Qualifying Involuntary Disenrollment Sample Clauses

Qualifying Involuntary Disenrollment. 2.4.13.4.1. The Contractor may request that an Enrollee be involuntarily disenrolled for the following reasons only: 2.4.13.4.1.1. Loss or downgrade of MassHealth eligibility; 2.4.13.4.1.2. Enrollee no longer meets SCO program participation requirements set forth in Section 2.4.1; 2.4.13.4.1.3. ▇▇▇▇▇▇▇▇ has confirmed to the Contractor that they have relocated out of the Service Area; 2.4.13.4.1.4. Fraud or abuse, which occurs when the Enrollee provides fraudulent information on an Enrollment form or the Enrollee willfully misuses or permits another person to misuse the Enrollee’s ID card. 2.4.13.4.2. Consistent with the requirements of Appendix M, the Contractor may submit a written request, accompanied by supporting documentation, to EOHHS to disenroll an Enrollee, for cause, for the following reason: 2.4.13.4.2.1. When 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 their individual needs. Such requests shall be approved by EOHHS in advance, and the Contractor shall follow the procedures described in Appendix M. 2.4.13.4.3. For Involuntary Disenrollments related to MassHealth eligibility changes, Enrollment continues until the last day of the month during which the Enrollee’s MassHealth last eligible day occurs or the Deemed Eligibility/Enrollment period ends, whichever is later.

Qualifying Involuntary Disenrollment. The Contractor may request that an Enrollee be involuntarily disenrolled for the following reasons only: Loss or downgrade of MassHealth eligibility; Enrollee no longer meets SCO program participation requirements set forth in Section 2.4.1; ▇▇▇▇▇▇▇▇ has confirmed to the Contractor that they have relocated out of the Service Area; Fraud or abuse, which occurs when the Enrollee provides fraudulent information on an Enrollment form or the Enrollee willfully misuses or permits another person to misuse the Enrollee’s ID card. Consistent with the requirements of Appendix M, the Contractor may submit a written request, accompanied by supporting documentation, to EOHHS to disenroll an Enrollee, for cause, for the following reason: When 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 their individual needs. Such requests shall be approved by EOHHS in advance, and the Contractor shall follow the procedures described in Appendix M. For Involuntary Disenrollments related to MassHealth eligibility changes, Enrollment continues until the last day of the month during which the Enrollee’s MassHealth last eligible day occurs or the Deemed Eligibility/Enrollment period ends, whichever is later. Initial Enrollee Contact and Onboarding The Contractor shall: Except as otherwise permitted during Medicare open enrollment, provide an onboarding to Enrollees within thirty (30) days, either prior to or following, the initial date of enrollment. The onboarding shall include: Engage with the Enrollee to identify any immediate health or social needs (e.g., immediately connecting an Enrollee with a dentist for urgent dental needs); and Working with the Enrollee to schedule a Comprehensive Assessment (see Section 2.5); Selection of a Primary Care Provider (PCP); For Enrollees with a current Primary Care Provider (PCP) non-network, making reasonable efforts to contract with their PCP (See Section 2.8.3); For Enrollees with a current PCP that is not in network and refuses to become a Network Provider or enter into a single case non-network agreement where applicable (see Section 2.8.2.2), assist the Enrollee to choose a PCP. The Enrollee...