Common use of Termination by STATE Clause in Contracts

Termination by STATE. An Enrollee’s coverage in the MCO may be terminated by the STATE for one of the following reasons: (A) Required Termination includes: (1) The Enrollee becomes ineligible for Medical Assistance. (2) The Enrollee becomes ineligible for Medicare Part A or Part B. If the Enrollee loses eligibility for both Parts A and B but remains eligible for Medical Assistance, the Enrollee remains eligible for SNBC. (3) The Enrollee moves out of the MCO’s Service Area as defined in section 3.1 of this Contract and the MMIS county of residence is updated per eligibility policy, except in the case where the Enrollee is receiving Inpatient Hospitalization services overnight on the last day of the month. (4) The Enrollee no longer meets the eligibility criteria for SNBC; (5) The Enrollee does not pay the Medical Spenddown to the STATE for three consecutive months. (6) The Enrollee elects to change MCOs as described in 42 CFR § 422.62 (election of coverage for Medicare Advantage plan.) (7) SNBC Enrollees rejected by CMS will be re-enrolled into fee-for-service unless the Enrollee is sixty-five (65) years or older and has no Spenddown, in which case the Enrollee will be enrolled in MSC+, and the capitation payment will be adjusted. (B) Optional Termination includes the circumstances as listed in 42 CFR § 422.74(b)(1) as follows: (1) The Enrollee has engaged in disruptive behavior, and the request for disenrollment meets the requirements listed in 42 CFR § 422.74(d)(2). Disenrollment will be allowed only upon review and approval by CMS; or (2) The Enrollee provided fraudulent information on his or her enrollment form or permits abuse of his or her enrollment card.

Termination by STATE. An Enrollee’s coverage in the MCO may be terminated by the STATE for one of the following reasons: (A) Required Termination includes:includes:‌ (1) The Enrollee becomes ineligible for Medical Assistance. (2) The Enrollee becomes ineligible for Medicare Part A or Part B. If the Enrollee loses eligibility for both Parts A and B but remains eligible for Medical Assistance, the Enrollee remains eligible for SNBC. (3) The Enrollee moves out of the MCO’s Service Area as defined in section 3.1 of this Contract and the MMIS county of residence is updated per eligibility policy, except in the case where the Enrollee is receiving Inpatient Hospitalization services overnight on the last day of the month. (4) The Enrollee no longer meets the eligibility criteria for SNBC; (5) The Enrollee does not pay the Medical Spenddown to the STATE for three consecutive months. (6) The Enrollee elects to change MCOs as described in 42 CFR § 422.62 (election of coverage for Medicare Advantage plan.) (7) SNBC Enrollees rejected by CMS will be re-enrolled into fee-for-service unless the Enrollee is sixty-five (65) years or older and has no Spenddown, in which case the Enrollee will be enrolled in MSC+, and the capitation payment will be adjusted. (B) Optional Termination includes the circumstances as listed in 42 CFR § 422.74(b)(1) as follows: (1) The Enrollee has engaged in disruptive behavior, and the request for disenrollment meets the requirements listed in 42 CFR § 422.74(d)(2). Disenrollment will be allowed only upon review and approval by CMS; or (2) The Enrollee provided fraudulent information on his or her enrollment form or permits abuse of his or her enrollment card.