Common use of Enrollee Handbook Clause in Contracts

Enrollee Handbook. Insurer shall provide an Enrollee handbook based on the model Enrollee handbook provided by FHKC. Insurer shall customize such material to the extent permitted or required by FHKC. The handbook shall include the following elements: a. A description of benefits and any associated cost sharing sufficient to ensure that Enrollees understand the benefits covered by this Contract, including the scope, amount, duration, and limitations associated with a Covered Service. b. A description of how to access services, including any requirements for prior authorization of any services, referrals for specialty care, or any other restrictions on choice among network Providers. c. Disclosure of any services Insurer does not cover because of moral or religious objections and instructions about how to obtain information from FHKC about how to access any such services. d. The extent to which, and how, Enrollees may obtain Covered Services. e. A description of Emergency Medical Conditions and services, including post-stabilization services, including what constitutes an emergency, the fact that prior authorization is not required, and that Enrollee has a right to use any hospital or setting for emergency care. f. The process for selecting and changing the Enrollee’s PDP; g. A description of the Grievance and Appeal process, including the right to file and the availability of assistance in the filing process; h. A description of the Enrollee’s rights and responsibilities; i. How to access auxiliary aids and services, including accessing information in alternative formats or languages; j. The toll-free telephone number for Enrollee services and any other unit providing services directly to Enrollees; k. How to report suspected Fraud or Abuse; and l. Any other information required by FHKC.

Enrollee Handbook. Insurer shall provide an Enrollee handbook based on the model Enrollee handbook provided by FHKC. Insurer shall customize such material to the extent permitted or required by FHKC. The handbook shall include the following elements: a. A description of benefits and any associated cost sharing sufficient to ensure that Enrollees understand the benefits covered by this Contract, including the scope, amount, duration, duration and limitations associated with a Covered Servicebenefit. b. A description of how to access services, including any requirements for prior authorization of any services, referrals for specialty care, care or any other restrictions on choice among network Providers. c. Disclosure of any services Insurer does not cover because of moral or religious objections and instructions about how to obtain information from FHKC about how to access any such services. d. The extent to which, and how, Enrollees may obtain Covered Servicesbenefits, including family planning services and supplies from out-of-network Providers and an explanation that Insurer cannot require an Enrollee to obtain a referral before choosing a family planning Provider. e. A description of Emergency Medical Conditions and services, including post-stabilization services, including what constitutes an emergency, the fact that prior authorization is not required, and that Enrollee has a right to use any hospital or setting for emergency care. f. The process for selecting and changing the Enrollee’s PDPPCP; g. A description of the Grievance and Appeal process, including the right to file and the availability of assistance in the filing process; h. A description of the Enrollee’s rights and responsibilities; i. An explanation about how to exercise an advance directive; j. How to access auxiliary aids and services, including accessing information in alternative formats or languages; j. k. The toll-free telephone number for Enrollee services Services and any other unit providing services directly to Enrollees; k. l. How to report suspected Fraud or Abuse; and l. m. Any other information required by FHKC.

Enrollee Handbook. Insurer shall provide an Enrollee handbook based on the model Enrollee handbook provided by FHKC. Insurer shall customize such material to the extent permitted or required by FHKC. {Insurer shall provide separate Enrollee handbooks for the Title XXI population and the Full-pay population (full-pay and subsidized)} The handbook shall include the following elements: a. : A description of benefits and any associated cost sharing sufficient to ensure that Enrollees understand the benefits covered by this Contract, including the scope, amount, duration, duration and limitations associated with a Covered Service. b. benefit. A description of how to access services, including any requirements for prior authorization of any services, referrals for specialty care, care or any other restrictions on choice among network Providers. c. Disclosure of any services Insurer does not cover because of moral or religious objections and instructions about how to obtain information from FHKC about how to access any such services. d. . The extent to which, and how, Enrollees may obtain Covered Services. e. benefits, including family planning services and supplies from out-of-network Providers and an explanation that Insurer cannot require an Enrollee to obtain a referral before choosing a family planning Provider. A description of Emergency Medical Conditions and services, including post-stabilization services, including what constitutes an emergency, the fact that prior authorization is not required, and that Enrollee has a right to use any hospital or setting for emergency care. f. . The process for selecting and changing the Enrollee’s PDP; g. PCP; A description of the Grievance and Appeal process, including the right to file and the availability of assistance in the filing process; h. ; A description of the Enrollee’s rights and responsibilities; i. ; An explanation about how to exercise an advance directive; How to access auxiliary aids and services, including accessing information in alternative formats or languages; j. ; The toll-free telephone number for Enrollee services Services and any other unit providing services directly to Enrollees; k. ; How to report suspected Fraud or Abuse; and l. and Any other information required by FHKC. Provider directory. Insurer shall make a Provider directory available on Insurer’s website in a machine-readable file and format, 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, the Provider directory must contain the following information for each PCP, specialist (including behavioral health Providers), hospital and pharmacy: Provider name; Provider group affiliation, if any; Specialty, as appropriate; Street Address(es); Telephone number(s); Website URL, if any; Office hours; Age limitations, if any; Non-English languages, including American Sign Language, spoken by the Provider or a skilled medical interpreter at the Provider’s office; Whether Provider has completed cultural competency training; Whether Provider’s office or facility has accommodations for people with physical disabilities, including offices, exam rooms and equipment; and Whether the Provider is accepting new patients. 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 on Insurer’s website in a machine-readable file and format, in accordance with state and federal regulations. 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 apply sixty (60) Calendar Days prior to the effective date of the change. 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 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 from a terminating network Provider within fifteen (15) Calendar Days of receipt or issuance of the Provider termination notice. Advance Directives. Insurer shall provide adult Enrollees with written information on 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 reflect 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 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 the intended final format, including quality of images used and removal of watermarks from stock photos. 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 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 the original submission if needed to effectively and efficiently review and provide feedback on the material.