Enrollee Handbook Requirements a. The Enrollee services handbook shall include the following information:
(1) Table of Contents;
(2) Terms and conditions of Enrollment including the reinstatement process;
(3) Description of the Open Enrollment process;
(4) Description of services provided, including limitations and general restrictions on Provider access, exclusions and out-of-network use;
(5) Procedures for obtaining required services, including second opinions, and authorization requirements, including those services available without Prior Authorization;
(6) Toll-free telephone number of the appropriate Area Medicaid Office;
(7) Emergency Services and procedures for obtaining services both in and out of the Health Plan’s Service Area, including, an explanation that Prior Authorization is not required for Emergency Services, the locations of any emergency settings and other locations at which Providers and Hospitals furnish Emergency Services and Post-Stabilization Care Services and use of the 911 telephone system, or its equivalent;
(8) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee has a right to use any Hospital or other setting for Emergency Care;
(9) Procedures for Enrollment, including Enrollee rights and protections;
(10) A notice advising Enrollees how to change PCPs;
(11) Grievance System components and procedures;
(12) Enrollee rights and procedures for Disenrollment, including the toll-free telephone number for the Agency’s contracted Choice Counselor/Enrollment Broker;
(13) Procedures for filing a request for Disenrollment for Cause;
(14) Information regarding Newborn enrollment, including the mother’s responsibility to notify the Health Plan and the mother’s DCF case worker of the Newborn’s birth and selection of a PCP;
(15) Enrollee rights and responsibilities, including the extent to which, and how, Enrollees may obtain services from out-of-network providers and the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, and other provisions in accordance with 42 CFR 438.100;
(16) Information on emergency transportation and non-emergency transportation, counseling and referral services available under the Health Plan, and how to access these services;
(17) Information that interpretation services and alternative communication systems are available, free of charge, for all foreign languages, and how to access these services;
(18) Information that ...
Enrollee Handbook Requirements a. The Enrollee services handbook shall include the following information:
Enrollee Handbook Requirements. 6.4.1 The Contractor shall produce at its sole cost, and shall mail to all new Enrollees, an Enrollee Handbook including information on both physical and behavioral health services offered under MiSalud. The Contractor shall collect from the MBHO the information on behavioral health services needed to compile the Enrollee Handbook. The Contractor shall distribute the Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.3.2 of this Contract or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.
6.4.2 The Contractor shall either:
6.4.2.1 Mail to all Enrollees an Enrollee Handbook at least annually on July 1, after the initial distribution of the Handbook; or
6.4.2.2 At least annually as required by 42 CFR 438.10(i), on July 1 mail to all Enrollees a Handbook supplement that includes information on the following:
6.4.2.2.1 The Contractor’s service area;
6.4.2.2.2 Benefits covered under MiSalud in the Service Regions;
6.4.2.2.3 Any cost-sharing imposed by ASES; and
6.4.2.2.4 To the extent available, quality and performance indicators, including Enrollee satisfaction.
6.4.3 The Contractor shall use the Universal Beneficiary Guide, provided by ASES and included as Attachment 3 to this Contract, as a model for its Handbook; however, the Contractor shall ensure that its Handbook meets all the requirements listed in this Section 6.4.
6.4.4 Pursuant to the requirements set forth in 42 CFR 438.10, the Enrollee Handbook shall include, at a minimum, the following:
6.4.4.1 A table of contents;
6.4.4.2 An explanation of the purpose of the Enrollee ID Card and a warning that transfer of the card to another person constitutes Fraud;
6.4.4.3 Information about the role of the PCP and how to choose a PCP;
6.4.4.4 Information about the PMG, how to choose a PMG, and which Benefits may be accessed through the PMG;
6.4.4.5 Information about the Preferred Provider Network associated with the Enrollee’s PMG, and the benefits of seeking services within the PPN;
6.4.4.6 Information about the circumstances under which Enrollees may change to a different PMG;
6.4.4.7 Information about what to do when family size changes, including the responsibility of new mothers who are Medicaid Eligible to register their newborn with the Puerto Rico Medicaid Program and to apply for Enrollment of the newborn;
6.4.4.8 Appointment procedures;
6.4.4.9 Information on Benefits and Covered Services, including how the scope of Benefits and C...
Enrollee Handbook Requirements a. The Managed Care Plan shall have enrollee handbooks that include the following information:
(1) Table of contents;
(2) Terms, conditions and procedures for enrollment including the reinstatement process and enrollee rights and protections;
(3) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s contracted enrollment broker. The Managed Care Plan shall include the following language verbatim in the enrollee handbook: If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in [INSERT MANAGED CARE PLAN NAME] or the state enrolls you in a plan, you will have ninety (90) days from the date of your first enrollment to try the managed care plan. During the first ninety (90) days you can change managed care plans for any reason. After the ninety (90) days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine (9) months. This is called “lock-in.”
Enrollee Handbook Requirements a. The Managed Care Plan shall furnish each new enrollee an enrollee handbook. The Managed Care Plan may choose not to distribute a printed version of the enrollee handbook via surface mail. In lieu of providing the printed version, the Managed Care Plan shall submit a written notification to the enrollee that explains how to obtain the enrollee handbook from the Managed Care Plan’s website in a manner approved by the Agency. This notification shall also detail how the enrollee can request a hard copy of the enrollee handbook from the Managed Care Plan by toll-free phone, mail, or email at no charge.
b. The enrollee handbook shall include, at a minimum, the following information:
(1) Table of contents;
(2) Terms, conditions and procedures for enrollment including the reinstatement process and enrollee rights and protections;
(3) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s enrollment broker. The Managed Care Plan shall include the following language verbatim in the enrollee handbook: If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in [INSERT MANAGED CARE PLAN NAME] or the state enrolls you in a plan, you will have 120 days from the date of your first enrollment to try the Managed Care Plan. During the first 120 days you can change Managed Care Plans for any reason. After the 120 days, if you are still eligible for Medicaid, you may be enrolled in the plan for the next eight months. This is called “lock- in.”
Enrollee Handbook Requirements. 6.4.1 The Contractor shall produce at its sole cost, and shall mail or make electronically available, subject to the requirements of Section 6.10.8 and 6.10.9, to all new Enrollees, an Enrollee Handbook including information on physical health, Behavioral Health, and all other Covered Services offered under the GHP. The Contractor shall distribute the Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.5.3 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.
6.4.2 Upon request of an Enrollee or his/her Authorized Representative for a replacement or additional copy of the Enrollee Handbook, the Contractor shall send an Enrollee Handbook within ten (10) Calendar Days. The Contractor shall give the person requesting an Enrollee Handbook the option to get the Information from the Contractor’s website or to receive a printed document.
6.4.3 The Contractor shall either: Mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees an Enrollee Handbook on at least an annual basis, after the initial distribution of the Handbook at Enrollment; or At least annually, as required by 42 CFR 438.10, mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees a Handbook supplement that includes Information on the following: The Contractor’s service area; Benefits covered under the GHP; Any cost-sharing imposed by the Contractor; and To the extent available, quality and performance indicators, including Enrollee satisfaction. The Contractor is not required to mail an Enrollee Handbook to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided an Enrollee Handbook within the past year. The Contractor is also not required to mail an Enrollee Handbook to new Enrollees under the age of twenty-one
Enrollee Handbook Requirements. 6.4.1 The Contractor shall produce at its sole cost, and shall mail to all new Enrollees, an Enrollee Handbook including information on both physical and behavioral health services offered under MiSalud. The Contractor shall collect from the MBHO the information on behavioral health services needed to compile the Enrollee Handbook. The Contractor shall distribute the Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.3.2 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail. The Contractor shall either:
6.4.2.1 Mail to all Enrollees an Enrollee Handbook at least annually, after the initial distribution of the Handbook at Enrollment; or
6.4.2.2 At least annually, as required by 42 CFR 438.1O(i), mail to all Enrollees a Handbook supplement that includes information on the following:
6.4.2.2.1 The Contractor's service area;
6.4.2.2.2 Benefits covered under MiSalud;
6.4.2.2.3 Any cost-sharing imposed by the Contractor; and
6.4.2.2.4 To the extent available, quality and performance indicators, including
Enrollee Handbook Requirements i. The CHIP-MCO must provide that the Enrollee handbook is written at no higher than a sixth-grade reading level and includes, at a minimum, the information outlined in the CHIP- MCO Enrollee Handbook Template as issued by DHS.
ii. The CHIP-MCO must notify members at least thirty (30) days in advance of the effective date of a significant change in the Enrollee handbook.
iii. The CHIP-MCOs must have written policies guaranteeing each enrollee’s righto be treated with respect and with due consideration for his or her dignity and privacy.
iv. The CHIP-MCOs must have written policies guaranteeing each enrollee’s right to receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee’s condition and ability to understand.
v. The CHIP-MCOs must have written policies guaranteeing each enrollee’s right to participate in decisions regarding his or her health care, including the right to refuse treatment.
vi. The CHIP-MCOs must have written policies guaranteeing each enrollee’s right to be free from any form of restrain t or seclusion used as a means of coercion, discipline, convenience, or retaliation.
vii. The CHIP-MCOs must have written policies guaranteeing each enrollee's right to request and receive a copy of his or her medical records, and to request that they be amended or corrected.
viii. The CHIP-MCOs must ensure that each enrollee is free to exercise his or her rights without the CHIP-MCO or its network providers treating the enrollee adversely.
Enrollee Handbook Requirements. 6.4.1 The Contractor shall produce at its sole cost, and shall mail or make electronically available, subject to the requirements of Section 6.10.8 and 6.10.9, to all new Enrollees, an Enrollee Handbook including information on physical health, Behavioral Health, and all other Covered Services offered under the GHP. The Contractor shall distribute the Enrollee Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.5.3 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.
6.4.2 Upon request of an Enrollee or his/her Authorized Representative for a replacement or additional copy of the Enrollee Handbook, the Contractor shall send an Enrollee Handbook within ten (10) Calendar Days. The Contractor shall give the person requesting an Enrollee Handbook the option to get the Information from the Contractor’s website or to receive a printed document.
6.4.3 The Contractor shall either:
6.4.3.1 Mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees an Enrollee Handbook on at least an annual basis, after the initial distribution of the Enrollee Handbook at Enrollment; or
6.4.3.2 At least annually, as required by 42 CFR 438.10, mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees a Handbook supplement that includes Information on the following:
3.2.1 The Contractor’s service area;
Enrollee Handbook Requirements. The handbook must include the following information which must adhere to the standards set forth in this contract:
1. Table of contents;
2. The phone number which can be used for assistance in obtaining emergency care;
3. A description of all available MHT or WVHB Contract services, including amount, duration, scope, and how to access those services (e.g., whether the enrollee can self-refer to the service or if a referral or prior authorization is needed); and an explanation of any service limitations or exclusions from coverage;
4. A description of any restrictions on the enrollee’s freedom of choice among network providers;
