Common use of Processing of Disenrollment Requests Clause in Contracts

Processing of Disenrollment Requests. a) Routine Disenrollment Unless otherwise specified in Appendix H, Section F disenrollment requests will be processed to take effect on the first (1st) day of the next month if the request is made before the date specified in Appendix H. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second 2nd) month after the month in which an Enrollee requests a disenrollment b) Expedited Disenrollment i) Enrollees with an urgent medical need to disenroll from the Contractor's plan may request an expedited disenrollment by the LDSS. Substantiation of the request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H. Individuals who are to be disenrolled from managed care based on their HIV, ESRD or SPMI/SED status are categorically eligible for an expedited disenrollment on the basis of urgent medical need. ii) Enrollees may request an expedited disenrollment by the LDSS based on a complaint of Non-consensual Enrollment. Substantiation of such a request by the LDSS shall result in an expedited disenrollment retroactive to the first day of the month of enrollment. iii) In New York City and other districts where homeless individuals are exempt, homeless Enrollees residing in the shelter system may request an expected disenrollment by the LDSS. Substantiation of such a request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H. c) Retroactive Disenrollment i) Retroactive disenrollments may be warranted in rare instances and include when an individual is enrolled or autoassigned while meeting exclusion criteria or when an Enrollee enters or stays in a residential institution under circumstances which render the SECTION 8 (DISENROLLMENT) October 1, 2004 8-2 individual excluded from managed care; is incarcerated; is an SSI infant less than six months of age; or dies - as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period.

Processing of Disenrollment Requests. a) Routine Disenrollment Unless otherwise specified in Appendix H, Section F disenrollment requests will be processed to take effect on the first (1st) day of the next month month, if the request is made before the date specified in Appendix H. In no event shall the Effective Date of Disenrollment be later than the first (1st) day of the second THE SECOND (2nd) month after the month in which an Enrollee requests a disenrollment b) . Expedited Disenrollment i) Enrollees with an urgent medical need to disenroll from the Contractor's plan may request an expedited disenrollment by the LDSS. Substantiation of the request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H. Individuals who are to be disenrolled from managed care based on their HIV, ESRD or - SPMI/SED status are categorically eligible for an expedited disenrollment on the basis of urgent medical need. ii) Enrollees may request an expedited disenrollment by the LDSS LOSS based on a complaint of Non-consensual Enrollment. Substantiation of such a request by the LDSS shall result in an expedited disenrollment retroactive to the first day of the month of enrollment. iii) In New York City and other districts where homeless individuals are exempt, homeless Enrollees residing in the shelter system may request an expected expedited disenrollment by the LDSS. Substantiation of such a request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H. c) H. Retroactive Disenrollment i) Retroactive disenrollments may be warranted in rare instances and include when an individual is enrolled or autoassigned while meeting exclusion exlusion criteria or when an Enrollee enters or stays in a residential institution under circumstances which render the SECTION 8 (DISENROLLMENT) October OCTOBER 1, 2004 8-2 individual excluded from managed care; is incarcerated; is an SSI infant less than six months of age; or dies - as long as payment rate. In such instances, the Contractor was shall not at risk be liable for provision of Benefit Package services for any portion the cost of the retroactive periodconsecutive stay. For the purposes of this Section, "hospital stay" does not include a stay in a hospital that is a) certified by Medicare as a long-term care hospital and b) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002; in such instances, Contractor liability will cease on the Effective Date of Disenrollment. The Contractor shall notify the LDSS that the Enrollee remains in the hospital and provide the LDSS, with information regarding his or her medical status. The Contractor is required to cooperate with the Enrollee and the new MCO (if applicable) on a timely basis to ensure a smooth transition and continuity of care.