SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of Medicaid eligibility or loss of Medicaid MHN Program eligibility; • Death of a Member; • Member is placed out of home (i.e. Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric Residential Treatment Facility (PRTF); • Member’s intentional submission of fraudulent information; • Becomes an inmate (see Appendix A – Definition of Terms and Acronyms) of a Public Institution; • Member moves out of state or MHN service area or plan does not operate in the new service area; • Member becomes institutionalized in a Long Term Care Facility/Nursing Home for more than thirty (30) days; • Member elects Home and Community Based Waiver Programs, with the exception of the Medically Complex Children’s Program; • Loss of Contractor's Participation; • Member enrolls in another Medicaid managed care plan; or, Member’s behavior is disruptive, unruly, abusive, or uncooperative and impairs the MHN’s ability to furnish services to the member or other enrolled members. The Contractor shall immediately notify SCDHHS when it obtains knowledge of any Medicaid MHN Program member whose enrollment should be terminated. See the MHN Policy and Procedure Guide. In an effort to minimize the number of disenrollments due to loss of Medicaid eligibility, SCDHHS or its designee will provide the Contractor with a monthly listing of Medicaid MHN Program members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain Medicaid eligibility.
SCDHHS Initiated Member Disenrollment. The SCDHHS will notify the Contractor of the member's disenrollment due to the following reasons: • Loss of SCHIP eligibility; • Member’s death; • Member’s intentional submission of fraudulent information; • Member becomes an inmate (see Appendix A – Definition of Terms) of a public institution; • Member moves out of state; • Member becomes Medicare Eligible; • Member becomes institutionalized in a long term care facility/nursing home for more than sixty (60) days; or • Loss of the Contractor's Participation. The Contractor shall immediately notify SCDHHS when it obtains knowledge of any member whose enrollment should be terminated prior to SCDHHS' knowledge. See the Policy and Procedure Guide. In an effort to minimize the number of disenrollments due to loss of eligibility, SCDHHS will provide the Contractor with a monthly listing of members who were mailed an Eligibility Redetermination/Review Form during the month. The Contractor may use this information to assist its members in taking appropriate action to maintain eligibility.
