MES Certification Navigator
EE

Disenroll Member

Member Enrollment

Description

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 or 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 Manage Care Organization (MCO), Primary Care Case Manager (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. NOTE: Enrollment brokers may perform some of the steps in this business process.

Business Process Template

Trigger events
Environment-based
  • Receive disenrollment request from member, provider or contractor.
  • Change in member’s information that no longer meets eligibility criteria.
  • Member modifies their selection of provider, MCO, PCCM or waiver provider.
  • Provider or contractor modifies network information that alters their service offering.
  • Modifications in health plan or health benefit that alters service offering.
Interaction-based
  • Receive disenrollment request from insurance affordability program.
  • Receive disenrollment request from Manage Compliance Incident Information business process for continued failure to make payments.
  • Receive disenrollment request from Determine Adverse Action Incident business process to remove member from services.
Results
  • Member disenrolled from specific health plans and health benefits.
  • Member disenrolled from elected provider or contractor.
  • Alert sent to Manage Applicant and Member Communication business process to notify member of disenrollment and fair hearing/procedural rights.
  • Alert sent to Perform Population and Member Outreach business process to notify affected members with the termination of health plan, health benefit, a provider or a contractor.
  • Alert sent to send disenrollment information to insurance affordability program.
  • If applicable, alert sent to Manage Member Financial Participation to stop premium payment arrangement.
  • If applicable, alert sent to Manage Case Information to discontinue care management.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive disenrollment request.
  • 2. Agency logs disenrollment request including source of disenrollment and type of request.
  • 3. Validate request meets State disenrollment rules.
  • 4. If applicable, terminate enrollment in Medicaid health plans and/or health benefits.
  • 5. If applicable, go to Enroll Member to enroll member in alternative health plans and/or health benefits.
  • 6. If applicable, terminate enrollment with provider or contractor.
  • 7. If applicable, enroll member with alternative provider or contractor.
  • 8. Send alert to Manage Applicant and Member Communication business process to notify member of disenrollment and procedural rights.
  • 9. Send alert to Perform Population and Member Outreach business process to notify affected members with the termination of health plan, health benefit, a provider or a contractor.
  • 10. If applicable, send alert to Manage Member Financial Participation to stop premium payment arrangement.
  • 11. If applicable, send alert to Manage Case Information to discontinue care management.
  • 12. Send alert to send disenrollment information to insurance affordability program.
  • 13. END
Predecessor processes
Successor processes
Shared data
  • Member data store including demographics and eligibility information
  • Plan data store including health policy information
  • Health Benefit data store including benefit package and benefit information
  • Provider data store including provider network information
  • Contractor data store including provider network information
Constraints

Programs have different termination criteria.

Failures
  • Duplicate disenrollment requests - Disregard second request.
  • Required fields missing or not correct - Request additional or corrected information from member, provider, contractor, Health Insurance Marketplace, or insurance affordability program.
  • Denial of member request for disenrollment from one health plan, health benefit, provider or contractor due to modifications in circumstances, such as residence, health status, or provider access issues because the request does not meet State rules or the member is not eligible for enrollment in an alternative program.
  • Denial of program, provider, or contractor request to disenroll the member (e.g., modified residence, health status or compliance issues because the request does not meet State rules).
Performance measures
  • Time to complete process: member is disenrolled within __ days or __ minutes
  • Accuracy of decisions
  • Consistency of decisions and disposition = ___%
  • Error rate is __% or less
  • Inquire Member Eligibility

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 18-22.

Business Capability Model (10 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automated?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automated processes to accomplish tasks.
  3. LEVEL 3SMA automates process through use of shared enrollment service to maximum extent possible with CHIP and the Marketplace.
  4. LEVEL 4SMA automates process through use of shared enrollment service integrated with CHIP and Marketplace disenrollment process.
  5. LEVEL 5SMA automates process through use of shared enrollment service and is fully integrated with CHIP and Marketplace disenrollment process.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
  3. LEVEL 3SMA adopts MITA Framework, industry standards (e.g., HIPAA, Affordable Care Act) and other nationally recognized standards for intrastate exchange of member disenrollment information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards (e.g., HIPAA, Affordable Care Act) and other nationally recognized standards for interstate exchange of member disenrollment information and actively participates in the ongoing development of related standards.
  5. LEVEL 5SMA adopts MITA Framework, industry standards e.g., HIPAA, Affordable Care Act), and other nationally recognized standards for national exchange of disenrollment information, actively participates in the ongoing development of standards, and works with other States and federal agencies to develop and adopt standards related to disenrollment process.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2The agency collaborates with other agencies and entities to adopt HIPAA standards and EDI transactions.
  3. LEVEL 3SMA collaborates with insurance affordability programs to develop and implement common disenrollment standards. The SMA documents the arrangement in an agreement.
  4. LEVEL 4SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the disenrollment and to conduct joint planning and population management efforts. The SMA documents the arrangement in an agreement that is dynamic and updated as conditions change.
  5. LEVEL 5SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the disenrollment and to conduct joint planning and population management efforts. The SMA works with state and national data sources, the Marketplace, and CHIP agency to establish data exchanges and supporting activities with programs in other States.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1SMA sometimes meets threshold or mandated requirements for timeliness (e.g., the process achieves results within the time specified by law, or regulation). Disenrollment may take multiple business days.
  2. LEVEL 2SMA improves timeliness through use of automation. Timeliness always meets legal requirements. SMA completes disenrollment in one (1) business day.
  3. LEVEL 3Timeliness improves via Marketplace, state and federal collaboration, use of member disenrollment information sharing, and standards. Timeliness exceeds Level 2.
  4. LEVEL 4Information is available in near real time. Processes that use interstate member disenrollment information result in immediate action, response, and results.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other regions, States and with federal agencies. Most processes execute at the point of service. Timeliness improves over Level 4.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
  3. LEVEL 3SMA automates the collection of member disenrollment information increasing the reliability of exchange. External sources of member disenrollment information use MITA Framework and industry standards for information exchange. Decision-making is automatic using business rule engines. Accuracy is 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework and industry standards for disenrollment information exchange with insurance affordability programs. Decision-making is automatic using business rule engines. Accuracy is 95% or higher.
  5. LEVEL 5SMA uses Marketplace, MITA Framework, and national standards for national disenrollment information exchange. Decision-making is automatic using business rule engines. Accuracy is 98% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Systems experience extended scheduled and unscheduled downtime
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. Systems experience extended scheduled and unscheduled downtime
  3. LEVEL 3SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. Accessibility is greater than Level 3.
  5. LEVEL 5SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automated, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, increasing cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts Marketplace, MITA Framework, and intrastate standard messages and other nationally recognized standards further increasing cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts Marketplace, MITA Framework, regional standard messages and other nationally recognized standards for disenrollment information exchange increasing cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts Marketplace, MITA Framework, industry standards, and other nationally recognized standards for national disenrollment information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and agency performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts automation of disenrollment process improving efficiency to 90% or higher.
  4. LEVEL 4SMA adopts shared enrollment services improving efficiency to 95% or higher.
  5. LEVEL 5SMA uses shared enrollment services improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes results in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and business rules reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts standard messages for interacting with other state agencies and entities, improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts standard messages for interacting with agencies and entities across some states improving accuracy to 95% or higher.
  5. LEVEL 5SMA adopts standard messages for interacting with agencies and entities across all states improving accuracy to 98% or higher.

Business Capability Quality: Utility or Value to Stakeholders

How satisfied are the stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts standard messages for interacting with other state agencies and entities, improving stakeholder satisfaction to 90% or higher.
  4. LEVEL 4SMA adopts standard messages for interacting with agencies and entities across some states, improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts standard messages for interacting with agencies and entities across all states, improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Eligibility and Enrollment Management BCM.pdf, pages 21-27.

Other Eligibility and Enrollment Management processes

Determine Member EligibilityDetermine Provider EligibilityDisenroll ProviderEnroll MemberEnroll ProviderInquire Member EligibilityInquire Provider Information