Enrollee Education. The MCO, or its subcontractor, is not prohibited from providing information to Enrollees for the purpose of educating Enrollees about Provider choices available through the MCO, subject to the limitations in this Contract
Enrollee Education. Within 14 days after an Enrollee makes a request for services, the LME shall provide the new Enrollee with written information on the Medicaid waiver program. The written information shall be available in Spanish and in any additional languages that are spoken by a substantial number of persons served by the LME. A “substantial number” is defined as the lesser of five percent of the LME’s Enrollees or 1,000 Enrollees. All new Enrollee material shall be approved in writing by DMA prior to its release, and shall include at least the following information, as specified in 42 C.F.R 438.10 (f)(6) and 42 C.F.R. 438.10 (g):
a. A description of the benefits and services provided by the LME and of any limitations or exclusions applicable to covered services. These descriptions must have sufficient detail to ensure that Enrollees understand the benefits to which they are entitled;
b. Updates regarding program changes;
c. A description of the procedures for obtaining benefits, including authorizations;
d. A description of the Enrollee’s responsibilities and rights and protections, as set forth in 42 C.F.R. 438.100;
e. An explanation of the Enrollee’s right to select and change Network Providers;
f. The restrictions, if any, on the Enrollee’s right to select or change Network Providers;
g. The procedures for selecting and changing Network Providers;
h. A list of all Network Providers, including their names, addresses, telephone numbers, qualifications, and whether they are accepting new patients;
i. The non-English languages, if any, spoken by each Network Provider;
j. The extent to which, and how, after-hours and emergency coverage are provided, including:
1. What constitutes an Emergency Behavioral Health Condition, Emergency Services, and Post Stabilization Services (Attachment U of this document);
2. The process and procedures for obtaining Emergency Services, including the use of 911 telephone services or the equivalent;
3. The locations at which Providers and hospitals furnish the Emergency Services and Post Stabilization services covered under this Contract;
4. That, subject to the provisions of this Contract, the Enrollee has a right to use any hospital or other setting for Emergency Care;
k. The LME’s policy on referrals for Specialty Care:
1. Cost sharing if any; and
2. How to access Medicaid benefits that are not covered under this contract;
l. Any limitations that may apply to services obtained from Out-of Network Providers, including disclosure of the Enr...
Enrollee Education. In the aggregate, without reference to individual Physicians/Providers or Enrollee identifying information, all Quality Assurance findings, conclusions, recommendations, actions taken, results or other documentation relative to QA shall be reported to Department on a quarterly basis or as requested by the Department. The Department shall be notified of any Provider or Subcontractor who ceases to be a Network Provider or Subcontractor for a quality of care issue.
Enrollee Education. NAMM shall make its facilities and staff available at all reasonable times for use in a program of enrollee health education, including education in the contribution each enrollee can make to the maintenance of his/her health, instruction on personal health care measures, nutritional education and counseling, information about services available from ElmCare and information on generally accepted medical standards for use and frequency of such services.
