Common use of Enrollee Handbook Requirements Clause in Contracts

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 Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicators, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served by the same PCP or they may choose different PCPs; (29) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days after the effective date of the change. d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify required procedural steps in the Grievance Procedure, including the address, telephone number and office hours of the Grievance staff. The Health Plan shall specify phone numbers for a grievant to call to present a Grievance or to contact the Grievance staff. Each phone number shall be toll-free within the grievant’s geographic area and provide reasonable access to the Health Plan without undue delays. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding the structure and operation of the Health Plan and any physician incentive plans, as set forth in 42 CFR 438.10(g)(3).

Enrollee Handbook Requirements. a. The Enrollee services handbook Health Plan shall have separate enrollee handbooks for Reform and non-Reform populations. The handbooks shall include the following information: (1) Table of Contentscontents; (2) Terms Terms, conditions and conditions of Enrollment procedures for enrollment including the reinstatement processprocess and enrollee rights and protections; (3) Description of the Open Enrollment processninety (90) day change period and the open enrollment process (see subparagraph (15), below, for required standardized language); (4) How to change PCPs; (5) Description of services provided, including limitations and general restrictions on Provider provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among network providers; (56) Procedures for obtaining required services, including second opinionsopinions at no expense to the enrollee, and authorization requirements, including those services available without Prior Authorization; (6) Toll-free telephone number of the appropriate Area Medicaid Officeprior authorization; (7) Information regarding newborn enrollment, including the mother’s responsibility to notify the Health Plan and DCF of the pregnancy and the newborn’s birth; (8) Information about how to select the newborn’s PCP; (9) Emergency Services services and procedures for obtaining services both in and out of the Health Plan’s Service Areaservice area, including, an including explanation that Prior Authorization prior authorization is not required for Emergency Servicesemergency or post-stabilization services, the locations of any WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract emergency settings and other locations at which Providers providers and Hospitals hospitals furnish Emergency Services emergency services and Postpost-Stabilization Care Services and stabilization care services, use of the 911 911- telephone system, system or its local equivalent, and other post-stabilization requirements in s. 1932(b)(2)(A)(ii) of the Social Security Act.; (8) 10) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee enrollee has a right to use any Hospital hospital or other setting for Emergency Care; (9) Procedures for Enrollment, including Enrollee rights and protections; (10) A notice advising Enrollees how to change PCPsemergency care; (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, which and how, Enrollees how enrollees may obtain services from out-of-network providers and providers; the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, prior authorization; and other provisions in accordance with 42 CFR 438.100; (1612) Information on emergency transportation about the Beneficiary Assistance program (BAP) 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 Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicatorsMedicaid Fair Hearing process, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served a review by the same PCP or they may choose different PCPs; BAP must be requested within one (291) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days year after the effective date of the change.occurrence that initiated the appeal, how to initiate a review by the BAP and the BAP address and telephone number: Agency for Health Care Administration Beneficiary Assistance Program Building 1, MS #26 2000 Xxxxx Xxxxx, Tallahassee, FL 32308 (000) 000-0000 (000) 000-0000 (toll-free) The address at DCF for the Medicaid Fair Hearing office is: Office of Public Assistance Appeals Hearings 1000 Xxxxxxxx Xxxxxxxxx, Xxxxxxxx 0, Xxxx 000 Xxxxxxxxxxx, XX 00000-0000 d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify (13) Clear specifics on the required procedural steps in the Grievance Proceduregrievance process, including the address, telephone number and office hours of the Grievance grievance staff. The Health Plan shall specify phone telephone numbers for a grievant to call to present a Grievance complaint, grievance, or to contact the Grievance staffappeal. Each phone telephone number shall be toll-free within the grievantcaller’s geographic area and provide reasonable access to the Health Plan without undue delays; (14) Information that services will continue upon appeal of a denied authorization and that the enrollee may have to pay in case of an adverse ruling; (15) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s contracted choice counselor/enrollment broker. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding include the structure and operation following language verbatim in the enrollee handbook: WellCare of the Health Plan and any physician incentive plansFlorida, as set forth in 42 CFR 438.10(g)(3).Inc., Medicaid HMO Non-Reform Contract

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 including 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 Services, and use of the 911 911-telephone system, 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 newborn enrollment, including the mother’s responsibility to notify the Health Plan and the mother’s DCF case worker of the Newbornnewborn’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 Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicators, including Enrollee beneficiary information; (23) How and where to access any benefits that are available under the Medicaid State Plan, Plan but are not covered under the Contract, including any cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents;. (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager behavioral health case manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served by the same PCP or they may choose different PCPs;PCPs based on each Enrollee’s needs (29) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraudfraud, Abuse abuse and Overpaymentoverpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or and where to obtain the servicesservice. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days after the effective date of the change. d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify required procedural steps in the Grievance Procedureprocess, including the address, telephone number and office hours of the Grievance staff. The Health Plan shall specify phone numbers for a grievant to call to present a Grievance or to contact the Grievance staff. Each phone number shall be toll-free within the grievant’s geographic area and provide reasonable access to the Health Plan without undue delays. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding the structure and operation of the Health Plan health plan and any physician incentive plans, as set forth in 42 CFR 438.10(g)(3).

Enrollee Handbook Requirements. a. The Enrollee services handbook Health Plan shall have separate enrollee handbooks for Reform and non-Reform populations. The handbooks shall include the following information: (1) Table of Contentscontents; (2) Terms Terms, conditions and conditions of Enrollment procedures for enrollment including the reinstatement processprocess and enrollee rights and protections; (3) Description of the Open Enrollment processninety (90) day change period and the open enrollment process (see subparagraph (15), below, for required standardized language); (4) How to change PCPs; (5) Description of services provided, including limitations and general restrictions on Provider provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among network providers; (56) 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 Officeprior authorization; (7) Information regarding newborn enrollment, including the mother’s responsibility to notify the Health Plan and DCF of the pregnancy and the newborn’s birth; (8) Information about how to select the newborn’s PCP; (9) Emergency Services services and procedures for obtaining services both in and out of the Health Plan’s Service Areaservice area, including, an including explanation that Prior Authorization prior authorization is not required for Emergency Servicesemergency or post-stabilization services, the locations of any emergency settings and other locations at which Providers providers and Hospitals hospitals furnish Emergency Services emergency services and Postpost-Stabilization Care Services and stabilization care services, use of the 911 911- telephone system, system or its local equivalent, and other post-stabilization requirements in 42 CFR 422.113(c); (8) 10) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee enrollee has a right to use any Hospital hospital or other setting for Emergency Care; (9) Procedures for Enrollment, including Enrollee rights and protections; (10) A notice advising Enrollees how to change PCPsemergency care; (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, which and how, Enrollees how enrollees may obtain services from out-of-network providers and providers; the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, prior authorization; and other provisions in accordance with 42 CFR 438.100;; AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract (1612) Information on emergency transportation and non-emergency transportation, counseling and referral services available under about the Health Plan, and how to access these services; Subscriber Assistance Program (17) Information that interpretation services and alternative communication systems are available, free of chargeSAP, for all foreign languagesHMOs only) and the Beneficiary Assistance program (BAP, for PSNs only) and how to access these services; (18) Information that Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicatorsMedicaid Fair Hearing process, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served a review by the same PCP or they may choose different PCPs; SAP/BAP must be requested within one (291) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days year after the effective date of the change.occurrence that initiated the appeal, how to initiate a review by the SAP/BAP and the SAP/BAP address and telephone number: Agency for Health Care Administration Subscriber Assistance Program/Beneficiary Assistance Program Xxxxxxxx 0, XX #00 0000 Xxxxx Xxxxx, Tallahassee, FL 32308 (000) 000-0000 (000) 000-0000 (toll-free) d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify (13) Clear specifics on the required procedural steps in the Grievance Proceduregrievance process, including the address, telephone number and office hours of the Grievance grievance staff. The Health Plan shall specify phone telephone numbers for a grievant to call to present a Grievance complaint, grievance, or to contact the Grievance staffappeal. Each phone telephone number shall be toll-free within the grievantcaller’s geographic area and provide reasonable access to the Health Plan without undue delays; (14) Information that services will continue upon appeal of a denied authorization and that the enrollee may have to pay in case of an adverse ruling; (15) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s contracted choice counselor/enrollment broker. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding include the structure and operation 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 HEALTH PLAN NAME] or the state enrolls you in a plan, you will have 90 days from the date of your first enrollment to try the Health Plan and health plan. During the first 90 days you can change health plans for any physician incentive plansreason. After the 90 days, as set forth if you are still eligible for Medicaid, you will be enrolled in 42 CFR 438.10(g)(3)the plan for the next nine months. This is called “lock-in.”

Enrollee Handbook Requirements. a. The Enrollee services handbook Health Plan shall have separate enrollee handbooks for Reform and non-Reform populations. The handbooks shall include the following information: (1) Table of Contentscontents; (2) Terms Terms, conditions and conditions of Enrollment procedures for enrollment including the reinstatement processprocess and enrollee rights and protections; (3) Description of the Open Enrollment processninety (90) day change period and the open enrollment process (see subparagraph (15), below, for required standardized language); (4) How to change PCPs; (5) Description of services provided, including limitations and general restrictions on Provider provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among network providers; (56) 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 Officeprior authorization; (7) Information regarding newborn enrollment, including the mother’s responsibility to notify the Health Plan and DCF of the pregnancy and the newborn’s birth; (8) Information about how to select the newborn’s PCP; (9) Emergency Services services and procedures for obtaining services both in and out of the Health Plan’s Service Areaservice area, including, an including explanation that Prior Authorization prior authorization is not required for Emergency Servicesemergency or post-stabilization services, the locations of any emergency settings and other locations at which Providers providers and Hospitals hospitals furnish Emergency Services emergency services and Postpost-Stabilization Care Services and stabilization care services, use of the 911 911-telephone system, system or its local equivalent, and other post-stabilization requirements in 42 CFR 422.113(c); (8) 10) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee enrollee has a right to use any Hospital hospital or other setting for Emergency Care; (9) Procedures for Enrollment, including Enrollee rights and protections; (10) A notice advising Enrollees how to change PCPsemergency care; (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, which and how, Enrollees how enrollees may obtain services from out-of-network providers and providers; the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, prior authorization; and other provisions in accordance with 42 CFR 438.100; ; HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract (1612) Information on emergency transportation and non-emergency transportation, counseling and referral services available under about the Health Plan, and how to access these services; Subscriber Assistance Program (17) Information that interpretation services and alternative communication systems are available, free of chargeSAP, for all foreign languagesHMOs only) and the Beneficiary Assistance program (BAP, for PSNs only) and how to access these services; (18) Information that Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicatorsMedicaid Fair Hearing process, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served a review by the same PCP or they may choose different PCPs; SAP/BAP must be requested within one (291) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days year after the effective date of the change. d. The occurrence that initiated the appeal, how to initiate a review by the SAP/BAP and the SAP/BAP address and telephone number: Agency for Health PlanCare Administration Subscriber Assistance Program/Beneficiary Assistance Program Xxxxxxxx 0, in its Enrollee handbook and provider manualXX #00 0000 Xxxxx Xxxxx, shall clearly specify required procedural steps in the Grievance ProcedureTallahassee, including the address, telephone number and office hours of the Grievance staff. The Health Plan shall specify phone numbers for a grievant to call to present a Grievance or to contact the Grievance staff. Each phone number shall be FL 32308 (000) 000-0000 (000) 000-0000 (toll-free within the grievant’s geographic area and provide reasonable access to the Health Plan without undue delays. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding the structure and operation of the Health Plan and any physician incentive plans, as set forth in 42 CFR 438.10(g)(3free).

Enrollee Handbook Requirements. a. The Enrollee services handbook Health Plan shall have separate enrollee handbooks for Reform and non-Reform populations. The handbooks shall include the following information: (1) Table of Contentscontents; (2) Terms Terms, conditions and conditions of Enrollment procedures for enrollment including the reinstatement processprocess and enrollee rights and protections; (3) Description of the Open Enrollment processninety (90) day change period and the open enrollment process (see subparagraph (15), below, for required standardized language); (4) How to change PCPs; (5) Description of services provided, including limitations and general restrictions on Provider provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among network providers; (56) 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 Officeprior authorization; (7) Information regarding newborn enrollment, including the mother’s responsibility to notify the Health Plan and DCF of the pregnancy and the newborn’s birth; (8) Information about how to select the newborn’s PCP; (9) Emergency Services services and procedures for obtaining services both in and out of the Health Plan’s Service Areaservice area, including, an including explanation that Prior Authorization prior authorization is not required for Emergency Servicesemergency or post-stabilization services, the locations of any emergency settings and other locations at which Providers providers and Hospitals hospitals furnish Emergency Services emergency services and Postpost-Stabilization Care Services and stabilization care services, use of the 911 911-telephone system, system or its local equivalent, and other post-stabilization requirements in 42 CFR 422.113(c); (8) 10) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee enrollee has a right to use any Hospital hospital or other setting for Emergency Care; (9) Procedures for Enrollment, including Enrollee rights and protections; (10) A notice advising Enrollees how to change PCPsemergency care; (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, which and how, Enrollees how enrollees may obtain services from out-of-network providers and providers; the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, prior authorization; and other provisions in accordance with 42 CFR 438.100;; WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract (1612) Information on emergency transportation and non-emergency transportation, counseling and referral services available under about the Health Plan, and how to access these services; Subscriber Assistance Program (17) Information that interpretation services and alternative communication systems are available, free of chargeSAP, for all foreign languagesHMOs only) and the Beneficiary Assistance program (BAP, for PSNs only) and how to access these services; (18) Information that Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicatorsMedicaid Fair Hearing process, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served a review by the same PCP or they may choose different PCPs; SAP/BAP must be requested within one (291) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days year after the effective date of the change.occurrence that initiated the appeal, how to initiate a review by the SAP/BAP and the SAP/BAP address and telephone number: Agency for Health Care Administration Subscriber Assistance Program/Beneficiary Assistance Program Xxxxxxxx 0, XX #00 0000 Xxxxx Xxxxx, Tallahassee, FL 32308 (000) 000-0000 (000) 000-0000 (toll-free) d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify (13) Clear specifics on the required procedural steps in the Grievance Proceduregrievance process, including the address, telephone number and office hours of the Grievance grievance staff. The Health Plan shall specify phone telephone numbers for a grievant to call to present a Grievance complaint, grievance, or to contact the Grievance staffappeal. Each phone telephone number shall be toll-free within the grievantcaller’s geographic area and provide reasonable access to the Health Plan without undue delays; (14) Information that services will continue upon appeal of a denied authorization and that the enrollee may have to pay in case of an adverse ruling; (15) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s contracted choice counselor/enrollment broker. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding include the structure and operation following language verbatim in the enrollee handbook: Enrollment: If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in [INSERT HEALTH PLAN NAME] or the state enrolls you in a plan, you will have 90 days from the date of your first enrollment to try the Health Plan and health plan. During the first 90 days you can change health plans for any physician incentive plansreason. After the 90 days, as set forth if you are still eligible for Medicaid, you will be enrolled in 42 CFR 438.10(g)(3)the plan for the next nine months. This is called “lock-in.”

Enrollee Handbook Requirements. a. The Enrollee services handbook Health Plan shall have separate enrollee handbooks for Reform and non-Reform populations. The handbooks shall include the following information: (1) Table of Contentscontents; (2) Terms Terms, conditions and conditions of Enrollment procedures for enrollment including the reinstatement processprocess and enrollee rights and protections; (3) Description of the Open Enrollment processninety (90) day change period and the open enrollment process (see subparagraph (15), below, for required standardized language); (4) How to change PCPs; (5) Description of services provided, including limitations and general restrictions on Provider provider access, exclusions and out-of-network use, and any restrictions on enrollee freedom of choice among network providers; (56) Procedures for obtaining required services, including second opinionsopinions at no expense to the enrollee, and authorization requirements, including those services available without Prior Authorization; (6) Toll-free telephone number of the appropriate Area Medicaid Officeprior authorization; (7) Information regarding newborn enrollment, including the mother’s responsibility to notify the Health Plan and DCF of the pregnancy and the newborn’s birth; (8) Information about how to select the newborn’s PCP; (9) Emergency Services services and procedures for obtaining services both in and out of the Health Plan’s Service Areaservice area, including, an including explanation that Prior Authorization prior authorization is not required for Emergency Servicesemergency or post-stabilization services, the locations of any WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract emergency settings and other locations at which Providers providers and Hospitals hospitals furnish Emergency Services emergency services and Postpost-Stabilization Care Services and stabilization care services, use of the 911 911- telephone system, system or its local equivalent, and other post-stabilization requirements in s. 1932(b)(2)(A)(ii) of the Social Security Act.; (8) 10) The extent to which, and how, after-hours and emergency coverage is provided, and that the Enrollee enrollee has a right to use any Hospital hospital or other setting for Emergency Care; (9) Procedures for Enrollment, including Enrollee rights and protections; (10) A notice advising Enrollees how to change PCPsemergency care; (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, which and how, Enrollees how enrollees may obtain services from out-of-network providers and providers; the right to obtain family planning services from any participating Medicaid provider without Prior Authorization for such services, prior authorization; and other provisions in accordance with 42 CFR 438.100; (1612) Information on emergency transportation about the Beneficiary Assistance program (BAP) 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 Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicatorsMedicaid Fair Hearing process, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served a review by the same PCP or they may choose different PCPs; BAP must be requested within one (291) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days year after the effective date of the change.occurrence that initiated the appeal, how to initiate a review by the BAP and the BAP address and telephone number: Agency for Health Care Administration Beneficiary Assistance Program Building 1, MS #26 0000 Xxxxx Xxxxx, Tallahassee, FL 32308 (000) 000-0000 (000) 000-0000 (toll-free) The address at DCF for the Medicaid Fair Hearing office is: Office of Public Assistance Appeals Hearings 0000 Xxxxxxxx Xxxxxxxxx, Xxxxxxxx 0, Xxxx 000 Xxxxxxxxxxx, XX 00000-0000 d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify (13) Clear specifics on the required procedural steps in the Grievance Proceduregrievance process, including the address, telephone number and office hours of the Grievance grievance staff. The Health Plan shall specify phone telephone numbers for a grievant to call to present a Grievance complaint, grievance, or to contact the Grievance staffappeal. Each phone telephone number shall be toll-free within the grievantcaller’s geographic area and provide reasonable access to the Health Plan without undue delays; (14) Information that services will continue upon appeal of a denied authorization and that the enrollee may have to pay in case of an adverse ruling; (15) Enrollee rights and procedures for enrollment and disenrollment, including the toll-free telephone number for the Agency’s contracted choice counselor/enrollment broker. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding include the structure and operation following language verbatim in the enrollee handbook: Enrollment: WellCare of the Health Plan and any physician incentive plansFlorida, as set forth in 42 CFR 438.10(g)(3).Inc., Medicaid HMO Non-Reform Contract

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 Post-Stabilization Services are provided without Prior Authorization and other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c); (19) Information that services will continue upon appeal of a suspended authorization and that the Enrollee may have to pay in case of an adverse ruling; (20) Information regarding health care Advance Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128; (21) Cost sharing for the Enrollee, if any; (22) Instructions explaining how Enrollees may obtain information from the Health Plan regarding quality performance indicators, including Enrollee information; (23) How and where to access any benefits that are available under the State Plan, but not covered under the Contract, including cost sharing; (24) Any restrictions on the Enrollee's ’s freedom of choice among network Providers; (25) A release document for each Enrollee authorizing the Health Plan to release medical information to the federal and State governments or their duly appointed Agents; (26) A notice that clearly states that the Enrollee may select an alternative Behavioral Health Care Case Manager or direct service provider within the Health Plan, if one is available; (27) A description of Behavioral Health Services provided, including limitations, exclusions and out-of-network use; (28) An explanation that Enrollees may choose to have all family members served by the same PCP or they may choose different PCPs; (29) A description of Emergency Behavioral Health Services procedures both in and out of the Health Plan's ’s Service Area; (30) Information to assist the Enrollee in assessing a potential behavioral health problem; (31) Procedures for reporting Fraud, Abuse and Overpayment; and (32) Information regarding HIPAA relative to the Enrollee’s personal health information (PHI). b. For a counseling or referral service that the Health Plan does not cover because of moral or religious objections, the Health Plan need not furnish information on how and/or where to obtain the services. c. Written information regarding Advance Directives provided by the Health Plan must reflect changes in State law as soon as possible, but no later than ninety (90) days after the effective date of the change. d. The Health Plan, in its Enrollee handbook and provider manual, shall clearly specify required procedural steps in the Grievance Procedure, including the address, telephone number and office hours of the Grievance staff. The Health Plan shall specify phone numbers for a grievant to call to present a Grievance or to contact the Grievance staff. Each phone number shall be toll-free within the grievant’s geographic area and provide reasonable access to the Health Plan without undue delays. The Grievance System must provide an adequate number of phone lines to handle incoming Grievances and Appeals. e. The Health Plan shall make information available upon request regarding the structure and operation of the Health Plan and any physician incentive plans, as set forth in 42 CFR 438.10(g)(3).