Constraint: No How accurate are the results of the process? 5 5 planned enhancements How satisfied are the stakeholders? 2 4 Business Process Assessment 2 4 Table 34: Enroll Member Business Process 2.2.4.3 Disenroll Member The Disenroll Member business process is responsible for the termination of a member’s enrollment in a health plan or health benefit. An enrollment termination may occur due to: A member is no longer eligible based on redetermination of Medicaid eligibility either on an annual basis or as a result of change reporting during the coverage year. Upon receipt of a notification of incarceration, SMA may suspend eligibility (if State policy indicates to do so). A member is no longer eligible based on change in residence. The denial of eligibility for a benefit that is based on a technical factor or non- financial characteristic. A member submits a disenrollment request. Disenrollment request from a provider or contractor due to issues with the member such as moving out of service area, fraud and abuse, disruptive behavior, non-compliance, or death. Member is deceased. Receive disenrollment request from Manage Compliance Incident Information business process for continued failure to make payments. Receive disenrollment request from Determine Adverse Action Incident due to fraudulent or abuse activity. The provider or contactor has a change of status or termination that requires a mass disenrollment of members. A health plan or health benefit has a change that requires a mass disenrollment of members. A member modifies their MCO, PCCM, or waiver provider: Member changes information during Open Enrollment period. As permitted by State rules, such as the following: Change in member’s residence. A provider whom the member has chosen no longer contracts with current program or MCO. Medicaid terminates the contract with the member’s MCO or PCCM. Member successfully appeals auto-assignment. The member has issues with the MCO, PCCM, or waiver provider that may affect quality of care.
How accurate are the results of the process? 5 5 Constraint: No planned enhancements How satisfied are the stakeholders? 2 4 Business Process Assessment 2 4 Table 34: Enroll Member Business Process 2.2.4.3 Disenroll Member The Disenroll Member business process is responsible for the termination of a member’s enrollment in a health plan or health benefit. An enrollment termination may occur due to: A member is no longer eligible based on redetermination of Medicaid eligibility either on an annual basis or as a result of change reporting during the coverage year. Upon receipt of a notification of incarceration, SMA may suspend eligibility (if State policy indicates to do so). A member is no longer eligible based on change in residence. The denial of eligibility for a benefit that is based on a technical factor or non- financial characteristic. A member submits a disenrollment request. Disenrollment request from a provider or contractor due to issues with the member such as moving out of service area, fraud and abuse, disruptive behavior, non-compliance, or death. Member is deceased. Receive disenrollment request from Manage Compliance Incident Information business process for continued failure to make payments. Receive disenrollment request from Determine Adverse Action Incident due to fraudulent or abuse activity. The provider or contactor has a change of status or termination that requires a mass disenrollment of members. A health plan or health benefit has a change that requires a mass disenrollment of members. A member modifies their MCO, PCCM, or waiver provider: Member changes information during Open Enrollment period. As permitted by State rules, such as the following: Change in member’s residence. A provider whom the member has chosen no longer contracts with current program or MCO. Medicaid terminates the contract with the member’s MCO or PCCM. Member successfully appeals auto-assignment. The member has issues with the MCO, PCCM, or waiver provider that may affect quality of care.