Common use of Enrollee Handbook Clause in Contracts

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 DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; • Information for potential enrollees about the basic functions of managed care; • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • DVHA responsibilities for coordination of enrollee care; • Information on specialty referrals, including long term services and supports under the Choices for Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees • The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA 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. {Insurer shall provide separate Enrollee handbooks for the Title XXI population and AHS will coordinate the development Full-pay population (full-pay and subsidized)} The handbook shall include the following elements: A description of the Global Commitment benefits and any associated cost sharing sufficient to Health Demonstration enrollee handbook, which is intended to help enrollees and potential enrollees ensure that Enrollees understand the requirements benefits covered by this Contract, including the scope, amount, duration and benefits of the various programs available through the Global Commitment to Health Demonstrationlimitations associated with a benefit. 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 A description of the Global Commitment to Health Demonstration, including a description of covered benefits, how to access services in urgent services, including any requirements for prior authorization of any services, referrals for specialty care or any other restrictions on choice among network Providers. The extent to which, and emergent situationshow, how to access services in other situations (Enrollees may obtain benefits, including family planning services and providers supplies from out-of-network Providers and an explanation that Insurer cannot participating in require an Enrollee to obtain a referral before choosing a family planning Provider. A description of Emergency Medical Conditions and services, including post-stabilization services, including what constitutes an emergency, the Vermont Medicaid program), complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment rights, advance directivesfact that prior authorization is not required, and that Enrollee has a right to use any hospital or setting for emergency care. The process for selecting and changing the methods by which a member can select a provider based on specific language requirements. With respect to information on grievanceEnrollee’s PCP; A description of the Grievance and Appeal process, appeal and Fair Hearing procedures and timeframes, including 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 right to file grievances and appeals; • Requirements and timeframes for filing a grievance or appeal; • Availability the availability of assistance in the filing process; • TollA description of the Enrollee’s rights and responsibilities; An explanation about how to exercise an advance directive; How to access auxiliary aids and services, including accessing information in alternative formats or languages; The 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 telephone number 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 DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; • Information for potential enrollees about the basic functions of managed care; • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • DVHA responsibilities for coordination of enrollee care; • Information on specialty referrals, including long term services and supports under the Choices for Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration Enrollee Services and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to enrolleesEnrollees; How to report suspected Fraud or Abuse; and Any other information required by FHKC. DVHA provides to its enrollees information about providersProvider directory. Insurer shall make a Provider directory available on Insurer’s website in a machine-readable file and format, which as specified by the Secretary of HHS, as well as in paper form upon request. Insurer shall also make a searchable electronic Provider Directory available on Insurer’s website. Information included in a hardcopy Provider directory or a printable electronic Provider directory must be updated at least monthly. Searchable electronic Provider directories must be updated no later than thirty (30) Calendar Days after Insurer receives updated Provider information. At a minimum, includes primary care physiciansthe Provider directory must contain the following information for each PCP, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, specialist (including specialists, hospitals, pharmacies, behavioral health providersProviders), hospital and LTSS providers will include the following informationpharmacy: • The provider’s name and any Provider name; Provider group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • if any; Specialty, as appropriate. • Whether the provider will accept new enrollees • The provider’s cultural and linguistic capabilities; Street Address(es); Telephone number(s); Website URL, including languages (if any; Office hours; Age limitations, if any; Non-English languages, including American Sign Language) offered , spoken by the provider Provider or a skilled medical interpreter at the providerProvider’s office, and whether the provider ; Whether Provider has completed cultural competence training • competency training; Whether the providerProvider’s office/office or facility has accommodations for people with physical disabilities, including offices, exam room(s) rooms and equipment; and Whether the Provider is accepting new patients. The provider directory will Preferred Drug List (PDL). Insurer shall make information about which generic and brand name medications are covered in Insurer’s formulary available in print and electronic formats. Insurer’s PDL must be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHAInsurer’s web site website in a machine-readable file and format, in accordance with state and federal regulations. DVHA Insurer shall notify Enrollees who have filled a prescription in the last twelve (12) months for a medication that is being removed from the PDL or for which additional utilization management requirements will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered apply sixty (both generic and name brand); and • Identify which tier each medication is on. DVHA will notify its enrollees in writing of any change that AHS defines as significant 60) Calendar Days prior to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions Enrollee Handbook Notice of Change. Insurer shall provide Enrollees with a notice of change for any significant changes, as determined by FHKC, made to the Enrollee handbook. Any such notices must be provided to Enrollees at least thirty (30) Calendar Days prior to the effective date of such change. Notice of Network Provider Termination. Insurer shall notify Enrollees who received services from a terminating provider within the past six (6) months of such termination at least sixty (60) Calendar Days before the effective date of the following managed termination. When such notice is not possible, Insurer shall make a good faith effort to provide written notice to Enrollees who received primary or regular care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In from a readily accessible format, o Placed in a location on terminating network Provider within fifteen (15) Calendar Days of receipt or issuance of the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent Provider termination notice. Advance Directives. Insurer shall provide adult Enrollees with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how advance directive policies, including a description of applicable Florida law, within five (5) Business Days of the Enrollee’s eighteenth birthday or enrollment in the event an Enrollee enrolls in coverage at age eighteen (18). Such information must be updated to request auxiliary aids and servicesreflect changes in State law within ninety (90) Calendar Days of the effective date of such change. Certificates of Creditable Coverage. Insurer is responsible for issuing certificates of creditable coverage to Enrollees upon the Enrollee’s request. Enrollee Material Review Process All Enrollee materials must be approved by FHKC prior to distribution. Insurer shall submit Enrollee materials to FHKC for approval no less than thirty (30) Calendar Days prior to Insurer’s intended publication or utilization date, unless otherwise approved or required by FHKC. The total Enrollee material review time from initial submission to final determination is dependent on multiple factors, including the provision condition of the original submission, the time Insurer takes to make any requested changes and the length and complexity of the materials. This provision in no way guarantees a final determination within the thirty (30) Calendar Days. For Enrollee materials with multiple versions, Insurer shall submit a copy of each version with the request. Insurer shall be responsive to FHKC’s comments, questions, requests for more information and other such requests. Failure to be responsive to such requests or failure to provide sufficient information or appropriate changes may result in denial of Insurer’s Enrollee materials. Insurer shall provide Enrollee materials in alternative formatsthe intended final format, including quality of images used and removal of watermarks from stock photos. Large print means printed Insurer may submit Enrollee materials that include marks such as stock photo watermarks during the review period, but must subsequently provide a copy of the final Enrollee material with all such marks removed. Such Enrollee materials are not considered approved until the submission of the unmarked form to FHKC, regardless of any approval of the draft, marked material. Insurer shall provide Enrollee materials electronically and in a font size no smaller format in which FHKC may use standard software functionality to create redlines or insert comments. FHKC may require Insurer to submit any Enrollee materials in a different format than 18 pointthe original submission if needed to effectively and efficiently review and provide feedback on the material.

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 for filing 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 by the 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 DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; • Information for potential enrollees about the basic functions of managed care; • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • DVHA responsibilities for coordination of enrollee care; • Information on specialty referrals, including long term services and supports under the Choices for Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providersnetworkproviders. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees • The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS will shall coordinate the development of the Global Commitment to Health Demonstration Waiver enrollee handbook, which is intended to shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health DemonstrationWaiver. DVHA will shall mail the enrollee handbook to all new enrollee households within 45 business days of determination of eligibility for the Global Commitment to Health DemonstrationWaiver. Enrollees may request and obtain an enrollee handbook at any time. The enrollee handbook must be specific to the Global Commitment to Health Demonstration Waiver and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a summary comprehensive description of the Global Commitment to Health DemonstrationWaiver, 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, and 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 Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe forfiling for filing a request, and rules that govern representation at the hearing; • Rights Right 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 can 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 of Vermont makes available to providers to challenge a denial by the failure of DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. ; The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; • Information for potential enrollees about the basic functions of managed care; • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • DVHA responsibilities for coordination of enrollee care; • Information on specialty referrals, including long term services and supports under the Choices for Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' enrollee right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100438.100 and IGA Section 2.15; • Information on enrollee cost sharing; and • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to enrollees. DVHA MCE provides to its enrollees information about providerson providers which, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providersinformation: • Includes provider names, locations, and telephone numbers; , • Identifies providers that speak any non-English languages; . • Information on specialty referrals; and . • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees • The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will shall notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration Waiver enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA and AHS will shall coordinate the development of the Global Commitment to Health Demonstration enrollee handbook, which is intended to shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health Demonstration. DVHA will shall 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 comprehensive 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 oninformation: • Rights Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe forfiling for filing a request, and rules that govern representation at the hearing; • Rights Right 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 can use to obtain assistance in filing a grievance or an appeal, including the Long-Term Care Ombudsmen and/or other independent advocates designated bythe by the 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 of Vermont makes available to providers to challenge a denial by the failure of DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information Information 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; . • Information for potential enrollees about the basic functions of managed care; • Which which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • and DVHA responsibilities for coordination of enrollee care; . • Information on specialty referrals, including long term services and supports under the Choices for Care programProgram; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the • Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits, benefits including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycareemergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to directlyto enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees enrollees. • The provider’s cultural and linguistic capabilities, including languages (including American Sign AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training training. • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its their web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will shall notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print Largeprint means printed in a font size no smaller than 18 point.

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 for filing 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 by the 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 DVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; . • Information for potential enrollees about the basic functions of managed care; • Which which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • and DVHA responsibilities for coordination of enrollee care; . • Information on specialty referrals, including long term services and supports under the Choices for Choicesfor Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- and after- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycareemergency care; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to directlyto enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees enrollees. • The provider’s cultural and linguistic capabilities, including languages (including American Sign AmericanSign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training training. • Whether the provider’s office/facility has accommodations for people with physical disabilitiesphysicaldisabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will notify its enrollees in writing of any change that AHS defines as significant to the information in the Global Commitment to Health Demonstration enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon charge upon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan in an appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print Largeprint means printed in a font size no smaller than 18 point.

Enrollee Handbook. DVHA The OVHA and the AHS will shall coordinate the development of the Global Commitment to Health Demonstration Waiver enrollee handbook, which is intended to shall help enrollees and potential enrollees understand the requirements and benefits of the various programs available through the Global Commitment to Health DemonstrationWaiver. DVHA will The OVHA shall mail the enrollee handbook to all new enrollee households enrollees 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 timeWaiver. The enrollee handbook must be specific to the Global Commitment to Health Demonstration Waiver and be written in language that is clear and easily understood by an elementary-level reader. The enrollee handbook must include a summary comprehensive description of the Global Commitment to Health DemonstrationWaiver, 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)situations, complaint and grievance procedures, appeal procedures (for eligibility determinations or service denials), enrollee disenrollment dis-enrollment rights, and 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 Waiver enrollee handbook must include the following information oninformation: • Rights Right to a State of Vermont Fair Hearing, method for obtaining a hearing, timeframe forfiling for filing a request, timeframes for resolution of the Fair Hearing, and rules that govern representation at the hearing; • Rights Right 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 can 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 of Vermont makes available to providers to challenge a denial by DVHA the failure of the OVHA to cover a service; and • Information about Advance Directives and the service providers’ obligation to honor the terms of such directives. The following additional information must also be included in the enrollee handbook: • Sufficient information on the amount, duration, ; and scope of benefits available under the contract in detail to ensure that enrollees understand the benefits to which they are entitled; • Information for potential enrollees about the basic functions of managed care; • Which populations are excluded from enrollment, subject to mandatory enrollment, or free to enroll voluntarily in the program; • DVHA responsibilities for coordination of enrollee care; • Information on specialty referrals, including long term services and supports under the Choices for Care program; • Information on unrestricted access to family planning services; • Information on accessing emergent and urgent care (including post-stabilization services andafter- hours care); • Information on enrollee disenrollment; • Information on enrollees' right to change providers; • Information on restrictions to freedom of choice among network providers; • Information on enrollee rights and protections, as specified in 42 CFR 438.100; • Information on enrollee cost sharing; • Additional information that is available upon request, including information on the structure of the Global Commitment to Health Demonstration Waiver and any physician incentive plans; and • Information on how enrollees can access benefits, including information about prior authorization requirements and services from out-of-network providers. The enrollee handbook also will include: • What constitutes an emergency medical condition and emergency services; • That prior authorization is not required for emergency services; • That the enrollee has the right to use any hospital or other setting for emergencycare; • Toll-free and TTY/TDY numbers for member services and any unit providing services directly to enrollees. DVHA provides to its enrollees information about providers, which at a minimum, includes primary care physicians, specialists, and hospitals. The information on providers: • Includes provider names, locations, and telephone numbers; • Identifies providers that speak any non-English languages; • Information on specialty referrals; and • Identifies providers that are not accepting new patients. DVHA’s provider directory for physicians, including specialists, hospitals, pharmacies, behavioral health providers, and LTSS providers will include the following information: • The provider’s name and any group affiliation. • Street address(es). • Telephone number(s). • Web site URL, as appropriate. • Specialty, as appropriate. • Whether the provider will accept new enrollees • The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office, and whether the provider has completed cultural competence training • Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment. The provider directory will be available in paper format upon request and must be updated at least monthly; electronic provider directories must be updated no later than 30 calendar days after DVHA receives updated provider information. Electronic provider directories must be made available on DVHA’s web site in a machine-readable file and format. DVHA will assure that the following information about its formulary is available on its web site in a machine-readable file and format and provide: • Which medications are covered (both generic and name brand); and • Identify which tier each medication is on. DVHA will OVHA shall notify its enrollees in writing of any change that the AHS defines as significant to the information in the Global Commitment to Health Demonstration Waiver enrollee handbook at least 30 business days before the intended effective date of the change. DVHA will assure that: • All informational material will adopt uniform AHS definitions of the following managed care terms: o Appeal, o Copayment, o Durable medical equipment, o Emergency medical condition, o Emergency medical transportation, o Emergency room care, o Emergency services, o Excluded services, o Grievance, o Habilitation services and devices, o Health insurance, o Home health care, o Hospice services, o Hospitalization, o Hospital outpatient care, o Medically necessary, o Network, o Non-participating provider, o Physician services plan, o Preauthorization, o Participating provider, o Premium, o Prescription drug coverage, o Prescription drugs, o Primary care physician, o Primary care provider, o Provider, o Rehabilitation services and devices, o Skilled nursing care, o Specialist, and o Urgent care; • Any information provided to enrollees electronically is: o In a readily accessible format, o Placed in a location on the Web site that is prominent and readily accessible, o In an electronic form, which can be electronically retained and printed, o Consistent with the content and language requirements of 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without chargeupon request and provided upon request within 5 business days. • All written materials for potential enrollees and enrollees must: o Use easily understood language and format; o Use a font size no smaller than 12 point; o Be available in alternative formats and through the provision of auxiliary aids and services inan appropriate manner that takes into consideration the special needs of enrollees or potential enrollees with disabilities or limited English proficiency; and o Include a large print tagline and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats. Large print means printed in a font size no smaller than 18 point.