Common use of Disenrollment Clause in Contracts

Disenrollment. The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollment

Disenrollment. ‌ The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or participant exhibits uncooperative or disruptive behavior resulting that results from his or his/her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for needs with the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollmentexception:

Disenrollment. An Enrollee may initiate disenrollment from the Contractor’s program for any reason and at any time. An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor shallContractor: Have Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planprogram, including the effective date of disenrollment, from CMS and MassHealth EOHHS systems. All enrollments and disenrollment‑related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor and approved by the last calendar business day of the month will be effective on the first calendar day of the following month; Be Must be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where May request that an Enrollee remains be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with or If approved in advance by EOHHS, when the EnrolleeContractor’s right ability to disenroll through threat, intimidation, pressure, furnish services to the Enrollee or otherwiseto other Enrollees is seriously impaired; Not and May not request that an Enrollee be involuntarily disenrolled for any of the disenrollment of any Enrollee due to an following reasons: An adverse change in the Enrollee’s health status or because of the status; The Enrollee’s utilization of treatment plan, medical services, ; The Enrollee’s diminished mental capacity, ; or The Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to (except when the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment seriously impairs the Contractor’s ability to furnish services to either this the Enrollee or other Enrollees); and Must transfer Enrollee record information to the new Provider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment for Enrollees for any amount of time without 30 calendar days advance notice and the approval of EOHHS. Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with the federal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or medications. Be developed by the PCP or PCT under the direction of the Enrollee (and/or the Enrollee’s behavior is determined representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be unrelated at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to an adverse change prepare for and fully participate in the Enrollee's care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/her health status, or because including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is not limited to: A summary of the Enrollee's utilization ’s health history; A prioritized list of medical servicesconcerns, diminished mental capacitygoals, and strengths; The plan for addressing concerns or uncooperative goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or disruptive behavior resulting from otherwise convey approval of his or her special ICP when it is developed and at the time of subsequent modifications to it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Discretionary Involuntary DisenrollmentAccepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the ASAP and the ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the Contractor’s Service Area, the Contractor may: Contract with all of the ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the Contractor; Coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services; Monitoring the provision and outcomes of community long-term care and support services, according to the enrollee's service plan, and making periodic adjustments to the enrollee's service plan as deemed appropriate by the primary care team; Tracking enrollee transfer from one setting to another; and Scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee's care plan. Other care management related activities as may be determined and contracted for by the Contractor.

Disenrollment. The Contractor shall: Have a mechanism Coverage of benefits shall end, and service fees shall be paid until the date the enrollee is no longer qualified for receiving timely information about all disenrollments from the Contractor’s One Care Planbenefits under Medicaid or Law No. 72, including the effective date of disenrollment, from CMS and MassHealth systemswhichever applies to that enrollee. All enrollments and disenrollment‑related transactions Disenrollment will be performed effected exclusively by a notification issued by the EOHHS customer service vendorADMINISTRATION. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from In the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by event of disenrollment on the last calendar day of the month of coverage while the enrollee is under inpatient status at a hospital, and the individual continues such inpatient status during the month following the enrollee’s disenrollment, the ADMINISTRATION will cover the payment of the services for that following month. However, if the enrollee remains hospitalized in subsequent months, the conversion clause of Section 2.7 of this Contract will be triggered automatically. The enrollee ceases to be eligible as of the disenrollment date specified in THE ADMINISTRATION’ report to the TPA. If the ADMINISTRATION notifies the TPA that the enrollee ceased to be eligible on or before the last working day of the month in which eligibility ceases, the disenrollment will be effective on the first calendar day of the following month; Be responsible for ceasing . Disenrollment will be effected exclusively by a notification issued and delivered by the provision ADMINISTRATION to enrollee. If following disenrollment, an enrollee’s contract is reinstated and the enrollee is re-enrolled on the same month of Covered Services to an Enrollee upon disenrollment, the effective contract will be reinstated as of the date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualre-enrollment. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s The TPA/HCO has a limited right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in a enrollee from HCO services without the Enrolleeenrollee’s/enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needsconsent. The Contractor, however, may submit ADMINISTRATION must approve any TPA/HCO disenrollment request of a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, enrollee for cause, for . Disenrollment of a enrollee/enrollee may be permitted under the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollmentcircumstances:

Disenrollment. The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Contractors are responsible for covered services it has authorized through the date of disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or participant exhibits uncooperative or disruptive behavior resulting that results from his or his/her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for needs with the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollmentexception:

Disenrollment. The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service fee-for-service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollment

Disenrollment. The Contractor shallICA shall comply with the following requirements and use Department issued forms related to disenrollment. Processing Disenrollments The disenrollment plan, developed in collaboration with the ADRC and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: Have a mechanism for receiving timely That the ICA is not directly involved in processing disenrollments although the ICA shall provide information about all disenrollments from relating to eligibility to the Contractor’s One Care Plan, including the effective date of disenrollment, from CMS and MassHealth systems. All income maintenance agency; That enrollments and disenrollment‑related transactions will disenrollments are accurately entered in ForwardHealth interChange so that correct monthly rate of service payments are made to the ICA and FEA; That timely processing occurs, in order to ensure that participants who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be performed by eligible, and to reduce administrative costs to the EOHHS customer ICA, FEA, and other service vendorproviders for claims processing; and That disenrollments are accurately entered in the Department case management system (WISITS) so that correct monthly rate of service payments are made to the ICA and FEA. Subject Contractor Influence Prohibited Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant due to 42 C.F.R. § 423.100his/her life situation (e.g., § 423.38 and § 438.56homelessness, increased need for supervision) or condition in such a way as to encourage disenrollment. Enrollees can elect Types of Disenrollment Participant-Requested/Voluntary Disenrollment All participants have the right to disenroll from the One Care Plan or ICA, FEA, and the Demonstration IRIS program without cause at any time time. If a participant expresses a desire to disenroll from IRIS, the ICA shall provide the participant with contact information for their local ADRC; and enroll with the participant’s approval, may make a referral to the ADRC for options counseling. If the participant chooses to disenroll, the participant will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the ICA. The ADRC will notify the ICA that the participant is no longer requesting services and the participant’s preferred date for disenrollment as soon as possible, but this notification will be no later than one (1) business day following the participant’s decision to disenroll. The ADRC will process the disenrollment. Disenrollment Due to Loss of Eligibility The participant will be disenrolled if he/she loses eligibility. The ICA is required to notify the income maintenance agency when it becomes aware of a change in another One Care Plana participant’s situation or condition that might result in loss of eligibility. Participants lose eligibility when the participant: Fails to meet functional eligibility requirements; Fails to meet financial eligibility requirements; Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due to the FEA pursuant to IRIS Policy; Initiates a move out of the State of Wisconsin; If the participant moves into a geographic service region not served by the ICA, the ICA shall assist the participant with a transfer to an ICA serving the region in which they are relocating within Wisconsin. Is incarcerated as an inmate in a public institution; Is relocated to a nursing home or hospice facility for long-term or permanent care; A participant age 21-64 is admitted to an Institution for Mental Disease (IMD) for longer than 90 days, or Dies. ICA-Requested Disenrollment with Cause When requested by the ICA, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or participant may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services be disenrolled in accordance with the CommonwealthIRIS Policy Manual and Work Instructions, if: The ICA is unable to assure the participant’s State plan health and any waiver programssafety. Disenrollments received by MassHealth The participant failed to complete a functional screen or the Contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who sign their ISSP. The participant is no longer eligible accepting services. The participant has been found to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individualhave mismanaged or abused their employer authority or budget authority. This includes where an Enrollee remains The participant is out of compliance with IRIS Policy. The ICA may not request a disenrollment if the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or participant exhibits uncooperative or disruptive behavior resulting that results from his or his/her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for needs with the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollmentexception:

Disenrollment. The Contractor shall: Have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planplan, including the effective date of disenrollment, from CMS and MassHealth systems. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan plan or the Demonstration at any time and enroll in another One Care Planplan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service fee-for-service and a prescription drug plan Plan and to receive Medicaid services in accordance with the Commonwealth’s State state plan and any waiver programs. Disenrollments received by MassHealth or the Contractorits contractor, or by CMS or its contractor by the last calendar day of the month will be effective on the first calendar day of the following month; Be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan ICO per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 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 his or her special needs. Discretionary Involuntary Disenrollment: 42 C.F.R. § 422.74 and Sections 40.3 and 40.4 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to One Care Plans on discretionary involuntary disenrollment. This Contract, the regulation, and other guidance provide procedural and substantive requirements the Contractor must follow prior to being approved to involuntarily disenroll an Enrollee. If all of the procedural requirements are met to the satisfaction of EOHHS and CMS, EOHHS and CMS will decide whether to approve or deny each request for involuntary disenrollment based on an assessment of the particular facts associated with each request. If EOHHS and CMS determine that the Contractor too frequently requests termination of enrollment for Enrollees, EOHHS and CMS reserve the right to deny such requests and require the Contractor to initiate steps to improve the Contractor’s ability to serve such Enrollees. To support EOHHS’ and CMS’ evaluation of a Contractor’s requests for involuntary disenrollment, the Contractor shall, in all cases, document what steps the Contractor has taken to locate and engage the Enrollee, and the impact of or response to each attempt.

Disenrollment. An Enrollee may initiate disenrollment from the Contractor’s program for any reason and at any time. An Enrollee may initiate disenrollment from the Contractor’s program by submitting a request to disenroll either to the State or to the Contractor. The Contractor shallContractor: Have Must have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Planprogram, including the effective date of disenrollment, from CMS and MassHealth EOHHS systems. All enrollments and disenrollment‑related transactions will be performed by the EOHHS customer service vendor. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. Enrollees can elect to disenroll from the One Care Plan or the Demonstration at any time and enroll in another One Care Plan, a Medicare Advantage plan, PACE, or Senior Care Options (if they meet applicable eligibility requirements); or may elect to receive services through Medicare fee‑for‑service and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan and any waiver programs. Disenrollments received by MassHealth or the Contractor, or by CMS or its contractor and approved by the last calendar business day of the month will be effective on the first calendar day of the following month; Be Must be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who is no longer eligible to remain enrolled in the One Care Plan per CMS enrollment guidance, in order for EOHHS to disenroll the individual. This includes where May request that an Enrollee remains be involuntarily disenrolled for the following reasons only: Loss of MassHealth eligibility; Remaining out of the Service Area or for whom residence in the One Care Plan Service Area cannot be confirmed for more than six (6) consecutive months; Not interfere with or If approved in advance by EOHHS, when the EnrolleeContractor’s right ability to disenroll through threat, intimidation, pressure, furnish services to the Enrollee or otherwiseto other Enrollees is seriously impaired; Not and May not request that an Enrollee be involuntarily disenrolled for any of the disenrollment of any Enrollee due to an following reasons: An adverse change in the Enrollee’s health status or because of the status; The Enrollee’s utilization of treatment plan, medical services, ; The Enrollee’s diminished mental capacity, ; or The Enrollee’s uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to (except when the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: The Enrollee’s continued enrollment seriously impairs the Contractor’s ability to furnish services to either this the Enrollee or other Enrollees); and Must transfer Enrollee record information to the new Provider upon written request signed by the disenrolled Enrollee; and Must make disenrollment determinations within the timeframe set forth in 42 CFR 438.56(e)(1). In the event that the Contractor fails to make a disenrollment determination within such timeframe, the disenrollment is considered approved. Closing Enrollment The Contractor shall not discontinue or suspend enrollment for Enrollees for any amount of time without 30 calendar days advance notice and the approval of EOHHS. Care Management and Integration General Service Delivery The Contractor must authorize, arrange, coordinate and provide all Covered Services for its Enrollees (see Covered Services in Appendix A). The Contractor’s provision of Covered Services must comply with the federal regulations for the availability of services as provided in 42 CFR 438.206. Individualized Plan of Care (IPC). The Contractor must develop for each Enrollee an IPC. The IPC must: Incorporate the results of the Initial Assessment and specify any changes in providers, services, or medications. Be developed by the PCP or PCT under the direction of the Enrollee (and/or the Enrollee’s behavior representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c)(3) and 42 C.F.R. 422.112(a)(6)(iii) and updated periodically to reflect changing needs identified in Ongoing Assessments. The Enrollee will be at the center of the care planning process. Reflect the Enrollee’s preferences and needs. The Contractor will ensure that the Enrollee receives any necessary assistance and accommodations to prepare for and fully participate in the care planning process, including the development of the IPC and that the Enrollee receives clear information about: His/her health status, including functional limitations; How family members and social supports can be involved in the care planning as the Enrollee chooses; Self-directed care options and assistance available to self-direct care; Opportunities for educational and vocational activities; and Available treatment options, supports and/or alternative courses of care. Specify how services and care will be integrated and coordinated among health care providers, and community and social services providers where relevant to the Enrollee’s care; Include, but is determined not limited to: A summary of the Enrollee’s health history; A prioritized list of concerns, goals, and strengths; The plan for addressing concerns or goals; The person(s) responsible for specific interventions; The due date for each intervention. The Contractor must: Establish and execute policies and procedures that provide mechanisms by which an Enrollee can sign or otherwise convey approval of his or her ICP when it is developed and at the time of subsequent modifications to be unrelated it; Inform an Enrollee of his or her right to approve the IPC; Provide mechanisms for an Enrollee to sign or otherwise convey approval of the ICP that meet his or her accessibility needs; and Inform an Enrollee of his or her right to an adverse Appeal of any denial, termination, suspension, or reduction in services, or any other change in providers, services, or medications, included in the IPC. Accepting and Processing Assessment Data For the purposes of quality management and Rating Category determination, the Contractor must accept, process, and report to EOHHS uniform person-level Enrollee data, based upon an Initial and Ongoing Assessment process that includes ICD-10 diagnosis codes, an assessment as designated by EOHHS, and any other data elements deemed necessary by EOHHS. Assessment and Determination of Complex Care Needs Upon enrollment, and as appropriate thereafter, the Contractor must perform Initial and Ongoing Assessments. This process will identify all of an Enrollee’s needs, and, in particular, the presence of Complex Care Needs. In performing these assessments, the Contractor must also comply with 42 CFR 438.208(c)(2) through (4) and M.G.L. c. 118E, § 9D(h)(3). Geriatric Support Services Coordinator (GSSC) The Contractor must provide a GSSC to members requiring certain long term services and supports through a contract with one or more of the ASAPs that complies with M.G.L. c. 118E, § 9D. The regions served by the ASAP and the ASAP’s qualification to deliver GSSC services shall be determined by EOEA. If more than one ASAP is operating in the Contractor’s Service Area, the Contractor may: Contract with all of the ASAPs; or Contract with a lead ASAP to coordinate all the GSSC work in the Contractor’s Service Area. The GSSC is responsible for: All of the activities set forth in M.G.L. c. 118E, § 9D(h)(2), which consist of: Arranging, coordinating and authorizing the provision of community long-term care and social support services with the agreement of other primary care team members designated by the Contractor; Coordinating non-covered services and providing information regarding other elder services, including, but not limited to, housing, home-delivered meals and transportation services; Monitoring the provision and outcomes of community long-term care and support services, according to the enrollee's service plan, and making periodic adjustments to the enrollee's service plan as deemed appropriate by the primary care team; Tracking enrollee transfer from one setting to another; and Scheduling periodic reviews of enrollee care plans and assessment of progress in reaching the goals of an enrollee's care plan. Other care management related activities as may be determined and contracted for by the Contractor. If there is only one ASAP operating in the Contractor’s service area and the Contractor identifies any of the following deficiencies in the performance of the ASAP with which it has contracted, the Contractor must follow the procedure in Section 2.4.A.5.e. The ASAP does not meet its responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor; The ASAP does not satisfy clinical or administrative performance standards, based on a performance review evaluation by the Contractor and subsequent failure by the ASAP to correct documented deficiencies; or The ASAP meets its basic responsibilities relating to the performance of GSSC functions and GSSC qualifications established by the Contractor, but is substantially less qualified than other ASAPs. The Contractor and an ASAP may enter into any appropriate reimbursement relationship for GSSC services, such as fee-for-service reimbursement, capitation, or partial capitation. If the Contractor is unable to execute or maintain a contract with any of the ASAPs operating in its Service Area due to lack of agreement on reimbursement-related issues, the Contractor must collaborate with EOHHS and EOEA to explore all reasonable options for reconciling financial differences, before terminating or failing to initiate a contract. If the Contractor fails to execute a contract with an ASAP operating in its service area, or determines that it must terminate a contract with an ASAP, and that is the only ASAP operating in its service area, the Contractor must follow the procedure in Section 2.4.A.5.e. The Contractor will cooperate with EOHHS and the Executive Office of Elder Affairs to ensure any claims submitted by the ASAPs are accepted and processed through a standardized system. The Contractor must ensure GSSC services are not duplicated by other care management functions delivered by the Contractor, Providers or other subcontractors and that care management is only counted once for each member in the Medicaid-only MLR calculation, as that term is defined in Section 2.13.Q.1. If the Contractor has identified any of the deficiencies set forth in Section 2.4.A.5.c; is unable to execute a contract with an ASAP; or determines that it must terminate a GSSC contract with an ASAP, and that is the only ASAP that operates in the Contractor’s Service Area; the Contractor must notify EOHHS in writing, within five business days of the triggering event, with detailed specific findings of fact that indicate the deficiencies. If EOHHS finds that the Contractor’s reasons are not substantiated with sufficient findings, EOHHS will develop a corrective action plan for the Contractor that ensures continuation of GSSC services and specifies the actions the Contractor will take. Nothing in this Section 2.4.A.5 precludes the Contractor from entering into a subcontracting relationship with any ASAP for functions beyond those required by M.G.L. c. 118E § 9D, including, but not limited to: Providing community-based services, such as homemaker, chore, and respite services; Performing initial and on-going assessments; and Conducting risk-assessment and care-planning activities regarding non-medical service needs of Enrollees without Complex Care Needs. Integration and Coordination of Services The Contractor must ensure effective linkages of clinical and management information systems among all Providers in the Provider Network, including clinical Subcontractors (that is, acute, specialty, behavioral health, and long term care Providers). The Contractor must ensure that the PCP or the PCT integrates and coordinates services including, but not limited to: An IPC, as described in Section 2.4.A.2 of this Contract; Written protocols for generating or receiving referrals and for recording and tracking the results of referrals; Written protocols for providing or arranging for second opinions, whether in or out of the Provider Network; Written protocols for sharing clinical and IPC information, including management of medications; Written protocols for determining conditions and circumstances under which specialty services will be provided appropriately and without undue delay to Enrollees who do not have established Complex Care Needs; Written protocols for obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers in the Provider Network, and with CMS and EOHHS for quality management and program evaluation purposes; Coordinating the services the Contractor furnishes to the Enrollee between settings of care, including appropriate discharge planning for short- and long-term hospital and institutional stay; and Coordinating services provided by the Contractor with the services: The Enrollee receives from any other managed care entity; The Enrollee receives in fee-for-service Medicaid; and The Enrollee receives from community and social support providers. The Contractor shall ensure that each Enrollee receives the contact information for the person or entity primarily responsible for coordinating the Enrollee’s care and services, whether that is the PCP or his or her designee on the PCT. Coordinating Access for Emergency Conditions and Urgent Care Services The Contractor must ensure linkages among the PCP, the PCT, and any appropriate acute, long term care, or behavioral health Providers to keep all parties informed about utilization of services for Emergency Conditions and Urgent Care. The Contractor may not require advance approval for the following services: Any services for Emergency Conditions; Emergency behavioral health care; Urgent Care sought out of the Service Area; Urgent Care under unusual and extraordinary circumstances provided in the Service Area when the contracted medical Provider is unavailable or inaccessible; Direct-access women’s services; and Out-of-area renal dialysis services. Centralized Enrollee Record (CER) To coordinate care, the Contractor must maintain a single, centralized, comprehensive record that documents the Enrollee's health medical, functional, and social status. The Contractor must make appropriate and timely entries describing the care provided, or because diagnoses determined, medications prescribed, and treatment plans developed. The organization and documentation included in the CER must meet all applicable professional requirements. The CER must contain the following: Enrollee identifying information; Documentation of each service provided, including the date of service, the name of both the authorizing Provider and the servicing Provider (if different), and how they may be contacted; Multidisciplinary assessments, using the assessment tool designated by EOHHS, including diagnoses, prognoses, reassessments, plans of care, and treatment and progress notes, signed and dated by the appropriate Provider; Laboratory and radiology reports; Reconciled medication list; Prescribed medications, including dosages and any known drug contraindications; Reports about the involvement of community agencies that are not part of the Provider Network, including any services provided; Documentation of contacts with family members and persons giving informal support, if any; Physician orders; Disenrollment agreement, if applicable; Enrollee's utilization ’s individual advance directives and health care proxy, recorded and maintained in a prominent place; Plan for Emergency Conditions and Urgent Care, including identifying information about any emergency contact persons; and Allergies and special dietary needs Documentation of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. Discretionary Involuntary DisenrollmentInitial and Ongoing Assessments; including verification that an Enrollee has received services for which Providers have billed the Contractor and in accordance with Section 2.4.A.11.b.iv.

Disenrollment. The Contractor shall: Have ICO shall have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plandisenrollments, including the effective date of disenrollment, from CMS and MassHealth systemsMDHHS or its authorized agent. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendorCMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. 423.100, Enrollees can elect to disenroll from the One Care Plan ICO or the Demonstration at any time and enroll in another One Care PlanICO, a Medicare Advantage MA-PD plan, PACE, or Senior Care Options PACE (if they meet applicable eligibility requirementseligible and the program has capacity); or may elect to receive services through Medicare fee‑for‑service FFS and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan FFS and any waiver programsprograms (if eligible). Disenrollments CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by MassHealth or the ContractorCMS, or by CMS MDHHS or its contractor authorized agent, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month; Be . The ICO shall be responsible for ceasing the provision of Covered Services to an Enrollee upon the effective date of disenrollment; Notify EOHHS . The ICO shall notify MDHHS of any individual who is no longer eligible to remain enrolled in the One Care ICO per Medicare-Medicaid Plan per CMS enrollment guidanceEnrollment and Disenrollment Guidance, in order for EOHHS MDHHS to disenroll the individualEnrollee. This includes where an Enrollee remains out of the Service Area or for whom residence in the One Care Plan ICO’s Service Area cannot be confirmed for more than six (6) consecutive months; Not . Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area or for whom residence in the ICO Service Area cannot be confirmed for more than six (6) consecutive months. When an Enrollee no longer resides in the Service Area (except for an Enrollee living in the Service Area who is admitted to a Nursing Facility outside the Service Area for up to six months and placement is not based on the family or social situation of the Enrollee). If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date. When requesting disenrollment, the ICO must submit verifiable information that an Enrollee has moved out of the Service Area. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of the ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date. MDHHS will automatically disenroll the Enrollee for the next available month. Until the Enrollee is disenrolled from the ICO, the ICO will receive a Capitation Payment for the Enrollee. The ICO is responsible for all Medically Necessary Services for the Enrollee until they are disenrolled. The ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of an Enrollee who resides out of the Service Area of the ICO before the effective date of Enrollment will be considered an "enrollment error". The ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the date of Enrollment. When CMS or MDHHS is made aware that an Enrollee is incarcerated in a county jail, Michigan Department of Corrections facility, or Federal penal institution. Termination of coverage shall take effect on the first of the month of the month following the State’s confirmation of a current incarceration if the start date is not known, or the first of the month following the start date of incarceration if the start date is known. The termination or expiration of this Contract terminates coverage for all Enrollees with the ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the last day of the month following the month the Disenrollment is processed. The ICO may not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because Discretionary Involuntary Disenrollments: 42 C.F.R. § 422.74 and Section 40.3 of the Enrollee’s utilization of treatment planMedicare-Medicaid Plan Enrollment and Disenrollment Guidance provide instructions to ICOs on discretionary Involuntary Disenrollment. This Contract and the Medicare-Medicaid Plan Enrollment and Disenrollment guidance provide procedural and substantive requirements the ICO, medical servicesMDHHS, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, and CMS must follow prior to the Contract Management Team (CMT) to disenroll involuntarily disenrolling an Enrollee. If all of the procedural requirements are met, MDHHS and CMS will decide whether to approve or deny each request for cause, Involuntary Disenrollment based on an assessment of whether the particular facts associated with each request satisfy the substantive evidentiary requirements. Bases for Discretionary Involuntary Disenrollment Disruptive conduct: When the following reason: The Enrollee’s continued enrollment Enrollee engages in conduct or behavior that seriously impairs the ContractorICO’s ability to furnish services Covered Items and Services to either this Enrollee or other Enrollees, Enrollees and provided the Enrollee’s behavior is determined ICO made and documented reasonable efforts to be unrelated to an adverse change in resolve the problems presented by 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 his or her special needs. Discretionary Involuntary Disenrollment.

Disenrollment. The Contractor shall: Have ICO shall have a mechanism for receiving timely information about all disenrollments from the Contractor’s One Care Plandisenrollments, including the effective date of disenrollment, from CMS and MassHealth systemsMDHHS or its authorized agent. All enrollments and disenrollment‑related disenrollment-related transactions will be performed by the EOHHS customer service vendorCMS, MDHHS or its authorized agent. Subject to 42 C.F.R. § 423.100, § 423.38 and § 438.56. 423.100, Enrollees can elect to disenroll from the One Care Plan ICO or the Demonstration at any time and enroll in another One Care PlanICO, a Medicare Advantage MA-PD plan, PACE, or Senior Care Options PACE (if they meet applicable eligibility requirementseligible and the program has capacity); or may elect to receive services through Medicare fee‑for‑service FFS and a prescription drug plan and to receive Medicaid services in accordance with the Commonwealth’s State plan FFS and any waiver programsprograms (if eligible). Disenrollments CMS and MDHHS may only permit disenrollment if the individual has a Valid Medicare Election Period. (see Appendix K) A disenrollment received by MassHealth or the ContractorCMS, or by CMS MDHHS or its contractor authorized agent, either orally or in writing, by the last calendar day of the month will be effective on the first calendar day of the following month; Be . The ICO shall be responsible for ceasing the provision of Covered Services to an Enrollee Enrollee upon the effective date of disenrollment; Notify EOHHS of any individual who . The ICO shall notify MDHHS if it has information that shows that an Enrollee is no longer eligible to remain enrolled in the One Care ICO per Medicare-Medicaid Plan per CMS enrollment guidanceEnrollment and Disenrollment Guidance, in order for EOHHS MDHHS to disenroll the individualEnrollee. This includes where an Enrollee Enrollee remains out of the Service Area or for whom residence in the One Care Plan ICO’s Service Area cannot be confirmed for more than six (6) consecutive months; Not . This includes where an Enrollee remains out of the Service Area, confirmed by the Enrollee or authorized representative. MDHHS will investigate and make an Enrollment decision as appropriate. Requests to disenroll from an ICO or enroll in a different ICO will be accepted at any point after an Enrollee’s initial Enrollment occurs and are effective on the first calendar day of the month following receipt of request, with the exception of Enrollment requests made after the Card Cut Off Date. Any time an Enrollee requests to Opt Out of Passive Enrollment or disenrolls from the Demonstration, MDHHS or the Enrollment Broker will send a letter confirming the disenrollment or Opt Out and providing information on the benefits available to the Enrollee once he or she has Opted Out or disenrolled. The ICO will notify the Enrollee in writing when the Enrollee no longer meets eligibility requirements for Enrollment in the ICO. Required Involuntary Disenrollments. MDHHS and CMS shall terminate an Enrollee’s coverage upon the occurrence of any of the conditions enumerated in Section 40.2 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance or upon the occurrence of any of the conditions described in this section. Except for the CMT’s role in reviewing documentation related to an Enrollee’s alleged material misrepresentation of information regarding third-party reimbursement coverage, as described in this section, the CMT shall not be responsible for processing disenrollments under this section. Further, nothing in this section alters the obligations of the parties for administering disenrollment transactions described elsewhere in this Contract. Upon the Enrollee’s death. Termination of coverage shall take effect at 11:59 p.m. on the last day of the month in which the Enrollee dies. Termination may be retroactive to this date. When an Enrollee remains out of the Service Area for more than 6 consecutive months confirmed by the Enrollee or authorized representative. It is allowable for an Enrollee residing in the Service Area to be admitted to a Nursing Facility outside the Service Area for a service that cannot be obtained in the service area (and placement is not based on the family or social situation of the Enrollee). This placement is allowable for up to six months, unless the local MDHHS updates the Enrollee address to outside of the Service Area sooner, in which case the Enrollee cannot stay enrolled in the ICO. If an Enrollee’s street address on the Enrollment file is outside of the ICO’s Service Area but the county code does not reflect the new address, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. When requesting disenrollment due to out of Service Area, the ICO must be able to provide upon request, verifiable information that an Enrollee has moved out of the Service Area, verified by the Enrollee or an authorized representative. MDHHS will expedite prospective disenrollments of Enrollees and process all such disenrollments effective the next available month after notification from MDHHS that the Enrollee has left the ICO’s Service Area. If the county code on the Enrollment file is outside of the ICO’s Service Area, the ICO is responsible for requesting disenrollment within fifteen (15) calendar days of being notified of the misalignment. MDHHS will automatically disenroll the Enrollee for the next available month. Until the Enrollee is disenrolled from the ICO, the ICO will receive a Capitation Payment for the Enrollee. The ICO is responsible for all Medically Necessary Services for the Enrollee until they are disenrolled. The ICO may use its UM protocols for hospital admissions and specialty referrals for Enrollees in this situation. The ICO may require the Enrollee to return to the Service Area to use network providers and provide transportation or the ICO may authorize out-of-network providers to provide Medically Necessary Services. Enrollment of an Enrollee who resides out of the Service Area of the ICO before the effective date of Enrollment will be considered an "enrollment error". The ICO is responsible for requesting disenrollment within fifteen (15) calendar days of the Enrollment effective date for such enrollment errors. MDHHS will retroactively disenroll the Enrollee associated with such enrollment errors effective on the date of Enrollment. When CMS or MDHHS is made aware that an Enrollee is incarcerated in a county jail, Michigan Department of Corrections facility, or Federal penal institution. Termination of coverage shall take effect on the first of the month of the month following the State’s confirmation of a current incarceration if the start date is not known, or the first of the month following the start date of incarceration if the start date is known. The termination or expiration of this Contract terminates coverage for all Enrollees with the ICO. Termination will take effect at 11:59 p.m. on the last day of the month in which this Contract terminates or expires, unless otherwise agreed to, in writing, by the Parties. When the CMT approves a request based on information sent from any party to the Demonstration showing that an Enrollee has materially misrepresented information regarding third-party reimbursement coverage according to Section 40.2.6 of the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. Unless otherwise outlined in Sections 2.3.7.4.2 and 2.3.7.4.5, termination of an Enrollee’s coverage shall take effect at 11:59 p.m. on the last day of the month following the month the Disenrollment is processed. The ICO may not interfere with the Enrollee’s right to disenroll through threat, intimidation, pressure, or otherwise; Not request the disenrollment of any Enrollee due to an adverse change in the Enrollee’s health status or because of the Enrollee’s utilization of treatment plan, medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. The Contractor, however, may submit a written request, accompanied by supporting documentation, to the Contract Management Team (CMT) to disenroll an Enrollee, for cause, for the following reason: 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 his or her special needs. Discretionary Involuntary DisenrollmentDisenrollments: