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IX. Disenrollment


The EEU will assume primary responsibilities for administering the disenrollment process. Responsibilities will include: final approval of a change in service status; final authorization of disenrollment from the DSAMH LTC system; and the processing of disenrollment information to the Division of Social Services/Medicaid Office for Medicaid beneficiaries.

A program participant may be disenrolled from the DSAMH LTC system under the following circumstances:

  • Improvement in behavioral health status, as indicated by a combination of the following:
    • a change in diagnosis and/or functioning no longer indicating a need for long term intensive service provision; evidence that the enrollee has not needed/utilized higher levels of care
    • stable medication history;
    • stable psychosocial factors as demonstrated by an assessment of functioning and quality of life scales; or
  • Placement in a correctional facility (detainee or un-sentenced vs. sentenced); or
  • Inpatient treatment in a nursing facility beyond a continuous sixty day period prior to the request for disenrollment; or
  • Relocation to another state; or
  • Death of participant.

In order to effect a disenrollment, the EEU will request that the primary service provider submit a DSAMH LTC Client Discharge Summary. The DSAMH LTC Discharge Summary will include: a summary of the enrollee's treatment plans; medications; and other pertinent information required to promote the most successful transfer for the client. The Discharge Summary will provide recommendations on treatment and support required to continue the consumer's recover, including the methods to be used for ongoing self-care and relapse prevention. As part of this process, the EEU will confirm the consumer's Medicaid eligibility before referring a consumer back to the DSHP MCO or a treatment provider for the basic benefit and will change the SPI flag in the MMIS for Medicaid beneficiaries.

When management of the consumer's behavioral health care is to be returned to a Medicaid DSHP MCO, the EEU will ensure that the Primary Service Provider coordinates with the consumer's/client's MCO to effect a clinically appropriate transition of care.



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