Common use of Disenrollment Clause in Contracts

Disenrollment. 12.1 ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌

Disenrollment. 12.1 ADFMs shall 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 disenrolled 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 TOP Prime/TOP Prime Remotethe One Care Plan or the Demonstration at any time and enroll in another One Care Plan, TOP Select when: • The enrollee loses 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 TOP 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 coveragein the One Care Plan per CMS enrollment guidance, • The enrollee has 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 requested enrollment transfer/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 TOP Prime/TOP Prime Remote within 60 calendar days following any Enrollee due to an adverse change in the end Enrollee’s health status or because of the overseas tour. 12.2 ADSMs shall be disenrolled Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote 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 at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime seriously impairs the Contractor’s ability to furnish services to either this Enrollee or TOP Prime Remote if they remain on permanent assignment other Enrollees, provided the Enrollee’s behavior is determined to be unrelated to an adverse change in an overseas location where these programs are offered. ADSM enrollment in TOP Prime the Enrollee's health status, or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days because of the end Enrollee's utilization of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new locationmedical services, (2) the enrollee disenrollsdiminished mental capacity, or (3) when enrollment transfer uncooperative or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour disruptive behavior resulting from TOP Prime his or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌her special needs.

Disenrollment. 12.1 ADFMs shall An Enrollee must be disenrolled from TOP Prime/TOP Prime Remotethe Plan if the Beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, TOP Select when: • or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The enrollee loses eligibility Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/the request if the reasons are for other than those specified above. An Enrollee may request disenrollment of TOP Prime/TOP Prime Remote within 60 calendar without cause during the ninety (90) days following the end date the Division sends the Enrollee notice of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from TOP Prime the CCO for cause if the CCO does not, because of moral or TOP TPR. Until December 31religious objections, 2017cover the service the Enrollee seeks, the disenrolled ADFM TOP Prime Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or TOP TPR beneficiary will revert another provider determines receiving the services separately would subject Enrollee to TRICARE Standardunnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Effective January 1, 2018, ADFMs disenrolled from TOP Prime Enrollee requests for disenrollment must be directed to the Division either orally or TOP TPR in writing. The effective date of any approved disenrollment will be only eligible for space available care at military treatment facilities.‌no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

Disenrollment. 12.1 ADFMs shall ‌ At the time of eligibility redetermination, the Member will be disenrolled from TOP Prime/TOP Prime RemoteCHIP and the Contractor if the Member: 1. No longer qualifies for CHIP under the eligibility categories in the eligible population; or 2. Becomes eligible for Medicaid coverage; 3. Becomes institutionalized in a public institution or enrolled in a waiver program; or 4. Becomes eligible for Medicare coverage. At any time, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall Member must be disenrolled from TOP Prime/TOP Prime Remote whenCHIP and the Contractor if the Member: 12.3 ADFMs who are enrolled 1. No longer resides in TOP Prime/TOP Prime Remote the State of Mississippi; 2. Is identified as pregnant and verified by the Division; 3. Is determined to have Creditable Coverage by the Division; 4. Is deceased; or 5. Becomes a Custodial Nursing Home resident. The Contractor may disenroll request Disenrollment of a Member at any timetime based upon one or more of the reasons listed herein. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during The Contractor must notify the enrollment year Division within three (October 1 to September 303) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end receipt of the overseas tour Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first (1st) day of the calendar month for which the Disenrollment appears on the Member Listing Report. The Contractor must notify the Division of Members identified with a diagnosis related to pregnancy within seven (7) calendar days of identification through a report, in a format and manner to be specified by the Division. If the Member is determined to be eligible for Medicaid, the Division will transmit a termination of eligibility date to the Contractor, along with the code indicating the reason for termination, via the eligibility/enrollment update. Coverage will continue until such time as the Contractor receives a termination code from the Division. The Contractor may not request disenrollment of a Member because of an adverse change in the Member's health status, or because of the Members’ utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Member’s special needs except when the ADSM departs Member’s continued enrollment in the Contractor impairs the Contractor's ability to a new area of assignmentfurnish services to either this particular Member or other Member(s). The TOP contractor Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor and Enrollment into another Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs; or 6. When the Division imposes intermediate sanctions, as defined by 42 U.S.C. § 1396u-2; on the Contractor and allows Members to disenroll without cause. In this event, Contractor shall provide continuing coverage until (1) the enrollment has been transferred be responsible for Member notification of ability to disenroll without cause. Member requests for Disenrollment must be directed to the new location, Division in writing. The effective date of any approved Disenrollment will be no later than the first (21st) day of the enrollee disenrolls, or second (32nd) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day month following the end date of month in which the overseas tour from TOP Prime Member or TOP TPRthe Contractor files the request with the Division. Until December 31, 2017If the Division fails to make a disenrollment determination within the specified time frames, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR disenrollment will be only eligible for space available care at military treatment facilities.‌considered approved.

Disenrollment. 12.1 ADFMs shall At the time of eligibility redetermination, the Member will be disenrolled from TOP Prime/TOP Prime RemoteCHIP and the Contractor if the Member: 1. No longer qualifies for CHIP under the eligibility categories in the eligible population; or 2. Becomes eligible for Medicaid coverage; 3. Becomes institutionalized in a public institution or enrolled in a waiver program; or 4. Becomes eligible for Medicare coverage. At any time, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall Member must be disenrolled from TOP Prime/TOP Prime Remote whenCHIP and the Contractor if the Member: 12.3 ADFMs who are enrolled 1. No longer resides in TOP Prime/TOP Prime Remote the State of Mississippi; 2. Is identified as pregnant and verified by the Division; 3. Is determined to have Creditable Coverage by the Division; 4. Is deceased; or 5. Becomes a Custodial Nursing Home resident. The Contractor may disenroll request Disenrollment of a Member at any timetime based upon one or more of the reasons listed herein. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during The Contractor must notify the enrollment year Division within three (October 1 to September 303) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end receipt of the overseas tour Member Listing Report of their request that a Member be disenrolled and provide written documentation of the reason for the Disenrollment request. The Division will make a final determination regarding Disenrollment. Approved Disenrollment shall be effective on the first (1st) day of the calendar month for which the Disenrollment appears on the Member Listing Report. The Contractor must notify the Division of Members identified with a diagnosis related to pregnancy within seven (7) calendar days of identification through a report, in a format and manner to be specified by the Division. If the Member is determined to be eligible for Medicaid, the Division will transmit a termination of eligibility date to the Contractor, along with the code indicating the reason for termination, via the eligibility/enrollment update. Coverage will continue until such time as the Contractor receives a termination code from the Division. The Contractor may not request disenrollment of a Member because of an adverse change in the Member's health status, or because of the Members’ utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Member’s special needs except when the ADSM departs Member’s continued enrollment in the Contractor impairs the Contractor's ability to a new area of assignmentfurnish services to either this particular Member or other Member(s). The TOP contractor Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor and Enrollment into another Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs; or 6. When the Division imposes intermediate sanctions, as defined by 42 U.S.C. § 1396u-2; on the Contractor and allows Members to disenroll without cause. In this event, Contractor shall provide continuing coverage until (1) the enrollment has been transferred be responsible for Member notification of ability to disenroll without cause. Member requests for Disenrollment must be directed to the new location, Division in writing. The effective date of any approved Disenrollment will be no later than the first (21st) day of the enrollee disenrolls, or second (32nd) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day month following the end date of month in which the overseas tour from TOP Prime Member or TOP TPRthe Contractor files the request with the Division. Until December 31, 2017If the Division fails to make a disenrollment determination within the specified time frames, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR disenrollment will be only eligible for space available care at military treatment facilities.‌considered approved.

Disenrollment. 12.1 ADFMs ‌ The ICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be disenrolled the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: That the ICA is not directly involved in processing disenrollments although the ICA shall provide information relating to eligibility to the income maintenance agency; That enrollments and disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be eligible, and to reduce administrative costs to the ICA, FEA, and other service providers for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to his/her life situation (e.g., homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from TOP Prime/TOP Prime Remotethe ICA, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverageFEA, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following and the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll IRIS program without cause at any time. They If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during earlier than the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of date the end of individual last received services authorized by the overseas tour when the ADSM departs to a new area of assignmentICA. The TOP contractor shall provide continuing coverage until ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the enrollment participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has been transferred authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in a participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the new locationFEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (2IMD) the enrollee disenrollsfor longer than 90 days, or (3) when enrollment transfer or disenrollment has not been Dies. ICA-Requested Disenrollment with Cause When requested by the TOP PrimeICA, a participant may be disenrolled in accordance with the IRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s health and safety. The participant failed to complete a functional screen or sign their ISSP. The participant is no longer accepting services. The participant has been found to have mismanaged or abused their employer authority or budget authority. The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the participant exhibits uncooperative or disruptive behavior that results from his/TPR enrollee by her special needs with the 60th day following exception: a) Due to the TOP contractor will automatically disenroll participant’s uncooperative or disruptive behavior, the beneficiary on participant’s continued enrollment in the 61st calendar day following IRIS program seriously impairs the end date ICA’s ability to verify health and safety of the overseas tour from TOP Prime participant or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌others.

Disenrollment. 12.1 ADFMs shall The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment-related transactions will be disenrolled performed by the EOHHS customer service vendor. Enrollees can elect to disenroll from TOP Prime/TOP Prime Remotethe One Care plan or the Demonstration at any time and enroll in another One Care plan, TOP Select when: • The enrollee loses 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 its 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 TOP 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 coveragein the ICO per CMS enrollment guidance, • The enrollee has 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 plan Service Area cannot requested enrollment transfer/be confirmed for more than six consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following any Enrollee due to an adverse change in the end Enrollee’s health status or because of the overseas tour. 12.2 ADSMs shall be disenrolled Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote 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 at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime seriously impairs the Contractor’s ability to furnish services to either this Enrollee or TOP Prime Remote if they remain on permanent assignment other Enrollees, provided the Enrollee’s behavior is determined to be unrelated to an adverse change in an overseas location where these programs are offered. ADSM enrollment in TOP Prime the Enrollee's health status, or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days because of the end Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. Discretionary Involuntary Disenrollment: 42 C.F.R. § 422.74 and Sections 40.3 and 40.4 of the overseas tour when Medicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to One Care Plans on discretionary involuntary disenrollment. This Contract, the ADSM departs regulation, and other guidance provide procedural and substantive requirements the Contractor must follow prior to a new area being approved to involuntarily disenroll an Enrollee. If all of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred procedural requirements are met to the new locationsatisfaction of EOHHS and CMS, (2) the enrollee disenrolls, EOHHS and CMS will decide whether to approve or (3) when enrollment transfer or deny each request for involuntary disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary based on the 61st calendar day following the end date an assessment of the overseas tour from TOP Prime or TOP TPRparticular facts associated with each request. Until December 31If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, 2017EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS’ evaluation of a Contractor’s requests for involuntary disenrollment, the disenrolled ADFM TOP Prime Contractor shall, in all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or TOP TPR beneficiary will revert response to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌each attempt.

Disenrollment. 12.1 ADFMs shall A Member must be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses the Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident. For the purposes of determining eligibility for TOP MississippiCAN, PRTFs and ICF/IIDs shall not be considered a long term care facility; 5. ▇▇▇▇▇▇▇ enrolled in a waiver program; 6. Becomes eligible for Medicare coverage, • ; or 7. Is diagnosed with hemophilia. The enrollee has not requested enrollment transfer/disenrollment Contractor may request Disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end a Member at any time based upon one or more of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any timereasons listed herein. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during The Contractor must notify the enrollment year Division within three (October 1 to September 303) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end receipt of the overseas tour when Member Listing Report of their request that a Member be disenrolled and provide written documentation of the ADSM departs to a new area of assignmentreason for the Disenrollment request. The TOP contractor Division will make a final determination regarding Disenrollment. Approved Disenrollment shall provide continuing coverage until be effective on the first (11st) day of the enrollment has been transferred calendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination by the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the new locationDivision, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1. The Contractor does not, because of moral or religious objections, cover the service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for Disenrollment must be directed to the Division either orally or in writing. The effective date of any approved Disenrollment will be no later than the first (21st) day of the enrollee disenrolls, or second (32nd) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day month following the end date of month in which the overseas tour from TOP Prime Member or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Contractor files the request with the Division.

Disenrollment. 12.1 ADFMs shall The Contractor shall: 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment-related transactions will be disenrolled performed by the EOHHS customer service vendor. Enrollees can elect to disenroll from TOP Prime/TOP Prime Remotethe One Care plan or the Demonstration at any time and enroll in another One Care plan, TOP Select when: • The enrollee loses 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 its 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; 2. Be responsible for TOP ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled coveragein the ICO per CMS enrollment guidance, • The enrollee has 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 plan Service Area cannot requested enrollment transfer/be confirmed for more than six consecutive months. 4. Not request the disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following any Enrollee due to an adverse change in the end Enrollee’s health status or because of the overseas tourEnrollee’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. 12.2 ADSMs shall 5. EOHHS and CMS through the CMT will determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be disenrolled from TOP Prime/TOP Prime Remote whengranted based on the criteria in Section 2.3.B.4 above. EOHHS and CMS will develop a process to evaluate disenrollment requests for Enrollees whose continued enrollment seriously impairs the Contractor’s ability to furnish services to this Enrollee or other Enrollees. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS' evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall: 12.3 ADFMs a. In all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt; b. Provide a quarterly report to the CMT of all Enrollees who are enrolled have not participated in TOP Prime/TOP Prime Remote may disenroll at any timeeither the Comprehensive Assessment or the care planning process or both, and whether this is because the Contractor could not locate or engage the Enrollee, because the Enrollee declined, or for another reason; 6. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE Transfer Enrollee record information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred promptly to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested provider upon written request signed by the TOP Prime/TPR enrollee disenrolled Enrollee; 7. If the Enrollee transfers to a plan offered by another One Care contractor, with the 60th day Enrollee’s written consent, in accordance with applicable laws and regulations, promptly transfer current Minimum Data Set-Home Care (MDS-HC) assessment information to the TOP contractor will automatically disenroll new One Care contractor; and 8. Notify EOHHS if the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime Contractor becomes aware that an Enrollee has comprehensive insurance other than Medicare or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Medicaid.

Disenrollment. 12.1 ADFMs shall ‌ The Contractor shall: 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment-related transactions will be disenrolled performed by the EOHHS customer service vendor. Enrollees can elect to disenroll from TOP Prime/TOP Prime Remotethe One Care plan or the Demonstration at any time and enroll in another One Care plan, TOP Select when: • The enrollee loses 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 its 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; 2. Be responsible for TOP ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled coveragein the ICO per CMS enrollment guidance, • The enrollee has 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 plan Service Area cannot requested enrollment transfer/be confirmed for more than six consecutive months; 4. Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; 5. Not request the disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following any Enrollee due to an adverse change in the end Enrollee’s health status or because of the overseas tour. 12.2 ADSMs shall be disenrolled Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from TOP Prime/TOP Prime Remote whenhis 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: 12.3 ADFMs who are enrolled a. 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 TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6Enrollee's health status, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days because of the end Enrollee's utilization of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new locationmedical services, (2) the enrollee disenrollsdiminished mental capacity, or (3) when enrollment transfer uncooperative or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour disruptive behavior resulting from TOP Prime his or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌her special needs.

Disenrollment. 12.1 ADFMs Contractor shall be disenrolled from TOP Prime/TOP Prime Remoteprocess an Enrollee disenrollment under the following conditions, TOP Select when: • The enrollee loses eligibility and shall report quarterly the reason for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/which disenrollment occurred A. Disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote an MCE Enrollee is mandatory when: 12.3 ADFMs who are enrolled 1) In accordance with Medicaid law and policy; such reasons include: Enrollee has been determined to be unable to provide documentation of citizenship; Enrollee does not provide or no longer meets program eligibility requirements; Enrollee exceeds income limits allowed for the program; Enrollee voluntarily disenrolls from the program; Enrollee is institutionalized in TOP Prime/TOP Prime Remote an Institutions for Mental Diseases (IMD); Enrollee attains the age of 65; Enrollee is no longer living; or 2) If Enrollee no longer resides in the county participating in the MCE program. B. Disenrollment of an HCCI Enrollee is mandatory when: 1) Enrollee has been determined to be unable to provide documentation of citizenship; 2) Enrollee does not provide or no longer meets program eligibility requirements 3) Enrollee exceeds income limits allowed for the program; 4) Enrollee voluntarily disenrolls from the program 5) Enrollee no longer resides in the county participating in the HCCI program; 6) Enrollee becomes incarcerated or is institutionalized in an IMD; 7) Enrollee attains the age of 65; 8) Enrollees no longer living; or 9) Enrollee obtains other health coverage. C. Enrollee may voluntarily disenroll without cause at any time. They will not be permitted time by submitting an oral or written request for disenrollment to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time framesLIHP. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in D. Disenrollment shall become effective promptly upon receipt by Contractor of all documentation necessary to process the disenrollment. The effective date of an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees approved disenrollment must either transfer enrollment or disenroll within 60 calendar days be no later than the first day of the end second month following the disenrollment request. On the first day after enrollment ceases, Contractor is relieved of the overseas tour when the ADSM departs all obligations to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred Covered Services to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Enrollee.

Disenrollment. 12.1 ADFMs shall Disenrollment requests will be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following processed as soon as possible and will generally be effective the end first day of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any timenext month of the request, unless otherwise specified. They The HMO must direct all members with disenrollment requests to the Department’s Enrollment Specialist. Disenrollment requests will not be permitted backdated, unless an exception is granted by the Department. The HMO will not be liable for services, as of the effective date of the disenrollment. The disenrollment charts located in Subsection 6 of this article indicate whether the disenrollment is applicable to make BadgerCare Plus or SSI HMO. 1. Voluntary Disenrollment a. BadgerCare Plus b. Medicaid SSI All mandatory Medicaid SSI or SSI-related Medicaid members have the right to disenroll from the HMO after completing a 60 day trial period. A voluntary disenrollment for the mandatory Medicaid SSI population shall be effective no earlier than the first day of the third month following enrollment. If the member, legal guardian or authorized representative does not elect disenrollment during the first four months of enrollment, the member will be locked-in to the HMO for the remainder of the 12 month enrollment period. The member is required to complete only one 60 day trial period. If there is a disenrollment and subsequent re- enrollment, the member is not required to complete another enrollment until after a trial period. All voluntary Medicaid SSI members shall have the right to disenroll from the HMO within the first 90 days of enrollment. Such voluntary Medicaid SSI disenrollment shall be effective no earlier than the first day of the month following the request to disenroll. If the member, legal guardian or authorized representative does not elect disenrollment during the first three months of enrollment, the member will be locked-in to the HMO for the remainder of the 12-month period enrollment period. Members may also request disenrollment upon automatic reenrollment under 42 CFR 438.56(c) if they have already changed their the temporary loss of BadgerCare Plus and/or Medicaid SSI enrollment status from enrolled has caused the member to disenrolled twice during miss the annual enrollment year (October 1 to September 30) for any reasonperiod. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6A member may also request disenrollment if an HMO does not, Section 1 for guidance regarding enrollment lock-outs. Effective January 1because of moral or religious objections, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of cover the end of service the overseas tour when the ADSM departs to a new area of assignmentmember seeks. The TOP contractor shall HMO must notify the Department, at the time of certification, of any services that they would not provide continuing coverage until (1) the enrollment has been transferred due to the new location, (2) the enrollee disenrolls, moral or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌religious objections.

Disenrollment. 12.1 ADFMs The ICO shall have a mechanism for receiving timely information about all disenrollments, including the effective date of disenrollment, from CMS and MDHHS or its authorized agent. All disenrollment-related transactions will be disenrolled performed by CMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.38 and § 423.100, Enrollees can elect to disenroll from TOP Prime/TOP Prime Remotethe ICO or the Demonstration at any time and enroll in another ICO, TOP Select when: • a MA-PD plan, PACE (if eligible and the program has capacity); or may elect to receive services through Medicare FFS and a prescription drug plan and to receive Medicaid FFS and any waiver programs (if eligible). CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by CMS, MDHHS or its authorized agent, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month. The enrollee loses ICO shall notify MDHHS of any individual who is no longer eligible to remain enrolled in the ICO per Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, in order for MDHHS to disenroll the Enrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the ICO’s Service Area cannot be confirmed for more than six (6) consecutive months. Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for TOP enrolled Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, • The enrollee has as described in this section, the CMT shall not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following be responsible for processing disenrollments under this section. Further, nothing in this section alters the end obligations of the overseas tour. 12.2 ADSMs parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled retroactive to this date. When an Enrollee remains out of the Service Area or for whom residence in TOP Prime/TOP Prime Remote may disenroll at any time. They will the ICO Service Area cannot be permitted confirmed for more than six (6) consecutive months. When an Enrollee no longer resides in the Service Area (except for an Enrollee living in the Service Area who is admitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled Nursing Facility outside the Service Area for up to disenrolled twice during six months and placement is not based on the enrollment year family or social situation of the Enrollee). If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (October 1 to September 3015) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end Enrollment effective date. When requesting disenrollment, the ICO must submit verifiable information that an Enrollee has moved out of the overseas tour when Service Area. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the ADSM departs to a new area next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of assignmentthe ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor MDHHS will automatically disenroll the beneficiary Enrollee for the next available month. Until the Enrollee is disenrolled from the ICO, the ICO will receive a Capitation Payment for the Enrollee. The ICO is responsible for all Medically Necessary Services for the Enrollee until they are disenrolled. The ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of an Enrollee who resides out of the Service Area of the ICO before the effective date of Enrollment will be considered an "enrollment error". The ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the 61st calendar date of Enrollment. The termination or expiration of this Contract terminates coverage for all Enrollees with the ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the last day of the month following the end date month the Disenrollment is processed. The ICO may not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Discretionary Involuntary Disenrollments: 42 C.F.R. § 422.74 and Section 40.3 of the overseas tour from TOP Prime Medicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to ICOs on discretionary Involuntary Disenrollment. This Contract and the Medicare-Medicaid Plan Enrollment and Disenrollment guidance provide procedural and substantive requirements the ICO, MDHHS, and CMS must follow prior to involuntarily disenrolling an Enrollee. If all of the procedural requirements are met, MDHHS and CMS will decide whether to approve or TOP TPRdeny each request for Involuntary Disenrollment based on an assessment of whether the particular facts associated with each request satisfy the substantive evidentiary requirements. Until December 31, 2017, Bases for Discretionary Involuntary Disenrollment Disruptive conduct: When the disenrolled ADFM TOP Prime Enrollee engages in conduct or TOP TPR beneficiary will revert behavior that seriously impairs the ICO’s ability to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime furnish Covered Items and Services to either this Enrollee or TOP TPR will be only eligible for space available care at military treatment facilities.‌other Enrollees and provided the ICO made and documented reasonable efforts to resolve the problems presented by the Enrollee.

Disenrollment. 12.1 ADFMs An Enrollee must be dis-enrolled from the Plan if the beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor may request disenrollment of an enrollee at any time based upon one or more of the reasons listed herein. The Contractor must notify the Division within three (3) days of their request that an Enrollee be dis-enrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be disenrolled effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not dis-enroll 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 TOP Prime/TOP Prime Remote, TOP Select when: • Enrollee’s special needs (except when Enrollee’s continued enrollment in the Contractor seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The enrollee loses eligibility Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for TOP enrolled coverage, • The enrollee has not requested the request if the reasons are for other than those specified above. An Enrollee who is eligible for voluntary enrollment transfer/may request disenrollment of TOP Prime/TOP Prime Remote within 60 calendar without cause during the ninety (90) days following the end date the Division sends the Enrollee notice of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. A mandatory enrolled eligible may request one change between Contractors within the first ninety (90) days following the first date of enrollment into the health plan. Any Enrollee may request disenrollment from TOP Prime the Contractor for cause if the Contractor does not, because of moral or TOP TPR. Until December 31religious objections, 2017cover the service the Enrollee seeks, the disenrolled ADFM TOP Prime Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or TOP TPR beneficiary will revert another provider determines receiving the services separately would subject Enrollee to TRICARE Standardunnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Effective January 1, 2018, ADFMs disenrolled from TOP Prime Enrollee requests for disenrollment must be directed to the Division either orally or TOP TPR in writing. The effective date of any approved disenrollment will be only eligible for space available care at military treatment facilities.‌no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

Disenrollment. 12.1 ADFMs shall The Contractor shall: 1. Have a mechanism for receiving timely information about all disenrollments from the Contractor’s plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment-related transactions will be disenrolled performed by the EOHHS customer service vendor. Enrollees can elect to disenroll from TOP Prime/TOP Prime Remotethe One Care plan or the Demonstration at any time and enroll in another One Care plan, TOP Select when: • The enrollee loses 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 its 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; 2. Be responsible for TOP ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 3. Notify EOHHS of any individual who is no longer eligible to remain enrolled coveragein the ICO per CMS enrollment guidance, • The enrollee has 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 plan Service Area cannot requested enrollment transfer/be confirmed for more than six consecutive months. 4. Not request the disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following any Enrollee due to an adverse change in the end Enrollee’s health status or because of the overseas tourEnrollee’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. 12.2 ADSMs shall 5. EOHHS and CMS through the CMT will determine when and if a Contractor’s request to terminate the enrollment of an Enrollee will be disenrolled from TOP Prime/TOP Prime Remote whengranted based on the criteria in Section 2.3.B.4 above. EOHHS and CMS will develop a process to evaluate disenrollment requests for Enrollees whose continued enrollment seriously impairs the Contractor’s ability to furnish services to this Enrollee or other Enrollees. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS' evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall: 12.3 ADFMs a. In all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt; b. Provide a quarterly report to the CMT of all Enrollees who are enrolled have not participated in TOP Prime/TOP Prime Remote may disenroll at any timeeither the Comprehensive Assessment or the care planning process or both, and whether this is because the Contractor could not locate or engage the Enrollee, because the Enrollee declined, or for another reason; 6. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE Transfer Enrollee record information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred promptly to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested provider upon written request signed by the TOP Prime/TPR enrollee disenrolled Enrollee; 7. If the Enrollee transfers to a plan offered by another One Care contractor, with the 60th day Enrollee’s written consent, in accordance with applicable laws and regulations, promptly transfer current Minimum Data Set-Home Care (MDS-HC) assessment information to the TOP contractor will automatically disenroll new One Care contractor; and 8. Notify EOHHS if the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime Contractor becomes aware that an Enrollee has comprehensive insurance other than Medicare or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Medicaid.

Disenrollment. 12.1 ADFMs The ICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be disenrolled the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: That the ICA is not directly involved in processing disenrollments although the ICA shall provide information relating to eligibility to the income maintenance agency; That enrollments and disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be eligible, and to reduce administrative costs to the ICA, FEA, and other service providers for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to his/her life situation (e.g., homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from TOP Prime/TOP Prime Remotethe ICA, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverageFEA, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following and the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll IRIS program without cause at any time. They If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during earlier than the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of date the end of individual last received services authorized by the overseas tour when the ADSM departs to a new area of assignmentICA. The TOP contractor shall provide continuing coverage until ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the enrollment has been transferred participant’s decision to disenroll. The ADRC will process the disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in a participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the new locationFEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (2IMD) the enrollee disenrollsfor longer than 90 days, or (3) when enrollment transfer or disenrollment has not been Dies. ICA-Requested Disenrollment with Cause When requested by the TOP PrimeICA, a participant may be disenrolled in accordance with the IRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s health and safety. The participant failed to complete a functional screen or sign their ISSP. The participant is no longer accepting services. The participant has been found to have mismanaged or abused their employer authority or budget authority. The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the participant exhibits uncooperative or disruptive behavior that results from his/TPR enrollee by her special needs with the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌exception:

Disenrollment. 12.1 ADFMs shall ‌ A Member must be disenrolled from TOP Primethe Contractor if the Member: 1. No longer resides in the State of Mississippi; 2. Is deceased; 3. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the eligible population; 4. Becomes a nursing home resident or a resident of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/TOP Prime Remote, TOP Select when: • The enrollee loses IID). For the purposes of determining eligibility for TOP MississippiCAN, PRTFs shall not be considered a long term care facility; 5. Becomes institutionalized in a facility that is not a Psychiatric Residential Treatment Facility (PRTF); 6. Becomes enrolled in a waiver program; 7. Becomes eligible for Medicare coverage, • ; or 8. Is diagnosed with hemophilia. The enrollee has not requested enrollment transfer/disenrollment Contractor may request Disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end a Member at any time based upon one or more of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any timereasons listed herein. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during The Contractor must notify the enrollment year Division within three (October 1 to September 303) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end receipt of the overseas tour when Member Listing Report of their request that a Member be disenrolled and provide written documentation of the ADSM departs to a new area of assignmentreason for the Disenrollment request. The TOP contractor Division will make a final determination regarding Disenrollment. Approved Disenrollment shall provide continuing coverage until be effective on the first (1st) day of the calendar month for which the Disenrollment appears on the Member Listing Report. If the Division fails to make a Disenrollment determination within the specified timeframes, the Disenrollment is considered approved. The Contractor must file a request to disenroll a Member with the Division in writing stating specifically the reasons for the request if the reasons differ from those specified above. Additionally, any Member may request Disenrollment from the Contractor for cause if: 1) . The Contractor does not, because of moral or religious objections, cover the enrollment has been transferred service the Member seeks; 2. Not all related services are available within the network; 3. The Member’s PCP or another Provider determines receiving the services separately would subject Member to unnecessary risk; poor quality of care; 4. There is a lack of access to services covered under the Contractor; or 5. There is a lack of access to Providers experienced in treating the Member’s health care needs. Member requests for Disenrollment must be directed to the new location, Division either orally or in writing. The effective date of any approved Disenrollment will be no later than the first (21st) day of the enrollee disenrolls, or second (32nd) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day month following the end date of month in which the overseas tour from TOP Prime Member or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Contractor files the request with the Division.

Disenrollment. 12.1 ADFMs The Agency shall be responsible for processing disenrollments. The PDHP’s responsibility is to ensure that disenrollees who wish to file a grievance are afforded the opportunity to do so, unless the proposed disenrollment is for one of the following reasons: disenrollment due to moving out of the service area; disenrollment due to loss of Medicaid eligibility; and disenrollment due to death. The following are unacceptable reasons for the PDHP, on its own initiative, to request disenrollment of a member: pre-existing dental condition, changes in health status, periodically missed appointments, or utilization of services. With proper written documentation, the PDHP shall promptly submit disenrollment requests to the Agency for members who have died. The PDHP shall ensure that disenrollment documents are maintained in an identifiable member record. The PDHP must report fraudulent use of the beneficiary ID card to DCF. a. If the PDHP discovers that an ineligible beneficiary has been enrolled, then it must notify the beneficiary in writing that the beneficiary shall be disenrolled from TOP Prime/TOP Prime Remotethe next contract month. Until the beneficiary is disenrolled, TOP Select when: • The enrollee loses eligibility the PDHP shall be responsible for TOP enrolled coveragethe provision of services to that beneficiary. b. On a monthly basis, • The enrollee has not requested the PDHP shall review its enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following report to ensure that all members are residing in the end PDHP's authorized service area. For beneficiaries with out-of-service-area addresses on the enrollment report, the PDHP shall notify the beneficiary in either by telephone or in writing that the beneficiary will be disenrolled and inform the beneficiary of the overseas tourrequirement to update their address on file at DCF or Social Security Administration (SSA). 12.2 ADSMs c. The PDHP shall assign a different dentist to a member whose behavior is disruptive, unruly, abusive, or uncooperative to the extent that his or her membership in the PDHP seriously impairs the organization's ability to furnish services to either the member or other members. The PDHP must maintain documentation of at least one oral and at least one written warning to the member regarding the implications of his or her actions. A written explanation of the reason for changing the primary care dentist must be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted given to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time framesmember. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in d. The PDHP shall provide disenrollment data via an overseas location where these programs are offeredAgency-approved transmission medium. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility Documentation must contain the following minimum information: name, address, telephone number, reason for TOP/TRICAREdisenrollment with brief explanation, date, and signature by PDHP staff. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer e. The PDHP shall keep a daily written log or electronic documentation of all oral and written enrollment or disenroll within 60 calendar days change requests and the disposition of the end of the overseas tour when the ADSM departs to a new area of assignmentsuch requests. The TOP contractor log shall provide continuing coverage until (1) include the enrollment has been transferred to following: the new location, (2) date the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested request was received by the TOP Prime/TPR enrollee by PDHP; the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, letter advising them of the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌enrollment change procedure; and the reason that the member is requesting an enrollment change.

Disenrollment. 12.1 ADFMs The ICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be disenrolled the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: That the ICA is not directly involved in processing disenrollments although the ICA shall provide information relating to eligibility to the income maintenance agency; That enrollments and disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be eligible, and to reduce administrative costs to the ICA, FEA, and other service providers for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to his/her life situation (e.g., homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from TOP Prime/TOP Prime Remotethe ICA, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverageFEA, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following and the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll IRIS program without cause at any time. They If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during earlier than the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of date the end of individual last received services authorized by the overseas tour when the ADSM departs to a new area of assignmentICA. The TOP contractor shall provide continuing coverage until ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the enrollment participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has been transferred authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in a participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the new locationFEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (2IMD) the enrollee disenrollsfor longer than 90 days, or (3) when enrollment transfer or disenrollment has not been Dies. ICA-Requested Disenrollment with Cause When requested by the TOP PrimeICA, a participant may be disenrolled in accordance with the IRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s health and safety. The participant failed to complete a functional screen or sign their ISSP. The participant is no longer accepting services. The participant has been found to have mismanaged or abused their employer authority or budget authority. The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the participant exhibits uncooperative or disruptive behavior that results from his/TPR enrollee by her special needs with the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌exception:

Disenrollment. 12.1 ADFMs The ICO shall have a mechanism for receiving timely information about all disenrollments, including the effective date of disenrollment, from CMS and MDHHS or its authorized agent. All disenrollment-related transactions will be performed by CMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.38 and § 423.100, Enrollees can elect to disenroll from the ICO or the Demonstration at any time and enroll in another ICO, a MA-PD plan, PACE (if eligible and the program has capacity); or may elect to receive services through Medicare FFS and a prescription drug plan and to receive Medicaid FFS and any waiver programs (if eligible). CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by CMS, MDHHS or its authorized agent, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month. The ICO shall be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment. The ICO shall notify MDHHS if it has information that shows that an Enrollee is no longer eligible to remain enrolled in the ICO per Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, in order for MDHHS to disenroll the Enrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the ICO’s Service Area cannot be confirmed for more than six (6) consecutive months. This includes where an Enrollee remains out of the Service Area, confirmed by the Enrollee or authorized representative. MDHHS will investigate and make an Enrollment decision as appropriate. Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area for more than 6 consecutive months confirmed by the Enrollee or authorized representative. It is allowable for an Enrollee residing in the Service Area to be admitted to a Nursing Facility outside the Service Area for a service that cannot be obtained in the service area (and placement is not based on the family or social situation of the Enrollee). This placement is allowable for up to six months, unless the local MDHHS updates the Enrollee address to outside of the Service Area sooner, in which case the Enrollee cannot stay enrolled in the ICO. If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. When requesting disenrollment due to out of Service Area, the ICO must be able to provide upon request, verifiable information that an Enrollee has moved out of the Service Area, verified by the Enrollee or an authorized representative. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of the ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. MDHHS will automatically disenroll the Enrollee for the next available month. Until the Enrollee is disenrolled from TOP Prime/TOP Prime Remotethe ICO, TOP Select when: • the ICO will receive a Capitation Payment for the Enrollee. The enrollee loses eligibility ICO is responsible for TOP enrolled coverage, • all Medically Necessary Services for the Enrollee until they are disenrolled. The enrollee has not requested enrollment transfer/disenrollment ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end an Enrollee who resides out of the overseas tour. 12.2 ADSMs shall Service Area of the ICO before the effective date of Enrollment will be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any timeconsidered an "enrollment error". They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year The ICO is responsible for requesting disenrollment within fifteen (October 1 to September 3015) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the date of Enrollment. When CMS or MDHHS is made aware that an Enrollee is incarcerated in a county jail, Michigan Department of Corrections facility, or Federal penal institution. Termination of coverage shall take effect on the first of the overseas tour when month of the ADSM departs to month following the State’s confirmation of a new area current incarceration if the start date is not known, or the first of assignmentthe month following the start date of incarceration if the start date is known. The TOP contractor shall provide continuing termination or expiration of this Contract terminates coverage until (1) for all Enrollees with the enrollment has been transferred ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the new locationDemonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, (2) termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the enrollee disenrollslast day of the month following the month the Disenrollment is processed. The ICO may not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌otherwise; Discretionary Involuntary Disenrollments:

Disenrollment. 12.1 ADFMs shall be disenrolled An Enrollee may initiate disenrollment from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility the Contractor’s program for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll any reason and at any time. They An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor: Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s program, including the effective date of disenrollment, from CMS and EOHHS systems. Disenrollments received and approved by the last business day of the month will be effective on the first calendar day of the following month; Must be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; May request that an Enrollee be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining out of the Service Area for more than six consecutive months; or If approved in advance by EOHHS, when the Contractor’s ability to furnish services to the Enrollee or to other Enrollees is seriously impaired; and May not request that an Enrollee be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to involuntarily disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end following reasons: An adverse change in the Enrollee’s health status; The Enrollee’s utilization of the overseas tour medical services; The Enrollee’s diminished mental capacity; or The Enrollee’s uncooperative or disruptive behavior (except when the ADSM departs Enrollee’s continued enrollment seriously impairs the Contractor’s ability to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) furnish services to the enrollment has been transferred Enrollee or other Enrollees); and Must transfer Enrollee record information to the new locationProvider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment for Enrollees for any amount of time without 30 calendar days advance notice and the approval of EOHHS. Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (2) see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with the enrollee disenrollsfederal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or (3) when enrollment transfer or disenrollment has not been requested medications. Be developed by the TOP PrimePCP or PCT under the direction of the Enrollee (and/or the Enrollee’s representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to prepare for and fully participate in the care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/TPR enrollee her health status, including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is not limited to: A summary of the Enrollee’s health history; A prioritized list of concerns, goals, and strengths; The plan for addressing concerns or goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or otherwise convey approval of his or her ICP when it is developed and at the time of subsequent modifications to it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Accepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the 60th day ASAP and the TOP contractor will automatically disenroll ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the beneficiary on Contractor’s Service Area, the 61st calendar day following the end date Contractor may: Contract with all of the overseas tour ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the Contractor; Coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services; Monitoring the provision and outcomes of community long-term care and support services, according to the enrollee's service plan, and making periodic adjustments to the enrollee's service plan as deemed appropriate by the primary care team; Tracking enrollee transfer from TOP Prime or TOP TPRone setting to another; and Scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee's care plan. Until December 31, 2017, Other care management related activities as may be determined and contracted for by the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Contractor.

Disenrollment. 12.1 ADFMs The HMO must direct all members with disenrollment requests to the Enrollment Specialist for assistance. Disenrollment requests will be processed as soon as possible and will be effective the first day of the next month of the request, unless otherwise specified. The HMO will not be liable for services, as of the effective date of the disenrollment. There are two types of disenrollment: Voluntary and system-based. Voluntary Disenrollment a. A member may voluntarily disenroll from an HMO for any reason when the member is not in the lock-in period. Voluntary disenrollment requests must come from the member, the member’s family, or legal guardian. Voluntary disenrollment shall be effective no later than the first day of the second month following the month in which the member requests disenrollment. b. A member may only disenroll from an HMO when in their lock-in period for the following reasons: Upon automatic reenrollment under 42 CFR § 438.56(c) the temporary loss of BadgerCare Plus and/or Medicaid SSI enrollment has caused the member to miss the annual enrollment period. If an HMO does not, because of moral or religious objections, cover the service the member seeks. The HMO must notify the Department, at the time of certification, of any services that they would not provide due to moral or religious objections. If the member needs related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk. The SSI HMO fails to complete the assessment and care plan during the first 90 days of enrollment, and is able to demonstrate a good faith process to complete the assessment, the voluntary disenrollment period will be extended an additional 30 days. Other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member’s care needs. System Based Disenrollments System based disenrollments happen automatically in the system as a result of changes to the member’s eligibility. If an HMO believes a member should have had a system-based disenrollment but has not, the HMO may request disenrollment through the Department’s HMO Enrollment Specialists. a. Loss of BadgerCare Plus and/or Medicaid SSI Eligibility The member shall be disenrolled from TOP Prime/TOP Prime Remotewhen a member loses BadgerCare Plus or Medicaid SSI eligibility. The date of disenrollment shall be the date of BadgerCare Plus or Medicaid SSI eligibility termination. No recoupments will be made to the capitation payment to reflect a mid-month disenrollment, TOP Select when: • but any capitation payment(s) made for months subsequent to the disenrollment month will be recouped. b. Out-of-Service Area Disenrollment The enrollee loses eligibility for TOP enrolled coverage, • member shall be disenrolled when a member moves to a location that is outside of the HMO’s service area but within the state of Wisconsin. The enrollee has not requested enrollment transfer/date of the disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following shall be the end of the overseas tourmonth in which the move occurred. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌

Disenrollment. 12.1 ADFMs Coverage of benefits shall end, and service fees shall be disenrolled from TOP Prime/TOP Prime Remotepaid until the date the enrollee is no longer qualified for benefits under Medicaid or Law No. 72, TOP Select when: • whichever applies to that enrollee. Disenrollment will be effected exclusively by a notification issued by the ADMINISTRATION. In the event of disenrollment on the last day of the month of coverage while the enrollee is under inpatient status at a hospital, and the individual continues such inpatient status during the month following the enrollee’s disenrollment, the ADMINISTRATION will cover the payment of the services for that following month. However, if the enrollee remains hospitalized in subsequent months, the conversion clause of Section 2.7 of this Contract will be triggered automatically. The enrollee loses ceases to be eligible as of the disenrollment date specified in THE ADMINISTRATION’ report to the TPA. If the ADMINISTRATION notifies the TPA that the enrollee ceased to be eligible on or before the last working day of the month in which eligibility for TOP ceases, the disenrollment will be effective on the first day of the following month. Disenrollment will be effected exclusively by a notification issued and delivered by the ADMINISTRATION to enrollee. If following disenrollment, an enrollee’s contract is reinstated and the enrollee is re-enrolled coverageon the same month of disenrollment, • the contract will be reinstated as of the date of re-enrollment. The enrollee TPA/HCO has not requested enrollment transfer/a limited right to request disenrollment of TOP Primea enrollee from HCO services without the enrollee’s/TOP Prime Remote within 60 calendar days enrollee’s consent. The ADMINISTRATION must approve any TPA/HCO disenrollment request of a enrollee for cause. Disenrollment of a enrollee/enrollee may be permitted under the following circumstances: a) Enrollee misuses or loans his/her membership card to another person to obtain services. b) Enrollee is disruptive, unruly, threatening or uncooperative to the end extent that enrollee’s membership seriously impairs TPA’s or provider’s ability to provide services to enrollees or to obtain new enrollees, and enrollee’s behavior is not caused by a physical or mental health condition. The TPA/HCO must undertake reasonable measures to allow a enrollee to improve his/her behavior prior to requesting disenrollment and must notify, in writing, said enrollee of its intent to disenroll. Reasonable measures may include, without limitation, providing education and counseling regarding the offensive acts or behavior. TPA/HCO must notify the enrollee in writing of its decision to disenroll after reasonable measures have failed to remedy the problem. Said written notification shall include information pertaining to the availability of the overseas tourComplaints and Grievances System set forth hereunder and the ADMINISTRATION’s fair hearing process, as provided by Law 72 of September 7, 1993, as amended. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌

Disenrollment. 12.1 ADFMs shall be disenrolled An Enrollee may initiate disenrollment from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility the Contractor’s program for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll any reason and at any time. They An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor: Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s program, including the effective date of disenrollment, from CMS and EOHHS systems. Disenrollments received and approved by the last business day of the month will be effective on the first calendar day of the following month; Must be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; May request that an Enrollee be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining out of the Service Area for more than six consecutive months; or If approved in advance by EOHHS, when the Contractor’s ability to furnish services to the Enrollee or to other Enrollees is seriously impaired; and May not request that an Enrollee be permitted involuntarily disenrolled for any of the following reasons: An adverse change in the Enrollee’s health status; The Enrollee’s utilization of medical services; The Enrollee’s diminished mental capacity; or The Enrollee’s uncooperative or disruptive behavior (except when the Enrollee’s continued enrollment seriously impairs the Contractor’s ability to furnish services to the Enrollee or other Enrollees); and Must transfer Enrollee record information to the new Provider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make another a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for Enrollees for any reasonamount of time without 30 calendar days advance notice and the approval of EOHHS. ADFMs Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with sponsors E-1 the federal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or medications. Be developed by the PCP or PCT under the direction of the Enrollee (and/or the Enrollee’s representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to prepare for and fully participate in the care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/her health status, including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is not limited to: A summary of the Enrollee’s health history; A prioritized list of concerns, goals, and strengths; The plan for addressing concerns or goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or otherwise convey approval of his or her ICP when it is developed and at the time of subsequent modifications to it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Accepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through E-4 (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the ASAP and the ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the Contractor’s Service Area, the Contractor may: Contract with all of the ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Other care management related activities as may be determined and contracted for by the Contractor. If there is only one ASAP operating in the Contractor’s service area and the Contractor identifies any of the following deficiencies in the performance of the ASAP with which it has contracted, the Contractor must follow the procedure in Section 2.4.A.5.e. The ASAP does not meet its responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor; The ASAP does not satisfy clinical or administrative performance standards, based on a performance review evaluation by the Contractor and subsequent failure by the ASAP to correct documented deficiencies; or The ASAP meets its basic responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor, but is substantially less qualified than other ASAPs. The Contractor and an ASAP may enter into any appropriate reimbursement relationship for GSSC services, such as fee-for-service reimbursement, capitation, or partial capitation. If the Contractor is unable to execute or maintain a contract with any of the ASAPs operating in its Service Area due to lack of agreement on reimbursement-related issues, the Contractor must collaborate with EOHHS and EOEA to explore all reasonable options for reconciling financial differences, before terminating or failing to initiate a contract. If the Contractor fails to execute a contract with an ASAP operating in its service area, or determines that it must terminate a contract with an ASAP, and that is the only ASAP operating in its service area, the Contractor must follow the procedure in Section 2.4.A.5.e. The Contractor will cooperate with EOHHS and the Executive Office of Elder Affairs to ensure any claims submitted by the ASAPs are exempt from these enrollment lockaccepted and processed through a standardized system. The Contractor must ensure GSSC services are not duplicated by other care management functions delivered by the Contractor, Providers or other subcontractors and that care management is only counted once for each member in the Medicaid-out provisionsonly MLR calculation, as that term is defined in Section 2.13.Q.1. See Chapter 6If the Contractor has identified any of the deficiencies set forth in Section 2.4.A.5.c; is unable to execute a contract with an ASAP; or determines that it must terminate a GSSC contract with an ASAP, Section 1 for guidance regarding enrollment lock-outs. Effective January 1and that is the only ASAP that operates in the Contractor’s Service Area; the Contractor must notify EOHHS in writing, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar five business days of the end triggering event, with detailed specific findings of fact that indicate the deficiencies. If EOHHS finds that the Contractor’s reasons are not substantiated with sufficient findings, EOHHS will develop a corrective action plan for the Contractor that ensures continuation of GSSC services and specifies the actions the Contractor will take. Nothing in this Section 2.4.A.5 precludes the Contractor from entering into a subcontracting relationship with any ASAP for functions beyond those required by M.G.L. c. 118E § 9D, including, but not limited to: Providing community-based services, such as homemaker, chore, and respite services; Performing initial and on-going assessments; and Conducting risk-assessment and care-planning activities regarding non-medical service needs of Enrollees without Complex Care Needs. Integration and Coordination of Services The Contractor must ensure effective linkages of clinical and management information systems among all Providers in the Provider Network, including clinical Subcontractors (that is, acute, specialty, behavioral health, and long term care Providers). The Contractor must ensure that the PCP or the PCT integrates and coordinates services including, but not limited to: An IPC, as described in Section 2.4.A.2 of this Contract; Written protocols for generating or receiving referrals and for recording and tracking the results of referrals; Written protocols for providing or arranging for second opinions, whether in or out of the overseas tour Provider Network; Written protocols for sharing clinical and IPC information, including management of medications; Written protocols for determining conditions and circumstances under which specialty services will be provided appropriately and without undue delay to Enrollees who do not have established Complex Care Needs; Written protocols for obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers in the Provider Network, and with CMS and EOHHS for quality management and program evaluation purposes; Coordinating the services the Contractor furnishes to the Enrollee between settings of care, including appropriate discharge planning for short- and long-term hospital and institutional stay; and Coordinating services provided by the Contractor with the services: The Contractor shall ensure that each Enrollee receives the contact information for the person or entity primarily responsible for coordinating the Enrollee’s care and services, whether that is the PCP or his or her designee on the PCT. Coordinating Access for Emergency Conditions and Urgent Care Services The Contractor must ensure linkages among the PCP, the PCT, and any appropriate acute, long term care, or behavioral health Providers to keep all parties informed about utilization of services for Emergency Conditions and Urgent Care. The Contractor may not require advance approval for the following services: Any services for Emergency Conditions; Emergency behavioral health care; Urgent Care sought out of the Service Area; Urgent Care under unusual and extraordinary circumstances provided in the Service Area when the ADSM departs to contracted medical Provider is unavailable or inaccessible; Direct-access women’s services; and Out-of-area renal dialysis services. Centralized Enrollee Record (CER) To coordinate care, the Contractor must maintain a new area of assignmentsingle, centralized, comprehensive record that documents the Enrollee's medical, functional, and social status. The TOP contractor shall provide continuing coverage until Contractor must make appropriate and timely entries describing the care provided, diagnoses determined, medications prescribed, and treatment plans developed. The organization and documentation included in the CER must meet all applicable professional requirements. The CER must contain the following: Enrollee identifying information; Documentation of each service provided, including the date of service, the name of both the authorizing Provider and the servicing Provider (1) if different), and how they may be contacted; Multidisciplinary assessments, using the enrollment has been transferred to the new locationassessment tool designated by EOHHS, (2) the enrollee disenrollsincluding diagnoses, or (3) when enrollment transfer or disenrollment has not been requested prognoses, reassessments, plans of care, and treatment and progress notes, signed and dated by the TOP Prime/TPR enrollee by appropriate Provider; Laboratory and radiology reports; Reconciled medication list; Prescribed medications, including dosages and any known drug contraindications; Reports about the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date involvement of community agencies that are not part of the overseas tour from TOP Prime or TOP TPR. Until December 31Provider Network, 2017including any services provided; Documentation of contacts with family members and persons giving informal support, if any; Physician orders; Disenrollment agreement, if applicable; Enrollee’s individual advance directives and health care proxy, recorded and maintained in a prominent place; Plan for Emergency Conditions and Urgent Care, including identifying information about any emergency contact persons; and Allergies and special dietary needs Documentation of Initial and Ongoing Assessments; including verification that an Enrollee has received services for which Providers have billed the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌Contractor and in accordance with Section 2.4.A.11.b.iv.