Member Handbook The Contractor shall develop a member handbook for its members. The Contractor’s member handbook shall be submitted annually for OMPP’s review. The member handbook shall include the Contractor’s contact information and Internet website address and describe the terms and nature of services offered by the Contractor, including the following information required under 42 CFR 438.10(f), which enumerates certain required information. The member handbook may be offered in an electronic format as long as the Contractor complies with 42 CFR 438.10(c)(6). The Hoosier Healthwise MCE Policies and Procedures Manual outlines the member handbook requirements. The Hoosier Healthwise member handbook shall include the following: Contractor’s contact information (address, telephone number, TDD number, website address); The amount, duration and scope of services and benefits available under the Contract in sufficient details to ensure that participants are informed of the services to which they are entitled, including, but not limited to the differences between the benefit options; The procedures for obtaining benefits, including authorization requirements; Contractor’s office hours and days, including the availability of a 24-hour Nurse Call Line; Any restrictions on the member’s freedom of choice among network providers, as well as the extent to which members may obtain benefits, including family planning services, from out-of-network providers; The extent to which, and how, after-hours and emergency coverage are provided, as well as other information required under 42 CFR 438.10(f), such as what constitutes an emergency; The post-stabilization care services rules set forth in 42 CFR 422.113(c); The extent to which, and how, urgent care services are provided; Applicable policy on referrals for specialty care and other benefits not provided by the member’s PMP, if any; Information about the availability of pharmacy services and how to access pharmacy services; Member rights and protections, as enumerated in 42 CFR 438.100, which relates to enrollee rights. See Section 4.8 for further detail regarding member rights and protections; Responsibilities of members; Special benefit provisions (for example, co-payments, deductibles, limits or rejections of claims) that may apply to services obtained outside the Contractor’s network; Procedures for obtaining out-of-network services; Standards and expectations to receive preventive health services; Policy on referrals to specialty care; Procedures for notifying members affected by termination or change in any benefits, services or service delivery sites; Procedures for appealing decisions adversely affecting members’ coverage, benefits or relationship with the Contractor; Procedures for changing PMPs; Standards and procedures for changing MCEs, and circumstances under which this is possible, including, but not limited to providing contact information and instructions for how to contact the enrollment broker to transfer MCEs due to one of the “for cause” reasons described in 42 CFR 438.56(d)(2)(iv), including, but not limited to, the following: Receiving poor quality of care; Failure to provide covered services; Failure of the Contractor to comply with established standards of medical care administration; Lack of access to providers experienced in dealing with the member’s health care needs; Significant language or cultural barriers; Corrective action levied against the Contractor by the office; Limited access to a primary care clinic or other health services within reasonable proximity to a member’s residence; A determination that another MCE’s formulary is more consistent with a new member’s existing health care needs; Lack of access to medically necessary services covered under the Contractor’s contract with the State; A service is not covered by the Contractor for moral or religious objections, as described in Section 6.3.3; Related services are required to be performed at the same time and not all related services are available within the Contractor’s network, and the member’s provider determines that receiving the services separately will subject the member to unnecessary risk; The member’s primary healthcare provider disenrolls from the member’s current MCE and reenrolls with another MCE; or Other circumstances determined by the office or its designee to constitute poor quality of health care coverage. The process for submitting disenrollment requests. This information shall include the following: Hoosier Healthwise members may change MCEs after the first ninety (90) calendar days of enrollment only for cause; Members are required to exhaust the MCE’s internal grievance and appeals process before requesting an MCE change ; Members may submit requests to change MCEs to the Enrollment Broker verbally or in writing, after exhausting the MCE’s internal grievance and appeals process; and The MCE shall provide the Enrollment Broker’s contact information and explain that the member must contact the Enrollment Broker with questions about the process. This information shall include how to obtain the Enrollment Broker’s standardized form for requesting an MCE change. The process by which an American Indian/ Alaska Native member may elect to opt-out of managed care pursuant to 42 USC § 1396u–2(a)(2)(C) and transfer to fee-for-service benefits through the State; Procedures for making complaints and recommending changes in policies and services; Grievance, appeal and fair hearing procedures as required at 42 CFR 438.10(g)(2)(xi), including the following: The right to file grievances and appeals; The requirements and timeframes for filing a grievance or appeal; The availability of assistance in the filing process; The toll-free numbers that the member can use to file a grievance or appeal by phone; The fact that, if requested by the member and under certain circumstances: (1) benefits will continue if the member files an appeal or requests a State fair hearing within the specified timeframes; and (2) the member may be required to pay the cost of services furnished during the appeal if the final decision is adverse to the member. For a State hearing describe (i) the right to a hearing, (ii) the method for obtaining a hearing, and (iii) the rules that govern representation at the hearing. Information about advance directives; How to report a change in income, change in family size, etc.; Information about the availability of the prior claims payment program for certain members and how to access the program administrator; Information on alternative methods or formats of communication for visually and hearing-impaired and non-English speaking members and how members can access those methods or formats; Information on how to contact the Enrollment Broker; Statement that Contractor will provide information on the structure and operation of the health plan; and In accordance with 42 CFR 438.10(f)(3), that upon request of the member, information on the Contractor’s provider incentive plans will be provided.
Employee Handbook Employee agrees to be bound by the terms and conditions of any employee handbook of Bank or its affiliates as may be in effect from time to time, except that in the event of a conflict between such employee handbook and the Agreement, the Agreement shall control.
Company Policies and Procedures 7.1.1 The Company will ensure that Employees are able to readily access Company policies and procedures that apply to the Employees.
7.1.2 The Employees will observe and act in accordance with Company policies and procedures that apply to the Employees, as implemented and amended from time to time.
Handbook A. The Contractor shall provide beneficiaries with a copy of the handbook and provider directory when the beneficiary first accesses services and thereafter upon request. (Cal. Code Regs., tit. 9, § 1810.360.)
B. The Contractor shall ensure that the handbook includes the current toll- free telephone number(s) that provides information in threshold languages and is available twenty-four hours a day, seven days a week. (Cal. Code Regs., tit. 9, § 1810.405, subd. (d).)
C. The beneficiary handbook shall include information that enables the beneficiary to understand how to effectively use the managed care program. This information shall include, at a minimum:
1) Benefits provided by the Contractor. (42 C.F.R. § 438.10(g)(2)(i).)
2) How and where to access any benefits provided by the Contractor, including any cost sharing, and how transportation is provided. (42 C.F.R. § 438.10(g)(2)(ii).)
a) The amount, duration, and scope of benefits available under the Contract in sufficient detail to ensure that beneficiaries understand the benefits to which they are entitled. (42 C.F.R. § 438.10(g)(2)(iii).)
b) Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the beneficiary’s provider. (42 C.F.R. § 438.10(g)(2)(iv).)
c) Any restrictions on the beneficiary’s freedom of choice among network providers. (42 C.F.R. § 438.10(g)(2)(vi).)
d) The extent to which, and how, beneficiaries may obtain benefits from out-of-network providers. (42 C.F.R. § 438.10(g)(2)(vii).)
e) Cost sharing, if any, consistent with the State Plan. (42 C.F.R. § 438.10(g)(2)(viii); State Plan § 4.18.)
f) Beneficiary rights and responsibilities, including the elements specified in § 438.100 as specified in Section 7 of this Attachment. (42 C.F.R. § 438.10(g)(2)(ix).)
g) The process of selecting and changing the beneficiary’s provider. (42 C.F.R. § 438.10(g)(2)(x).)
h) Grievance, appeal, and fair hearing procedures and timeframes, consistent with 42 C.F.R. §§ 438.400 through 438.424, in a state-developed or state-approved description. Such information shall include:
1) The right to file grievances and appeals;
2) The requirements and timeframes for filing a grievance or appeal;
3) The availability of assistance in the filing process;
4) The right to request a state fair hearing after the Contractor has made a determination on a beneficiary’s appeal which is adverse to the beneficiary;
5) The fact that, when requested by the beneficiary, benefits that the Contractor seeks to reduce or terminate will continue if the beneficiary files an appeal or a request for state fair hearing within the timeframes specified for filing, and that the beneficiary may, consistent with state policy, be required to pay the cost of services furnished while the appeal or state fair hearing is pending if the final decision is adverse to the beneficiary. (42 C.F.R. § 438.10(g)(2)(xi).)
i) How to exercise an advance directive, as set forth in 42 C.F.R. 438.3(j). (42 C.F.R. § 438.10(g)(2)(xii).)
j) How to access auxiliary aids and services, including additional information in in alternative formats or languages. (42 C.F.R. § 438.10(g)(2)(xiii).)
k) The Contractor’s toll-free telephone number for member services, medical management, and any other unit providing services directly to beneficiaries. (42 C.F.R. § 438.10(g)(2)(xiv).)
l) Information on how to report suspected fraud or abuse. (42 C.F.R. § 438.10(g)(2)(xv).)
m) Additional information that is available upon request, includes the following:
1) Information on the structure and operation of the Contractor.
2) Physician incentive plans as set forth in 42 C.F.R. § 438.3(i). (42 C.F.R. § 438.10(f)(3).)
D. The Contractor shall give each beneficiary notice of any significant change (as defined by the Department) to information in the handbook at least 30 days before the intended effective date of the change. (42 C.F.R. § 438.10(g)(4).)
E. Consistent with 42 Code of Federal Regulations part 438.10(g)(3) and California Code of Regulations, title 9, section 1810.360, subdivision (e), the handbook will be considered provided if the Contractor:
1) Mails a printed copy of the information to the beneficiary’s mailing address before the beneficiary first receives a specialty mental health service;
2) Mails a printed copy of the information upon the beneficiary’s request to the beneficiary’s mailing address;
3) Provides the information by email after obtaining the beneficiary’s agreement to receive the information by email;
4) Posts the information on the Contractor’s website and advises the beneficiary in paper or electronic form that the information is available on the internet and includes the applicable internet addresses, provided that beneficiaries with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost; or,
5) Provides the information by any other method that can reasonably be expected to result in the beneficiary receiving that information. If the Contractor provides the handbook in-person when the beneficiary first receives specialty mental health services, the date and method of delivery shall be documented in the beneficiary’s file.
Compliance with Federal Law, Regulations, and Executive Orders This is an acknowledgement that FEMA financial assistance will be used to fund all or a portion of the contract. The contractor will comply with all applicable Federal law, regulations, executive orders, FEMA policies, procedures, and directives.
Policies and Procedures i) The policies and procedures of the designated employer apply to the employee while working at both sites.
ii) Only the designated employer shall have exclusive authority over the employee in regard to discipline, reporting to the College of Nurses of Ontario and/or investigations of family/resident complaints.
iii) The designated employer will ensure that the employee is covered by WSIB at all times, regardless of worksite, while in the employ of either home.
iv) The designated employer will ensure that the employee is covered by liability insurance at all times, regardless of worksite, while in the employ of either home.
v) The designated employer shall have exclusive authority over the employee’s personnel files and health records. These files will be maintained on the site of the designated employer.
References to Statutes, Public Acts, Regulations, Codes and Executive Orders All references in this Contract to any statute, public act, regulation, code or executive order shall mean such statute, public act, regulation, code or executive order, respectively, as it has been amended, replaced or superseded at any time. Notwithstanding any language in this Contract that relates to such statute, public act, regulation, code or executive order, and notwithstanding a lack of a formal amendment to this Contract, this Contract shall always be read and interpreted as if it contained the most current and applicable wording and requirements of such statute, public act, regulation, code or executive order as if their most current language had been used in and requirements incorporated into this Contract at the time of its execution.
COMPLIANCE WITH POLICIES AND PROCEDURES During the period that Executive is employed with the Company hereunder, Executive shall adhere to the policies and standards of professionalism set forth in the policies and procedures of the Company and IAC as they may exist from time to time.
Limitation on Out-of-State Litigation - Texas Business and Commerce Code § 272 This is a requirement of the TIPS Contract and is non-negotiable. Texas Business and Commerce Code § 272 prohibits a construction contract, or an agreement collateral to or affecting the construction contract, from containing a provision making the contract or agreement, or any conflict arising under the contract or agreement, subject to another state’s law, litigation in the courts of another state, or arbitration in another state. If included in Texas construction contracts, such provisions are voidable by a party obligated by the contract or agreement to perform the work. By submission of this proposal, Vendor acknowledges this law and if Vendor enters into a construction contract with a Texas TIPS Member under this procurement, Vendor certifies compliance.
COMPLIANCE WITH GOVERNMENTAL RULES AND REGULATIONS; RECORDS The Trust assumes full responsibility for its compliance with all securities, tax, commodities and other laws, rules and regulations applicable to it.
