Common use of Enrollee Information Clause in Contracts

Enrollee Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE: (A) Certificate of Coverage (COC). A Certificate of Coverage (COC) that has received prior approval by the STATE and CMS, and that includes the following: (1) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (2) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations and exclusions; (3) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (4) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (5) A description of Enrollee appeal rights for denial of prescription drug coverage; (6) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (7) Cost sharing, if applicable; (8) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (9) Information about providing coverage for prescriptions that are dispensed as written (DAW); (10) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and services; (11) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments; (12) A description of how Enrollees may access services to which they are entitled under Medical Assistance, as described in Article 6, but are not provided under this Contract; (13) A description of Medical Necessity for mental health services listed in Minnesota Statutes, § 62Q.53; (14) A description of how transportation is provided; (15) A description of how the Enrollee may obtain services, including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Plan care; and 7) how to obtain accessibility information required under section 6.48. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers; (16) A toll-free telephone number that the Enrollee may contact regarding MCO coverage or procedures, and updated information regarding Providers, language spoken and open and closed panels of Providers; (17) The number of the 24-hour telephone nurse line where an RN can be reached for assistance related to urgent medical needs or emergency care; (18) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s internal Grievance System procedures, the availability of an expert medical opinion from an external organization pursuant to section 8.3.1(B)(11)(g), the ability of internal Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion within the MCO. This includes, but is not limited to: (a) For State Fair Hearing: the right to a hearing; the method for obtaining a hearing; and the rules that govern representation at the hearing. (b) The right to file Grievances and Appeals. (c) The requirements and timeframes for filing a Grievance or Appeal. (d) The availability of assistance in the filing process. (e) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (f) An explanation that when an Appeal is requested by the Enrollee: (i) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing; and (ii) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (19) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (20) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services, and Out of Service Area Urgent Services; (21) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (22) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the prepaid plan uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results; and (23) A description of the Enrollee’s right to request the results of an external quality review study and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.

Enrollee Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE:STATE:‌ (A1) Certificate of Coverage (COC). A Certificate of Coverage (COC) that has received prior approval been Prior-Approved by the STATE and CMS, and that includes the following: (1) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (2a) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations limitations, and exclusions; (3) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (4) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (5) A description of Enrollee appeal rights for denial of prescription drug coverage; (6b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (7c) Cost sharing, if applicable; (8) d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (9e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (10f) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and servicesservices according to title VI of the Civil Rights Act and federal regulations adapted under that law, or any guidance from the United States Department of Health and Human Services; (11g) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments; (12h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, as described in Article 6section 6.6, but are not provided under this Contract; (13i) A description of Medical Necessity for mental health services listed in under Minnesota Statutes, § 62Q.53;; Section 20.2 to 20.2.8 39 (14j) A description of how transportation is provided; (15k) A description of how the Enrollee may obtain services, including: 1) including hours of service; 2) , appointment procedures; 3) , Service Authorization requirements and procedures; 4) , what constitutes Medical Emergency and Post Stabilization care; 5) care and the process and procedures for obtaining both Medical Emergency and Post Stabilization careboth, including a 24twenty-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Plan care; and 7) how to obtain accessibility information required under section 6.48. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers; (16) A toll-free telephone number that the Enrollee may contact regarding MCO coverage or procedures, and updated information regarding Providers, language spoken and open and closed panels of Providers; (17) The number of the 24-hour telephone nurse line where an RN can be reached for assistance related to urgent medical needs or emergency care; (18) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s internal Grievance System procedures, the availability of an expert medical opinion from an external organization pursuant to section 8.3.1(B)(11)(g), the ability of internal Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion within the MCO. This includes, but is not limited to: (a) For State Fair Hearing: the right to a hearing; the method for obtaining a hearing; and the rules that govern representation at the hearing. (b) The right to file Grievances and Appeals. (c) The requirements and timeframes for filing a Grievance or Appeal. (d) The availability of assistance in the filing process. (e) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (f) An explanation that when an Appeal is requested by the Enrollee: (i) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing; and (ii) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (19) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (20) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services, and Out of Service Area Urgent Services; (21) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (22) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the prepaid plan uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results; and (23) A description of the Enrollee’s right to request the results of an external quality review study and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.four

Enrollee Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE:STATE:‌ (A1) Certificate of Coverage (COC). A Certificate of Coverage (COC) that has received been prior approval approved by the STATE and CMS, and that includes the following: (1a) A statement that Enrollees are accountable to make efforts to maintain their health and inform their coordinator and health care Providers of changes in their health. (2b) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations and exclusions;. (3) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (4) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (5) A description of Enrollee appeal rights for denial of prescription drug coverage; (6c) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100;. (7d) Cost sharing, if applicable;. (8) e) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14;. (9f) Information about providing coverage for prescriptions that are dispensed as written (DAW);. (10g) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and services;services according to title VI of the Civil Rights Act and federal regulations adapted under that law, or any guidance from the United States Department of Health and Human Services. (11h) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments;. (12i) A description of how Enrollees may gain access to services to which they are entitled under Medical Assistance, as described in Article 6, but are which the MCO does not provided provide under this Contract;. (13j) A description of Medical Necessity for mental health services listed in under Minnesota Statutes, § 62Q.53;. (14k) The COC must also include a notice that MnDHO Enrollees who are eligible for CADI or TBI waiver programs may retain their eligibility for these programs should they disenroll from MnDHO, if the county has a waiver slot available and if the Enrollee meets county or State eligibility criteria. (l) A description of how transportation is provided;. (15m) A description of how the Enrollee may obtain services, including: 1) hours of service; 2) appointment procedures; 3) Service Authorization requirements and procedures; 4) what constitutes Medical Emergency and Post Stabilization care; 5) the process and procedures for obtaining both Medical Emergency and Post Stabilization care, including a 24-hour telephone number for Medical Emergency Services; and 6) procedures for Urgent Care, and Out of Plan care; care and 7) how to obtain accessibility information required under section 6.48Enrollees may access Home and Community-Based Services. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers;. (16n) A toll-free telephone number that the Enrollee may contact regarding MCO coverage or procedures, and updated information regarding Providers, language spoken and open and closed panels of Providers; (17) The number of the 24-hour telephone nurse line where an RN can be reached for assistance related to urgent medical needs or emergency care; (18) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s internal Grievance System procedures, the availability of an expert medical opinion from an external organization pursuant to section 8.3.1(B)(11)(g), the ability of internal Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion within the MCO. This includes, but is not limited to: (a) For State Fair Hearing: the right to a hearing; the method for obtaining a hearing; and the rules that govern representation at the hearing. (b) The right to file Grievances and Appeals. (c) The requirements and timeframes for filing a Grievance or Appeal. (d) The availability of assistance in the filing process. (e) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (f) An explanation that when an Appeal is requested by the Enrollee: (i) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing; and (ii) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (19) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (20) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services, and Out of Service Area Urgent Services; (21) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (22) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the prepaid plan uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results; and (23) A description of the Enrollee’s right to request the results of an external quality review study and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.

Enrollee Information. The MCO shall present to all new Enrollees the following information within fifteen (15) calendar days of availability of readable enrollment data from the STATE:STATE:‌ (A1) Certificate of Coverage (COC). A Certificate of Coverage (COC) that has received prior approval been Prior-Approved by the STATE and CMS, and that includes the following: (1) A statement that Enrollees are accountable to make efforts to maintain their health and inform health care Providers of changes in their health. (2a) A description of the MCO’s medical and remedial care program, including specific information on benefits, limitations limitations, and exclusions; (3) A description of the MCO’s policies related to access to Case Management or Care Management services from the MCO; (4) An explanation of the MCO’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT), known in Minnesota and hereinafter as the Child and Teen Checkups (C&TC) program; (5) A description of Enrollee appeal rights for denial of prescription drug coverage; (6b) A description of the Enrollee’s rights and protections as specified in 42 CFR § 438.100; (7c) Cost sharing, if applicable; (8) d) Notification of the open access of Family Planning Services and services prescribed by Minnesota Statutes, § 62Q.14; (9e) Information about providing coverage for prescriptions that are dispensed as written (DAW); (10f) A statement informing Enrollees that the MCO shall provide language assistance to Enrollees that ensures meaningful access to its programs and servicesservices according to title VI of the Civil Rights Act and federal regulations adapted under that law, or any guidance from the United States Department of Health and Human Services; (11g) A description of how American Indian Enrollees may directly access Indian Health Service and certain tribal Providers and how such Enrollees shall obtain referral services. In prior approving this portion of the COC, the STATE shall consult with tribal governments; (12h) A description of how Enrollees may access services to which they are entitled under Medical Assistance, as described in Article 6section 6.6, but are not provided under this Contract; (13i) A description of Medical Necessity for mental health services listed in under Minnesota Statutes, § 62Q.53; (14j) A description of how transportation is provided; (15k) A description of how the Enrollee may obtain services, including: 1) including hours of service; 2) , appointment procedures; 3) , Service Authorization requirements and procedures; 4) , what constitutes Medical Emergency and Post Stabilization care; 5) care and the process and procedures for obtaining both Medical Emergency and Post Stabilization careboth, including a 24twenty-hour telephone number for Medical Emergency Services; 6) procedures for Urgent Care, and Out of Plan care; and 7) how to obtain accessibility information required under section 6.48. The MCO must indicate that Service Authorization is not required for Medical Emergencies and that the Enrollee has a right to use any hospital or other setting for Emergency Care. If the MCO does not allow direct access to specialty care, the MCO must inform Enrollees the circumstances under which a referral may be made to such Providers; (16) A toll-free telephone number that the Enrollee may contact regarding MCO coverage or procedures, and updated information regarding Providers, language spoken and open and closed panels of Providers; (17) The number of the 24-hour telephone nurse line where an RN can be reached for assistance related to urgent medical needs or emergency care; (18) A description of all Grievance, Appeal and State Fair Hearing rights and procedures available to Enrollees, including the MCO’s internal Grievance System procedures, the availability of an expert medical opinion from an external organization pursuant to section 8.3.1(B)(11)(g), the ability of internal Grievances, Appeals and State Fair Hearings to run concurrently, and the availability of a second opinion within the MCO. This includes, but is not limited to: (a) For State Fair Hearing: the right to a hearing; the method for obtaining a hearing; and the rules that govern representation at the hearing. (b) The right to file Grievances and Appeals. (c) The requirements and timeframes for filing a Grievance or Appeal. (d) The availability of assistance in the filing process. (e) The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal by phone. (f) An explanation that when an Appeal is requested by the Enrollee: (i) Benefits will continue if the Enrollee files an Appeal or a request for State Fair Hearing within the timeframes specified for filing; and (ii) The Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee. (19) Any Appeal rights under state law available to Providers to challenge the failure of the MCO to cover a service; (20) A description of the MCO’s obligation to assume financial responsibility and provide reimbursement for Medical Emergency Services, Post- Stabilization Care Services, and Out of Service Area Urgent Services; (21) General descriptions of the coverage for durable medical equipment, level of coverage available, criteria and procedures for any Service Authorizations, and also the address and telephone number of an MCO representative whom an Enrollee can contact to obtain (either orally or in writing upon request) specific information about coverage and Service Authorization. The MCO shall provide information that is more specific to a prospective Enrollee upon request; (22) A description of the Enrollee’s right to request information about Physician Incentive Plans from the MCO, including whether the prepaid plan uses a Physician Incentive Plan that affects the use of referral services, the type of incentive arrangements, whether stop-loss protection is provided, and a summary of survey results; and (23) A description of the Enrollee’s right to request the results of an external quality review study and a description of the MCO’s Quality Assurance System, pursuant to 42 CFR § 438.364.four