Beneficiary Brochure and Provider List Sample Clauses
The "Beneficiary Brochure and Provider List" clause requires the distribution of informational materials and a list of available service providers to beneficiaries. Typically, this means that beneficiaries must receive a brochure outlining their rights, benefits, and procedures, along with an up-to-date directory of approved providers or facilities. This clause ensures that beneficiaries are well-informed about their options and how to access services, thereby promoting transparency and facilitating informed decision-making.
Beneficiary Brochure and Provider List. The Contractor shall be responsible for ensuring that the following requirements are met and notice thereof is provided in the beneficiary brochure upon automatic mandatory enrollment of the beneficiaries. The production and update of its booklet section(s) and provider list in accordance with 42 CFR 438.10. The Contractor shall establish criteria to update its booklet and provider list.
A. Contractor shall provide all enrollment notices, informational materials and instructional materials in a manner and format that may be easily understood in language and format. Contractor shall provide notice to all potential beneficiaries and beneficiaries regarding the availability of materials in alternative formats to ensure comprehension and understanding of the requirements and benefits of the plan. Contractor shall provide instructions on how to access those alternative format materials.
1) Contractor shall make oral interpretation services available and provide those services free of charge to each potential beneficiary and beneficiary.
2) Contractor shall ensure written materials:
a. Use easily understood language and format; and
b. Be available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency.
3) All enrollees and potential enrollees shall be informed by the Contractor that information is available in alternative formats and how to access those formats.
B. Pursuant to 42 CFR 438.10(e)(2)(i), upon automatic mandatory enrollment, the Contractor shall provide the following information to potential beneficiaries:
1) The basic features of managed care;
2) Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; and
3) The Contractor’s responsibility for coordination of the beneficiary’s care.
C. Pursuant to 42 CFR 438.10(e)(2)(ii), upon automatic mandatory enrollment, the Contractor shall provide potential beneficiaries with a summary of the following information:
1) Benefits covered;
2) Cost sharing, if any;
3) Service area;
4) Names, locations, telephone numbers of, and non-English language spoken by current contracted providers, and including identification of providers that are not accepting new patients. For MCOs, PIHPs, and PAHPs this includes at a minimum information on primary care physicians, specialists and hospitals;
5) Benefits that are available unde...
Beneficiary Brochure and Provider List. A. The Contractor shall be responsible for the production and update of its booklet section(s) and provider list in accordance with 42 C.F.R. § 438.10 and Cal. Code Regs., tit. 9, §1810.360. The Contractor shall establish criteria to update its booklet and provider list. Pursuant to 42 C.F.R. § 438.10, the Contractor shall:
1) Notify all beneficiaries of their right to change providers;
2) Notify all beneficiaries of their right to request and obtain the following information:
a) Names, locations, telephone numbers of, and non-English languages spoken by current contracted providers in the beneficiary’s service area, including identification of providers that are not accepting new patients.
b) Any restrictions on the beneficiary’s freedom of choice among network providers.
c) Beneficiary rights and protections, as specified in 42 CFR § 438.100.
d) The amount, duration, and scope of benefits available under this Contract in sufficient detail to ensure that beneficiaries understand the benefits to which they are entitled.
e) Procedures for obtaining benefits, including authorization requirements.
f) The extent to which, and how, beneficiaries may obtain benefits from out-of-network providers.
g) The extent to which, and how, after-hours and emergency coverage are provided, including:
i. What constitutes an emergency medical condition, emergency services, and post-stabilization services, with reference to the definitions in 42 C.F.R. § 438.114(a).
ii. The fact that prior authorization is not required for emergency services.
iii. The process and procedures for obtaining emergency services, including use of the 911-telephone system or its local equivalent.
iv. The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
v. The fact that, subject to the provisions of 42 C.F.R. § 438.10(f)(6), the beneficiary has a right to use any hospital or other setting for emergency care.
vi. The post-stabilization care services rules set forth in 42 C.F.R. § 422.113(c).
h) Cost sharing, if any.
i) How and where to access any benefits that are available under the State Plan but are not covered under this Contract, including any cost sharing, and how any necessary transportation is provided. Pursuant to 42 C.F.R. § 438.102(a)(2), for a counseling or referral service that the Contractor does not cover because of moral or religious objections, the Contractor ne...
Beneficiary Brochure and Provider List. A. The Contractor shall be responsible for the production and update of its booklet and provider list in accordance with Title 42, CFR, Section 438.10 and Title 9, CCR, Section 1810.360. The Contractor shall establish criteria to update its booklet and provider list. Pursuant to Title 42, CFR, 438.10, the Contractor shall:
1) Notify all beneficiaries of their right to change providers;
2) Notify all beneficiaries of their right to request and obtain the following information:
a) Names, locations, telephone numbers of, and non-English languages spoken by current contracted providers in the beneficiary’s service area, including identification of providers that are not accepting new patients.
b) Any restrictions on the beneficiary’s freedom of choice among network providers.
c) Beneficiary rights and protections, as specified in ▇▇▇▇▇ ▇▇, ▇▇▇ 438.100.
d) The amount, duration, and scope of benefits available under this Contract in sufficient detail to ensure that beneficiaries understand the benefits to which they are entitled.
e) Procedures for obtaining benefits, including authorization requirements.
f) The extent to which, and how, beneficiaries may obtain benefits.
g) The extent to which, and how, after-hours and emergency coverage are provided, including:
i. What constitutes an emergency medical condition, emergency services, and post-stabilization services, with reference to the definitions in Title 42, CFR, 438.114(a).
ii. The fact that prior authorization is not required for emergency services.
iii. The process and procedures for obtaining emergency services, including use of the 911-telephone system or its local equivalent.
iv. The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
v. The fact that, subject to the provisions of Title 42, CFR, 438.10(f)(6), the beneficiary has a right to use any hospital or other setting for emergency care.
vi. The post-stabilization care services rules set forth in Title 42, CFR, 422.113(c).
h) Cost sharing, if any.
i) How and where to access any benefits that are available under the State Plan but are not covered under this Contract, including any cost sharing, and how any necessary transportation is provided. Pursuant to Title 42, CFR, Section 438.102(a)(2), for a counseling or referral service that the Contractor does not cover because of moral or religious objections, the Contractor need not...