New Enrollees Clause Samples
The "New Enrollees" clause defines how individuals who are newly joining a program, plan, or service are to be treated under the agreement. It typically outlines the eligibility criteria, enrollment procedures, and the effective date of coverage or participation for these new members. For example, it may specify waiting periods before benefits begin or detail any required documentation for enrollment. The core function of this clause is to ensure clarity and consistency in the onboarding process for new participants, preventing misunderstandings and disputes regarding their rights and obligations from the outset.
New Enrollees. Each MCO Enrollee with no FFS claim experience or managed care encounters in the assessment period will be assigned a risk score equal to the average risk score for the MCO’s Enrollees in the same rate cell.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if, (1) the Enrollee has a life-
New Enrollees. Participating Provider shall provide no less than 30 days’ prior written notice of Participating Provider’s decision to no longer accept new Enrollees. In no event shall any current patient of Participating Provider who becomes an Enrollee be considered a new Enrollee for purposes of this Section 2.3.
New Enrollees. At the time of eligibility determination, individuals who are mandated to participate must receive information about managed care plan choices in their area. They must be informed of their options in selecting an authorized managed care plan. Individuals must be provided the opportunity to meet or speak with a choice counselor to obtain additional information in making a choice. New enrollees will be required to select a plan within 30 days of eligibility determination. If the individual does not select a plan within the 30-day period, the state may auto-assign the individual into a capitated managed care plan or a FFS PSN in the Reform Counties or the MMA program when implemented. Once individuals have made their choice, they will be able to contact the state or the state’s designated choice counselor to register their plan selection. Once the plan selection is registered and takes effect, the plan must communicate to the enrollee, in accordance with 42 CFR 438.10, the benefits covered under the plan, including dental benefits, and how to access those benefits.
New Enrollees. The State will utilize diagnoses from fee-for-service and encounter data to determine new enrollee risk scores. The first quarter risk scores will be calculated by the STATE based on fee-for-service data and/or encounter data. Risk scores in subsequent quarters will be calculated by the STATE based on fee-for-service data and/or encounter data submitted by any MCO in which a given recipient was enrolled during the assessment period pursuant to section 4.4.4 of this contract as available from both sources. If an Enrollee has no fee-for-service or encounter claim experience, the Enrollee will be assigned the MCO risk score plan average.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the Contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if (1) the Enrollee has a life-threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to:
i) accept reimbursement from the Contractor at rates established by the Contractor as payment in full, which rates shall be no more than the level of reimbursement applicable to similar providers within the Contractor's network for such services; and
ii) adhere to the Contractor's quality assurance requirements and provide to the Contractor necessary medical information related to such care; and
iii) otherwise adhere to the Contractor's policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization in a treatment plan approved by the Contractor. In no event shall this requirement be construed to require the Contractor to provide coverage for benefits not otherwise covered.
New Enrollees. New Enrollees to the GHP will have the opportunity to select a contractor during the Medicaid eligibility process with the Puerto Rico Medicaid Program. If the New Enrollee does not select a contractor, the Puerto Rico Medicaid Program will select a contractor on behalf of the New Enrollee. New Enrollees shall be permitted to select a different contractor once without cause, regardless of how the initial selection of contractor was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Effective Date of Enrollment.
New Enrollees. The OVHA shall be responsible for educating individuals at the time of their enrollment into the Global Commitment to Health Waiver. Education activities may be conducted via mail, by telephone and/or through face-to-face meetings. The OVHA may employ the services of an enrollment broker to assist in outreach and education activities. The OVHA shall provide information and assist enrollees in understanding all facets pertinent to their enrollment, including the following: • What services are covered and how to access them • Restrictions on freedom-of-choice • Cost sharing • Role and responsibilities of the primary care provider (PCP) • Importance of selecting and building a relationship with a PCP • Information about how to access a list of PCPs in geographic proximity to the enrollee and the availability of a complete network roster • Enrollee rights, including appeal and Fair Hearing rights (described in greater detail below); confidentiality rights; availability of the Office of Health Care Ombudsman; and enrollee-initiated dis-enrollment • Enrollee responsibilities, including making, keeping, canceling appointments with PCPs and specialists; necessity of obtaining prior authorization (PA) for certain services and proper utilization of the emergency room (ER)
New Enrollees. Risk scores will be calculated by the STATE based on FFS data and/or encounter data diagnoses during the assessment period pursuant to section 3.6.1(O) of this contract. If an enrollee has no Medical Assistance eligibility during the assessment period the enrollee will be assigned the MCO risk score plan average.
New Enrollees. If a new Enrollee has an existing relationship with a health care provider who is not a member of the Contractor's provider network, the contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provide during a transitional period of up to sixty (60) days from the Effective Date of Enrollment, if, (1) the Enrollee has a life SECTION 15 (EQUALITY OF ACCESS AND TREATMENT) OCTOBER 1, 2004 15-2 threatening disease or condition or a degenerative and disabling disease or condition, or (2) the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery up until sixty (60) days post partum. If the Enrollee elects to continue to receive care from such Non-Participating Provider, such care shall be authorized by the Contractor for the transitional period only if the Non-Participating Provider agrees to: