Disenrollments Sample Clauses

Disenrollments. The term “disenrollment” will be used to refer to beneficiaries who leave the MCO in which they are enrolled. Disenrolled beneficiaries will generally enroll in another MCO or the PAAS program. Disenrollment may be initiated by the enrollee, MCO, or BMS. The MCO must inform recipients of their right to terminate enrollment through the enrollee handbook. The MCO must have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when an enrollee is disenrolled from the MCO and enrolled in another MCO. Involuntary beneficiary disenrollment from the MCO may occur for the following reasons:

Disenrollments. If a disenrollment form is signed by the Enrollee (or Enrollee’s representative) and submitted to EOHHS on or before the last business day of the month, the disenrollment will be effective on the first calendar day of the following month. The final capitation payment made by EOHHS to the Contractor for this Enrollee will be for the month in which the disenrollment was submitted.

Disenrollments. The term “disenrollment” will be used to refer to beneficiaries who leave the MCO in which they are enrolled. Disenrolled beneficiaries will generally enroll in another MCO. Disenrollment may be initiated by the enrollee, MCO, or BMS. The MCO must inform recipients of their right to terminate enrollment through the enrollee handbook. The MCO must have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when an enrollee is disenrolled from the MCO and enrolled in another MCO. Involuntary beneficiary disenrollment from the MCO may occur for the following reasons: 1. Loss of eligibility for Medicaid or for participation in Medicaid managed care; 2. The beneficiary’s permanent residence changes to a location outside the MCO’s Medicaid service area. However, if the resident moves to a location serviced by other MCOs, the resident must reenroll into a new MCO as soon as administratively possible; 3. Continuous placement in a nursing facility, State institution or intermediate care facility for the mentally retarded for more than thirty (30) calendar days; 4. Error in enrollment. This may occur if the beneficiary was inaccurately classified as eligible for enrollment in an MCO, if the beneficiary does not meet the eligibility requirements for eligibility groups permitted to enroll in an MCO, or after a request for exemption is approved if the enrollment broker enrolled the beneficiary while their exemption request was being considered; or

Disenrollments. The final per member per month capitation payment made by CMS and EOHHS to the Contractor for each Enrollee will be for the month in which the disenrollment was submitted, the Enrollee loses eligibility, or the Enrollee dies (see Section 2.3.B). Enrollee Contribution to Care Amounts If, in the financial eligibility process conducted by EOHHS, an Enrollee residing in a nursing facility is determined to owe a monthly Enrollee-paid amount, such amounts are the Enrollee’s contribution to care. At the time of enrollment, and as adjusted thereafter, EOHHS will advise the Contractor of the amount of the Enrollee’s contribution to care. When an Enrollee contribution to care is established, MassHealth will subtract that amount from the monthly capitation payment for that Enrollee. The Contractor is responsible for collecting this amount from the Enrollee subject to the Enrollee rights provisions of the Contractor’s Evidence of Coverage (see Appendix C). Modifications to Capitation Rates CMS and EOHHS will jointly notify the Contractor in advance and in writing of any proposed changes to the Capitation Rates, and the Contractor shall accept such changes as payment in full as described in Section 4.7. Rates will be updated using a similar process for each calendar year. Subject to Section 4.3.C.2, changes to the Medicare and MassHealth baselines outside of the annual Medicare Advantage and Part D rate announcements will be made only if and when CMS and EOHHS jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes or discrepancies in Federal law and/or State policy compared to assumptions about Federal law and/or state law or policy used in the development of baseline estimates; and changes in coding intensity.

Disenrollments. Definition: Participants who disenrolled from the program for reasons other then death. 1. Total number of participants; 2. Number of voluntary disenrollments; 3. Number of involuntary disenrollments; and 4. Reason for each disenrollment: leaving the service area, failure to pay premium, disruptive or threatening behavior, no longer meets States level of care, program agreement with CMS terminates or not renewed, organization is unable to offer services due to loss of State license, keep personal physician, wishes to access out of network or other.

Disenrollments. The Administrative Services Contractor must handle all disenrollments. CONTRACTOR is not allowed to discuss, induce or accept disenrollment from a CHIP Member except to refer to the CHIP Administrative Services Contractor. If CONTRACTOR approaches or is approached by a person who states that he or she is enrolled in another CHIP health plan, CONTRACTOR must end the conversation.