Common use of Disenrollment Clause in Contracts

Disenrollment. 2.3.2.1. The Contractor shall: 2.3.2.1.1. Have a mechanism for receiving timely information about all disenrollments from the Contractor‘s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment- related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth‘s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; 2.3.2.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 2.3.2.1.3. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; 2.3.2.1.4. Not interfere with the Enrollee‘s right to disenroll through threat, intimidation, pressure, or otherwise; 2.3.2.1.5. Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee‘s health status or because of the Enrollee‘s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 2.3.2.1.5.1. 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.

Disenrollment. 2.3.2.1. The Contractor shall: 2.3.2.1.1. Have a mechanism for receiving timely information about all disenrollments from the Contractor‘s Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment- disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth‘s 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; 2.3.2.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 2.3.2.1.3. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; 2.3.2.1.4. Not interfere with the Enrollee‘s Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; 2.3.2.1.5. Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee‘s Enrollee’s health status or because of the Enrollee‘s Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 2.3.2.1.5.1. The Enrollee‘s Enrollee’s continued enrollment seriously impairs the Contractor‘s Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee‘s 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.

Disenrollment. 2.3.2.11. The Contractor shall: 2.3.2.1.1. Have a mechanism for receiving timely a. On each business day, obtain from EOHHS, via the HIPAA 834 Enrollment File, and process information about pertaining to all disenrollments from the Contractor‘s One Care PlanEnrollee disenrollments, including the effective date Effective Date of disenrollmentDisenrollment and disenrollment reason code; b. No later than 30 days prior to the Enrollee’s MassHealth redetermination date, from CMS and MassHealth systems. All enrollments at the Contractor’s discretion, contact the Enrollee and disenrollment- related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options provide assistance (if they meet applicable eligibility requirements); or may elect required) to receive complete and return to MassHealth the redetermination form; c. At a minimum, continue to provide ACO Covered Services, and all other services required under this Contract, to Enrollees 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 11:59 p.m. on the first calendar day Effective Date of the following monthDisenrollment, as specified by EOHHS; 2.3.2.1.2. Be responsible d. Demonstrate a satisfactorily low voluntary Enrollee disenrollment rate, as determined by EOHHS, as compared with other MassHealth Accountable Care Partnership Plans and MassHealth-contracted MCOs for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollmentEnrollees in comparable Rating Categories; 2.3.2.1.32. Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order The Contractor’s Request 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 canDisenrollment a. The Contractor shall not be confirmed for more than six (6) consecutive months; 2.3.2.1.4. Not interfere with the Enrollee‘s right to disenroll through threat, intimidation, pressure, or otherwise; 2.3.2.1.5. Not request the disenrollment of any Enrollee due to because of: 1) an adverse change in the Enrollee‘s Enrollee’s health status or because of status; 2) the Enrollee‘s Enrollee’s utilization of treatment plan, medical services, including but not limited to the Enrollee making treatment decisions with which a provider or the Contractor disagrees (such as declining treatment or diagnostic testing); 3) missed appointments by the Enrollee; 4) the Enrollee’s diminished mental capacity, or or 5) the Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to needs (except when the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 2.3.2.1.5.1. The Enrollee‘s ’s continued enrollment with the Contractor seriously impairs the Contractor‘s Contractor’s ability to furnish services to either this the particular Enrollee or other Enrollees). b. As further specified by EOHHS and in accordance with 130 CMR 508.003(D), provided the Enrollee‘s behavior is determined Contractor may submit a written request to be unrelated EOHHS to disenroll an adverse change Enrollee as follows: 1) The Contractor shall submit the written request in a form and format specified by EOHHS and accompanied by supporting documentation specified by EOHHS; 2) The Contractor shall follow all policies and procedures specified by EOHHS relating to such request, including but not limited to the Enrollee's health statusfollowing: a) The Contractor shall take all serious and reasonable efforts specified by EOHHS prior to making the request. Such efforts include, but are not limited to: (i) attempting to provide Medically Necessary ACO Covered Services to the particular Enrollee through at least three PCPs or because of other relevant Network Providers that: (a) Meet the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.access requirements specified in Section

Disenrollment. 2.3.2.12.3.5.1. The Contractor shall: 2.3.2.1.12.3.5.1.1. Have a mechanism for receiving timely information about all disenrollments from the Contractor‘s One Care PlanMMP, including the effective date of disenrollment, from CMS and MassHealth systemsDMAS or its authorized agent. All enrollments and disenrollment- disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56DMAS or its authorized agent. Enrollees can elect to disenroll from the One Care Plan MMP or the Demonstration at any time and enroll in another One Care PlanMMP, 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 Virginia Medicaid State plan Plan and any waiver programsprograms (if eligible). Disenrollments received by MassHealth DMAS or the Contractorits authorized agent, or by CMS or its contractor contractor, 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;. 2.3.2.1.22.3.5.1.2. Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment;. 2.3.2.1.32.3.5.1.3. Notify EOHHS DMAS or its authorized agent of any individual who is no longer eligible to remain enrolled in the One Care Plan MMP per CMS enrollment Enrollment guidance, in order for EOHHS DMAS or its authorized agent to disenroll the individualEnrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan MMP Service Area cannot be confirmed for more than six (6) consecutive months;. 2.3.2.1.42.3.5.1.4. Not interfere with the Enrollee‘s Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; 2.3.2.1.52.3.5.1.5. Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee‘s Enrollee’s health status status, unless they enter a hospice program, or because of the Enrollee‘s Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) CMT to disenroll an Enrollee, for cause, for the following reason: 2.3.2.1.5.12.3.5.1.5.1. The Enrollee‘s Enrollee’s continued enrollment Enrollment seriously impairs the Contractor‘s Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee‘s 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. 2.3.5.1.6. DMAS and CMS through the CMT will determine when and if the Contractor’s request to terminate the Enrollment of an Enrollee will be granted based on the criteria in Section

Disenrollment. 2.3.2.1. The Contractor shall: 2.3.2.1.1. : Have a mechanism for receiving timely information about all disenrollments from the Contractor‘s Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment- disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth‘s 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; 2.3.2.1.2. ; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; 2.3.2.1.3. ; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; 2.3.2.1.4. ; Not interfere with the Enrollee‘s Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; 2.3.2.1.5. ; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee‘s Enrollee’s health status or because of the Enrollee‘s Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 2.3.2.1.5.1. : The Enrollee‘s Enrollee’s continued enrollment seriously impairs the Contractor‘s Contractor’s ability to furnish services to either this Enrollee or other Enrollees, provided the Enrollee‘s 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.