Member Disenrollment Sample Clauses

Member Disenrollment. The PH-MCO may not request Disenrollment of a Member because of an adverse change in the Member’s health status, or because of the Member’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her Special Needs. The PH-MCO may not reassign or remove Members involuntarily from Network Providers who are willing and able to serve the Member.
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Member Disenrollment. Disenrollments may be initiated by: (1) the Member, (2) the Department, or (3) the CONTRACTOR. A Member may be Disenrolled from the CONTRACTOR’s Health Plan only when authorized by the Department. The Department or its designee is responsible for any Disenrollment action to remove a Member from the CONTRACTOR’s Health Plan.
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Member Disenrollment. In accordance with 42 CFR 438.3(d)(3), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of his or her health care needs or a change in health care status. A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. The Contractor must notify the DFR, in the manner prescribed by the State, within thirty (30) calendar days of the date it becomes aware of the death of one of its members, giving the member's full name, address, Social Security Number, member identification number and date of death. The Contractor will have no authority to pursue recovery against the estate of a deceased Medicaid member.
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Member Disenrollment. In accordance with 42 CFR 438.3(d)(3), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of his or her health care needs or a change in health care status. A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. The Contractor must notify the DFR, in the manner prescribed by the State, within thirty (30)
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Member Disenrollment. The PH-MCO may not reassign or remove Members involuntarily from Network Providers who are willing and able to serve the Member.
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Member Disenrollment. Disenrollments may be initiated by: (1) the Member, (2) the Department, or (3) the CONTRACTOR. A Member may be Disenrolled from the CONTRACTOR’s Health Plan only when authorized by the Department. The Department or its designee is responsible for any Disenrollment action to remove a Member from the CONTRACTOR’s Health Plan. Member Disenrollment Requests A Member may request Disenrollment from the CONTRACTOR’s Health Plan (1) for cause at any time, or (2) without cause for the reasons listed in Section 3 of this contract. All Member requests for Disenrollment must be referred to the Department or its designee. Effective date of an approved Disenrollment request must be no later than the first day of the second month following the month in which the Medicaid MCO Member filed the request. A Member’s request to Disenroll must be acted on by the Department no later than the first day of the second month following the month in which the Member filed the request. If not, the request shall be considered approved. Disenrollment Requests For Cause A Member may request Disenrollment from the CONTRACTOR’s health plan for cause at any time. The following are considered acceptable for-cause Disenrollments: Change in Member Residence The Member moves out of the CONTRACTOR’s Service Area, Contract Termination The CONTRACTOR or the Department has terminated the contract, The member is in need of related services (for example, a Cesarean Section and a tubal ligation) to be performed at the same time; not all related services are available within the Provider network; and the Enrollee's primary care Provider or another Provider determines that receiving the services separately would subject the Enrollee to unnecessary risk. For members that use Managed Long Term Care Support Services (MLTSS), the Enrollee would have to change their residential, institutional, or employment supports Provider based on that Provider's change in status from an in-network to an out-of-network Provider with the CONTRACTOR. Members may Disenroll without cause if the Plan does not, because of moral or religious objections, cover the service the Enrollee seeks. Other Acceptable Reasons Other reasons, as approved by the Department on a case by case basis, including, but not limited to: (a) poor quality of care; (b) lack of access to Core Benefits; or (c) lack of access to Providers experienced in dealing with the Member’s health care needs. For cause Disenrollment requests must be initiated with the E...
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Member Disenrollment. Upon Group’s notification to Coventry, Coverage for a Member will terminate on the last day of the month of an Employee termination or loss of eligibility.
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Member Disenrollment. A. CONTRACTOR Requests for Disenrollment Member disenrollment shall only be considered in rare circumstances. The CONTRACTOR may request that a particular member be disenrolled. Disenrollment requests shall be submitted in writing to HSD. The request and supporting documentation shall meet requirements specified by HSD. If the disenrollment request is granted the CONTRACTOR retains responsibility for the member's care until such time as the member is enrolled with a new CONTRACTOR. If a request for disenrollment is approved the member shall not be re-enrolled with the CONTRACTOR for a period of time to be determined by HSD. Conditions that may permit lock-out or disenrollment are:
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Member Disenrollment 
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Related to Member Disenrollment

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

  • Open Enrollment There shall be an open enrollment period each enrollment year during which eligible employees may change plans. The District shall establish and announce the dates of such open enrollment period, and shall mail open enrollment materials to employees fourteen or more days before the beginning of the open enrollment period. If an eligible employee requests a change of plan, he or she shall continue to be covered under his or her existing plan until coverage under the new plan can be instituted.

  • 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.

  • Open Enrollment Period Open Enrollment is a period of time each year when you and your eligible dependents, if family coverage is offered, may enroll for healthcare coverage or make changes to your existing healthcare coverage. The effective date will be on the first day of your employer’s plan year. Special Enrollment Period A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health coverage. You and your eligible dependents may enroll for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days of the following events: • you get married, the coverage effective is the first day of the month following your marriage. • you have a child born to the family, the coverage effective date is the date of birth. • you have a child placed for adoption with your family, the coverage effective date is the date of placement. Special note about enrolling your newborn child: You must notify your employer of the birth of a newborn child and pay the required premium within thirty -one (31) days of the date of birth. Otherwise, the newborn will not be covered beyond the thirty -one (31) day period. This plan does not cover services for a newborn child who remains hospitalized after thirty-one (31) days and has not been enrolled in this plan. If you are enrolled in an Individual Plan when your child is born, the coverage for thirty- one (31) days described above means your plan becomes a Family Plan for as long as your child is covered. Applicable Family Plan deductibles and maximum out-of-pocket expenses may apply. In addition, if you lose coverage from another plan, you may enroll or add your eligible dependents for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days following the date you lost coverage. Coverage will begin on the first day of the month following the date your coverage under the other plan ended. In order to be eligible, the loss of coverage must be the result of: • legal separation or divorce; • death of the covered policy holder; • termination of employment or reduction in the number of hours of employment; • the covered policy holder becomes entitled to Medicare; • loss of dependent child status under the plan; • employer contributions to such coverage are being terminated; • COBRA benefits are exhausted; or • your employer is undergoing Chapter 11 proceedings. You are also eligible for a Special Enrollment Period if you and/or your eligible dependent lose eligibility for Medicaid or a Children’s Health Insurance Program (CHIP), or if you and/or your eligible dependent become eligible for premium assistance for Medicaid or a (CHIP). In order to enroll, you must provide required information within sixty (60) days following the change in eligibility. Coverage will begin on the first day of the month following our receipt of your application. In addition, you may be eligible for a Special Enrollment Period if you provide required information within thirty (30) days of one of the following events: • you or your dependent lose minimum essential coverage (unless that loss of coverage is due to non-payment of premium or your voluntary termination of coverage); • you adequately demonstrate to us that another health plan substantially violated a material provision of its contract with you; • you make a permanent move to Rhode Island: or • your enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, or inaction by us or an agent of HSRI or the U.S. Department of Health and Human Services (HHS).

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