Disenrollment Initiated by the Enrollee Sample Clauses

Disenrollment Initiated by the Enrollee. All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56. Such notification shall clearly explain the process for exercising this disenrollment right, as well as the coverage alternatives available to the Enrollee based on their specific circumstance. An Enrollee wishing to request Disenrollment or his or her representative must submit an oral or written request to ASES or to the Contractor. If the request is made to the Contractor, the Contractor shall forward the request to ASES, within five (5) Business Days of receipt of the request, with a recommendation of the action to be taken. An Enrollee may request Disenrollment from the Contractor’s Plan without cause once during the applicable Open Enrollment Period in accordance with Section 5.2.5. An Enrollee may request Disenrollment from the Contractor’s Plan for cause at any time. The Enrollee’s request must be processed in accordance with this Section 5.3.5. ASES shall determine whether the reason constitutes a valid cause. The following constitute cause for Disenrollment by the Enrollee: The Enrollee moves outside of Puerto Rico; The Contractor’s Plan does not, due to moral or religious objections, cover the health service the Enrollee seeks. The Enrollee needs related services to be performed at the same time, and not all related services are available within the network. The Enrollee’s PCP or another Provider in the Contractor’s Network have determined that receiving services separately would subject the Enrollee to unnecessary risk. Other acceptable reasons for Disenrollment at Enrollee request, per 42 CFR 438.56(d)(2)(v), including, but not limited to, poor quality of care, lack of Access to Covered Services, or lack of Providers experienced in dealing with the Enrollee’s health care needs; and The Enrollee has become eligible for a Platino Program, or has experienced a change in his or her eligibility as a member of the Domestic Violence or Xxxxxx Care Populations. If the Contractor fails to refer a Disenrollment request within the timeframe specified in Section 5.3.3, or if ASES fails to make a Disenrollment determination so that the Enrollee may be disenrolled by the first day of the second month following the month when the Disenrollment request was made, per Section 5.3.3, the Disenrollment shall be deemed approved for the effective date that would have been established had ASES or the Contractor complied with Section 5.3.3. AS...
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Related to Disenrollment Initiated by the Enrollee

  • Disenrollment Adverse Benefit Determination taken by the Division, or its Agent, to remove a Member's name from the monthly Member Listing report following the Division's receipt and approval of a request for Disenrollment or a determination that the Member is no longer eligible for Enrollment in the Contractor.

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Re-enrollment Any eligible employees who wish to join the Sick Leave Bank after their first year of eligibility will contribute two (2) days upon joining. Such membership may only be made during the month of October using the appropriate forms. The two (2) required days of leave shall be donated from their account upon enrollment in the Classified Employee Council (CEC).

  • Procurement Related Complaints and Administrative Review 49.1 The procedures for making a Procurement-related Complaint are as specified in the TDS.

  • School-Initiated Closure Should the School choose to voluntarily surrender this Contract before the end of the Contract term, it may do so in consultation with the Commission at the close of any school year and upon written notice to the Commission given at least ninety (90) days before the end of the school year.

  • Maximum Enrollment The maximum number of students who may be enrolled in the School shall be 550 students, unless the School and District mutually agree to increase this number. This maximum enrollment was determined pursuant to negotiations between the District and the Network for the School and is consistent with facilitating the academic success of students enrolled in the School and facilitating the School’s ability to achieve the other objectives specified in this Contract. If the School wishes to enroll more than the maximum number of students listed above, the Network for the School must submit a written request to the District, in form and substance acceptable to the District, for review and consideration as an amendment to this Contract. The District shall approve any reasonable requests as determined by the District. This maximum enrollment should not exceed the capacity of the School facility. Each year, the School will be asked to affirm an annual maximum enrollment that will be used to determine mid-year enrollment and School Choice numbers.

  • Medical Benefits - Prescription Drugs Administered by a Provider (other than a pharmacist) This plan covers prescription drugs as a medical benefit, referred to as “medical prescription drugs”, when the prescription drug requires administration (or the FDA approved recommendation is administration) by a licensed healthcare provider (other than a pharmacist). Please note: Specialty prescription drugs meeting these requirements or recommendations are covered as a pharmacy benefit and not a medical benefit. These medical prescription drugs include, but are not limited to, medications administered by infusion, injection, or inhalation, as well as nasal, topical or transdermal administered medications. For some of these medical prescription drugs, the cost of the prescription drug is included in the allowance for the medical service being provided, and is not separately reimbursed.

  • Enrollment The School shall maintain accurate and complete enrollment data and daily records of student attendance.

  • Enrollment Process The Department may, at any time, revise the enrollment procedures. The Department will advise the Contractor of the anticipated changes in advance whenever possible. The Contractor shall have the opportunity to make comments and provide input on the changes. The Contractor will be bound by the changes in enrollment procedures.

  • Initial Enrollment Upon retirement, each new retiree who is eligible to enroll in plans under the Health Benefits Program shall receive uninterrupted coverage under the plan in which he or she was enrolled as an active employee, provided the employee submits all necessary applications and other required documentation in a timely fashion.

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