Enrollment Activities Clause Samples
The Enrollment Activities clause defines the actions and processes required for an individual or entity to officially join or participate in a program, service, or plan. This typically includes submitting necessary documentation, completing application forms, and meeting eligibility criteria within specified timeframes. By outlining these steps, the clause ensures that all parties understand the requirements for enrollment, thereby reducing confusion and establishing a clear process for participation.
Enrollment Activities. 2.3.1. Enrollment
2.3.1.1. EOHHS will begin self-selection (opt-in) enrollment prior to the initiation of Passive Enrollment. During this period, Medicare- Medicaid Beneficiaries eligible for the Demonstration may choose to enroll into a particular One Care plan. The first Effective Enrollment Date for this initial opt-in period is scheduled for no earlier than January 1, 2022. Eligible Medicare-Medicaid Beneficiaries who do not select a One Care plan or who do not opt out of the Demonstration will be assigned to a One Care plan during Passive Enrollment.
2.3.1.2. EOHHS may conduct Passive Enrollment during the term of the Contract to assign eligible Medicare-Medicaid Beneficiaries who do not select a One Care plan and who do not opt out of the Demonstration. Individuals who opt out of the Demonstration will not be included in Passive Enrollment for the remainder of the Demonstration. Individuals currently enrolled in PACE may not be passively enrolled into a One Care plan. EOHHS will provide notice of Passive Enrollments at least sixty (60) days prior to the effective dates to Eligible Beneficiaries, and will accept opt-out requests prior to the effective date of enrollment. EOHHS will apply intelligent methodologies, to the extent approved by CMS, to assign Eligible Beneficiaries to a One Care plan. Such methodologies may include, but not be limited to, past provider relationships. CMS and EOHHS may stop Passive Enrollment to the Contractor if the Contractor does not meet reporting requirements necessary to maintain Passive Enrollment as set forth by CMS and EOHHS.
2.3.1.3. Enrollments and disenrollments will be processed through the EOHHS customer service vendor, consistent with the Effective Enrollment Date requirements outlined in the Medicare-Medicaid Plan Enrollment and Disenrollment Guidance. EOHHS or its vendor will then submit Passive Enrollment transactions at least sixty (60) days in advance of the effective date, to the CMS Medicare Advantage Prescription Drug (▇▇▇▇) enrollment system directly or via a third-party CMS designates to receive such transactions, and MassHealth or its vendor will receive notification on the next Daily Transaction Reply Report. The Contractor will then receive enrollment transactions through the EOHHS customer service vendor. The Contractor will also use the third-party CMS designates to submit additional enrollment-related information to ▇▇▇▇, and receive files from CMS.
2.3.1.4. Enrollments received by the last ca...
Enrollment Activities. Enrollment in the Senior Care Options Program is voluntary. For a MassHealth Member to be eligible to enroll in the Senior Care Options Program, the Member must be MassHealth Standard eligible and meet all other eligibility requirements as set forth in 130 CMR 508.008(A). Medicare eligibility is not a prerequisite for enrollment in the Senior Care Options Program. MassHealth Members with or without Medicare may enroll in the Senior Care Options Program, provided they meet all eligibility requirements as set forth in 130 CMR 508.008(A). Note: An individual enrolled in Medicare but not eligible for MassHealth Standard (i.e. not a Dual Eligible Senior) is not eligible to enroll in the Senior Care Options Program. In accordance with Section 2.1, prior to commencing the initial enrollment of MassHealth Members, the Contractor must demonstrate to EOHHS that it has been designated by CMS as a Medicare Advantage Special Needs Plan for persons dually eligible for Medicare and Medicaid and has Medicare Part D authority in the counties in which services are to be rendered under this Contract.
A. Opt-In Enrollment The Contractor may submit Opt-In Enrollments to EOHHS on behalf of MassHealth Members eligible for, and seeking to enroll in, the Senior Care Options Program. Prior to submitting such an enrollment to EOHHS, the Contractor shall verify through EOHHS’s electronic on-line Eligibility Verification System (EVS) that the MassHealth Member is MassHealth Standard eligible. The Contractor must utilize enrollment forms that are approved by EOHHS and CMS, and must maintain on file any such forms that have been signed by Enrollees.
B. Passive Enrollment
1. EOHHS may conduct Passive Enrollment during the term of the Contract. Individuals who Opt Out will not be included in future Passive Enrollments.
2. The schedule for Passive Enrollment will be determined by EOHHS. EOHHS reserves the right to make changes to the Passive Enrollment schedule at its discretion and at any time.
3. EOHHS will provide notice to each Passive Enrollee at least 60 days prior to the effective date of his or her enrollment with the Contractor.
4. EOHHS will accept Opt Out requests from Passive Enrollees prior to the effective date of enrollment.
5. EOHHS may stop Passive Enrollment in the Contractor’s plan at its discretion, and for any reason, including if the Contractor does not comply with this Contract.
6. EOHHS will monitor Passive Enrollment assignments to all SCO plans, and may make adjus...
Enrollment Activities. Enrollment in the Senior Care Options Program is voluntary. For a MassHealth Member to be eligible to enroll in the Senior Care Options Program, the Member must be on MassHealth Standard and meet all other eligibility requirements as listed under 130 CMR 508.008 (A). Medicare eligibility is not an eligibility requirement for enrollment in the Senior Care Options program and MassHealth Members with or without Medicare may enroll in the program, provided they meet all eligibility requirements as listed under 130 CMR 508.008(A). Note: An individual enrolled in Medicare but not eligible for MassHealth Standard (i.e. not a Dual Eligible Senior) is not eligible for enrollment into the Senior Care Options program. In accordance with Section 2.1, prior to commencing the initial enrollment of MassHealth Members, the Contractor must demonstrate to EOHHS that it has been designated by CMS as a Medicare Advantage Special Needs Plan for persons dual eligible for Medicare and Medicaid and with Medicare Part D authority.
Enrollment Activities. The EBS shall complete the following enrollment activities for mandatory clients (and also for potential mandatory clients, if requested), in coordination with the plan and the Department:
(a) Educate clients concerning the full range of Medicaid benefits, including all NHC options and covered services, including -
(1) A general explanation of NHC;
(2) Mandatory and excluded groups of clients;
(3) The purpose/benefits of managed care, including the “ medical home” concept and the difference between fee-for-service and managed care;
(4) The role of the PCP;
(5) An explanation of how the client shall choose a PCP/plan;
(6) An explanation of auto-assignment;
(7) An explanation that the PCP/plan shall either provide or approve services included in the Basic Benefits Package;
(8) An explanation of the HEALTH CHECK (EPSDT) program, if age appropriate, including information on how to access screening services (health, dental, vision, and hearing);
(9) An explanation of services not covered under NHC and how the client may access these services;
(10) An explanation of those services which do not require any PCP/plan approval or prior authorization (e.g., family planning and emergency services);
(11) An explanation of the 24-hour Helpline and the availability of the TTY/TDD and interpreter services;
(12) An explanation of transfers and disenrollment;
(13) An explanation of client/provider rights and responsibilities;
(14) An explanation of the complaint/grievance/appeal/process; and
(15) An explanation of how to be an effective health care consumer;
(b) Provide the client with brochures, written materials, etc., explaining the NHC that are easily understood by the client, and developed in ways appropriate to meet the needs of the client;
(c) Provide an assessment of health and social needs;
Enrollment Activities. Enrollment in the Senior Care Options Program is voluntary. In accordance with Section 2.1, prior to commencing the initial enrollment of members, the Contractor must demonstrate to EOHHS that it has been designated by CMS as a Medicare Advantage Special Needs for persons dual eligible for Medicare and Medicaid and with Medicare Part D authority.
Enrollment Activities