Common use of Member Disenrollment from MCE Clause in Contracts

Member Disenrollment from MCE. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of a member’s health care needs, adverse change in a member’s health care status, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members). A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i)-(iii), members have the right to disenroll from the Contractor: ▪ For cause, at any time. ▪ Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. ▪ Without cause at least once every twelve (12) months. ▪ Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438. Per 42 CFR 438.796(b)-(d) and section 1932(e)(2)(B)(ii) of the Social Security Act. ▪ Without cause upon reenrollment if a temporary loss of enrollment has caused the enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2)(i)-(v), members may request disenrollment if the: ▪ Member moves out of the service area. ▪ Contractor does not cover the service the enrollee seeks, because of moral or religious objections. ▪ Member needs related services to be performed at the same time and not all related services are available within the provider network. The member’s provider must determine that receiving the services separate would subject the member to unnecessary risk. ▪ Contractor’s provider status changes from in-network to out-of-network causes the member to have to change their residential, institutional, or employment supports provider, and, as a result, the member would experience a disruption in their residence or employment. ▪ Member experiences poor quality of care, lack of access to services covered under the Contract, or lack of access to providers experienced in dealing with the member’s care needs. See additional standards and procedures allowing for change of Contractor in the Member Handbook section. The Contractor shall notify FSSA in the manner outlined in the Hoosier Healthwise MCE Policies and Procedures Manual, 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. Additional information about the member disenrollment process is provided in Exhibit 4 and the Hoosier Healthwise MCE Policies and Procedures Manual. Members must file a grievance with their MCE before a determination will be made upon their just cause request for disenrollment and the Contractor must ensure it reviews the grievance in time to permit the disenrollment to be effective no later than the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker per 42 CFR 438.56(d)(5)(ii), 42 CFR 438.56(e)(1) and 42 CFR 438.228(a). Per 42 CFR 438.56(e)(2), if a disenrollment determination is not made within the specified timeframes (i.e., the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker), the disenrollment is considered approved for the effective date that would have been established had the determination been made in the specified timeframe.

Member Disenrollment from MCE. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of a member’s health care needs, adverse change in a member’s health care status, diminished mental capacity, or because of uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members)) . A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i)-(iii), members have the right to disenroll from the Contractor: ▪ For cause, at any time. ▪ Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. ▪ Without cause at least once every twelve (12) months. ▪ Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438. Per 42 CFR 438.796(b)-(d) 438 and section 1932(e)(2)(B)(ii) of the Social Security Act. ▪ Without cause upon reenrollment if a temporary loss of enrollment has caused the enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2)(i)-(v), members may request disenrollment if the: ▪ Member moves out of the service area. ▪ Contractor does not cover the service the enrollee seeks, because of moral or religious objections. ▪ Member needs related services to be performed at the same time and not all EXHIBIT 1.A SCOPE OF WORK related services are available within the provider network. The member’s provider must determine that receiving the services separate would subject the member to unnecessary risk. , ▪ Contractor’s provider status changes from in-network to out-of-network causes the member to have to change their residential, institutional, or employment supports provider, and, as a result, the member would experience a disruption in their residence or employment. ▪ Member experiences poor quality of care, lack of access to services covered under the Contract, or lack of access to providers experienced in dealing with the member’s care needs. See additional standards and procedures allowing for change of Contractor in the Member Handbook section. The Contractor shall notify FSSA in the manner outlined in the Hoosier Healthwise HIP MCE Policies and Procedures Manual, 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. Additional information about the member disenrollment process is provided in Exhibit 4 and the Hoosier Healthwise HIP MCE Policies and Procedures Manual. Members must file a grievance with their MCE before a determination will be made upon their just cause request for disenrollment and the Contractor must ensure it reviews the grievance in time to permit the disenrollment to be effective no later than the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker per 42 CFR 438.56(d)(5)(ii), 42 CFR 438.56(e)(1) and 42 CFR 438.228(a). Per 42 CFR 438.56(e)(2), if a disenrollment determination is not made within the specified timeframes (i.e., the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker), the disenrollment is considered approved for the effective date that would have been established had the determination been made in the specified timeframe.

Member Disenrollment from MCE. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of a member’s health care needs, adverse change in a member’s health care status, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members). A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i)-(iii438.56(c)(2)(i)- (iii), members have the right to disenroll from the Contractor: ▪ For cause, at any time. ▪ Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. ▪ Without cause at least once every twelve (12) months. ▪ Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438. Per 42 CFR 438.796(b)-(d) and section 1932(e)(2)(B)(ii) of the Social Security Act. ▪ Without cause upon reenrollment if a temporary loss of enrollment has caused the enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2)(i)-(v), members may request disenrollment if the: ▪ Member moves out of the service area. ▪ Contractor does not cover the service the enrollee seeks, because of moral or religious objections. ▪ Member needs related services to be performed at the same time and not all related services are available within the provider network. The member’s provider must determine that receiving the services separate would subject the member to unnecessary risk. ▪ Contractor’s provider status changes from in-network to out-of-network causes the member to have to change their residential, institutional, or employment supports provider, and, as a result, the member would experience a disruption in their residence or employment. ▪ Member experiences poor quality of care, lack of access to services covered under the Contract, or lack of access to providers experienced in dealing with the member’s care needs. See additional standards and procedures allowing for change of Contractor in the Member Handbook section. The Contractor shall notify FSSA in the manner outlined in the Hoosier Healthwise MCE Policies and Procedures Manual, 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. Additional information about the member disenrollment process is provided in Exhibit 4 and the Hoosier Healthwise MCE Policies and Procedures Manual. Members must file a grievance with their MCE before a determination will be made upon their just cause request for disenrollment and the Contractor must ensure it reviews the grievance in time to permit the disenrollment to be effective no later than the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker per 42 CFR 438.56(d)(5)(ii), 42 CFR 438.56(e)(1) and 42 CFR 438.228(a). Per 42 CFR 438.56(e)(2), if a disenrollment determination is not made within the specified timeframes (i.e., the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker), the disenrollment is considered approved for the effective date that would have been established had the determination been made in the specified timeframe.supports

Member Disenrollment from MCE. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of a member’s health care needs, adverse change in a member’s health care status, diminished mental capacity, or because of uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members)) . A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i)-(iii), members have the right to disenroll from the Contractor: ▪ For cause, at any time. ▪ Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. ▪ Without cause at least once every twelve (12) months. ▪ Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438. Per 42 CFR 438.796(b)-(d) 438 and section 1932(e)(2)(B)(ii) of the Social Security Act. ▪ Without cause upon reenrollment if a temporary loss of enrollment has caused the enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2)(i)-(v), members may request disenrollment if the: ▪ Member moves out of the service area. ▪ Contractor does not cover the service the enrollee seeks, because of moral or religious objections. ▪ Member needs related services to be performed at the same time and not all EXHIBIT 1.A SCOPE OF EXHIBIT related services are available within the provider network. The member’s provider must determine that receiving the services separate would subject the member to unnecessary risk. , ▪ Contractor’s provider status changes from in-network to out-of-network causes the member to have to change their residential, institutional, or employment supports provider, and, as a result, the member would experience a disruption in their residence or employment. ▪ Member experiences poor quality of care, lack of access to services covered under the Contract, or lack of access to providers experienced in dealing with the member’s care needs. See additional standards and procedures allowing for change of Contractor in the Member Handbook section. The Contractor shall notify FSSA in the manner outlined in the Hoosier Healthwise HIP MCE Policies and Procedures Manual, 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. Additional information about the member disenrollment process is provided in Exhibit 4 and the Hoosier Healthwise HIP MCE Policies and Procedures Manual. Members must file a grievance with their MCE before a determination will be made upon their just cause request for disenrollment and the Contractor must ensure it reviews the grievance in time to permit the disenrollment to be effective no later than the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker per 42 CFR 438.56(d)(5)(ii), 42 CFR 438.56(e)(1) and 42 CFR 438.228(a). Per 42 CFR 438.56(e)(2), if a disenrollment determination is not made within the specified timeframes (i.e., the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker), the disenrollment is considered approved for the effective date that would have been established had the determination been made in the specified timeframe.

Member Disenrollment from MCE. In accordance with 42 CFR 438.56(b)(2), the Contractor may neither terminate enrollment nor encourage a member to disenroll because of a member’s health care needs, adverse change in a member’s health care status, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment seriously impairs the Contractor’s ability to furnish services to the member or other members). A member’s health care utilization patterns may not serve as the basis for disenrollment from the Contractor. In accordance with 42 CFR 438.3(q)(5); 42 CFR 438.56(c)(1); and 42 CFR 438.56(c)(2)(i)-(iii438.56(c)(2)(i)- (iii), members have the right to disenroll from the Contractor: ▪ For cause, at any time. ▪ Without cause within ninety (90) days after initial enrollment or during the ninety (90) days following notification of enrollment, whichever is later. ▪ Without cause at least once every twelve (12) months. ▪ Without cause when a Contractor repeatedly fails to meet substantive requirements in sections 1903(m) or 1932 of the Social Security Act or 42 CFR 438. Per 42 CFR 438.796(b)-(d) and section 1932(e)(2)(B)(ii) of the Social Security Act. ▪ Without cause upon reenrollment if a temporary loss of enrollment has caused the t he enrollee to miss the annual disenrollment period. In accordance with 42 CFR 438.56(d)(2)(i)-(v), members may request disenrollment if the: ▪ Member moves out of the service area. ▪ Contractor does not cover the service the enrollee seeks, because of moral or religious objections. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE ▪ Member needs related services to be performed at the same time and not all related services are available within the provider network. The member’s provider must determine that receiving the services separate would subject the member to unnecessary risk. ▪ Contractor’s provider status changes from in-network to out-of-network causes the member to have to change their residential, institutional, or employment supports provider, and, as a result, the member would experience a disruption in their residence or employment. ▪ Member experiences poor quality of care, lack of access to services covered under the Contract, or lack of access to providers experienced in dealing with the member’s care needs. See additional standards and procedures allowing for change of Contractor in the Member Handbook section. The Contractor shall notify FSSA in the manner outlined in the Hoosier Healthwise MCE Policies and Procedures Manual, 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. Additional information about the member disenrollment process is provided in Exhibit 4 and the Hoosier Healthwise MCE Policies and Procedures Manual. Members must file a grievance with their MCE before a determination will be made upon their just cause request for disenrollment and the Contractor must ensure it reviews the grievance in time to permit the disenrollment to be effective no later than the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker per 42 CFR 438.56(d)(5)(ii), 42 CFR 438.56(e)(1) and 42 CFR 438.228(a). Per 42 CFR 438.56(e)(2), if a disenrollment determination is not made within the specified timeframes (i.e., the first day of the second month following the month in which the enrollee requests disenrollment or the Contractor refers the request to the broker), the disenrollment is considered approved for the effective date that would have been established had the determination been made in the specified timeframe.