For reasons specifically identified in the Contractor’s approved Enrollee handbook; (2) When the Enrollee ceases to be eligible for medical assistance under the State’s Title XXI State Plan and as finally determined by the Department; (3) Upon expiration of the Contractor’s Contract with the Department; (4) Confinement of an Enrollee in an institution when confinement is not a Covered Service under this contract; (5) Violation of enrollment requirements developed by the Contractor and approved by the Department but only after the Contractor and/or the Enrollee has exhausted the Contractor’s applicable internal Grievance procedure; or (6) When the Contractor has determined that the Enrollee has other valid health insurance coverage. (C) To initiate disenrollment of an Enrollee’s participation in the Contractor’s Dental Plan, the Contractor shall provide the Department with documentation justifying the proposed disenrollment. (1) The Department shall approve or deny the disenrollment request by email or in writing within thirty days of receipt of the request. Failure by the Department to deny a disenrollment request within thirty days shall constitute an approval of the Contractor’s disenrollment request. (2) If the Department approves the Contractor’s disenrollment request, the Contractor shall give the Enrollee thirty days written notice of the proposed disenrollment, and shall notify the Enrollee of his or her right to file a
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Disenrollment Initiated by Contractor 
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Related to Disenrollment Initiated by Contractor

  • Disenrollment The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment seriously impairs the Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee’s behavior is determined to be unrelated to 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 his or her special needs.

  • Enrollment You are responsible for i) having all of the required information in this Agreement completed and