Enrollee Handbook. (A) The Contractor shall provide each Enrollee an Enrollee handbook within a reasonable time after receiving notice of the Enrollee’s enrollment.
(B) The Contractor shall use the model Enrollee handbook developed by the Department. The Department shall designate which areas in the model Enrollee handbook that the Contractor is allowed to customize.
(C) The Contractor shall ensure that its Enrollee handbook contains the following information:
(1) that enables the Enrollee to understand how to effectively use the Contractor’s Managed Care Program;
(2) on benefits provided by the Contractor;
(3) on how and where to access any benefits provided by the Department, including any cost sharing, and how transportation is provided;
(4) regarding cost sharing on any benefits provided by the Contractor;
(5) which details that in the case of a counseling or referral service that the Contractor does not cover because of moral or religious objections, the Contractor shall inform Enrollees that the service is not covered by the Contractor and how they can obtain information from the Department about how to access those services;
(6) on the amount, duration, and scope of benefits available under the Contract in sufficient detail to ensure that Enrollees understand the benefits to which they are entitled;
(7) procedures for obtaining benefits, including Service Authorization requirements and/or referrals for specialty care;
(8) on the extent to which, and how, after-hours care is provided;
(9) on how emergency care is provided;
(10) regarding what constitutes an Emergency Medical Condition;
(11) regarding what constitutes an Emergency Service;
(12) that prior authorization is not required for Emergency Services;
(13) that the Enrollee has the right to use any hospital or other setting for emergency care;
(14) that includes cost sharing for services furnished by the Contractor, if any is imposed under the State Plan;
(15) on the Poststabilization Care Services rules set forth at 42 CFR § 422.113(c);
(16) on any restrictions on the Enrollee’s freedom of choice among Network Providers;
(17) on the extent to which, and how, Enrollees may obtain benefits from Non-Network Providers;
(18) on time frames for offering first service for emergent, urgent and non- urgent care specified in Article 10.4.4 of this attachment;
(19) on Enrollee rights as outlined in Article 9.1.2 of this attachment;
(20) on Grievance, Appeal, and State Fair Hearing procedures and timeframes developed by or ...
Enrollee Handbook. DVHA and AHS will coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which is intended to help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA will mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health Demonstration. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a summary description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent and emergent situations, how to access services in other situations (including family planning services and providers not participating in the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directives, and the methods by which a member can select a provider based on specific language requirements. With respect to information on grievance, appeal and Fair Hearing procedures and timeframes, the Global Commitment to Health Demonstration enrollee handbook must include the following information on: • Rights to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe forfiling a request, and rules that govern representation at the hearing; • Rights to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability of assistance in the filing process; • Toll-free numbers that the enrollee may use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated bythe State to assist participants; • The fact that, when requested by the enrollee, benefits will continue if the enrollee files an appeal or a request for a State of Vermont Fair Hearing within the timeframes specified for filing; and that the enrollee may be required to pay the cost of any services furnished while the appeal is pending if the denial is upheld; • Any appeal rights that the State makes available to providers to challenge a denial by DV...
Enrollee Handbook. The Contractor shall submit a copy of the Enrollee Handbook to the Division for approval thirty (30) calendar days prior to distribution. The Division will respond within thirty (30) calendar days of the date of the Division’s receipt of the request. The Contractor must update the Enrollee Handbook annually, addressing changes in policies through submission of a cover letter identifying sections that have changed and/or a red- lined handbook showing before and after language. The red-lined document may be submitted on paper or electronically. Such changes must be approved by the Division prior to dissemination to enrollees and shall be submitted to the Division at least thirty
Enrollee Handbook. Contractor shall submit an Enrollee Handbook to the Department for Prior Approval before the first enrollment, when revised, and upon the Department’s request. Contractor shall not be required to submit format changes for Prior Approval, provided there is no change in the information conveyed. Contractor shall mail an Enrollee Handbook to new Enrollees no later than five (5) Business Days following receipt of the Enrollee’s initial enrollment record on the 834 Audit File. At a minimum, the Enrollee Handbook must contain: 5.18.5.1 Contractor’s contact information.
Enrollee Handbook. The Contractor shall submit the handbook to the Department for prior approval initially and as revised. The Contractor shall not be required to submit for prior approval format changes, provided there is no change in the information conveyed.
Enrollee Handbook. Insurer shall provide an Enrollee handbook based on the model Enrollee handbook provided by FHKC. Insurer shall customize such material to the extent permitted or required by FHKC. The handbook shall include the following elements:
a. A description of benefits and any associated cost sharing sufficient to ensure that Enrollees understand the benefits covered by this Contract, including the scope, amount, duration and limitations associated with a benefit.
b. A description of how to access services, including any requirements for prior authorization of any services, referrals for specialty care or any other restrictions on choice among network Providers.
c. Disclosure of any services Insurer does not cover because of moral or religious objections and instructions about how to obtain information from FHKC about how to access any such services.
d. The extent to which, and how, Enrollees may obtain benefits, including family planning services and supplies from out-of-network Providers and an explanation that Insurer cannot require an Enrollee to obtain a referral before choosing a family planning Provider.
e. A description of Emergency Medical Conditions and services, including post-stabilization services, including what constitutes an emergency, the fact that prior authorization is not required, and that Enrollee has a right to use any hospital or setting for emergency care.
f. The process for selecting and changing the Enrollee’s PCP;
g. A description of the Grievance and Appeal process, including the right to file and the availability of assistance in the filing process;
h. A description of the Enrollee’s rights and responsibilities;
i. An explanation about how to exercise an advance directive;
j. How to access auxiliary aids and services, including accessing information in alternative formats or languages;
k. The toll-free telephone number for Enrollee Services and any other unit providing services directly to Enrollees;
l. How to report suspected Fraud or Abuse; and
m. Any other information required by FHKC.
Enrollee Handbook. The Contractor shall publish an Enrollee Handbook and make the handbook available to Enrollees upon enrollment, to be delivered to the Enrollee within five (5) Business Days of Contractor’s notification of Enrollee’s enrollment. With the exception of a new Enrollee assigned to the Contractor, the Contractor is in compliance with this requirement if the Enrollee’s handbook is:
A. Mailed within five (5) Business Days by a method that will not take more than three (3) Days to reach the Enrollee;
B. Provided by email after obtaining the Enrollee’s agreement to receive the information by email;
C. Posted on the Contractor’s website and the Contractor advises the Enrollee in paper or electronic form that the information is available on the internet and includes the internet address, provided that Enrollee’s with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost; or
D. Provided by any other method that can reasonably be expected to result in the Enrollee receiving that information. For any new Enrollee assigned to the Contractor, the Contractor shall mail a hard copy of the Enrollee Handbook within five (5) Business Days of notification of the assignment.
Enrollee Handbook. Contractor shall submit an Enrollee handbook to the Department for Prior Approval before the first enrollment, when revised, and upon the Department’s request. Contractor shall not be required to submit format changes for Prior Approval, provided there is no change in the information conveyed. Contractor shall mail an Enrollee handbook to new Enrollees no later than five (5) Business Days following receipt of the Enrollee’s initial enrollment record on the 834 Audit File. Contractor must include terms defined by the Department as provided in42 CFR §438.10(c)(4)(i) and follow the requirements of 42 CFR §438.10(g). At a minimum, the Enrollee handbook must contain:
Enrollee Handbook. Insurer must use the model Enrollee handbook, model Enrollee notices and any definition for managed care terminology FHKC develops. Insurer may customize such material to the extent permitted or required by FHKC. Customized model materials must be approved by FHKC prior to use.
Enrollee Handbook. Insurer shall provide an Enrollee handbook based on the model Enrollee handbook provided by FHKC. Insurer shall customize such material to the extent permitted or required by FHKC. The handbook shall include the following elements:
a. A description of benefits and any associated cost sharing sufficient to ensure that Enrollees understand the benefits covered by this Contract, including the scope, amount, duration, and limitations associated with a Covered Service.
b. A description of how to access services, including any requirements for prior authorization of any services, referrals for specialty care, or any other restrictions on choice among network Providers.
c. Disclosure of any services Insurer does not cover because of moral or religious objections and instructions about how to obtain information from FHKC about how to access any such services.
